Annals of Plastic Surgery最新文献

Objectives: The aims of the study were to evaluate the clinical efficacy of the ear remnant incision expander method for ear reconstruction in conchal-type (Grade II in Marx classification) microtia and analyze its advantages, limitations, and optimization strategies.

Methods: This retrospective study included 159 patients with conchal-type microtia treated between 2013 and 2023. The surgical procedure involved a standardized tissue expansion protocol followed by a 3-step reconstruction process: (1) incision design along the longitudinal axis of the remnant ear and expander removal, (2) selective excision of cartilage tissue from the upper wall of the conchal region of the remnant ear, and (3) carving and implantation of a 3-dimensional ear framework using rib cartilage (6th-8th), with the inferior crus of the antihelix positioned at the site of remnant cartilage removal. Outcomes were evaluated by 2 independent physicians using a validated anatomical scoring system and patient satisfaction assessment, with follow-up ranging from 6 months to 10 years.

Results: Among the 159 patients, 147 (92.5%) reported satisfactory results. Physician evaluation showed excellent outcomes in 127 patients (79.9%), good in 29 patients (18.2%), and poor in 3 patients (1.9%). The highest scores were observed for helix and lowest for triangular fossa. Complications included pigmentation (2.5%) in the conchal cavity and scar hyperplasia (3.8%) on the reconstructed ear. Age subgroup analysis revealed better outcomes in pediatric patients (5-12 years) compared to adults ( P < 0.05).

Conclusions: The ear remnant incision expander method is effective for conchal-type microtia, providing good aesthetic outcomes with high patient satisfaction. This approach is particularly beneficial for pediatric patients, with complications effectively managed through conservative measures. The technique offers a valuable option for auricular reconstruction in selected patients with conchal-type microtia.

Background: Over 20,000 medical malpractice lawsuits are filed annually, with plastic surgeons being particularly vulnerable. The evolving medico-legal landscape-shaped by tort reform measures, such as damage caps, medical review panels, and rising defensive medicine costs-demands ongoing evaluation. This study provides a comprehensive and up-to-date analysis of recent legislative changes in medical malpractice law and their implications for Plastic Surgery.

Methods: Medical malpractice laws across all 50 states were reviewed using the LexisNexis Academic Database. Key legal parameters assessed included the presence of medical review panels, caps on noneconomic, economic, and punitive damages, minimum malpractice insurance requirements, and statutes of limitations for malpractice claims.

Results: Fourteen states have implemented medical review panels. Economic damage caps exist in 6 states, ranging from $500,000 to $2,250,000 (average: $1,133,333). Noneconomic damage caps are present in 32 states, ranging from $350,000 and $2,250,000 (average: $516,414). While 3 states prohibit punitive damages entirely, 19 states impose no limits, and the remaining 28 enforce caps, often linked to other compensatory awards. Most states enforce a 2-year statute of limitations, although variations exist based on injury discovery rules.

Conclusions: Despite extensive research on tort reform and malpractice trends, the long-term effects of recent legislative changes remain uncertain. Variability in medico-legal policies across states may influence physician availability, underscoring the need for ongoing analysis and advocacy. Physicians must remain vigilant in high-risk specialties, while broader collaboration between the medical and legal communities is essential to fostering a legal framework that supports-rather than obstructs-high-quality patient care.

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: 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.