Annals of Plastic Surgery最新文献

Introduction: Inmates represent a vulnerable health care population within the United States, with inconsistent access to surgical specialty care. Facial fractures are common among the incarcerated population, comprising approximately 14% of all traumatic injuries. However, few studies have evaluated facial fracture outcomes in this population. The aim of this study is to identify disparities in mandible fracture outcomes in the incarcerated population.

Methods: A retrospective review of all isolated traumatic mandible fractures at a single academic medical center from 2018 to 2023 was conducted. Mandible fractures were treated by plastic surgery, otolaryngology, or oral and maxillofacial surgery. Outcome measures such as rates of persistent malocclusion, motor deficits, surgical site infection, reoperation, and readmission were compared between inmate and civilian subgroups.

Results: A total of 205 patients (mean age, 33.1 years; 81.5% male) who were treated for isolated traumatic mandible fracture were included. A minority of patients (11.7%; n = 24) were inmates, whereas 88.3% (n = 181) were civilians. The mean time to operative intervention was 10.2 days in the incarcerated group and 4.4 days in the civilian group ( P < 0.05). Persistent subjective malocclusion after surgery was noted in 20.8% (n = 5) of incarcerated patients and 7.2% (n = 13) of civilian patients ( P < 0.05). There were no significant differences in rates of surgical site infection, reoperation, persistent motor deficits, or readmissions within 30 days.

Conclusions: Incarcerated patients with traumatic mandible fractures have increased time to operative intervention and increased rates of subjective malocclusion postoperatively. Increased time to operative intervention may reflect barriers in access to specialty surgical care, which could adversely affect patient outcomes.

Abstract: Vascularized soft tissue coverage of open wounds of the lower extremity has long been predicated on the zone of injury and the available local flap donor site options found therein. A hypothesis was presented decades ago in this journal that attempted to extend a similar approach to simplify upper extremity coverage as well, but appears to have long been forgotten. However, with the emergence of the fasciocutaneous flap and its offspring the perforator flap, now a plethora of additional local flap options within the upper extremity may justify this idea being further considered. Indeed, the upper extremity can arbitrarily be divided into distinct anatomical regions that each has unique characteristics. However, soft tissue requirements that must be restored cannot so simply be restricted by anatomical boundaries, so instead an "expanded zone" concept is more appropriate where comparable regions can be treated in a similar as long as functional fashion. All this must be with the realization that if a suitable local flap option does not exist, the selection of a free tissue transfer with the same preferable composition should instead be chosen, just as would be done in the lower extremity.

Background: Extra-articular but severely comminuted distal basal fractures of the proximal phalanx (PP) are rarely reported. Therefore, the aim of this study was to achieve proper union and desirable outcomes using low-profile locking plates/screws. We introduced our own surgical approach and reported the clinical/radiographic outcomes via retrospective case series.

Methods: Thirty-eight patients diagnosed with comminuted basal fracture of the PP were admitted between January 2014 and December 2020. Nineteen of these patients met the inclusion/exclusion criteria and were investigated in this retrospective study. Focusing only on preventing the volar tilt/collapse of the articular cartilage from the vertical position due to comminuted metaphysis, such as the "buttress concept by locking plate," the defect was filled with bone grafts. Meticulous repair of the incised central tendon effectively stabilized it by tightening the sagittal band and capsule of the metacarpophalangeal joint. It also acted as an envelope with proper sealing to minimize the loss of grafted bone materials.

Results: Among the 19 patients, the mean patient age was 58.94 years, and the male/female ratio was 6:13. The mean follow-up period was 3.15 years, and the mean BMD was -0.15. Complete union was achieved after a mean of 9.63 weeks, without complications requiring secondary intervention. Two patients complained of skin lesion associated with PDS suture material, but this material spontaneously resolved by 4 weeks postoperatively. The mean extension lag at the proximal interphalangeal joint was 3.68 degrees, and the total active range of motion (TAM) was 256.38 degrees. Among the 19 patients, 6 were categorized as having a "good" modified Belsky classification, and the other patients all had an "excellent" classification. The mean articular-dorsal cortex angle was 85 ± 3.33 degrees at the final follow-up, which was slightly less than the normal value with statistical difference ( P < 0.05); however, it did not correlate with the TAM statistically ( r = 0.126, P = 0.608). Clinical outcomes were also satisfactorily evaluated using the VAS and DASH scores.

