Annals of Plastic Surgery最新文献

Background: Forefoot and heel fat pad atrophy are debilitating conditions that compromise structural integrity of the plantar soft tissues, resulting in pain and disability. This localized destruction of soft tissue integrity has been associated with increased age, diabetes, and repetitive trauma. Although autologous fat grafting has shown improvements to short-term patient pain levels and quality of life, there is limited evidence as to the long-term benefit of this treatment.

Objectives: This study aims to evaluate the long-term outcomes of autologous fat grafting to the foot for fat pad atrophy treatment.

Methods: This was a cross-sectional long-term follow-up of patients who underwent autologous fat grafting for pedal fat pad atrophy between 2015 and 2018. Patients received grafting at presentation (interventional cohort) or after 1 year of conservative management (crossover cohort). Demographic and procedural data were collected. Patient-reported outcomes were assessed using the Manchester Foot and Disability Index (MFDI) at baseline, final in-office follow-up, and long-term follow-up (mean: 9 y). After correction of raw data outliers, statistical analyses included Fisher exact and Wilcoxon rank-sum for baseline associations, Mann-Whitney U tests for long-term between-group comparisons, and repeated-measures ANOVA for within-group changes in forefoot patients only. Heel outcomes were reported descriptively due to small sample size.

Results: Of 36 eligible patients, 25 participated (69.4% response rate; mean follow-up 9.0±1.2 y). Interventional (n=14) and crossover (n=11) cohorts showed no significant long-term differences across all domains (pain, function, appearance, work/leisure). Forefoot grafting significantly improved appearance (mean change: -2.9 to 0.8, P<0.001) but demonstrated functional decline at long-term follow-up (mean: 12.9 to 7.2, P=0.020). Heel grafting was associated with durable functional improvement (median difference, P=0.004) and trended towards pain reduction, although appearance outcomes were lower compared with forefoot patients (P=0.002). Work/leisure outcomes showed no significant long-term differences (P=0.087).

Conclusions: Autologous foot grafting confers durable, site-specific benefits nearly a decade post-procedure. Heel grafting restores long-term function, whereas forefoot grafting primarily improves cosmesis. Importantly, timing of grafting (immediate vs. delayed) does not alter durability, underscoring the need for location-specific treatment counseling and potential repeat procedures in forefoot patients.

Background: Implant-based reconstruction represents the most common method of breast reconstruction today. Many surgeons approach implant-based breast reconstruction in 2 stages, with the first stage being placement of a tissue expander at the time of mastectomy. Neoadjuvant chemotherapy can have systemic effects that may place patients at risk for TE/implant loss, infection, wound, and other complications.

Methods: A retrospective review of all cases of TE breast reconstruction at a single institution between 2017 and 2024 was performed. A total of 210 patients, representing 319 total breasts that underwent reconstruction, met the inclusion criteria. Sixty-five patients underwent neoadjuvant chemotherapy and 145 did not. Patients were separated into neoadjuvant chemotherapy (NACT) and nonneoadjuvant chemotherapy (non-NACT) cohorts. Primary outcomes of TE loss, wound, infection, and seroma were analyzed. Regression analysis was performed, matching patients for known risk factors.

Results: The rate of all-cause TE loss in patients who underwent NACT was 18%, and 11% for patients who did not. The rate of pathologic TE loss was significantly higher at 14% in patients who underwent NACT and 7% in patients who did not undergo NACT (P=0.032). On regression analysis, neoadjuvant chemotherapy increased the rate of all-cause and pathologic TE loss by 17% (P<0.05). There were no statistically significant differences in wound, seroma, and infection.

Conclusions: In this study, neoadjuvant chemotherapy is an independent risk factor for TE loss after immediate tissue expander-based breast reconstruction. Further analysis of adjuncts, implant factors, and specific chemotherapeutic agents is needed.

Background: Reconstructing upper-quadrant defects in oncoplastic breast reduction (OBR) can be challenging due to upper-pole concavity after tumor resection. To address this, we adopted a dual-component technique using 2 separate flaps: (1) a superiorly based flap for the nipple-areola complex (NAC) and (2) an inferior advancement flap from the quadrant ipsilateral to the lumpectomy defect, "mirroring" the laterality of the defect. This study evaluates outcomes using this algorithm for superior pole reconstruction in OBR.

Methods: A retrospective review was conducted of OBR cases performed by a single surgeon from September 2022 to November 2024. All were performed for oncologic indications and used an inferior flap for upper-quadrant volume displacement according to the senior author's algorithm demonstrated in Figure 1.

Results: A total of 47 patients (51 breasts) underwent lumpectomy and immediate OBR. Most tumors were located in the upper outer quadrant (UOQ; 70.6%), followed by the upper inner quadrant (UIQ; 29.4%). Superomedial NAC pedicles were used for UOQ defects, and superolateral pedicles for UIQ. All UOQ defects were filled with inferolateral advancement flaps, and all UIQ defects with inferomedial flaps. Over 13.2 ± 7.5 months of follow-up, 15.7% of breasts experienced complications. One breast (2.0%) had upper-pole concavity not requiring revision. Six breasts (11.8%) underwent revision secondary to complications related to radiation (5/6) or dehiscence (1/6).

Conclusions: The proposed dual-component mirror flap technique reliably reconstructs superior quadrant defects with low rates of contour deformity.

Background: Autologous fat grafting (AFG) is commonly used in breast reconstruction for volume restoration or contour correction. Our previous study demonstrated that standard decantation yields inferior volume retention compared to active wash and filtration (AWF) and low-pressure decantation (LPS). Building upon these findings, we replaced standard decantation with a new processing technique, active wash with surfactant (AWFS). This study aims to evaluate long-term volume retention among AWF, LPS, and AWFS.

