Annals of Plastic Surgery最新文献

Background: Sacral pressure ulcers present a major reconstructive challenge, especially in elderly and bedridden patients. Although negative pressure wound therapy (NPWT) has been widely used in wound management, its integration into surgical protocols for pressure ulcer closure is underreported in midlevel medical centers. We aimed to evaluate the safety, efficacy, and reproducibility of a streamlined surgical strategy for sacral pressure ulcers combining debridement, primary closure, and closed-incision-NPWT (CI-NPWT) and examine the outcomes in patients treated in 2 institutional settings with different resource levels.

Methods: This retrospective observational cohort study included 35 patients (median age, 76 years; 66% female) with stage III-IV sacral pressure ulcers who underwent surgical reconstruction using a standardized approach involving debridement, tension-reducing wound closure, and CI-NPWT. All procedures were performed by a single reconstructive surgeon at both a medical center and a regional hospital.

Results: Among the 35 patients, 33 were treated at the tertiary center and 2 at the regional hospital. The median wound size was 9 × 6 cm (range 3 × 5-13 × 12 cm). Most patients were elderly with multiple comorbidities. CI-NPWT effectively supported primary wound closure with no major complications. Minor wound-edge dehiscence occurred in a few patients and was managed conservatively. All wounds healed completely.

Conclusion: A simple and consistent surgical protocol combining primary closure with CI-NPWT is safe, effective, and reproducible in both medical center and regional hospital settings.

Objective: Breast implant associated anaplastic large cell lymphoma with a single T cell clone is an uncommon complication especially related to implants with a textured surface. Moreover, there are few reports of breast implant-associated Epstein-Barr virus-positive diffuse large B-cell lymphoma (BIA-EBV-positive DLBCL), which typically presents unilaterally. Here, we present a case of bilateral BIA-EBV-positive DLBCL.

Patient: A 79-year-old woman who underwent breast implantation 40 years prior presented with unilateral capsular contracture. However, after bilateral total capsulectomy, the final diagnosis was bilateral BIA-EBV-positive DLBCL. The tumor cells found in the intracapsular effusion and fibrin tissue covering the luminal side of the capsule were positive for LCA, CD20, CD79a, CD30, BCL2, MUM1, and PD-L1 according to immunohistochemical staining, and EBER in situ hybridization revealed a high Ki67 index (60%-70%). The patient was disease free during the postoperative follow-up period of 43 months.

Conclusions: Latent EBV infection plays an important pathogenic role, contributing to the indolent nature and restrictive proliferation of such cases, which are currently classified as fibrin-associated DLBCL. We aim to highlight the reasons for the delayed diagnosis of the disease, the possible pathologic findings on the contralateral side, and the potential need for prophylactic bilateral total capsulectomy. We also reviewed reported cases of BIA-EBV-positive DLBCL to gain a better understanding of its incidence, risk factors, diagnostic tools, pathogenesis, and prognosis.

Background: Fat grafting is commonly utilized to enhance outcomes in breast reconstruction. Despite their routine implementation, perioperative antibiotics lack sufficient evidence in reducing rates of surgical site infection (SSI). Leveraging the largest patient cohort to date, this study examines the association between perioperative antibiotics and SSI after fat grafting for breast reconstruction.

Methods: The Epic Cosmos database (Verona, Wisconsin) was queried for patients who underwent fat grafting within one year following either implant-based or autologous breast reconstruction from January 2017 to January 2025. SSIs within 30 days were identified using either International Classification of Diseases (ICD) codes or identification of a new antibiotic prescription starting >7 days post-surgery. Perioperative antibiotics, age, body mass index (BMI), diabetes, smoking status, intraoperative intravenous antibiotics, and volume of fat grafted were included for multivariable regression.

Results: We analyzed 12,247 fat grafting procedures (8416 implant-based, 3831 autologous). In the implant-based cohort, perioperative antibiotics (OR, 1.21; P = 0.031), diabetes (OR, 1.65; P < 0.0001), higher BMI (OR, 1.02; P = 0.001), and younger age (OR, 0.99; P = 0.021) were significant risk factors for infection, defined by additional postoperative antibiotic prescriptions. For infections defined by ICD codes, only BMI was significantly associated with SSI (OR, 1.04; P = 0.001). In the autologous cohort, diabetes was the only significant risk factor for SSI (OR, 1.3; P = 0.033).

Conclusion: Perioperative antibiotic prescriptions do not decrease SSI after fat grafting in either implant or autologous breast reconstruction patients. However, they are associated with increased additional postoperative antibiotic prescriptions in implant-based breast reconstruction patients. These data suggest reconsidering routine perioperative antibiotic prophylaxis and focusing on patient-specific risk factors.