Conclusions: A low-profile locking plate is an effective option for extra-articular, severely comminuted basal fractures of the PP using the buttress concept in terms of clinical outcomes, such as finger movement and proper union.

Background: Adults living with head and neck burn injuries experience psychosocial consequences due to scarring as well as functional disabilities. However, the impact of head and neck burns on long-term self-reported psychosocial outcomes, return to work, and need for reconstructive surgery has not been well described. This study investigates the unique longitudinal problems in psychosocial and functional recovery faced by adults with head and neck burn injuries.

Methods: Utilizing the multicenter Burn Model System (BMS) National Database, long-term psychosocial and functional outcomes as well as postdischarge reconstructive surgery rates between adult participants with and without head and neck burns injured after 2014 were compared.

Results: Of 1247 participants, 579 had head and neck burns and 668 had non-head and neck burns. Head and neck burn was a significant predictor of worse anxiety (β = 1.63, P = 0.049) and body image (β = -0.30, P = 0.011) at 6 months post burn; worse anxiety (β = 2.68, P = 0.004), depression (β = 2.14, P = 0.021), and body image (β = -0.41, P = 0.001) at 12 months post burn; and worse life satisfaction (β = -1.64, P = 0.036) at 24 months post burn. Head and neck burn participants reported significantly worse anxiety ( P = 0.001), depression ( P = 0.0026), and life satisfaction ( P < 0.001) at 12 months post burn and worse body image at 6 ( P < 0.001), 12 ( P < 0.001), and 24 ( P < 0.001) months post burn. The head-and-neck group had a significantly greater proportion of participants who had undergone contracture surgery at 12 months post burn ( P < 0.001) and a smaller proportion who had returned to work by 6 ( P < 0.001) and 12 ( P < 0.001) months post burn.

Conclusions: This study suggests that adults with head and neck burns might strongly benefit from additional counseling, psychotherapy, and greater aftercare.

Background: Electromagnetic treatments have recently been combined with radiofrequency to reduce the fat layer and simultaneously increase muscle thickness. Studies report treatment efficacy, using photographs and imaging methods.

Methods: A literature review was conducted. Measurement data were tabulated. The EmSculpt Neo device (BTL Industries, Boston, MA) was used in all studies.

Results: Seven studies evaluated the fat thickness and muscle thickness using either ultrasound (1 study) or magnetic resonance imaging methods (6 studies). The abdomen was treated in 2 studies. The other studies treated the lateral thighs, flanks, buttocks, inner thighs, and upper arms. The mean reduction in fat thickness was 8.0 mm, and the mean increase in muscle thickness was 5.5 mm. All 7 studies were authored by BTL medical advisors. Measured changes were likely within the margin of error and of questionable clinical relevance. Few adverse events were reported.

Discussion: Photographs were frequently not standardized, showing changes in treated areas, but unexplained changes in nontreated areas as well. The magnetic resonance imaging scans were affected by differing levels of the axial slice. Measured changes were incremental and likely not indicative of a true treatment effect. The scientific basis for efficacy is tenuous, both for fat reduction and muscle hypertrophy.

Conclusions: A scientific evaluation of the results fails to produce reliable evidence of a clinically meaningful result for this combination energy-based treatment. Financial conflict is a major factor. Liposuction remains the gold standard.

Introduction: The reverse sural flap (RSF) is a random-type, pedicled flap based on sural artery perforators indicated for traumatic lower-extremity wounds. The RSF has demonstrated comparable results to free flap placement in the adult population for reconstruction of distal third defects, but few reports describe its application and outcomes in the pediatric population.

Methods: We investigated RSF application in pediatric patients (<18 years of age) through systematic review and meta-analysis. PubMed, Scopus, CINAHL, and ProQuest databases were utilized. Inclusion criteria included case series and chart studies reporting on pediatric RSF patients. Primary outcomes included overall flap survival rate, venous congestion, and necrosis. Screening of 244 initial articles yielded 16 studies for further review and statistical analysis.

