Annals of Plastic Surgery最新文献

Background: Conventional peripheral neurorrhaphy techniques often yield suboptimal functional outcomes. The addition of polyethylene glycol (PEG), a hydrophilic polymer, has emerged as a promising adjunct to enhance axonal regeneration and expedite recovery following nerve transection. This manuscript provides a comprehensive overview of the biochemical properties of PEG with its unique features used in peripheral nerve injuries, and the technical considerations underlying its application in acute peripheral nerve repair.

Methods: We review preclinical and clinical literature evaluating PEG-mediated axonal fusion, including meta-analyses of animal studies and recent human trials. Emphasis is placed on PEG's mechanism of action, as well as the role of complementary agents such as methylene blue. Additionally, we describe our institution's standardized surgical protocol for PEG-assisted end-to-end neurorrhaphy, supported by intraoperative technical rationale.

Results: Data from rodent models and human patients consistently demonstrate accelerated sensory and motor recovery when PEG is integrated into neurorrhaphy protocols. PEG's nonspecific dehydration of axonal membranes facilitates immediate axonal fusion, restoring neural continuity and reducing the latency of regenerative processes. Clinical outcomes are particularly favorable in clean transections repaired within 72 hours, with no significant PEG-related adverse events reported to date.

Conclusions: PEG-mediated fusion represents a potential enhancement to standard microsurgical nerve repair. While further investigation is needed to optimize application parameters, address axonal specificity, and define long-term efficacy, current evidence supports PEG as a safe, effective, and accessible technique to improve outcomes in peripheral nerve repair.

Background: Online ratings may very well determine how patients choose their plastic surgeons. However, the specific drivers of extremely negative feedback remain underexplored. We analyzed 1-star Yelp reviews to characterize clinical and nonclinical factors that most commonly trigger public discontent.

Methods: Yelp.com was queried for "plastic surgeon" in New York, Miami, Los Angeles, and Chicago. Board-certified surgeons with at least one 1-star review were included. Two reviewers independently coded every discrete complaint as clinical (poor outcome, complications) or nonclinical (staff behavior, billing). Reviews that mentioned an operation were tagged "surgical." Frequencies were compared with χ 2 tests ( α = 0.05).

Results: Eighty-six surgeons generated 955 1-star reviews comprising 2,423 complaints (2.54 ± 1.31 per review). Nonclinical grievances out-numbered clinical 1,502 versus 921 (62% vs. 38%). Staff discourtesy (14.0%), rude bedside manner (12.4%), and billing disputes (10.5%) led the nonclinical category. Dissatisfaction with aesthetic outcome (17.8%) and complications (10.2%) headed clinical concerns. Surgical reviewers (n = 482) cited poor results and complications three times more often than nonsurgical reviewers. The latter focused on staff and access issues. Geographic profiles differed: Miami complaints centered on customer service, whereas New York was overwhelmingly outcome driven.

Conclusions: Two thirds of 1-star plastic-surgery reviews stem from interpersonal or administrative shortcomings, not operative misadventures. Because nonclinical issues are comparatively easier to correct, investments in staff training, transparent pricing, and streamlined scheduling may improve online reputation as effectively as technical refinements in the operating room.

Purpose: Capsular contracture is a common major complication of implant-based breast surgery. Although its etiology is incompletely understood, biofilm formation on implant surfaces is considered a central factor. Plastic surgeons have adopted many risk-reducing measures; however, these measures are heterogeneous, and capsular contracture rates remain high. Recent studies have demonstrated the antibiofilm effects of hyaluronic acid on various surgical prostheses. Our study tests the in vitro antibiofilm properties of hyaluronic acid as a breast implant submersion adjunct.

Methods: Six-millimeter-diameter silicone disks were cut from smooth tissue expanders and treated with different concentrations of hyaluronic acid alone or combined with triple antibiotic solution (clindamycin, cefazolin, and gentamicin at 450, 1000, and 80 mg/mL, respectively). Following treatment, the disks were submerged in tryptic soy broth inoculated with Staphylococcus epidermidis strain RP62A and incubated for 60 hours to allow biofilm formation. Biofilms were stained with crystal violet, and the stain was extracted to measure optical density as a marker of biofilm formation.

Results: Hyaluronic acid submersion exerted dose-dependent antibiofilm effects; hyaluronic acid 1.2% (wt/vol) solution produced a biofilm reduction similar to that achieved by the triple antibiotic solution. Synergistic effects were observed in the combination treatments, with hyaluronic acid 0.8% (wt/vol) in triple antibiotic solution producing the greatest biofilm reduction. This treatment produced a mean optical density of 0.313, which is significantly lower than that of the positive control (2.539; P < 0.001) and triple antibiotic solution alone (0.877; P < 0.001). These findings represent biofilm reductions of 87.7% and 64.3%, respectively.

Conclusion: Hyaluronic acid shows potential as an adjunct to triple antibiotic breast implant submersion. Pretreating silicone disks with hyaluronic acid 0.8% (wt/vol) in triple antibiotic solution led to biofilm reductions of 87.7% and 64.3% compared with the positive control and the triple antibiotic solution, respectively. These effects, combined with hyaluronic acid's biocompatibility, resorbability, and viscosity, demonstrate its promise for the prevention of capsular contracture in implant-based breast surgery.

Background: Doctor of osteopathic medicine (DO) applicants are underrepresented in integrated plastic surgery. We hypothesized they would match at a lower rate compared to similarly qualified doctor of medicine (MD) applicants.

