Annals of Plastic Surgery最新文献

Background: This study examines clinical outcomes of Ovine-Reinforced Hybrid Mesh (OviTex) in alloplastic breast reconstruction by a single surgeon.

Methods: A retrospective chart review was conducted on patients who underwent immediate or delayed breast reconstruction with OviTex between 2019 and 2023 without indocyanine green angiography. Outcomes analyzed included reoperation rates, implant exposure, infection, seroma, and hematoma. Even in patients with thin mastectomy skin flaps, immediate reconstruction was essentially performed whenever planned.

Results: Seventy-nine patients (134 breasts) were included. The majority of reconstructions involved direct-to-implant procedures (65% vs 35% tissue expander), with a predominance of immediate reconstructions (97% vs 3% delayed) and prepectoral placement (72% vs 28% dual-plane). Reoperation occurred in 29 breasts (22%), all in immediate reconstructions, primarily due to exposure (20%), infection (10%), or a combination of both (8%). Four breasts (3%) developed a seroma, two of which also required surgical intervention for exposure. No hematomas were observed. Reoperation was significantly more likely on breasts treated direct-to-implant compared to those with tissue expanders (P < 0.001) and on the cancer side compared toprophylactic reconstructions (P < 0.001). No significant differences in reoperation were noted regarding placement location (prepectoral vs dual-plane) or radiation treatment.

Conclusion: This study provides clinical outcomes on OviTex use in alloplastic breast reconstruction. Reoperation was significantly more likely in direct-to-implant reconstruction and on the side with cancer, likely due to skin flap perfusion rather than intrinsic mesh properties. The lack of access to indocyanine green angiography, as others have reported, in all likelihood contributed to the higher-than-expected rate of reoperation. In addition, significantly smaller implants might have led to a higher rate of reconstructive success.

Abstract: Checkpoint inhibitor-associated pneumonitis (CIP) is a rare but potentially life-threatening immune-related adverse event in patients receiving immunotherapy. Its occurrence especially in the immediate postoperative period following major reconstructive breast surgery has not been previously described and poses unique diagnostic and management challenges.We report the case of a 59-year-old BRCA+ female with history of right-sided triple-negative breast cancer status-post bilateral mastectomy with negative right sentinel lymph node biopsy who had undergone bilateral abdominal based free flap breast reconstruction over 1 month after the completion of pembrolizumab, an immune checkpoint inhibitor (ICI). This patient subsequently had worsening postoperative respiratory function to the point of being high-flow nasal cannula dependent on rest. Appropriate postoperative etiologies (i.e., pulmonary embolism, pneumonia, etc) were ruled out, and CIP was diagnosed with supporting imaging. The patient recovered with a treatment combination of corticosteroids, IVIG, and MMF, and the patient was discharged home on supplemental oxygen via nasal cannula on postoperative day 15. She has since followed up only on room air and excellent postreconstructive outcomes.This case report underscores a highly surgically relevant topic of breast cancer reconstructive surgery timing and clinical management of those patients treated with ICI. Especially with personalized immunomodulator chemotherapy regimens becoming more prevalent, breast and reconstructive surgeons, alike, should be aware of this likely growing phenomenon of CIP.

Introduction: Midazolam is commonly used as a traditional sedative for the postoperative care of patients with head and neck cancer undergoing free flap reconstruction. To improve the quality of postoperative management, this study aimed to investigate whether the use of dexmedetomidine (DEX) in such patients reduces the risks of agitation, delirium, and postoperative complications compared with traditional sedatives.

Materials and methods: Patients who underwent wide excision of head and neck cancer followed by immediate microvascular free flap reconstruction between July 2021 and December 2023 were enrolled. All patients received either midazolam or DEX for sedation in the intensive care unit (ICU). Data collected included patient demographics, cancer-related history, perioperative characteristics, and postoperative outcomes, such as duration of mechanical ventilation, incidence of agitation and delirium, pulmonary infections, ICU length of stay, and complications related to free flap reconstruction.

Results: A total of 265 patients were included and divided into a traditional sedative group (n = 204) and a DEX group (n = 61). The DEX group demonstrated a significantly lower incidence of postoperative delirium. In addition, both the duration of sedative use and the length of ICU stay were reduced in the DEX group. Multivariate analysis revealed that DEX use was significantly associated with reduced agitation (odds ratio, 2.25; 95% confidence interval, 1.17-4.36; P = 0.016) and shorter mechanical ventilation time. No significant differences were observed between the 2 groups in terms of pulmonary infections or free flap complications.

Conclusions: The use of DEX following head and neck cancer resection with immediate microvascular free flap reconstruction may enhance the quality of postoperative care in the ICU by reducing delirium, agitation, and length of ICU stay without increasing surgical complications.

