Plastic and Reconstructive Surgery Global Open最新文献

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.

Diagnosing late-onset complications after hyaluronic acid (HA) fillers can be challenging, particularly when clinical symptoms are mild. Although ultrasound (US) is widely regarded as the gold standard for evaluating facial fillers, it has limitations in certain scenarios. We report the case of a 30-year-old woman who developed a persistent sensation of pressure in the mental region 2 years after chin augmentation with a high-G-prime HA filler (brand unknown). Two high-frequency US examinations performed by experienced radiologists identified only a small supraperiosteal bolus, without significant deposits to explain the symptoms. High-resolution facial magnetic resonance imaging (MRI) unexpectedly revealed a substantial amount of HA diffusely dispersed within the subcutaneous fat of the chin, undetectable by US. A targeted injection of hyaluronidase (150 IU) was administered, resulting in complete symptom relief. Follow-up MRI confirmed the resolution of the HA deposits. This case highlighted a diagnostic blind spot of US when filler material was diffusely infiltrated into adipose tissue and lacked nodular morphology. MRI, although not routinely used due to cost and availability, may provide crucial complementary information in cases of clinical-radiological discordance. This case suggested that MRI may provide useful complementary information in selected scenarios of clinical-radiological discrepancy.

Background: Prevention of wound complications of the neoumbilicus in deep inferior epigastric perforator breast reconstruction increases patient cosmetic satisfaction. The reported incidence of umbilical wound complications is between 3% and 18% in the current literature, necessitating improved prediction of such complications.

Methods: The authors evaluated a retrospective cohort of 30 consecutive patients who underwent deep inferior epigastric perforator breast reconstruction during a 1.5-year period at the University Health Network by a single surgeon. Umbilical perfusion was intraoperatively measured by the SPY quantification of perfusion (QP) system with indocyanine green angiography. Postoperative outcomes were assessed in the outpatient clinic and classified as no wound complication, minor wound dehiscence, partial, or total necrosis.

Results: A total of 30 patients were included: 19 with no complications, 2 had minor wounds, 3 had dehiscence, 3 had partial necrosis, and 3 had total necrosis. The average patient age was 50 ± 10 years; the average body mass index was 28 ± 4 kg/m². Seven (23%) patients had a smoking history, and 1 (3%) patient was an active smoker. Patients with an average SPY-QP of 66% or higher had no umbilical wound complications. An average SPY-QP of 31% or lower predicts minor wound complications, 26% or lower predicts partial or total necrosis, and 13% or lower predicts total necrosis.

Conclusions: Intraoperative indocyanine green angiography is an excellent adjunct to clinical assessment for predicting umbilical wound complications. A surgeon can use SPY-QP to make intraoperative decisions to improve outcomes if quantitative perfusion is poor.

Discharge destination following hospitalization plays a critical role in surgical recovery, long-term outcomes, and healthcare resource use. Although postacute care facilities are increasingly used, there is limited literature within plastic surgery addressing their role and implications. This review outlined the continuum of discharge options available to plastic surgery patients, including long-term acute care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, assisted living facilities, postoperative guest suites, and home with or without home health care. Each destination differs significantly in patient acuity, level of available services, and payer coverage. Plastic surgery patients undergoing complex procedures such as free tissue transfer, trauma reconstruction, or burn care may require specialized facilities for wound management, rehabilitation, or close monitoring. Medicare and Medicaid policies influence access, and coverage varies widely across facility types and states. Home discharge is generally associated with superior outcomes and more predictable costs, but nonhome postacute care facilities remain essential for patients with higher medical and functional needs. For plastic surgeons, knowledge of these discharge settings is essential to effective discharge planning, directly impacting readmission rates, reimbursement, and patient recovery. Plastic surgeons must engage actively in discharge planning by advocating for the most appropriate level of care, aligning patient safety, functional recovery, and financial stewardship.

