Annals of Plastic Surgery最新文献

Background: The anterolateral thigh free flap is widely utilized for reconstructing complex wounds. Despite considerable advances in free flap procedures, partial flap loss remains a challenge, particularly with larger perforator flaps. This study explored the outcomes of bipedicle anterolateral thigh free flap procedures by comparing single-pedicle free flaps in cases involving larger flaps.

Methods: This retrospective study included 70 patients who underwent procedures (N = 72) involving extremely large anterolateral thigh free flaps (≥240 cm2 in area and >30 cm in length) at our hospital between January 2020 and December 2024. Patient characteristics and medical records were comprehensively reviewed, focusing on variables such as age, sex, flap size, surgical technique, perioperative characteristics, and postoperative outcomes.

Results: A comparison of patient demographics revealed no statistically significant differences across the entire group. A total of 8 bipedicle anterolateral thigh free flap reconstruction procedures were performed. No flap complications were observed in patients undergoing bipedicle free flap reconstruction; this outcome differed significantly from that noted in patients undergoing single-pedicle free flap reconstruction (P = 0.0215). Besides, no significant between-procedure difference was observed in ischemic time, operative time, or donor site complications.

Conclusions: The bipedicle anterolateral thigh free flap procedure appears to be a reliable approach for reconstructing extensive soft tissue defects with a single, substantial flap.

Purpose: Autologous fat transfer is widely used in reconstructive and aesthetic surgery; however, its efficacy is often limited by suboptimal fat graft survival. Various pharmacological adjuncts have been proposed to enhance fat graft viability. This study aims to assess and rank potential adjuvant agents based on their effectiveness, safety, Food and Drug Administration (FDA) approval for human use, and clinical applicability to identify the most promising candidate for future clinical trials.

Methods: In this targeted literature review, a weighted scoring analysis was conducted to evaluate several adjuncts proposed to improve fat graft viability. The scoring framework incorporated 6 key domains: FDA approval for human use, effectiveness in animal models, dosing optimization, safety in humans, mechanistic rationale, and cost-effectiveness. Each of the first 5 domains was scored on a 1-to-5 scale based on strength of supporting evidence, whereas cost-effectiveness was scored on a 1-to-3 scale. Total scores were calculated by summing all 6 domain scores, allowing a comparative ranking of adjuncts with the highest translational potential. The agents evaluated included deferoxamine, insulin with β-fibroblast growth factor, poloxamers, ADE4+ endothelial cells, hyaluronan hydrogel, botulinum toxin A, and a combination of prostaglandin E2 with polydeoxyribonucleotide.

Results: Deferoxamine received the highest total score (22/28) and demonstrated robust preclinical evidence supporting its ability to promote angiogenesis, reduce oxidative stress, and enhance fat graft retention by up to 50%. Insulin combined with β-fibroblast growth factor scored 18, showing promising effectiveness but limited by lack of FDA approval. Hyaluronan hydrogel and poloxamers followed with scores of 17 and 16, respectively. Botulinum toxin A scored 15, limited by inconsistencies in efficacy data in fat grafting. Prostaglandin E2 with polydeoxyribonucleotide scored 15, and ADE4+ endothelial cells scored 14 because of limited approval and less compelling results in improving fat graft viability.

Conclusion: Deferoxamine emerged as the top translational candidate due to its dual role as an iron chelator and hypoxia-mimetic, reducing oxidative injury and promoting vascular regeneration. Our team is currently conducting ex vivo studies exposing human adipose grafts to deferoxamine and assessing viability with confocal microscopy. These results will inform optimal delivery and design of future clinical trials.

Background: Postmastectomy radiation therapy (PMRT) is a key component of breast cancer care, reducing locoregional recurrence in appropriately selected patients. Concurrently, use of mastectomy with implant-based breast reconstruction has expanded, heightening attention to how patient, surgical, and radiation factors interact. There is a knowledge gap in how reconstructive strategies and PMRT parameters jointly influence complications, toxicities, and treatment timing across the expander-implant continuum.

Objective: The aim of this study was to determine how reconstructive and radiation therapy (RT) parameters relate to surgical-site complications, delays in PMRT initiation, acute radiation toxicities, delays in expander-to-implant exchange, and capsular contracture.

