Plastic and Reconstructive Surgery Global Open最新文献

Bullous pemphigoid (BP) is a rare but devastating autoimmune dermatologic condition and can be triggered by infection, trauma, radiation, or surgery, all conditions routinely encountered by reconstructive surgeons. Chronic wounds secondary to BP are difficult to manage with local wound care and can necessitate soft tissue coverage, yet there remains a paucity of literature surrounding the evaluation and management of autoimmune skin conditions as they relate to the reconstructive surgeon. A 57-year-old man presented with a chronic left heel wound secondary to BP, and despite medical therapies, continued to have worsening ulcerations. He underwent debridement of the wound followed by free anterolateral thigh flap reconstruction. On postoperative day 3, he developed erythema and blistering of the distal edge skin flap. The dangle protocol was halted, and dermatology was consulted, who recommended 0.05% clobetasol cream applied to the areas of erythema. By the day of discharge on postoperative day 16, the flap remained stable in appearance, and erythema had significantly improved. Literature surrounding the management of chronic wounds in patients with pemphigoid diseases remains scarce. This case report added to the literature on the evaluation and management of wounds in these patients. The ideal treatment of chronic wounds secondary to BP necessitates the involvement of a multidisciplinary team, stabilization of the dermatologic disease preoperatively, aggressive resection of diseased tissue, and adequate wound bed preparation. Following this, the preferred method of reconstruction should take into consideration the pathophysiologic mechanism of the disease, followed by close postoperative monitoring and early intervention for postoperative skin changes.

Background: Surgical intervention, particularly sentinel lymph node and lymph node dissection, is essential in managing melanoma, targeting locoregional disease. Our aim was to elucidate risk factors for postoperative lymphatic complications in melanoma patients undergoing lymph node surgery in Peru.

Methods: A retrospective cohort study was conducted, reviewing records of melanoma patients who underwent lymphatic surgery at the Instituto Nacional de Enfermedades Neoplásicas from 2010 to 2019. Descriptive statistics and logistic regression analyses were performed to identify predictors of lymphatic complications.

Results: The study included 699 melanoma patients (mean age 60.70 y, 51.4% women). Most patients were Hispanic (99.3%) and from Lima (52.8%), with lower extremity involvement being common. Surgical interventions included wide local excision (56.9%), sentinel lymph node surgery (67%), and lymph node dissection (32.3%). Complications at the site of lymph node dissection included wound dehiscence (1.6%), infection (6.2%), lymphoceles (5.7%), and lymphedema (2.7%). Multivariate analysis identified lymphatic invasion (odds ratio [OR] = 2.601, 95% confidence interval [CI]: 1.232-5.491) and positive lymph node pathology (OR = 2.066, 95% CI: 1.034-4.127) as risk factors, whereas primary lesion location in the upper extremity (OR = 0.055, 95% CI: 0.007-0.408) and trunk (OR = 0.106, 95% CI: 0.014-0.818) were protective factors.

Conclusions: Key risk factors for postoperative lymphatic complications in melanoma patients undergoing lymph node surgery include lower extremity involvement, lymph node dissections, lymphatic invasion, and positive lymph nodes. Understanding these risk factors can help clinicians optimize management strategies to reduce postoperative lymphatic complications.

[This corrects the article DOI: 10.1097/GOX.0000000000007323.].

Background: Despite the ability of both plastic surgeons and orthopedic surgeons to treat hand and wrist injuries, significant differences exist in clinical practice between hand surgeons with differing residency training backgrounds. This study sought to investigate the influence of residency training on medicolegal exposure among hand surgeons trained in orthopedic and plastic and reconstructive surgery (PRS).

Methods: The Westlaw database was queried for all jury verdicts and settlements related to hand and wrist surgery and filed directly against an orthopedic or PRS hand surgeon. Extracted data included patient and defendant demographics, alleged negligence, damages, and payouts.

Results: A total of 66 cases out of 3933 were included. A defendant verdict was reached in 55 (83.3%) cases. The average monetary award was $2.1 million. The most common preceding treatment was fracture repair (n = 20, 30.3%) and carpal tunnel release (n = 13, 19.7%). Out of 66 cases, 52 (78.8%) were levied against orthopedic-trained hand surgeons. Therapeutic delay (P = 0.0068) or patient death (P = 0.0242) were predictive factors of a plaintiff verdict. PRS surgeons faced greater risks of litigation in cases following soft tissue repair, therapeutic delay, or negligence requiring an amputation. Conversely, orthopedic surgeons were more likely to face litigation following fracture repair.

Conclusions: Although specialty training of hand surgeons alone does not considerably influence the risk of facing medical malpractice litigation, differences in medicolegal trends within hand surgery reflect key differences in prevailing residency training emphases, clinical exposure, and geographic practice distribution between orthopedic- and PRS-trained hand surgeons.

Background: "Pipelining" is a phenomenon whereby a residency program repeatedly matches individuals from the same medical school across several application cycles. This is potentially disadvantageous to qualified applicants without a history of institutional legacy at their schools. We aimed to evaluate the prevalence of pipelining by US integrated plastic surgery residency programs to promote an equitable playing field for future applicants.

Methods: An analysis of every Accreditation Council for Graduate Medical Education-accredited US integrated plastic surgery residency program was conducted. The graduated medical schools of 2229 current and former plastic surgery residents were collected. Pipeline scores were defined as the ratio of total residents to number of unique medical schools represented at the program (Pipeline^C, current residents; Pipeline^C+F, current and former residents). Programs were stratified by geographic location and by affiliation with the top 25 medical schools that graduate plastic surgery residents.