Background: Since the first facial vascularized composite allotransplantation (fVCA) performed in France in 2005, the procedural, ethical, and legal structures regarding donor procurement and institutions have significantly evolved. Initially developed by local institutions that were pioneering the procedure, the regulations progressively became more standardized with national oversight. This study reviews the global evolution of bodies governing face transplant regulation and procurement process, highlighting a shift toward more formalization and national standards through 3 distinct eras.

Methods: A review of publicly available literature was conducted to identify all face transplant procedures performed worldwide from 2005 to 2023. Each documented procedure was classified based on the level of local, regional, and national institutions involvement. Information on the procedure approval, ethics approval, consent models, and fVCA procurement was analyzed.

Results: Forty-eight face transplants across 11 countries were identified. Pioneering procedures (2005-2008) were approved mostly by local or university committees. Between 2008 and 2014, although more and more national entities were participating in protocol approval and donor allocation, VCA-specific policies remained limited. Finally, since 2014, we noted the trend toward national standardization with an important shift marked by the United States, the country executing most face transplant procedures around the world, incorporating face transplantation within formal national frameworks.

Conclusion: The evolution of fVCA governance from locally governed and experimental surgeries toward nationally standardized frameworks demonstrates the field's growth into a viable therapeutic option, which will continue to play a key role in promoting safety, patient education, and long-term success in fVCA.

Background: The primary aim of this study was to investigate the effects of Incisional Negative Pressure Wound Therapy (iNPWT) on surgical site complication rates for abdominal body contouring following bariatric surgery that resulted in massive weight loss.

Methods: A large 15-hospital retrospective case-control study was conducted. Inclusion criteria consisted of nonsmokers who achieved massive weight loss, defined as >100 lb or >50% excess body weight, and had an abdominal body contouring surgery between January 2021 and June 2024. We conducted separate unadjusted analyses comparing the iNPWT cohort to the control cohort using separate chi-square or Fisher exact tests for categorical variables, and independent samples t tests or Mann-Whitney rank sums tests for normally distributed and skewed continuous variables, respectively. Statistical significance was set to P = 0.05.

Results: Basic demographics were similar for a majority of the variables between the iNPWT cohort and the standard cohort. Minor wound complications following abdominal body contouring surgery did not significantly differ between the standard and iNPWT (40.54% vs 36.36%, P = 0.070) cohorts. However, among major wound complications, rates of wound dehiscence (22.97% vs 2.27%, P = 0.003) and infection (21.62% vs 6.82%, P = 0.040) were significantly lower in the iNPWT cohort. There was no significant difference in hematoma or seroma formation between the 2 groups.

Conclusion: Given the high volume of patients undergoing abdominal body contouring surgery following bariatric surgery, iNPWT dressings can provide plastic surgeons with an adjunct to further reduce the incidence of wound dehiscence and wound infection.

Background: Primary rhinoplasty (PR) to correct the cleft nasal deformity at the time of unilateral cleft lip repair seeks to achieve durable improvement of nasal symmetry and projection. However, neither the components of primary cleft rhinoplasty nor their expected outcomes are well-established. This study presents a component-based cleft rhinoplasty technique and compares immediate to intermediate-term results.

Methods: The following 6 components of cleft nasal deformity are addressed: absent (1) nasal floor and (2) nasal sill, (3) tethered and malrotated alar base, (4) deviated caudal septum, (5) dysmorphic alar rim, and (6) deficient tip. Technical maneuvers to counteract each component are presented. Subjects who underwent component PR between 2018 and 2024 were retrospectively reviewed. Anthropometric measurements on standardized 2D and 3D photographs preoperatively, immediately postoperatively, and 1 year postoperatively were compared.

Results: Complete photographic data were present for 29 subjects with unilateral cleft lip and nasal deformity. Symmetry from preoperatively to immediately postoperatively increased for most measures, including nostril width (1.95 ± 0.63 vs 0.95 ± 0.15), nasal base width (1.75 ± 0.50 vs 0.99 ± 0.14), columellar height (0.77 ± 0.20 vs 1.13 ± 0.27), and alar height (0.82 ± 0.17 vs 1.02 ± 0.16; each P < 0.05). Columellar deviation angle similarly decreased (14.09°± 7.7° vs 6.3°±2.3°, P < 0.05). Each of these measures remains significantly improved from preoperatively to 1 year postoperatively. However, from immediately to 1 year postoperatively, multiple anthropometric measures of symmetry showed recapitulation toward the original deformity, including: nostril width (0.95 ± 0.15 vs 1.15 ± 0.23), nasal base width (0.99 ± 0.14 vs 1.16 ± 0.22), columellar height (1.13 ± 0.27 vs 0.91 ± 0.17), and alar height (1.02 ± 0.16 vs 0.88 ± 0.07; each P < 0.05).

