Annals of Plastic Surgery最新文献

Abstract: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly used for weight management and cardiometabolic health. Common peroneal neuropathy (CPN) associated with rapid weight loss is attributed to adipose tissue reduction and subsequent nerve compression at the fibular head. Cases of "Slimmer's Palsy" have been described in conditions involving rapid weight loss, including anorexia, malignancy, and post-biliary surgery, yet it remains underrecognized as a potential complication of GLP-1RA therapy. This case report describes two nondiabetic patients who developed acute foot drop after losing 14% and 18% of their total body weight over 3-6 months of semaglutide and tirzepatide use, respectively. As use of GLP-1RAs continues to rise, peripheral nerve surgeons should be aware of Slimmer's Palsy as a predictable and treatable complication of rapid weight loss and be prepared to intervene before permanent denervation occurs.

Background: Mohs Micrographic Surgery (MMS) is the gold standard for minimizing damage to healthy tissue surrounding nonmelanoma skin cancer. However, extensive or complex lesions may require reconstructive plastic surgery to restore form, function, and aesthetic outcomes for patients. Social determinants of health (SDOH)-including socioeconomic status, geographic location, healthcare access, and insurance coverage-significantly shape patient outcomes. Disparities in access to MMS and subsequent reconstruction remain underexplored. This review highlights the need for Mohs and reconstructive plastic surgeons involved in post-MMS reconstruction to consider social determinants of health (SDOH) in their practice.

Methods: A structured literature review was conducted through PubMed and Web of Science, adhering to the PRISMA guidelines. Search terms used included "facial reconstruction," "Mohs surgery," "social determinants of health," "social determinants," and "disparities," limiting the review to head and neck post-MMS cases. Eighteen articles met inclusion.

Results: Among the 18 studies that met the inclusion criteria, 11% (2/18) focused on skin cancer detection, 28% (5/18) focused on barriers to accessing MMS, 22% (4/18) explained patients' post-MMS outcomes, and 28% (5/18) focused on the desires for reconstructive surgery and outcomes, but only 11% (2/18) discussed reconstructive surgery post-MMS.

Conclusion: Although all included studies examined disparities in the Mohs surgery care continuum, only 2 of 18 specifically addressed disparities in access to post-MMS plastic surgery reconstruction. This highlights critical gaps in interdisciplinary collaboration between Mohs and reconstructive surgeons in initial skin cancer detection, MMS, and post-MMS reconstruction. These findings reflect real-world barriers, where patients face systemic challenges in obtaining timely and equitable reconstructive care. Future studies should examine how systemic, socioeconomic, and geographic barriers impact referrals and outcomes, and develop coordinated strategies between dermatology and plastic surgery to improve equitable access to reconstruction.

Background: Scalp burns pose a unique challenge to the reconstructive surgeon given the anatomical characteristics of the head and neck. This challenge is magnified in severe burn injuries extending to the calvarial bone. Several algorithms for scalp and calvarial reconstruction have been presented in the past. However, no consensus exists about the optimal reconstructive approach. Our aim is to develop a novel algorithm for scalp burn reconstruction based on the relevant literature as well as case observations from the growing multidisciplinary field of neuroplastic surgery.

Methods: A literature review of articles on PubMed, SCOPUS, and Web of Science focused on scalp and calvarial burn management was conducted. We also present relevant cases from our institution that demonstrate the neuroplastic surgery approach to reconstruction of complex burns in this region. An algorithmic approach based on relevant anatomy, reconstructive principles, and surgical techniques ranging from primary closure to cranioplasty to reconstruct scalp and skull defects following burns is proposed.

Results: A novel algorithmic approach based on the Harrison classification of injury was developed based on our literature review. We also present 2 relevant cases from our neuroplastic surgery practice. We determined that the initial and most important factor in scalp and calvarial management is the integrity of the pericranium. Other factors such as patient's compliance and cosmetic needs may also determine treatment approach.

Conclusions: Management of scalp burns can be simplified using an algorithmic approach. We anticipate this work will help guide and improve reconstructive management for scalp and calvarial burn patients for reconstructive surgeons, burn surgeons, and particularly surgeons in resource-poor settings faced with treating severe scalp and calvarial burns.

Background: Bioresorbable hyaluronate-carboxymethylcellulose membranes (HA membrane) have been applied to prevent adhesion formation following gynecologic and abdominal procedures. However, the use of HA membrane to enhance flap delay has not been well described. We present a novel application of HA membranes as barriers in delayed flaps for reconstructive surgery.

Methods: All cases where HA membrane was utilized as a barrier to separate the undersurface of the flap from its respective wound bed during a delay procedure by the senior surgeon were reviewed. Indications for use of the HA membrane included patient risk factors, flap selection, or wound size.

Results: The HA membrane was used in 4 patients undergoing flap reconstruction with a delay procedure. Flaps included were the reverse sural fasciocutaneous flap, trapezius myocutaneous flap, and 2 paramedian forehead flaps. All of the donor wound beds showed no residual HA membrane and no tissue adherence, thus allowing minimal repeat dissection. All flaps were viable without signs of infection. All of the flaps in this study healed without any complications. There were no instances of infection, venous congestion, or delayed wound healing.

Conclusion: HA membranes can safely serve as degradable barriers in flaps undergoing the delay phenomenon. We speculate that HA membrane reduces reestablishment of microvascular network between the flap and its wound bed and may contribute to augmentation of the remaining circulation within the delayed flap.

Introduction: American Cleft Palate and Craniofacial Association (ACPA) teams consist of trained professionals collaborating in an interdisciplinary approach to optimize outcomes for patients with cleft palate. Orthodontic care is essential to correct dental malocclusion, guide maxillary growth, enhance surgical outcomes, and improve oral function and aesthetics. Although ACPA approval requires an orthodontist in the multidisciplinary team, the methods of delivering orthodontic care remain unclear. This project aims to elucidate how orthodontic care is integrated into ACPA teams.