Results: There were 207 patients treated with a mean age of 9.51 ± 2.27 years and follow-up of 20.07 months. The majority of studies focus on the distal third as the primary site for RSF reconstruction, with fasciocutaneous being the most commonly used flap type. Trauma was the predominant etiology of soft-tissue defect (91.0%). Analysis of outcomes shows a 91.0% survival rate for reverse sural flaps. Approximately 13.0% of patients experienced venous congestion. Flap necrosis rate was 15.0%, although most cases were subtotal (93.1%) and successfully managed through additional skin grafting.

Conclusions: With comparable efficacy to free flaps for distal third defects in the pediatric population as well as similar success rates to adult RSF patients, the RSF should be considered a first-line therapy for lower-extremity soft-tissue reconstruction in pediatric patients.

Introduction: The aging neck is a prevalent aesthetic concern, with over 160,000 neck procedures performed in 2020. It is characterized by increased soft tissue laxity and displacement of cervical structures. While nonsurgical interventions like cryoablation and laser resurfacing show promise, their variable responses highlight the necessity for surgical solutions. Traditional neck lifts address superficial structures but often neglect the subplatysmal plane. Recently, deep plane neck lifts have gained attention for addressing deeper anatomical structures. This paper systematically reviews the literature on subplatysmal modifications in cervicoplasty, aiming to clarify the risks and benefits of these evolving surgical techniques.

Methods: On February 20, 2024, a systematic review adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 guidelines was performed. MEDLINE, PubMed, Cochrane, and Scopus databases were searched for terms related to neck rejuvenation. Independent reviewers screened titles, abstracts, and full texts, including all relevant studies. Data extracted included patient numbers, procedures, outcomes, and complications.

Results: From an initial 771 articles, 57 studies encompassing 8648 patients met inclusion criteria. The most commonly altered anatomical structures during "deep plane" neck lift (DPNL) were the submandibular gland (69.9%), digastric muscles (58.6%), and subplatysmal fat (48.6%). Postoperative complications were reported in 59.6% of studies, with nerve palsy (0.2%-12%) and hematoma (0.2%-4%) being most common. Aesthetic outcomes were less frequently reported (56% of studies); patient satisfaction ranged from 81.6% to 98.6%, while objective measures were reported in only 12% of studies.

Conclusions: Recent surveys indicate a growing concern over excess laxity under the chin, with patients increasingly seeking neck rejuvenation. Our review found that DPNL techniques vary widely, with the submandibular gland and digastric muscles being the most frequently altered structures. Despite a general lack of standardized outcome measures, patient satisfaction was high. However, DPNL showed a higher rate of postoperative nerve palsy compared to traditional neck lift. Overall, while DPNL demonstrates potential aesthetic benefits, the increased risk necessitates thorough patient counseling and further studies for standardization and comparison.

Background: Nasal septal defects cause considerable morbidity and represent a challenging reconstructive problem. Traditional repair techniques have employed local intranasal tissues and allograft adjuncts. For large septal defects (>4-5 cm2), less than half are successfully resolved.

Methods: We conducted a retrospective review of patients presenting with large (>4 cm2) nasal septal defects treated by microsurgical septal reconstruction using various engineered or prelaminated flaps.

Results: Nine consecutive patients were included in this study. Defect size averaged 7.89 cm2 (range 4.5-13.5 cm2). There were 4 males/5 females. Average age was 49.3 years (range 34.4-76.2 years). Follow-up averaged 10.1 years (range 1.3-25.8 years). Etiology of the septal defects included cocaine (4), neoplasm (2), surgery (1), autoimmune disease (1), and infection (1). Flaps utilized: prelaminated radial forearm flap (3), prelaminated (skin only) radial forearm flap (3), folded radial forearm flap (1), first dorsal metacarpal artery flap (1), and engineered superficial inferior epigastric artery flap (1). There were no flap losses. Recurrent septal perforation occurred in 3 patients. The first patient developed a small 0.5-cm diameter anterior perforation that was the result of a local infection. This was successfully closed using local mucosal flaps. Recurrent septal perforations (each less than 1-cm diameter) were identified in 2 additional patients. In each of these patients, the perforation was located at the posterior, inferior aspect of the septal repair site. An attempt to repair one of these defects was unsuccessful but the defect has remained stable and asymptomatic. Similarly, the other recurrent perforation has also remained asymptomatic and is being managed conservatively. The remaining healed septal defects have remained stable over time without airway obstruction.

