Plastic and Reconstructive Surgery Global Open最新文献

Background: The deep inferior epigastric perforator (DIEP) flap provides an effective and popular means for autologous breast reconstruction. However, with the complexity of the pathway, the environmental impact of the pathway has yet to be evaluated.

Methods: A retrospective analysis of 42 unilateral DIEPs at a single reconstructive center was performed. Process mapping and life-cycle analyses were performed for equipment, staff, patients, and land. A bottom-up approach was adopted to calculate carbon dioxide equivalent estimates for the initial consultation, preoperative, intraoperative, and immediate postoperative periods.

Results: This study estimated the carbon footprint of a patient undergoing DIEP flap surgery to be approximately 233.96 kg CO₂eq. Induction, maintenance, and running of anesthesia had the highest overall contribution to the carbon footprint (158.17 kg CO₂eq, 67.60% overall). Patient and staff travel contributed more than 15% overall carbon emissions in this study. The impact of sterilization was less than half of that from waste management (0.81 versus 1.81 kg CO₂eq, respectively). Waste management alone contributed 4.21 kg CO₂eq of the overall carbon emissions, the majority of which was accountable to the incineration of 14.75 kg of noninfectious offensive waste.

Conclusions: This study estimates the carbon footprint of the DIEP pathway. Strategies to mitigate the impact of carbon emissions including usage of reusable vs single-use equipment, virtual consultations, standardization of equipment packs, and optimizing waste disposal were suggested areas for improvement. Data from manufacturers on life-cycle assessments were limited, and further work is needed to fully understand and optimize the impact of DIEP surgery on the environment.

Background: The multifactorial nature of aging necessitates a comprehensive assessment addressing contour, volume, and facial laxity, and a holistic treatment plan. We evaluated combined use of HArmonyCa with HA fillers to improve laxity and overall aesthetic outcomes. A detailed guide is also presented regarding facial shapes, special areas, and volume needs.

Methods: This retrospective case series evaluates 10 patients' facial laxities with Facial Laxity Rating Scale using 2-dimensional before and after photographs (posttreatment and 6-month mark). Overall improvement was assessed by the investigator and patients by comparing to baseline. Patient satisfaction was measured with a questionnaire.

Results: The Facial Laxity Rating Scale scores (jowl and neck) were highest at baseline and lowest at 6-month mark. Facial laxity significantly improved over time for jowl (P < 0.001) and neck (P = 0.007). At the sixth month, facial laxity significantly improved compared with baseline both in jowl (P = 0.001) and neck (P = 0.011). Global Aesthetic Improvement Score evaluations improved significantly during the 6-month period (P < 0.001). Global Aesthetic Improvement Score was significantly higher at 6-month posttreatment compared with immediate posttreatment evaluation (P < 0.001). Patients were satisfied immediately after treatment and 6 months after. The satisfaction significantly improved at the sixth month compared with immediately after treatment (P = 0.033).

Conclusions: A combined use of HArmonyCa and HA fillers improves laxity in the lower face and neck and enhances aesthetic outcomes with high patient satisfaction. Overall improvement and patient satisfaction are higher at the sixth month, which is attributable to biostimulation.

Background: Concurrent panniculectomy with abdominal wall reconstruction (CP-AWR) as a single-stage operation has reported increased complications, but constant quality improvement can improve results. This study describes outcomes for 21 years, impacted by evidence-based-practice changes.

Methods: Prospectively maintained database was reviewed for CP-AWR and separated by surgery date: "early" (2002-2016) and "recent" (2017-2023). A 1:1 propensity-scored matching was performed based on age, tobacco use, body mass index (BMI), American Society of Anesthesiologists (ASA) score, wound class, and defect size.

Results: Of 701 CP-AWRs, 196 pairs matched. Match criteria were not significantly different between early and recent groups, except for BMI (34.6 ± 7.2 versus 32.1 ± 6.01 kg/m²; P = 0.001). Groups were comparable in sex and diabetes, but recent patients had fewer recurrent hernias (71.4% versus 56.1%; P = 0.002). Recent patients had more biologic (21.9% versus 49.0%; P < 0.001) and preperitoneal mesh (87.2% versus 97.4%; P = 0.005). Readmission and reoperation did not significantly differ, but length of stay (8.3 ± 6.7 versus 6.5 ± 3.4 d; P = 0.001) and wound complications decreased over time (50.5% versus 25.0%; P < 0.001). Hernia recurrence rates improved (6.6% versus 1.5%; P = 0.019), but follow-up was shorter (50.9 ± 52.8 versus 22.9 ± 22.6 months; P < 0.0001).