Methods: A list of ACPA teams (n = 204) and reported orthodontists (n = 374) was obtained from the ACPA directory. Teams outside the US. and duplicate listings were excluded. Each team's website was reviewed to identify orthodontists, care delivery types (university/hospital, private practice, mixed, not listed), and orthodontic craniofacial fellowship status. Team geographic distribution was compared across the 4 US Centers for Disease Control and Prevention (CDC) Census regions: West, Midwest, South, and Northeast.

Results: Among 184 ACPA-approved teams, only 46.7% listed an orthodontist on their public websites, despite guidelines requiring orthodontic inclusion. The most common care model was university/hospital-based (25%), followed by private practice (18.5%), with variation across teams (P < 0.001). Only 16.3% of teams included a craniofacial fellowship-trained orthodontist, whereas over half did not report training status. Private practice teams were less likely to include a fellowship-trained orthodontist compared to university/hospital-based teams (OR, 0.086; P < 0.001). Most teams had 1 to 2 orthodontists (mean, 1.84), with no difference by region or care model. Regionally, the South had the highest proportion of teams (33.2%) and orthodontists (33.2%), whereas the Northeast had the fewest. Fellowship-trained orthodontists were most common in the South but showed no regional difference (P = 0.989).

Discussion: Orthodontists are inconsistently represented across ACPA teams with limited public reporting and low rates of fellowship training. Variation in care delivery models and regional access highlights structural gaps in interdisciplinary cleft care. Standardizing orthodontic integration and increasing fellowship training may improve the consistency and equity of craniofacial care nationwide.

Abstract: Outreach medical programs refer to medical or surgical care initiatives provided by volunteer teams typically from higher income countries and last from a few days to 8 weeks. To appreciate the development and empowerment of the onsite team, the use of "Sustainable Health Programs" (SHP) has become the preferred terminology at Global Smile Foundation. This study aims to review the challenges faced with implementing SHPs and propose a framework with the goal of implementing successful and sustainable programs. The cornerstone of such success is forging long-term, bidirectional partnerships with local healthcare teams, empowering them not only with clinical skills but also with the ability to mobilize resources independently. A SHP's success is gauged by how well it strengthens the local system to carry the mission forward long after the international team departs.

Background: Although the indications for the dangle protocol following lower extremity free flap reconstruction (LEFFR) are well established, significant heterogeneity in the postoperative day (POD) of protocol initiation is observed in clinical practice. This study aims to evaluate the outcomes associated with different initiation times of the dangle protocol following LEFFR.

Methods: A retrospective chart review included adult patients who underwent LEFFR at a level 1 trauma center from January 2016 to December 2022. Patients were grouped according to initiation of extremity dangling: early (POD 4-6) versus late (POD 7-8). The primary outcome was flap failure. Secondary outcomes were postoperative and dangle-related complications, including rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, wound dehiscence, infection, and pulmonary embolism.

Results: A total of 103 patients (mean age, 43.5 ± 14.5 years) were included: 46 in the early group and 57 in the late group. No significant difference in flap failure was observed between groups (4.3% vs 1.8%, P = 0.585). The early group displayed a significant reduction in average hospital LOS (21.5 vs 25 days, P = 0.010). The rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, infection, and pulmonary embolism did not differ significantly between groups.

Conclusion: Our results suggest that early initiation of the dangle protocol may decrease hospital LOS without adversely affecting flap outcomes. Future prospective studies are needed to provide additional evidence to determine the optimal timing of dangle protocol initiation.

Background: Traction neurectomy (TN) remains the standard of care for digital nerve management in partial and ray digital amputations but is associated with both neuroma formation and chronic postoperative pain. The purpose of this study is to evaluate if digital nerve coaptation (DNC) is associated with lower postoperative pain and complication rates compared to standard TN. We hypothesize that patients undergoing digital amputations with DNC will demonstrate lower postoperative complications, reduced rates of persistent pain, and fewer reoperations for nerve-related pain.

Materials and methods: A retrospective cohort study was conducted, analyzing 95 patients who underwent partial or ray amputation at a single institution from 2019 to 2024. Patients were stratified by nerve management technique: DNC (n = 26) vs TN (n = 69). Primary outcomes included postoperative pain scores and complication rates including neuroma formation, infection, wound dehiscence, persistent pain, and functional stiffness. Pain scores were assessed using the Neuropathic Pain Scale (NPS, 0-100) and a numerical pain rating scale (NPRS, 0-10). Of the 95 patients, 48 (TN = 33, DNC = 15) were successfully contacted for postoperative pain assessment. Statistical comparisons were made using independent t tests, Mann-Whitney U tests, and chi-square analyses, with significance set at P < 0.05.

Results: Patients with a digit amputation that underwent DNC experienced a lower percentage of complications compared to traction neurectomy (26.9% vs 55.1%, P = 0.030). Furthermore, although not statistically significant, patients undergoing DNC reported lower average NPS (36.1 vs 43.8, P = 0.263) and NPRS (3.79 vs 4.20, P = 0.590) scores compared to neurectomy alone. This trend of decreased pain scores reported by patients who received DNC was true regardless of whether the amputation was due to acute injury or other causes. Similarly, patients described reduced pain at all amputation levels except the middle phalanx.

Conclusions: These data indicate a positive observable outcome when comparing patients' postoperative pain and rate of complications with DNC vs TN at the time of amputation. Though a larger sample size is needed to solidify these results, these findings do suggest that DNC is a potentially superior alternative for nerve management in digital amputations, with the potential to improve long-term pain control and patient outcomes.