Abstract: In 1948, Dr Jerome P. Webster-"father of plastic surgery education" and founding member of the American Board of Plastic Surgery-taught plastic surgery to 13 Chinese surgeons through the American Bureau for Medical Aid to China (ABMAC). Founded in 1937, the ABMAC worked with the Chinese government to transfer medical knowledge and supplies from the United States. The founding of the ABMAC in 1937 coincided with the second Sino-Japanese War and increased American aid to China following Pearl Harbor. Webster's course featured lectures on wound healing, surgical management of burns, and defects of the face. Reading assignments included techniques such as neck-tubed pedicles and Webster's own articles on war wounds of lips and cheeks and ear deformities. After 4 weeks of lectures, dog surgeries, and cadaver dissections, Webster and students operated at 2 Shanghai hospitals, including the National Defense Medical Center Hospital where they treated combat-injured soldiers. In correspondence, one student wrote that he later "carried out a number of rather minor operations using the technique and methods" taught by Webster, viewing his Shanghai experience as an incentive to study plastic surgery. Many of Webster's students proceeded to found plastic surgery departments in their corresponding hospitals, establishing a lasting legacy of this educational exchange. Through a review of the Jerome P. Webster Papers available at Columbia University including lecture materials and correspondence, this article examines Webster's contributions to plastic surgery education in China and its impact on Sino-American medical exchange. It ultimately highlights a lesser-known aspect of the history of plastic surgery, as well as Webster's role in shaping plastic surgery in China.

Background: Congenital muscular torticollis (CMT) is characterized by unilateral contraction of the sternocleidomastoid muscle, which causes head tilting and rotation. Treatment follows a stepwise approach, in which physical therapy (PT) serves as the first-line intervention, followed by botulinum toxin (Botox) injections for nonresponders and surgical lengthening of the sternocleidomastoid muscle in refractory cases. This study aims to evaluate the effectiveness of a stepwise treatment approach for CMT by assessing resolution rates following PT, Botox injections, and surgery.

Methods: A retrospective review was conducted on 109 patients diagnosed with CMT and treated at the Atlantic Center of Aesthetic and Reconstructive Surgery between 2016 and 2021. Data on patient demographics, onset of torticollis, treatment interventions, and resolution rates were collected. Statistical analysis assessed differences in treatment outcomes and timing of intervention.

Results: All patients initially underwent PT, and 71% (n = 77) achieved resolution. Botox injections were administered to nonresponders to PT (29%, n = 32), resulting in successful treatment in 56% (n = 18) of cases. Patients who were unresponsive to Botox (13%, n = 14) required surgical intervention. Earlier treatment initiation was significantly associated with improved outcomes ( P < 0.00001). No major complications were reported with Botox or surgery. The average follow-up duration was the longest in the surgery group (27.2 months).

Conclusions: This study highlights the role of each treatment within a progressive management strategy for CMT. Both Botox and surgery are safe and effective options for cases that do not respond to PT, with surgery reserved for most refractory cases. These findings reinforce the importance of early intervention for optimizing patient outcomes.

Background: The anterolateral thigh (ALT) flap is widely used for head and neck reconstruction because of its versatility and reliable vascular supply. However, anatomical variability of ALT perforators complicates their consistent identification, which is critical for successful flap harvest. Conventional methods such as Doppler ultrasound often produce false-positive results, making perforator localization challenging. Indocyanine green (ICG) angiography enables real-time intraoperative visualization of vascular flow, but interpretation remains largely subjective. This study integrates artificial intelligence (AI) with ICG angiography to enhance perforator detection, hypothesizing that AI-assisted analysis improves mapping precision and sensitivity.

Methods: This prospective cohort study included 51 patients undergoing ALT flap surgery between February and October 2024. Intraoperative indocyanine green angiography (ICG-A) was performed to identify perforators, followed by grayscale analysis of angiography videos to quantify pixel intensity over time. Perforators were classified as septocutaneous or musculocutaneous and annotated using the Roboflow platform for AI model training. The YOLOv11 object detection algorithm was applied. Model performance was compared with Doppler ultrasound and subjective ICG interpretation in terms of sensitivity and positive predictive value (PPV), with corresponding 95% confidence intervals (CIs). Statistical analysis used the independent t test, with significance set at P < 0.05.

Results: A prototype AI model for ALT perforator detection was developed using ICG-A data. Sensitivity was highest with subjective ICG interpretation (78%; 95% CI, 68%-85%), followed by Doppler ultrasound (53%; 95% CI, 43%-62%) and AI-assisted ICG-A (45%; 95% CI, 26%-65%); PPVs were 28%, 29%, and 21%, respectively. Quantitative pixel analysis showed a mean inflow time of 36 seconds, maximal slope time of 45 seconds, and maximal intensity time of 64 seconds, with a mean maximal intensity of 110 grayscale units. No significant differences were found between musculocutaneous and septocutaneous perforators.