Conclusions: Despite patient complexity, outcomes of CP-AWR improved with implementation of evidence-based-practice changes in preoperative optimization, intraoperative technique, and postoperative care. This large dataset demonstrates the safety of a single-stage repair that should be part of hernia surgeons' repertoire.

Chronic postoperative pain after breast surgery is a significant concern, with studies indicating varying rates depending on the type of surgical procedure. The risk of developing neuropathic pain is notably increased with axillary lymph node dissection due to potential nerve injuries. Additionally, the method of breast reconstruction may influence postsurgical pain rates, with conflicting findings on the impact of reconstruction type. Recent advancements in techniques such as targeted muscle reinnervation, among others, show promise in addressing postoperative pain in these patients. As the prevalence of these procedures rises, future research is likely to focus on assessing and managing pain in this patient population. The development of patient-reported outcome measures specific to breast surgery pain can aid in clinical assessment and treatment planning. This review emphasizes the importance of gaining a deeper understanding of risk factors, nerve anatomy, and treatment options to enhance outcomes and quality of life for individuals undergoing breast surgery.

Abdominoplasty is a commonly performed procedure for patients after significant weight loss and in postpregnancy women. Stable weight and completed family planning are critical for optimal outcomes, as pregnancy postabdominoplasty can increase risks for both mother and fetus and potentially compromise aesthetic results. We present the first reported case of a patient undergoing abdominoplasty while unknowingly pregnant. A 40-year-old woman, 4 years postbariatric bypass surgery, presented for abdominoplasty with a body mass index of 28 kg/m². She had 3 children and had concluded her family planning. The surgery was performed without complications. Four months later, an unexpected pregnancy at 24 weeks was discovered. The patient developed gestational diabetes and hypertension but had no complications related to the abdominoplasty. The male newborn, delivered at 38 weeks, was small for gestational age but healthy. Ten years postsurgery, the patient maintained excellent aesthetic results with no abdominal complications. This case highlights that although family planning completion is recommended preoperatively to avoid complications, pregnancy postabdominoplasty can still result in favorable maternal and fetal outcomes. Although performing abdominoplasty on pregnant women is not advised, this case demonstrates that an undetected pregnancy during the procedure did not lead to adverse outcomes for the mother or child.

Background: There are advantages and disadvantages to both immediate 1-stage and 2-stage autologous-breast reconstruction. The 2-stage procedure may suffer from a hitherto overlooked difficulty: the tissue expander may induce chest wall depression that may require using a heavier-than-expected flap to generate symmetrical breasts. We conducted a retrospective observational study to assess this phenomenon.

Methods: Consecutive patients who underwent 1-stage or 2-stage unilateral autologous-breast reconstruction with a deep inferior epigastric perforator flap were included. The 2 groups were compared in terms of age, body mass index, mastectomized tissue weight, inset-flap weight, and percentage additional flap weight (defined as [inset-mastectomy]/mastectomy × 100). The latter reflects the amount of additional flap tissue relative to mastectomized tissue that was needed to generate symmetrical breasts. The chest wall deformity after tissue expansion in the 2-stage patients was quantitated with computed tomography.

Results: Patients' healthy and affected breasts were symmetrical before surgery (P > 0.05). Compared with the 1-stage patients (n = 37), the 2-stage patients (n = 31) only differed in terms of a significantly higher mean percentage additional flap weight (28% versus 12%, P = 0.0077). Relative to preoperative values, nearly all 2-stage patients had mild (74%) or moderate (19%) chest wall deformity before tissue expander removal.

Conclusions: Due to tissue expander-induced chest wall deformity, 2-stage breast reconstruction may require a larger flap volume than is anticipated on the basis of preoperative volumetric measurements. Considering this phenomenon when choosing between immediate 1-stage and 2-stage reconstruction could potentially help improve patient outcomes.

Background: Keloids are growing scars that arise from injury to the reticular dermis and subsequent chronic local inflammation. The latter may be promoted by vascular hyperpermeability, which permits the ingress of chronic inflammatory cells/factors. Cutaneous capillaries consist of endothelial cells that generate, and are anchored by, a vascular basement membrane (VBM). Because VBM blocks immune cells/factors ingress, we investigated whether keloids are associated with altered VBM structure and/or VBM component expression by local endothelial cells.