Methods: Applications to a large integrated plastic surgery residency program with a dedicated DO position were analyzed 2020-2023. Residents and faculty scored applications on research (1-5), letters of recommendation (LOR; 1-5), and USMLE Steps 1 and 2 (>240 = 1, >250 = 2), which summed to the total score. Residency match outcomes were verified online. Logistic regression modeling was used to assess MD versus DO odds of successful applications in the full dataset and a 3:1 MD-to-DO cohort matched by USMLE, research, and LOR scores. Applications were placed into quartiles based on total scores, and successful match outcomes were compared.

Results: In the full dataset (MDs = 1100, DOs = 47), MDs had significantly stronger metrics (P < 0.05) compared to DOs. In the adjusted logistic regression of the full dataset, MDs had 9.56 times the odds of success compared to DOs (95% CI, 3.84-27.62; P < 0.01). In the matched cohort, MDs had 5.89 times the odds of success compared to similarly qualified DOs (95% CI, 2.43-16.71; P < 0.01). Although MD applicants were evenly distributed across the quartiles, DO applicants were concentrated in the lowest quartile and were significantly less successful within this group.

Conclusion: DO applicants with similar credentials to their MD counterparts have lower odds of matching into integrated plastic surgery, suggesting potential bias. However, disparities in overall scored metrics highlight areas to improve competitiveness.

Background: Post-breast surgery pain syndrome (PBSPS) is a chronic neuropathic pain condition that affects up to 50% of patients undergoing various breast surgeries, including mastectomy, lumpectomy, reconstruction, reduction, and gender-affirming procedures. The pain is believed to result from peripheral nerve injury, neuroma formation, fibrosis, and maladaptive central nervous system changes. Despite the prevalence of PBSPS, treatment options remain limited, with most management strategies focusing on pharmacologic interventions that provide inconsistent pain relief. There is growing interest in surgical approaches targeting nerve injury to improve outcomes. This systematic review and meta-analysis evaluate the efficacy of nerve surgery in reducing pain severity in PBSPS patients.

Methods: A comprehensive literature search was conducted using PubMed, Scopus, and clinicaltrials.gov to identify studies published between 2008 and 2022 that examined surgical treatments for PBSPS. Inclusion criteria required original studies that reported preoperative and postoperative pain scores using the visual analog scale (VAS). Surgical techniques analyzed included neurectomy with transposition into muscle, regenerative peripheral nerve interfaces (RPNI), targeted muscle reinnervation (TMR), and cadaveric nerve grafting. Studies that did not report numerical pain outcomes were excluded. A meta-analysis was conducted on five studies that met the statistical inclusion criteria, with a subset analysis focusing on neurectomy and muscle transposition.

Results: Our literature yielded 8 studies that met the inclusion criteria, of which 5 were included in the meta-analysis. A significant reduction in VAS scores was observed following surgical intervention (preoperative, 8.7 ± 0.84; postoperative, 1.59 ± 1.15; P < 0.001). In the subset analysis of neurectomy with transposition into muscle, pain scores also showed a statistically significant reduction (preoperative, 8.63 ± 0.95; postoperative, 1.74 ± 1.27; P < 0.001). RPNI demonstrated promising pain relief in a small cohort, with patients experiencing median pain score reductions from 9 to 1 ( P = 0.02). TMR was evaluated in a small case series and suggested potential for prophylactic neuroma prevention.

Conclusions: Surgical management of PBSPS significantly reduces pain severity, supporting nerve surgery as a viable treatment option. Neurectomy with transposition into muscle remains the most studied and widely utilized technique, with consistently positive outcomes. Emerging strategies, including RPNI and TMR, show promise for both treatment and prevention of PBSPS but require further validation in larger studies. Although high-quality data are limited, a focus on surgical intervention is emerging. PSBPS remains a significant problem, and surgical techniques to treat it have shown promise yet require further validation.

Background: Direct-to-implant (DTI) breast reconstruction offers immediate aesthetic and psychological benefits, but the role of acellular dermal matrix (ADM) remains debated. Using a multi-institutional database, this study evaluates and compares outcomes between ADM-assisted and non-ADM DTI procedures.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2022 was queried to identify female patients who underwent DTI breast reconstruction for oncological purposes. Patients were divided into 2 groups: DTI breast reconstruction with ADM and without. Thirty-day postoperative complications were compared using multivariate analysis and propensity score matching.

Results: Among 10,177 patients, 45% (n = 4605) underwent ADM-assisted DTI, while 55% (n = 5572) had non-ADM DTI. While both groups showed comparable mean ages (ADM: 52 ± 12 years vs non-ADM: 51 ± 11 years; P = 0.190), ADM patients were significantly less likely to present with comorbidities such as obesity (ADM: 21.5% vs non-ADM: 26%; P < 0.001), hypertension (20.5% vs 2.6%; P = 0.01), diabetes (4.8% vs 5.1%; P = 0.002), and smoking history (6.4% vs 10.1%; P < 0.001). Still, surgical complication rates were comparable (ADM: 4.7%, non-ADM: 5.5%; P = 0.08), including superficial infections (2.0% vs 2.4%; P = 0.19), deep infections (0.6% vs 0.9%; P = 0.17), wound dehiscence (0.8% vs 1.0%; P = 0.24), and bleeding (0.6% vs 0.7%; P = 0.54). Medical complications were generally rare and also showed no significant differences (ADM: 1.4%, non-ADM: 1.7%; P = 0.27). Confounder-adjusted multivariable analysis and propensity score matching confirmed no increased risk of surgical (odds ratio 0.93, 95% confidence interval 0.75-1.16, P = 0.52) or medical complications (odds ratio 0.87, 95% confidence interval 0.59-1.26, P = 0.46).

Conclusions: The use of ADM in DTI breast reconstruction is not associated with a higher risk of short-term complications, supporting its continued use in clinical practice. This information is crucial for surgeons and patients in making informed decisions regarding the incorporation of ADM in DTI breast reconstruction.