Conclusions: Component PR improves symmetry in the immediate and extended postoperative period. However, multiple measures, including alar and columellar height as well as nasal base and nostril width all show approximately 20% relapse over the first year postoperatively. Overcorrection by approximately 20% may therefore be beneficial to optimize long-term symmetry.

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.

Background: Age-related physiological changes may influence surgical outcomes following breast reduction. This study investigates the association between patient age and postoperative complications using a large institutional cohort.

Methods: We retrospectively reviewed 985 patients who underwent bilateral reduction mammaplasty between 2002 and 2024 by a single surgeon. Patients were stratified by age into 3 groups: <31, 31 to 50, and >50 years. Baseline demographics, comorbidities, surgical techniques, and complication rates were analyzed. Univariable and multivariable logistic regression was used to assess associations between age and minor and major complications, adjusting for diabetes, hypertension, smoking history, and prior radiation.

Results: Our patient cohort's mean age was 39.3 (13-76) years. A total of 276 (28.0%) had either a minor or major complication. The minor complications across the cohort (154) included seroma, skin necrosis, delayed wound healing, infection, nipple necrosis, hematoma, and fat necrosis. Major complications (122) included cases requiring readmission and/or reoperation. Patients in the 31- to 50-year age group were more likely to have a minor complication (17.9%) compared to those in the <31-year age group (13.1%) (P = 0.05). Patients aged 31 to 50 years (13.0%) and >50 years (18.7%) were more likely to develop major complications than those aged <31 years (6.56%) (P < 0.05 and P = 0.0001, respectively). The >50-year age group was more likely to be readmitted (7.4% vs 1.3%, P = 0.05) and reoperated (11.3% vs 5.3%, P < 0.05) compared to the <31-year age group. However, no statistically significant relationship was found with minor or major complication rates in senior groups with age ≥ 60 years. In adjusted models, age was not an independent predictor of minor or major complications; instead, diabetes (minor; odds ratio, 1.80; 95% confidence interval, 1.04-3.07; P = 0.03) and smoking (major; odds ratio, 2.16; 95% confidence interval, 1.12-3.98; P = 0.02) were associated with increased risk.

Conclusion: Older patients show higher unadjusted morbidity after reduction mammaplasty, but age itself is not an independent risk factor once comorbidities are considered. Preoperative counseling and optimization should prioritize diabetes, hypertension, and smoking over rigid age thresholds.

Background: The quantification of phantom limb pain (PLP) is challenging due to the heterogeneity of patient experiences. This study evaluated the use period prevalence questionnaires in assessing PLP in patients with lower limb osseointegrated implant (OI) prostheses.

Methods: The study included patients who received single-stage lower limb OI prostheses at our institution. Period prevalence questionnaires included questions regarding frequency and duration of PLP prior to OI implantation and in the last year postoperatively. The frequency of PLP was assessed by asking participants how often they experienced PLP pain. The duration of each episode was evaluated by asking how long the PLP pain lasted. Nerve reconstruction procedures included targeted muscle reinnervation (TMR) or combined TMRpni.

Results: A total of 11 patients completed the questionnaire (7 transtibial and 4 transfemoral). The median age was 52 years, and the median BMI was 29.7 kg/m2. Of the 11 patients, 8 underwent nerve reconstruction (72%): 5 with combined TMRpni and 2 with TMR. Six patients reported a reduction of PLP episodes (54%), whereas the remaining 5 patients experienced the same frequency of PLP. Statistical analysis revealed a significant reduction in PLP frequency from preop to postoperative time points (median, 4 vs 3; P = 0.016). For PLP duration, 5 patients reported shorter episodes (45.5%), 5 patients reported the same duration (45.5%), and 1 patient experienced a longer duration (9%). There was no significant difference in duration between preoperative and postoperative assessments. When examining the total scores, there was a significant reduction of PLP from preoperative to postoperative time points (median, 6 vs 5; P = 0.048).

Conclusions: We introduced a novel method to assess PLP using period prevalence instead of pain intensity. OI prostheses, with or without nerve reconstruction, significantly reduced PLP frequency and combined frequency-duration measures. Future work will validate the period prevalence survey against established PLP instruments.