Annals of Plastic Surgery最新文献

Introduction: Although primary tumors of the brachial plexus (BP) are rare, schwannomas are the most frequently encountered type. This study evaluated the clinicopathological presentation, surgical outcomes, and prognosis of patients with BP schwannomas.

Methods: A systematic review was conducted using PubMed/MEDLINE, Embase, and Cochrane on the 25th of March 2024. All English human studies that reported surgically managed BP schwannomas were included.

Results: This review included 341 patients from 82 studies, with a mean age of 41.49 years and a female majority (55.72%). The most common clinical presentation was swelling, observed in 245 patients (71.85%). Surgical intervention was performed in all cases, with gross total resection (86.80%) being the most common approach. Surgical complications included new motor deficits in 41 (12.02%), sensory deficits in 33 (9.68%), and new-onset pain in 6 cases (1.76%). Prognostic information was available for all the 280 patients. At the last follow-up, only a small number of patients showed no postoperative improvement. Of the 164 patients initially presenting with pain, 3 (1.83%) reported persistent symptoms. In addition, continued sensory deficits were noted in 13 (8.67%) of the 150 cases, and continued motor deficits in 4 (9.30%) of the 43 cases. Furthermore, 14 (19.71%) of 71 postoperative new-onset symptoms persisted at the last follow-up. One (16.67%) of the 6 patients experienced constant pain. Additionally, sensory deficits persisted in 8 (28.57%) of the 28 patients, and motor deficits persisted in 5 (13.51%) of the 37 patients. No local recurrence has been reported.

Conclusions: This systematic review highlights the complexity of BP schwannoma. Despite the occurrence of postoperative complications, the overall prognosis remains favorable with minimal rates of persistent preoperative symptoms and permanent surgical complications. Accurate diagnosis and effective surgical management are necessary to improve the outcomes of patients with this rare, yet clinically significant condition.

Background: Traumatic defects of the lower extremity (LE) require robust soft tissue to cover critical structures and facilitate healing. Free tissue transfer (FTT) is often necessary when local tissue is inadequate. While much of the literature emphasizes free flap viability in successful limb salvage, there is limited understanding regarding the need for additional surgeries or eventual amputation. We investigated a single institution's limb salvage efforts to better understand the need for additional procedures.

Methods: All patients who underwent LE limb salvage were retrospectively reviewed from 2014 to 2022 at a single level 1 trauma center. Our primary clinical outcome was the incidence and indication of secondary surgeries following FTT.

Results: Ninety-two LE free flaps were performed during the study period. The mean age was 45 and majority were male. Seventy-two percent of flaps were fasciocutaneous while 28% were muscle flaps. Seventy-two percent of patients required a secondary surgery following FTT, with a mean of 7 total surgeries per salvage attempt. Ten percent of patients proceeded to amputation. Body mass index >30, higher frailty scores, flap type, and masquelet technique were significantly associated with subsequent amputation ( P = 0.017, P = 0.024, P = 0.005, P = 0.04, respectively). Older age, the need for bony reconstruction, and longer period from injury to flap coverage were significantly associated with the need for secondary surgeries ( P = 0.05, P < 0.001, and P = 0.22 respectively).

Conclusions: FTT is an important component of limb salvage. Patients undergoing limb salvage should be counseled on the need for secondary surgeries, as the process is often not complete following FTT. Furthermore, risk factors identified in this study may increase the likelihood of subsequent amputation. Thorough preoperative counseling is necessary to optimize the postoperative course and expectations in this population.