Conclusions: AI-assisted ICG angiography is an emerging tool with potential to support perforator mapping. Although the current AI model demonstrated limited sensitivity, its accuracy can be enhanced by expanding training datasets, integrating temporal fluorescence dynamics, and refining fluorescence-time curve analysis. Future advancements in AI-driven image processing may further optimize intraoperative perforator identification, ultimately improving surgical precision and patient outcomes.

Introduction: Free flap phalloplasty and genital reconstruction have advanced significantly since the first reported case in 1982. Commonly used flaps include the radial forearm, anterolateral thigh (ALT), and ulnar forearm. However, less attention has been given to recipient vessel selection, which is critical for surgical success. This study evaluates the descending branch of the lateral circumflex femoral artery (DLCFA) as a potential recipient artery. We reviewed its reliability, anatomical characteristics, and suitability relative to established recipient vessel systems, including the deep inferior epigastric artery (DIEA) and the femoral artery.

Methods: Cadaveric dissections were performed with thigh incision to expose the rectus femoris and vastus lateralis muscles, allowing identification and dissection of the DLCFA and its venae comitantes. The DLCFA was transposed toward the pubic region to simulate its use in genital reconstruction. The great saphenous vein (GSV) was also dissected and transposed as its potential for venous supercharging. Sensory nerves, including superior and median perforator branches, were noted for potential coaptation.

Results: The DLCFA was consistently present, was easily accessible, and could be transposed to the pubic region without significant risk to nearby structures. Compared to the DIEA and femoral artery, the DLCFA was more superficial and simpler to dissect. It allowed for end-to-end anastomosis, which is technically less complex than the end-to-side technique required for larger-caliber arteries. These features suggest reduced intraoperative difficulty and potential for fewer complications.

Discussion: The DLCFA presents several distinct advantages. Unlike the DIEA, its dissection avoids the intra-abdominal space, thereby reducing the risk of hernia formation or visceral injury. Although its caliber is smaller than that of the femoral artery, the DLCFA facilitates microsurgical handling and anastomosis. Its relatively superficial course, compatibility with venous supercharging via the GSV, and potential for sensory nerve coaptation further underscore its suitability as a recipient vessel in genital reconstruction.

Conclusion: The DLCFA represents a reliable, readily accessible, and anatomically favorable recipient vessel for free flap phalloplasty and pelvic reconstruction. Its utilization may decrease operative complexity and enhance surgical outcomes, supporting its consideration as a preferred recipient vessel in appropriate clinical contexts.

Introduction: Lower eyelid blepharoplasty is performed via transconjunctival and subciliary approaches. In the subciliary approach, we have compared 2 methods: biplanar flaps versus a composite flap, with the goal of improved short-term recovery.

Materials and methods: Preoperative and 6-day postoperative 2-dimensional patient photographs were reviewed from each patient assigned to 1 of the 2 groups. Two blinded surgeons who neither performed the procedure nor were aware of the technique used reviewed the postoperative pictures from each patient and scored the results based on the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) Questionnaire.

Results: Forty-one patients (82 eyes) underwent subciliary lower blepharoplasty in the stated time frame. The primary outcome of the modified SPREE survey showed that patients who underwent the composite technique had an average edema score of 1.06 (from a 1-4 increasing severity scale) compared to 1.52 scored on patients with the biplanar technique ( P < 0.00228). For ecchymosis, patients who underwent the composite technique had an average score of 0.25 (from a 0-3 increasing severity scale) compared to 0.60 scored on patients with the biplanar technique ( P < 0.04444).

Conclusions: Composite flaps were shown to have a statistically significant decreased Modified SPREE score compared to biplanar flaps.

Objective: While numerous tools exist for grip strength measurement, there is a lack of research for assessing the individual finger flexor strength. This study aimed to evaluate the test-retest reliability of measuring individual finger flexion strength in healthy adults using the smallest bulb of the Martin Vigorimeter (MV).

Methods: Grip strength of 100 adults without hand pathology was measured using the large bulb of the MV, while individual finger flexor strength was assessed using the small bulb. Measurements were repeated after 3 weeks to evaluate test-retest reliability. Contribution of each finger flexor was calculated and compared to the previously reported values obtained using specialized equipment or protocol.

Results: The MV showed excellent reliability for grip strength (intraclass correlation coefficient > 0.9) and good-to-excellent reliability for individual finger flexor strength (intraclass correlation coefficient = 0.805-0.914). The middle finger contributed the most (approximately 30%), followed by the index and ring fingers (25%-26%), which were comparable to values previously reported using specialized equipment or protocols. Normalized minimal detectable change values for finger flexor strength ranged from 9.7% to 14.2%.

Conclusions: These findings suggest that the smallest bulb of the MV is a reliable and accessible tool for measuring individual finger flexor strength in healthy adults, with results comparable to those obtained using specialized equipment or protocols.