Archives of Plastic Surgery-APS最新文献

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally-terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively ( p  = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

Background  Lipedema is a chronic, incurable disorder characterized by painful fat accumulation in the extremities. While the application of liposuction in lipedema management has become increasingly popular, the safety and effectiveness of this approach remain contentious. Our systematic review and meta-analysis aimed to assess various liposuction modalities in lipedema management to verify their safety and efficacy. Methods  In-line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed a comprehensive literature review from inception until March 2023 using the following electronic databases: CENTRAL, MEDLINE, Google Scholar, and EMBASE. Results  From the 562 initially identified articles, 20 met our inclusion/exclusion criteria for evaluation. Our review encompassed 14 prospective cohort studies, 3 retrospective studies, 2 case series, and 1 cross-sectional study. A meta-analysis of nine articles revealed a notable improvement in the quality of life, pain, pressure sensitivity, bruising, cosmetic impairment, heaviness, walking difficulty, and itching among lipedema patients who underwent liposuction. Although complications such as inflammation, thrombosis, seroma, hematoma, and lymphedema-related skin changes were reported, severe complications were rare. Crucially, no instances of shock, recurrence, or mortality were reported. Conclusion  Liposuction is a safe and beneficial therapeutic intervention for managing lipedema symptoms and enhancing quality of life. However, the impact of liposuction on secondary lymphedema remains unreported in the literature. Further high-quality, large-scale trials are necessary to assess the safety and effectiveness of different liposuction modalities. These studies will contribute valuable insights to optimize liposuction as a therapeutic option for individuals with lipedema. Level of Evidence  I, risk/prognostic study.

Background  Posterior Component Separation (PCS) is a surgical technique used in abdominal wall reconstruction. Understanding the relationship between the rectus abdominis and transversus abdominis muscles and the location of intercostal nerves is crucial for minimizing nerve injury during PCS. This cadaveric study aimed to investigate these anatomical relationships and propose practical guidelines for safer PCS procedures. Methods  Eighteen fresh cadavers were dissected to assess the overlap or separation of the rectus abdominis and transversus abdominis muscles at seven abdominal levels. The distance of intercostal nerves from the lateral border of the rectus abdominis was measured. Results  The study found that the muscles overlapped at the xiphoid and upper abdominal levels but began to separate below the 2/4 upper to umbilicus level. Intercostal nerves entered at varying distances from the lateral edge of the rectus abdominis, suggesting that levels above the 3/4 upper to umbilicus level are relatively safe for dissection. Conclusion  The study recommends initiating the first incision for PCS between the subxiphoid and 2/4 upper to the umbilicus, based on observed muscle relationships and nerve distances. This practical approach enhances safety and simplifies decision-making during surgery.

Although many studies reported the safety and efficacy of high-intensity focused ultrasound (HIFU) therapy, there are still worries about internal organ injury. However, reports of abdominal wall hernias after HIFU therapy are rare. We present three cases of abdominal wall hernias without skin injury after HIFU therapy in uterine adenomyosis or fibroids. The diagnosis was often delayed because of vague symptoms, inadequate clinical suspicion, and delayed proper image studies. Abdominal wall hernia should be recognized as a possible complication after HIFU and be suspected when the patient presents with unordinary abdominal swelling and/or pain that lasts for more than a few months after the procedure.