Abstract: Grafts and flaps play significant roles in rhinoplasty procedures, while spreader grafts are commonly used. Spreader grafts are placed into submucosal pockets between the upper lateral cartilage and nasal septum. Occurrence of deviation can be seen on nondeviated noses after let-down or push-down methods are performed as the part of the upper septum that has been let-down may cause pressure on the lower septum and that results in deviation. In the present study, the author aimed to demonstrate the benefits of using a proximal intact spreader graft to support the nondeviated nasal septum or to correct the deviated septum in patients undergoing dorsal preservation rhinoplasty. In deviated noses, the upper septum is brought down to the opposite side of the deviation, and a proximal intact spreader graft is placed between the upper and lower septum to correct the deviation and make the dorsum nondeviated. This technique is suitable for patients with a slight to moderately deviated caudal part of the septum. It is unsuitable for patients with severe, cross, or S-shaped deviation. This technique aims to preserve the condition of the nondeviated nose and convert it into a nondeviated state in the let-down technique. The combination of proximal intact spreader graft and dorsal preservation rhinoplasty techniques effectively addresses dorsal hump and dorsal deviation deformities, enhances upper lateral cartilage concavity, prevents W-ASA segment collapse, and both prevents and improves internal nasal valve collapse. The data of patients who underwent dorsal hump reduction with the let-down technique were screened. According to inclusion and exclusion criteria, 95 patients were included in the study (68 females and 27 males). The ROE score before the operation was 51.5. After 12 months, it was found to be 91.5 points, and the change in the ROE median score was significant ( P < 0.001). This new proximal intact spreader graft method presents a suitable approach for surgeons to prevent any let-down-induced deviation problems that may occur after the procedure and to correct the present deviation. It will also lead to better cosmetic and functional outcomes for patients who have hump deformity.

Abstract: The Brussels Breast Surgery Fellowship at Brussels University Hospital offers a unique 3-month clinical immersion in reconstructive and aesthetic breast surgery. Under the guidance of fellowship director Prof. Moustapha Hamdi and his esteemed colleagues, the fellow is exposed to a high volume and wide breadth of cases spanning autologous and implant-based breast reconstruction, oncoplastic surgery, breast reduction and mastopexy, implant augmentation, revision breast surgery, and fat grafting. The multidisciplinary team approach, involving close collaboration with breast surgeons, provides valuable experience in oncoplastic planning and execution. In addition to time in the operating theater, the fellow gains knowledge through outpatient clinics, didactic teaching sessions, and clinical research opportunities leveraging the department's extensive prospective database. As the 2023 fellowship awardee, I had the privilege of learning directly from Prof. Dr. Moustapha Hamdi and participating in over 130 cases across the reconstructive and aesthetic spectrum. Unique features of the fellowship included exposure to lymphedema surgery utilizing the Symani robotic system, advanced techniques like the internal bra, volume distribution mastopexies, observation of private aesthetic clinic cases, and optional participation in academic workshops. This fellowship represents an outstanding opportunity to refine one's skills in breast surgery and microsurgery while experiencing the rich culture of Belgium.

Abstract: Women and racial and ethnic minorities have historically been underrepresented in medicine, making up a minority of all physicians and a smaller subset of plastic surgeons. Furthermore, these groups represent an even smaller fraction of plastic surgeons in research and leadership roles. Parallel to the general recognition of the importance of increasing diversity in the medical field, there has been a surge in the literature detailing current issues and highlighting potential areas for intervention within plastic surgery. Various initiatives have been piloted to address the underrepresentation of certain demographic groups in the field. These have largely targeted the medical student level, with a focus on increasing mentorship, targeted recruitment, exposure to the field, and scholarly opportunities. With the growing body of research conducted in this realm, this review seeks to synthesize our understanding of the modern landscape of gender, racial, and ethnic diversity within plastic surgery, with an emphasis on identifying successful initiatives that have positively impacted representation and inclusivity.

Background: An ideal 3D cartilage framework and accurate anatomical location are the most important factors to carry out a satisfactory reconstruction of the ear. To streamline this process, we developed an augmented reality assistance system, HoloLens Ear Image Guidance, which is based on computed tomography (CT) data, tailor-made navigation kits to guide reconstruction, data processing software, and HoloLens hardware. The objective of this study is to verify its feasibility in a clinical setting.

Methods: This study first validated our system in healthy controls and then extrapolated data to test on patients with microtia. First, three healthy volunteers were recruited, and reconstructive navigation kits were made using 3D printing. CT data were collected for the head and neck and imported into the HoloLens Ear Image Guidance Application to generate a personalized 3D virtual ear image. Volunteers then wore the navigation kits while researchers observed them through the HoloLens to check accuracy, track delay, and view the ear image guide.Ten patients with unilateral microtia were recruited and CT data were collected, and reconstructive navigation kits were made to assist with surgery. The procedure was monitored to record the surgeon's experience wearing the HoloLens, the patients' complications associated with wearing navigation kit, and to measure the symmetry between the reconstructed ear and the reference counterpart.