Methods: A prospective, randomized controlled trial was conducted at our institution between 2023 and 2025. Thirty patients were randomized in a 1:1:1 ratio to receive fat grafting processed by either AWF, LPS, or AWFS. Three-dimensional scans of the upper torso were obtained preoperatively and at 3 months postoperatively. Breast volume was measured using Autodesk Meshmixer, and volume retention was calculated as a percentage of the initial grafted volume. Differences in volume retention across groups were analyzed using one-way ANOVA.

Results: The volume of fat injected during the procedure did not differ significantly between groups: 89.0 ± 56.0 cm3 for AWF, 125.8 ± 68.9 cm3 for LPS, and 127.5 ± 78.7 cm3 for AWFS (P=0.33). Average volume retention at 3 months was 55.3% ± 17.2% for AWF, 58.7% ± 17.8% for LPS, and 62.7% ± 15.7% for AWFS. No significant difference in volume retention was observed across groups (P=0.52).

Conclusions: Although AWFS demonstrated the highest average volume retention, differences between techniques were not statistically significant. These findings suggest comparable long-term outcomes among the 3 processing methods.

Secondary cleft lip deformities (SCLD) are common, diverse, and individually unique due to their multifactorial etiology and varied clinical presentation. They are the result of postoperative complications of primary cleft lip repair, such as lip dehiscence, delayed wound healing, hematoma, infection, trauma, suture abscesses, poor operative planning, and inadequate surgical technique. The broad spectrum of these deformities and the absence of a standardized stratification framework necessitated the development of a comprehensive and universally applicable classification system. This system was designed to provide a simplified, consistent approach to identifying and categorizing residual cleft deformities. By doing so, it enhances communication among cleft care providers and facilitates the planning and execution of appropriate corrective procedures. The proposed classification organizes SCLD into 5 types (type I to V) based on the anatomic structures involved: skin, mucosa, orbicularis oris muscle, nose, and premaxilla. Each type corresponds to a specific pattern of tissue involvement and is associated with a tailored surgical approach described in this chapter. A careful preoperative assessment using this classification system significantly improves surgical planning, guides anesthetic considerations, ensures more accurate time and resource allocation, and promotes effective interdisciplinary communication.

Introduction: Distal radius fractures are among the most common orthopedic injuries. Despite adequate fracture management, some patients experience delayed onset of compressive conditions, increasing the overall treatment burden. Identifying risk factors for these complications is important to improve patient outcomes. We sought to identify independent preoperative factors associated with the delayed development of compressive conditions following distal radius fracture management.

Methods: A retrospective review was conducted of patients with distal radius fractures over a decade. Data collected included demographic information, fracture characteristics, treatment modality (operative vs. nonoperative), and the subsequent incidence of compressive pathologies for 1 year after injury. Multivariate regression was performed to isolate the most predictive factors.

Results: Of 462 patients, 15.4% developed a compressive condition, with carpal tunnel syndrome being the most common (11%). Significant predictors for delayed development of compressive condition were diabetes (odds ratio [OR], 3.34) and increasing age (OR, 1.02). Complex fractures and operative treatment of fractures predicted treatment for a compressive condition, whereas increasing age was the only factor associated with requiring a secondary surgery (OR, 0.92). Preoperative diagnoses were not found to be a significant risk factor.

Conclusion: Diabetes and increasing age were the primary predictors for development of delayed onset of compressive neuropathy or tendinopathy following distal radius fracture treatment, with age being the only factor associated with increased need for surgical intervention. Although operative treatment of distal radius fracture was not correlated with development of delayed compressive conditions, it was associated with an increased need for subsequent interventions.

Level of evidence: III.

Background: Radiation therapy following surgical excision is an effective strategy for recurrent keloids in adults. However, concerns about radiation-induced malignancy in children have limited its use and study in younger populations. This study aimed to assess clinical outcomes of postoperative radiation for recurrent pediatric keloids through a pooled literature analysis and review of our institutional experience.

Methods: A retrospective review was conducted of all pediatric patients treated at the Children's Hospital of Philadelphia from 2000 to 2024 who underwent reexcision followed by postoperative radiation for recurrent keloids. Recurrence was defined as clinical evidence of regrowth beyond scar borders. A systematic review was also performed in March 2025 in accordance with PRISMA guidelines, using terms related to "keloid," "radiation," and "pediatric." Studies' eligibility criteria were assessed for quality using the Oxford Levels of Evidence.

Results: Five published studies and 1 institutional series comprising 60 patients and 85 keloids were included (mean age, 14.4 ± 3.5 years). Most lesions were on the earlobes (38.3%). Brachytherapy (53.3%) and external beam radiation (46.7%), most commonly at 12 Gy in 3 fractions, were the primary modalities, typically delivered within 24 hours postoperatively. Adjunctive treatments included corticosteroids (21.7%) and compression therapy (20.0%). Overall recurrence was 22.4%. Hyperpigmentation (53.3%) and transient pruritus (15.0%) were common side effects. No cases of secondary malignancy or growth disturbance were observed (mean follow-up, 32.3 ± 24.0 months).

Conclusion: Postoperative radiation following reexcision may serve as an effective treatment for recurrent pediatric keloids. Further long-term prospective studies are warranted to evaluate durability and oncologic safety in the long term.

Abstract: This case report describes a 44-year-old woman who suffered a radial nerve compression injury from self-administered myofascial release using a lacrosse ball. She underwent decompression of the right radial nerve at the spiral groove of the humerus with intraoperative nerve stimulation. At 18-month follow-up, the patient had regained partial function of the radial nerve. This case highlights mechanisms of radial nerve compression injuries and discusses nonoperative versus operative treatment options.