Most tracheostomy scars are depressive and adherent to the underlying trachea, which causes up and down movement when swallowing. This tracheocutaneous tethering causes discomfort, pain, dysphagia, and bad appearance. A tracheocutaneous fistula may be accompanied. Here, we present a new method for reconstructing a tracheostomy scar deformity with tracheocutaneous tethering: layer-by-layer restoration of the anatomical structure with a subcutaneous fat tissue blanket. The scar tissue was fully excised, with the associated skin and subcutaneous tissue. The bilateral strap muscles around the scar were dissected proximally and distally and approximated to the midline, secured without tension. Bilateral platysma muscle flaps cover them firmly. The subcutaneous tissue around the incision margin, which included the superficial cervical fascia was elevated to form a fat blanket, closed transversely. The skin was closed after confirming the absence of retraction upon swallowing. From 2010 to 2018, 10 patients with tracheocutaneous tethering and one patient with tracheocutaneous fistula underwent surgery. All patients were functionally and aesthetically satisfied with the results. The only complication was a hypertrophic scar in one patient, which was managed with a triamcinolone injection. An anatomical layer-by-layer restoration with a fat blanket provided consistent, satisfying results for correcting tracheostomy scar deformities without using additional tissue. This simple method was effective for reconstructing tracheocutaneous tethering.

Carotid-cavernous fistula (CCF) is a rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is noncontrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein (SOV) enlargement was observed on the routine noncontrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room (ER), we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was readmitted to the ER. When we reanalyzed the first CT scan, an enlarged SOV was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through noncontrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.

Background  The best timing of closure of the hard palate in individuals with cleft lip, alveolus, and palate (CLAP) to reach the optimal speech outcomes and maxillary growth is still a subject of debate. This study evaluates changes in compensatory articulatory patterns and resonance in patients with unilateral and bilateral CLAP who underwent simultaneous closure of the hard palate and secondary alveolar bone grafting (ABG). Methods  A retrospective study of patients with nonsyndromic unilateral and bilateral CLAP who underwent delayed hard palate closure (DHPC) simultaneously with ABG at 9 to 12 years of age from 2013 to 2018. The articulatory patterns, nasality, degree of hypernasality, facial grimacing, and speech intelligibility were assessed pre- and postoperatively. Results  Forty-eight patients were included. DHPC and ABG were performed at the mean age of 10.5 years. Postoperatively hypernasal speech was still present in 54% of patients; however, the degree of hypernasality decreased in 67% ( p  < 0.001). Grimacing decreased in 27% ( p  = 0.015). Articulation disorders remained present in 85% ( p  = 0.375). Intelligible speech (grade 1 or 2) was observed in 71 compared with 35% of patients preoperatively ( p  < 0.001). Conclusion  This study showed an improved resonance and intelligibility following DHPC at the mean age of 10.5 years, however compensatory articulation errors persisted. Sequential treatments such as speech therapy play a key role in improvement of speech and may reduce remaining compensatory mechanisms following DHPC.

Background  The risk of flap necrosis in tissue reconstruction surgery is elevated in patients with vascular disorders, such as diabetes mellitus. Chronic hyperglycemia causes endothelial cell dysfunction and increases inflammatory process, causing vascular insufficiency. Platelet-rich plasma (PRP) contains high levels of platelets, growth factors, and fibrinogens. Its regenerative properties spark interest in supporting flap survival in relation to diabetic complications. Methods  Thirty Wistar rats were divided into three groups. The first group included diabetic rats without PRP injection, which underwent flap procedure. The second group included diabetes-induced rats receiving PRP subcutaneous injection 1 day prior to flap procedure. The third group included nondiabetic rats receiving PRP injection 1 day prior to flap procedure. Flap tissue samples were taken on the seventh day to measure vascular endothelial growth factor (VEGF) levels using enzyme-linked immunosorbent assay method; angiogenesis and collagen density were measured from histopathology examination, and flap viability was analyzed using digital measurements. Results  Analysis showed that flap viability, angiogenesis, and VEGF levels were significantly higher in the PRP-injected diabetic rats compared with diabetic rats that did not receive PRP. The levels of VEGF, angiogenesis, and viability of flaps in diabetic rats given PRP did not differ significantly compared with nondiabetic rats that received PRP. Conclusion  Flap preconditioning through local injection of activated PRP enhances flap viability, VEGF levels and angiogenesis, in random skin flaps in diabetic rats, to the level where it does not differ significantly to nondiabetic rats that were given PRP.