Results: The average Pipeline^C score was 1.23, and the average Pipeline^C+F score was 1.45. Programs in the Northeast had the highest Pipeline^C (P < 0.001) and Pipeline^C+F (P = 0.042) scores. Programs affiliated with the top 25 medical schools had higher Pipeline^C (P < 0.001) and Pipeline^C+F (P = 0.015) scores than all other programs. Overall, 17.4% of current and 22.6% of former residents matched at their home residency programs.

Conclusions: There is a measurable prevalence of pipelining in plastic surgery, especially in the Northeastern US and at programs affiliated with medical schools with historical match success. Fostering an inclusive and meritocratic match process will benefit the field of plastic surgery entirely.

Background: Orthoplastic surgery integrates orthopedic and plastic surgical expertise and principles in the context of complex lower limb pathologies involving bone and soft tissue. Rapid advancements in the field have revolutionized the multidisciplinary approach to such conditions and have allowed for advancements in techniques used and outcomes achieved. We performed the first bibliometric analysis focused on the 100 most-cited articles related to lower limb orthoplastic surgery (LLOS) to analyze emerging trends and provide guidance for future research in the field.

Methods: The 100 most-cited articles related to LLOS were identified on Web of Science across all databases and all years. Study details, including total citation count, study outcomes, primary orthoplastic pathology, and the modality used, were extracted, and the level of evidence was also assessed.

Results: The 100 most-cited articles in LLOS were referenced by a total of 12,225 articles. Citation counts per article ranged significantly from 62 to 691 (mean: 103 ± 88.9). The majority of studies were retrospective cohorts (n = 59, mean citations: 139.8 ± 110.5). Only 1 study achieved level I status, highlighting a significant gap in methodological quality research within the field. Most studies focused on clinical outcomes (n = 88), whereas trauma and open fractures were the most common pathologies (n = 94), and flap coverage was the most common orthoplastic modality (n = 79) discussed.

Conclusions: Overall, the majority of the most influential articles in LLOS are of lower level evidence. Future research should prioritize improving methodological rigor and applying orthoplastic principles beyond trauma care.

Background: Restoring upper extremity (UE) function has consistently been ranked by tetraplegic patients as the most important function that would improve functional independence and quality of life. Given the reported underuse of UE reconstruction in spinal cord injury (SCI) and the complexity of these patients, an interdisciplinary clinic offering the full spectrum of UE reconstruction for this population was developed, taking into account known barriers.

Methods: We describe the development and functioning of our interdisciplinary TetraHand clinic with consideration for recognized barriers to implementation. We herein share the lessons we have learned and describe our experience since the introduction of the clinic in 2019.

Results: In the initial 5-year period since the establishment of the interdisciplinary Montreal TetraHand Clinic, 65 tetraplegic patients were seen in consultation, and 23 underwent UE reconstructive surgery (18 bilateral, 5 unilateral), yielding a 35.4% conversion rate. Compared with the previous model of care under which only 10 patients underwent unilateral UE reconstructive surgery over a 12-year period, the interdisciplinary clinic achieved a 5.75-fold increase in annual case volume.

Conclusions: Building a successful TetraHand program requires the recruitment of a dedicated interdisciplinary team including hand surgeons, physiatrists, therapists, the establishment of a vast referral network, and a targeted clinical strategy to address barriers to providing care for the complex SCI population. This interdisciplinary clinical model has led to a significant increase in operative volumes and referrals, enabling us to provide comprehensive UE reconstructive surgery for SCI patients.

Cancer-related hypercalcemia typically indicates poor prognosis and occurs most commonly in squamous cell carcinoma cases. However, its occurrence in patients with verrucous carcinoma, a clinically indolent subtype, has never been reported. We present the first documented case of verrucous carcinoma-related hypercalcemia caused by parathyroid hormone-related protein (PTHrP) production. A 49-year-old man presented with weight loss, fatigue, and severe hypercalcemia. He had a 3-year history of a scrotal mass that was diagnosed as perineal verrucous carcinoma based on histopathologic examination. Laboratory results revealed markedly elevated calcium (13.0 mg/dL) and PTHrP (6.6 pmol/L) levels, confirming tumor-associated hypercalcemia. The cauliflower-like tumor measuring 17 × 15 cm involved the penis and scrotum. Complete surgical resection with bilateral inguinal lymph node dissection was performed. Split-thickness skin grafts provided wound coverage over the large perineal defect. Immunohistochemical staining confirmed PTHrP production by tumor cells that had invaded beyond the basement membrane. Postoperative calcium (9.8 mg/dL) and PTHrP (<1.1 pmol/L) levels normalized rapidly. Histopathology confirmed verrucous carcinoma with dermal invasion; however, no lymph node metastasis occurred. Pseudomonas aeruginosa infection developed but resolved with topical treatment. Six-month follow-up magnetic resonance imaging showed no recurrence with sustained hypercalcemia resolution. This first documented case linking PTHrP-mediated hypercalcemia to verrucous carcinoma demonstrates that paraneoplastic hypercalcemia can occur in this typically indolent malignancy when dermal invasion occurs. Recognition of this rare syndrome is crucial for optimal management. Complete surgical excision achieved both oncological control and resolution of systemic complications, highlighting the importance of aggressive treatment when basement membrane invasion is present.