Methods: This study examined a single-center retrospective cohort of women undergoing mastectomy with immediate tissue expander or direct-to-implant reconstruction and PMRT (2017-2022). Complications classified as postmastectomy pre-RT, intra-RT, and post-RT. Associations between clinical and radiation factors and complications, toxicities, and delays were estimated using generalized estimating equation logistic models.

Results: One hundred forty-six patients underwent 260 mastectomies, and 152 reconstructions received PMRT. The majority underwent dual-stage reconstruction (87.5%). Adverse surgical site outcomes occurred in approximately one-quarter of breasts before PMRT and in a similar proportion after PMRT. Neither pre-RT surgical site outcomes delayed PMRT (P = 0.61) nor did severe dermatitis delay expander-to-implant exchange (P = 0.63). Severe dermatitis was less frequent with intensity-modulated RT (P < 0.01) and proton therapy (P < 0.02) than with three-dimensional conformal RT, whereas bolus use increased the risk of dermatitis (P < 0.01). Severe capsular contracture occurred less frequently after prepectoral versus submuscular reconstruction, but the difference did not reach statistical significance (P = 0.30).

Conclusions: In an integrated care setting where PMRT and reconstruction are performed in the same institution, pre-RT complications do not correlate with delaying PMRT, nor do post-RT complications or acute toxicities alter the implant exchange course. Complications were substantial during the pre-RT period, suggesting further opportunities for improvement. These findings emphasize the importance of multidisciplinary planning/communication to optimize patient treatment and outcomes.

Background: Multiple perforator deep inferior epigastric perforator (DIEP) flaps demonstrate superior perfusion. The selection of perforators is influenced by several factors, including the number of perforators, the running layer, the pedicle length, and the branching pattern. This study aimed to investigate the relationship between the basic and anatomical characteristics and flap dissection time in patients undergoing unilateral breast reconstruction using multiple perforator DIEP flaps.

Methods: This was a cohort study including 134 patients. Patients were divided into 2 groups based on the flap dissection time: short-time and long-time groups. The anatomical characteristics of the perforators were analyzed using preoperative and intraoperative images. The lengths of the submuscular and intramuscular vessels were measured, and the intramuscular course rate was calculated.

Results: The short-time group demonstrated significantly lower intramuscular course rates (mean, 43.6% vs 50.3%; P = 0.006), elevated flap weights (629.1 vs 886.9 g, P = 0.04), total operative time (419.9 vs 457.3 minutes, P < 0.001), and vertical and horizontal flap widths (10.2 vs 10.7 cm, P = 0.02; 31.6 vs 35.2 cm, P = 0.004, respectively). The multivariate analysis indicated that the intramuscular course rate (P < 0.001) and horizontal flap width (P = 0.044) were significant predictors of flap dissection time.

Conclusions: Perforators with an intramuscular course may be associated with a higher likelihood of increasing flap dissection time. The perforator running layer should be considered when selecting the pedicle side.

Background: Lower eyelid retraction is caused by neurogenic, myogenic, mechanical, and congenital factors. The effectiveness and safety of acellular dermal allografts for this condition remain uncertain.

Objective: This systematic review and single-arm meta-analysis aims to evaluate the effectiveness of acellular dermal allografts in correcting lower eyelid retraction.

Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane was performed to identify studies using acellular dermal allografts for lower eyelid retraction correction. Outcomes included margin reflex distance 2 (MRD2) improvement, inferior scleral show (ISS) improvement, complications, and reoperation rates. Statistical analyses were conducted using R Studio, and heterogeneity was assessed with I2 statistics.

Results: Fifteen studies with 330 participants (413 eyelids) were included. The pooled mean change in MRD2 was 2.12 mm (95% CI, 1.63-2.61 mm; I2 = 94.69%, P < 0.001), reduced to I2 = 66% after excluding Graves' disease-only studies. ISS improved by 2.21 mm (95% CI, 1.23-3.19 mm; I2 = 96.22%, P < 0.001). Complication and reoperation rates were 8.97% and 0.04%, respectively. Common complications included granulomas, pain, tearing, and discharge.

Conclusion: Acellular dermal matrix grafts demonstrate the effectiveness and safety of lower eyelid retraction correction.

Background: Gender-affirming (GA) surgeries have increased over 400% in the past decade, yet plastic surgery (PRS) residents receive limited training in GA genital reconstruction. Although plastic and reconstructive surgery is central to GA care, urology also plays a key role. This cross-sectional study compares genital surgery training in urology and PRS residency programs, availability of GA fellowships, and geographic distribution, and outlines the history and growth of GA fellowships in PRS.