Methods: In total, 54 keloid (n = 27) and adjacent normal skin (n = 27) samples from 14 patients underwent transmission electron microscopy (TEM). Cross-sections of whole capillaries were identified. VBM thickness, continuity, and the number of layers in keloid and normal skin tissues were quantified. The differential expression of 222 previously reported VBM component genes in keloid and normal skin endothelial cells was analyzed using the GSE121618-microarray dataset.

Results: TEM images showed that keloid VBMs were significantly thinner than adjacent skin VBMs (0.053 versus 0.078 nm; P < 0.001). They were also greatly fragmented (continuity was 46% versus 85% in normal skin; P < 0.001) and had fewer (1.2 versus 2.4) layers (P < 0.001). Keloidal endothelial cells demonstrated downregulation of 22 genes, including papilin, laminin-α5, and laminin-α2, and upregulation of 28 genes, including laminin-β1, laminin-β2, laminin-γ1, and laminin-γ2.

Conclusions: VBMs are greatly fragmented in keloids. These changes support the notion that keloids are initiated/promoted, at least partly, by vascular hyperpermeability.

Background: Almost half of all spontaneously occurring keloids are acne keloids on the anterior chest. These keloids often grow in a crab-claw shape due to predominant tractional stresses on the scar; such stresses are risk factors for keloid growth/progression. To understand the relationship between acne keloid growth and mechanical stress, we conducted finite element analysis (FEA), measured the long/short dimensions of photographed acne keloids, and subjected acne keloids to microscopy.

Methods: FEA was conducted on 10 identically shaped ellipsoidal keloids whose long-axis length rose from 5 to 50 mm in 5-mm increments. They were embedded in the skin and subjected to traction. The stress on the keloid and its surrounding tissues was determined. Dimensions of 220 acne keloids were measured. Electron/light microscopy was conducted on the center, margins, and surrounding tissues of chest acne keloids.

Results: FEA showed that as the keloid "grew," the tractional stress centered on its core, then became evenly distributed, and then focused increasingly on the tractioned keloid margin, especially its shallow dermis. This is associated with increasing stress in the surrounding tissues at the keloid margin. Clinical dimension measurements showed that acne keloids remained round until 4-5 mm, after which they elongated rapidly. Electron microscopy showed that in the surrounding skin, fragments of keratinocyte, fibrin, and numerous cell fragments were observed just below the epidermal basement membrane.

Conclusions: Keloid-prone acne should be treated with steroid tape or other keloid therapy when it reaches 4-5 mm in diameter.

True parenchymal breast changes following COVID-19 vaccination are exceedingly rare. Equally rare are incidences of pseudoangiomatous stromal hyperplasia (PASH)-associated gigantomastia. The patient in this case report presented with both occurrences and experienced massive breast enlargement 1 week postadministration of the Pfizer/BioNTech COVID-19 vaccine, which worsened after her second dose. Definitive treatment was achieved through reduction mammoplasty, with the final pathology report confirming uniformly dense terminal duct lobular units with interspersed PASH units. The association between the COVID-19 vaccine, PASH, and breast hypertrophy warrants further investigation to comprehend the spectrum of reactions to the vaccine.

Background: Three-dimensional (3D) models generated from computed tomography (CT) images efficiently and accurately complement surgical comprehension. Additionally, computer modeling provides a substrate for comparative analysis of the treated orbit volume. This study aimed to investigate cases of orbital bone fractures with regard to orbital-defect correction, through 3D computational structural modeling and evaluation of orbital volume.

Methods: A total of 136 cases of orbital fractures with a diagnosis and surgical treatment were identified, of which 15 were selected based on inclusion and exclusion criteria. The construction of the preoperative and postoperative 3D models was based on CT images, supported by a medical imaging design system; this technique enabled the calculation of orbital volumetric measurements with the normal contralateral orbit as a reference.

Results: Three-dimensional modeling in the preoperative and postoperative periods was performed for each patient. This study revealed that (1) preoperatively, the affected side had greater volume followed by postoperative reduction and (2) after surgical correction, the affected side had smaller volume and was equivalent to the unaffected side. However, there were no statistically significant differences between the periods (preoperative and postoperative) with regard to the mean and distribution of orbital volume or between the mean orbital volumes of the 2 sides.

Conclusions: Using 3D computer modeling of bone structures, it is possible to evaluate orbital bone fractures after surgical correction. The effectiveness of preoperative and postoperative treatments was confirmed by comparing orbital volumetrics. It was not possible to assess soft tissues due to postoperative edema.