Background: Cartilage regenerative medicine presents promising therapeutic options; however, mature cartilage tissue reconstruction remains challenging. Although techniques for expanding chondrocytes are clinically available, the production of mature articular and auricular cartilage tissues remains to be achieved. Similarly, although epidermal sheets from cell cultures have been clinically used for skin regeneration, dermal tissue reconstruction remains elusive. This study aimed to develop a rotational culture method to produce cartilage and dermal tissue without scaffold materials.

Methods: The articular and auricular cartilage and dermis were isolated from patients with polydactyly or accessory auricles. The chondrocytes and fibroblasts were transferred to culture vessels and subjected to different rotational culture conditions: lateral rotational to rapidly form sheets for articular cartilage, box rotational to thicken tissue for auricular cartilage, and bottom rotational to form large tissue sheets for dermal fibroblast and articular cartilage. Sections and cultured cells were subjected to hematoxylin-eosin, Alcian blue, and type I collagen staining.

Results: The lateral rotational method produced articular cartilage-like sheets, as confirmed by Alcian blue staining, which identifies mucopolysaccharides that make up the cartilage matrix. The box rotational method produced auricular-like cartilage tissue from auricular chondrocytes, whereas the bottom rotational method produced dermal-like sheets expressing type I collagen from human skin fibroblasts. All tissues were produced without using scaffold materials through repeated cell seeding and culture rotation.

Conclusions: The tissues produced without scaffolds exhibited properties suitable for clinical applications, including elasticity, stretchability, and suturing capability, demonstrating a potentially promising breakthrough in cell manipulation technology for cartilage and dermis.

The unique anatomy of the ear makes it difficult to reconstruct. In terms of restoring the natural curvature of this anatomic site, repair of large defects involving the helical rim after skin tumor removal presents a unique surgical challenge. We present a case of a patient with a partial-thickness surgical defect involving more than one-third of his right helical rim. The defect was reconstructed using a double transposition flap, with the flap taken from the surrounding skin. There was no need to interpose a cartilage graft, as there was no damage to the patient's own cartilage during the surgery. Both flaps survived with no complications. This single-staged surgical technique was performed under local anesthesia. The immediate and long-term outcomes were satisfactory, and cosmetic results were good. We describe the double transposition flap as an innovative technique for reconstructing specific ear defects. In particular, it is an excellent surgical option for the reconstruction of large surgical defects involving the helical rim. For defects such as the one outlined here, this flap may be considered as an alternative reconstructive option, provided the patient's medical condition allows.

Background: Imaging studies have become indispensable tools in the perforator flap surgeon's armamentarium, significantly enhancing operative outcomes and reducing complications. We conducted the first bibliometric analysis on imaging studies for flap reconstruction to characterize any emerging trends and assess the methodological quality of the field.

Methods: The 100 most-cited articles in imaging studies for flap reconstruction were identified on Web of Science, across all available journals and years (1950-2024). Study details, including the citation count, main subject, outcome measures, imaging type, and evidence level, were extracted.

Results: The most-cited articles involved 21,619 patients and amassed a total of 9689 citations. Citations per article ranged from 41 to 302. The evidence base relied heavily on level 3 (n = 37) and level 4 (n = 34) studies, reflecting the prevalence of retrospective cohorts and case series. Only 1 study was a randomized trial achieving level 1 evidence. Validated patient-reported outcome measures were reported in only 1 study. Imaging outcomes were the most explored, followed by flap anatomy and comparisons of imaging modality, with cost-effectiveness being the least investigated. Imaging was most frequently used for preoperative flap planning (n = 62), with fewer studies using intraoperative (n = 27) and postoperative (n = 19) imaging for perfusion assessment and complication detection. Computed tomography angiography, Doppler ultrasound, and indocyanine green ICG angiography were the most frequently used imaging modalities.

Conclusions: The most influential studies lacked randomization and were conducted by single-center efforts. Promoting global collaboration and incorporating patient-reported outcome measures into high-quality research can advance a more patient-centered, holistic evaluation of reconstructive success.