Methods: United States-based, accredited integrated PRS and urology residency programs were identified via the Accreditation Council for Graduate Medical Education (ACGME) and American Urology Association (AUA) databases. Residency and institutional websites were then reviewed for rotation schedules, GA fellowships, and presence of GA surgical services. Unaccredited genital reconstruction fellowships were included if they trained plastic or urologic surgeons. Programs were grouped by US region. Analyses were performed using SPSS v28.0.1.

Results: Of 232 programs, 88 were PRS and 144 were urology. Gender-affirming fellowships existed at 8 PRS institutions (9.1%) and 9 urology institutions (6.3%) (P = 0.42). However, 59 urology programs (41%) offered fellowships that included genital reconstruction (P < 0.001). There was no significant geographic difference in fellowship distribution. Interestingly, 41.2% of programs with a GA fellowship did not advertise GA procedures, whereas 46.7% of those without fellowships did. Programs with fellowships more often referenced a "gender" clinic or rotation (P = 0.009). Since 2017, PRS GA fellowships have steadily expanded, with several major institutions launching programs through 2026.

Conclusion: Despite increasing demand for GA care, PRS residents have limited exposure to genital reconstruction, with urology offering more training opportunities. Specialized GA surgical education remains limited and insufficient given the growing needs of the transgender population.

Background: Breast infection during tissue expander (TE)-based breast reconstruction remains a significant clinical challenge. This study evaluates the effectiveness of absorbable antibiotic beads compared to nonabsorbable antibiotic plates in preventing infection in TE-based breast reconstruction.

Methods: This was a single-surgeon retrospective cohort study of patients undergoing mastectomy and immediate prepectoral, drainless TE reconstruction between April 2024 and August 2025. At the time of TE reconstruction, patients either underwent placement of absorbable antibiotic beads (vancomycin/gentamicin: April 2024-August 2024; vancomycin/tobramycin: July 2024-October 2024) or nonabsorbable antibiotic plates (November 2024-August 2025: vancomycin/tobramycin). The primary outcome was clinical breast infection during the TE postoperative period.

Results: Ninety-three breasts from 52 patients were included (48 breasts with beads, 45 breasts with plates). The bead cohort had a significantly higher rate of clinical infection compared to the plate cohort (18.8% vs 2.2%, P = 0.016), with infection occurring at a mean of 93 days postoperatively. Subgroup analysis revealed that among the breast infections with beads, 3 occurred with the vancomycin and gentamicin combination and 6 occurred with the vancomycin and tobramycin combination (10.7% vs 30%, P = 0.137). There were no differences between cohorts in seroma rates, postoperative pain scores, or additional analgesic requirements after discharge.

Conclusions: Nonabsorbable antibiotic plates were associated with reduced infection rates without compromising postoperative comfort, drainage, or analgesic needs after discharge. These findings suggest that antibiotic plates are a safe and effective strategy for infection prevention in TE-based breast reconstruction.

Purpose: The purpose of this analysis is to highlight trends in Medicare reimbursement rates in recent years and examine any regional differences in reimbursements that may exist over the past decade.

Methods: The CMS Physician and Other Practitioners database was used to extract the top 20 plastic surgery HCPCS codes in 2022 by volume. The Medicare Physician Fee Schedule Database was then used to analyze trends in reimbursements for these procedure codes from 2012 to 2025. Dollar amounts were inflation adjusted to 2025 estimates based on consumer price index (CPI) values.

Results: From 2012 to 2025, the mean overall reimbursement rate for plastic surgery procedures fell 34.2% from $373.21 to $245.65, with a 14.9% decrease in MP RVU * GPCI. A majority of codes analyzed were integumentary procedures. Nevada (40.4%, $408.26-$243.40) and Wyoming (39.0%, $396.83-$241.89) had the most dramatic decreases in reimbursement rate, whereas Massachusetts (30.5%, $378.12-$262.86) and New York (30.7%, $392.55-$272.15) had the smallest decreases in reimbursement rate. The West had the largest decrease in reimbursement rate (36.6%, $411.44-$260.66).

Conclusion: Medicare reimbursement rates for plastic surgery are decreasing nationally, most drastically in the West region. These trends may have important indications for shaping practice and fair compensation for services.