Archives of Plastic Surgery-APS最新文献

Background  In addressing subungual melanoma, this study presents the efficacy of wide excision followed by reconstruction using a serratus anterior fascial free flap. Methods  The study covers four patients treated between 2017 and 2020 for melanoma in the great toe or thumb, highlighting the successful application of the flap and split-thickness skin graft over exposed distal phalanx cortical bone. Results  The Breslow depths of the melanomas ranged from 0.2 to 6 mm, with four to seven lymph nodes dissected per patient, revealing no metastasis. Over follow-ups of 26 to 57 months, no local or distant recurrences were observed. The serratus anterior fascial free flaps, averaging 2.1 mm in thickness, precisely matched defect depths, negating the need for further debulking. Conclusion  This technique offered satisfactory functional and aesthetic outcomes, proposing the serratus anterior fascial free flap as a viable alternative for acral region reconstruction in subungual melanoma cases after wide excision.

Abdominal wall endometriosis (AWE) is a rare condition representing 1% of patients operated for endometriosis. We describe a case of a 26-year-old woman, with a history of cesarean delivery, who presented with cyclical pain and a subcutaneous mass in the lower abdomen. Where most AWE lesions may be surgically managed by a single surgeon, imaging revealed an unusually large lesion (13 × 4 × 10 cm) involving the rectus abdominis muscle. Plastic, gynecologic, and general surgeons combined their expertise to conduct AWE excision combined with miniabdominoplasty in a single procedure. After resection, a retrorectus mesh (Rives-Stoppa technique) reinforced the primarily closed posterior rectus sheath and an inlay mesh bridged the defect left in the anterior rectus sheath. The patient was discharged 3 days postoperatively, had minimal pain complaints, and was satisfied with cosmetic results at 1-month and later follow ups. One year postoperatively, she gave uncomplicated vaginal birth. We conclude that, in select cases, management of a large, symptomatic AWE may benefit from a multidisciplinary approach, where symptom relief and an aesthetically pleasing result for the patient can be achieved in a single procedure. We distinctively describe double mesh repair as a viable consideration for reconstruction in AWE and review current considerations in mesh repair of the abdominal wall. Further studies into this topic are warranted.

Background  Free flap reconstruction can be performed in patients with chronic limb-threatening ischemia (CLTI). However, early walking training may increase the risk of wound dehiscence and prolong hospitalization. Total contact cast (TCC) treatment effectively addresses diabetic plantar ulcers by immobilizing the foot and distributing weight away from the ulcer area. This study aimed to assess the effect of postoperative TCC use on early limb loading and hospital stay in patients with CLTI with free flaps. Methods  Patients with CLTI who underwent free flap reconstruction between 2006 and 2023 were enrolled in this study. Postoperative time until weight-bearing initiation was compared between the TCC ( n  = 5) and non-TCC groups ( n  = 7). Results  The time to the initiation of weight-bearing on the affected limb was 52.3 ± 33.2 days in the non-TCC group and 19.8 ± 3.56 days in the TCC group ( p  = 0.105). The wound dissection rates were 42.9% (3/7) in the non-TCC group and 20% (1/5) in the TCC group ( p  = 0.408). At discharge, 28.6% (2/7) of the non-TCC group and 20% (1/5) of the TCC group had ulcers ( p  = 0.735). The average flap size was 149 ± 69.1 cm ² in the non-TCC group and 95.6 ± 73.1 cm ² in the TCC group ( p  = 0.268). Conclusion  Postoperative TCC use after free flap foot reconstruction may lead to early weight-bearing of the affected limb. Further studies with larger numbers of cases are needed.

The relatively recent discovery of a novel lymphatic system within the brain meninges has spurred interest in how waste products generated by neurons and glial cells-including proteins associated with Alzheimer's disease (AD) pathology such as amyloid beta (Aβ) and tau-are disposed of. Evidence is building that suggests disease progression in AD and other cognitive impairments could be explained by dysfunction in the brain's lymphatic system or obstruction of drainage. An interesting implication of this hypothesis is that, by relieving the obstruction of flow, lymphatic reconstruction along the drainage pathway could serve as a potential novel treatment. Should this concept prove true, it could represent a surgical solution to a problem for which only medical solutions have thus far been considered. This study is meant to serve as a primer for reconstructive microsurgeons, introducing the topic and current hypotheses about the potential role of lymphatic drainage in AD. A preview of current research evaluating the feasibility of lymphatic reconstruction as a surgical approach to improving Aβ clearance is provided, with the aim of inspiring others to design robust preclinical and clinical investigations into this intriguing hypothesis.