Conclusions: This experience underscores the significant clinical challenges confronting repair of large nasal septal defects. Our results demonstrate the safety and utility of microsurgical reconstruction in this setting. Technical precision in flap inset has emerged as a key requisite for a successful outcome. The application of engineered/prelaminated flaps for these defects represents a novel approach to management.

Background: Postoperative complications in body contouring surgery have been linked to several factors, including body mass index, diabetes, cardiovascular disease, and skin resection weight. Prior weight loss by surgical means is another predisposing factor for postoperative complications following body contouring. This study aims to examine these previously identified variables, and several others, in the context of a spectrum of abdominal body contouring techniques following bariatric surgery. Our goal is to highlight that current evidence supports the notion that the prior history of bariatric surgery does not significantly impact body contouring surgery's success and its associated complications.

Methods: A retrospective cohort study including all consecutive patients (N = 198) who underwent abdominal body contouring between January 2011 and January 2022 following bariatric surgery was performed. Data collected included patient demographics, medical history, perioperative variables, and postoperative outcomes. Univariate and multivariate statistical analysis was performed.

Results: Sixty-four (32%) patients developed a postoperative complication. In the univariate analysis, patients who developed a postoperative complication were more likely to have a mental health disorder (63% vs 44%, P = 0.015) and to have undergone abdominal surgery other than panniculectomy (P = 0.002). They also had significantly longer median operative time (160 minutes, σ = 68.9, vs 140 minutes, σ = 72.3, P = 0.037) and longer follow-up time (99 days, σ = 471.1 vs 23 days, σ = 430.5, P < 0.001). In a multivariate logistic regression model including diabetes, hypertension, abdominoplasty type, operative time, skin excision weight, and concurrent body contouring procedure, the only significant factor in complication rate was the type of abdominal body contouring. Specifically, the traditional (odds ratio: 2.72, 95% confidence interval: 1.25-5.93) and vertical abdominoplasty (odds ratio: 5.50, 95% confidence interval: 1.17 to 25.87) techniques were more likely to lead to complications compared with panniculectomy abdominoplasty, respectively.

Conclusions: Previously cited risk factors such as diabetes, body mass index, and skin resection weight did not increase the chance of complications. Panniculectomy appears to be a safer option for those with a history of bariatric surgery.

Introduction: Giant basal cell carcinoma (GBCC) is a rare and aggressive subtype of basal cell carcinoma (BCC), characterized by a diameter of ≥5 cm and a potential for deep tissue invasion. This study aimed to present our experience with the surgical management of GBCC in the maxillofacial region, focusing on resection and immediate reconstruction strategies.

Methods: We conducted a retrospective analysis of 5926 patients with BCC in the maxillofacial region from 2010 to 2020, with a specific emphasis on 32 patients diagnosed with GBCC. Associations between patient and tumor characteristics were analyzed, treatment approaches evaluated, and clinical outcomes assessed.

Results: The cohort comprised 20 males (62.5%) and 12 females (37.5%) (P > 0.05), with a median age of 71 years (range: 40-86 years). The median time from tumor onset to presentation was 4 years (range: 2-7 years). A total of 24 GBCCs (75%) developed de novo, whereas 8 (25%) were recurrent BCCs (P < 0.05). The median tumor diameter was 8 cm (range: 5-15 cm), with local invasiveness extending to cartilage in 31.25% of cases, facial muscles in 29.41%, neural tissues in 21.87%, and bone in 18.75%. Surgical resections included orbital exenteration (3 cases, 9.38%), total parotidectomy (2 cases, 6.25%), partial maxillectomy (2 cases, 6.25%), frontal craniofacial resection (2 cases, 6.25%), partial petrosectomy with mastoidectomy (1 case, 3.13%), and near-total rhinectomy (1 case, 3.13%). For reconstruction, a skin graft was used in 3 patients (9.38%), local skin flaps in 15 (46.88%), locoregional flaps in 10 (31.25%), and free flaps in 4 (12.5%). The 5-year overall survival, disease-free survival, and disease-specific survival for the cohort were 87.5%, 93.75%, and 96.88%, respectively.

Conclusions: Our findings suggest that a single-stage procedure featuring aggressive surgical resection and reconstruction achieves low complication rates, excellent oncologic control, and acceptable cosmetic outcomes.