Results: In control patients, the deviation between the virtual image and the real ear was less than 2.4% (±0.22%); the tracking delay was less than 1.26 s (±0.09 s), the display effect was good, and surgeons did not report discomfort or dizziness while wearing the HoloLens. Volunteers did not report any pain from holding the navigation reference in their mouth during the test. Following validation, the HoloLens-assisted procedures were not associated with surgeon discomfort or dizziness. No complications were noted in patients including injury to the oral mucosa. Symmetry between the reconstructed ear and the contralateral ear was noted to be satisfactory in HoloLens-assisted surgery.

Conclusions: The HoloLens Ear Image Guidance initially met clinical demands in registration accuracy, tracking speed, and subjective user experience, which can be used as the basis for continual software improvements and clinical application.

Introduction: Tissue expansion is a commonly used breast reconstructive strategy. Although the procedure is regarded as safe, tissue expander to implant-based breast reconstruction is reported to have the highest rates of postoperative infection among plastic surgery operations. During the COVID-19 pandemic, face masks were required at all hospital facilities at our institution. The purpose of this study is to investigate the effects of COVID-19 mask mandate on in-office breast tissue expansion procedures.

Methods: An institutional review board-approved, retrospective review was completed on all patients who underwent unilateral or bilateral tissue expansion following mastectomy at a single institution in 2017 (prior to the COVID-19 mask mandate) and 2021 (following implementation of the mandate). Variables included were demographics, procedure information, and postoperative outcomes.

Results: The analysis included 118 patients in the premandate group and 147 patients in the postmandate group. There was no difference in age, body mass index, smoking status, or diabetes mellitus between the 2 groups ( P > 0.05). More patients in the postmandate group underwent bilateral reconstruction as opposed to unilateral when compared with the premandate group (70.7% vs 55.9%, P = 0.014). There were no differences in major complication rate (26.3% vs 30.6%, P = 0.495) or minor complication rate 30.5% vs 26.5%, P = 0.495) between the pre-mask and post-mask mandate groups.

Conclusion: Our results demonstrated that the use of face masks did not play a significant role in complication rates relating to in-office tissue expansion procedures. It remains up to the discretion and comfortability of the provider if masks should be worn during the procedure.

Background: Collagenase Clostridium histolyticum (CCH) injection, an effective enzymatic fasciotomy treatment for Dupuytren disease (DD), was abruptly withdrawn from the healthcare market outside the United States in 2020. The impact on patients, physicians and hospitals of this helpful surgical alternative no longer being available has been little studied.

Methods: To investigate the impact of the withdrawal of CCH in Japan, we used the National Database Open Data Japan from 2014 to 2020. Published by the government, it contains summary data of the National Database of Health Insurance Claims and Specific Health Checkups of Japan. We extracted the numbers of CCH injections with Xiaflex, the product name in Japan, and surgeries identified by "Dupuytren contracture surgery codes." Each treatment was further parsed into one of 12 predefined regions in which it had taken place and by whether it had been delivered on an inpatient or outpatient basis.

Results: From its introduction in 2015, the number of DD patients treated with CCH increased in each successive year, reaching a peak in 2019, while the number of surgeries decreased with time. After the withdrawal in 2020, the number of surgeries increased to 1.5 times the 2019 number notwithstanding the impact of COVID-19, but the total number of patients treated decreased by 43%. In the initial regional analysis, CCH accounted for approximately 40% of all DD treatments in the less populous areas, with the exception of the Tohoku region, and more than 50% in the other regions. By 2019, the share of CCH treatment had increased in all regions. There was no significant correlation between the number of hand surgeons authorized to use CCH and the number of CCH cases within each region.

Conclusions: CCH increased treatment options for patients and surgeons. The withdrawal of this valuable pharmaceutical resulted in an increase in the number of surgeries amidst a decrease in the total number of treatments and lost opportunities for patients.

Background: Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning.

Methods: The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed.

Results: No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans.

Conclusions: Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.