Background  Basal cell carcinoma (BCC) is the predominant nonmelanocytic skin cancer, with preservation of both function and aesthetics being essential during tumor removal. Existing surgical margin guidelines primarily target ill-defined BCCs prevalent in Western countries. Therefore, this study aims to demonstrate the efficacy of surgical removal, propose modified guidelines for wide excision tailored to Asian patients, and share experiences with various reconstruction methods. Methods  This study encompasses 418 patients (447 cases) who underwent BCC excision from March 2015 to June 2023 at our institution. Wide excision extended 2 mm beyond the tumor edge universally, with an additional 2 mm resected if tumor cells persisted in the frozen biopsy, followed by appropriate reconstruction. Patient demographics, tumor features, reconstruction methods, complications, and recurrence rates were analyzed. Results  Predominantly, reconstructions involved local flaps (244), skin grafts (102), and direct closure (72). Significant differences were noted in age, location, and tumor size among these groups. The rate of second resection increased from upper to lower facial subunits, peaking at 11.1% in the lower subunit, with a statistically significant difference ( p  = 0.024). Additional resection was required in 5.50% of cases, with a significantly higher incidence of ill-defined borders, pigmentation, and the infiltrative subtype compared with others. Complications were minor; recurrence occurred in only one case, 6 months postinitial nasal dorsum surgery. Conclusion  Surgical excision is highly effective, supported by various reconstruction options. We propose narrower guidelines for wide excision considering tumor characteristics and recurrence locations, resulting in smaller defects addressed with simpler reconstruction methods.

Eyelid lymphedema is a rare condition that presents as persistent swelling and non-pitting edema of the eyelids. Treatment options for this disease are limited, including surgical debulking and medications, which do not achieve complete resolution. Few studies have demonstrated the use of lymphovenous anastomosis (LVA) in the preauricular area for eyelid lymphedema treatment. In this report, we demonstrate the successful treatment of primary eyelid lymphedema by performing multiple LVAs in the periorbital region, where dermal backflow was visualized using indocyanine green lymphography. A total of four LVAs were performed through two separate incisions at the lateral canthal area and lateral eyebrow in a patient with unilateral upper eyelid lymphedema that resulted in significant improvement without recurrence.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin T-cell lymphoma diagnosed in patients with a history of breast implants. Most patients develop a periprosthetic effusion at early stages of disease while less common presentations include a palpable mass, severe capsular contracture, lymphadenopathy, or cutaneous erythema. Due to the complex nature of this disease, a multidisciplinary approach is necessary for optimal management, particularly in locally advanced disease or inoperable patients. We present the successful use of neoadjuvant therapeutic protocols in two cases of locally advanced BIA-ALCL. The first case was a 52-year-old patient with a left breast mass-like stage III disease who underwent combined targeted immunotherapy and chemotherapy (brentuximab vedotin [BV]-cyclophosphamide, doxorubicin, prednisone [CHP]). Following a complete radiological and metabolic response, the patient underwent bilateral implant removal, right total intact capsulectomy, left en bloc capsulectomy, and skin resection from the left inframammary fold in continuity with the capsule. The second case was a 65-year-old patient with right breast swelling and mass-like stage IIA disease who received targeted immunotherapy, BV. Following a complete metabolic response, she underwent bilateral implant removal and en bloc capsulectomy. A literature review and the reported cases suggest the effectiveness of targeted immunotherapy as monotherapy or in combination with chemotherapy in locally advanced BIA-ALCL in disease downstaging, surgical de-escalation, reduction of significant postoperative complications, and an acceptable tolerance profile. Although surgery is an essential part of treatment, the timing and type of intervention should be carefully planned, especially when primary, radical resection is uncertain.

Background  Cleft lip and palate (CLP) impact nasolabial appearance, influencing the physical, psychological, and quality of life (QoL) of affected individuals. Evaluations of the nasolabial aesthetics by patients and medical professionals (both experienced and inexperienced) are critical for enhancing patient care. Methods  This cross-sectional study enrolled 32 patients aged 16 to 20 years with CLP who underwent continuous treatment at a university hospital in Thailand. Participants were asked to complete the Thaicleft QoL questionnaire for nasolabial aesthetic self-assessment and had their two-dimensional facial images captured and then evaluated by two groups of medical evaluators: four experienced and four inexperienced professionals. Data are presented as means and percentages, with analysis including standard deviations, Cronbach's α for evaluator consistency, kappa for interrater reliability, and the Wilcoxon signed-rank test to compare aesthetic judgments between the experienced and inexperienced medical evaluators. Results  Among the 32 patients, 19 (59.37%) were females, and 22 (68.75%) had unilateral CLP and 10 (31.25%) had bilateral CLP, all reporting high nasolabial aesthetic satisfaction. Inexperienced evaluators assigned higher aesthetic scores than their experienced counterparts ( p  = 0.01), with statistically significant agreement among inexperienced evaluators in their assessments ( p  < 0.05). Both group of evaluators demonstrated high reliability in terms of the lip. Conclusion  Experienced evaluators assigned lower aesthetic scores than inexperienced evaluators did. The patients themselves expressed high levels of satisfaction with their nasolabial appearance, indicating that the treatment outcomes were favorable from the patients' perspective.