Annals of Plastic Surgery最新文献

Background: Several methods of penile reconstruction have been described. Free flaps are considered the most functional and aesthetically appropriate treatment method. The main purpose of this reconstruction is to create the urinary tract and provide the most aesthetically similar structure to the biological penile tissue while also providing penile tissue of a size that will ensure adequate sexual intercourse.This method was investigated through a retrospective analysis of patients who underwent penile reconstruction with a latissimus dorsi free flap, which we believe provides all these features. Thirty patients who underwent surgery between 2020 and 2023 were included in the study group.

Methodology: Latissimus dorsi flap is an important option for patients who need penile reconstruction, including those who want the donor site morbidity to be in a hidden area and those who have concerns about penis size.

Result: Tissue of a size that provides sexual function and a structure in which a penile prosthesis can be easily inserted is obtained in patients who have undergone penile reconstruction with the latissimus dorsi. In addition, there was no problem in creating a glans penis or corona using this method. Pendular urethral reconstruction was not performed in this case series.

Conclusions: We think that penile reconstruction with Latissimus dorsi, together with some of the modifications described, is one of the most functional and aesthetically appropriate methods.

Background: Traumatic brain injury (TBI) associated with facial fractures is a major public health concern worldwide. The rate of TBI in patients with mandibular fractures ranges from 21.3% to 39.6%. However, the risk factors for TBI in patients with mandibular fractures remain unknown. Our study evaluates these risk factors.

Methods: We retrospectively reviewed patients who presented with traumatic mandibular fractures in 2018 and 2019. Excluded were patients with no documentation of Glasgow Coma Scale. Our primary outcomes were: (1) prevalence of concomitant TBI on presentation defined as having a positive head computed tomography scan (hemorrhage, parenchymal contusion, diffuse axonal injury), or a negative scan with Glasgow Coma Scale < 15 or any neurologic symptom/sign; (2) prevalence of posttraumatic neurologic symptoms assessed at ≥4 weeks after injury. The mandibular injury severity score (MISS) was calculated for all patients. Bivariate analysis and multivariable logistic regression were performed.

Results: Of 390 patients with mandibular fractures, 165 (42.3%) had concomitant TBI on presentation. Of those, 61% (n = 101) had mild TBI, 12% (n = 20) had moderate TBI, and 27% (n = 44) had severe TBI. Almost half of the mandibular fractures were due to assault (182 [47%]). Older age at injury and the presence of other facial fractures were associated with significantly greater odds of TBI on presentation (adjusted odds ratio 95% confidence interval [CI] 1.016 [1.001-1.032], P = 0.040; 2.457 [1.551-3.891], P < 0.001). Of 195 patients who were assessed at ≥4 weeks after injury, 99 (51%) had neurologic symptoms, most commonly facial numbness (74 [38%]). Mandibular body fracture and a high MISS were associated with significantly greater odds of having neurologic sequelae at ≥4 weeks after injury (adjusted odds ratio [95% CI] 3.12 [1.31-7.50], 1.12 [1.04-1.20]).

Conclusions: Older patients and those with mandibular body fractures and a high MISS may benefit from TBI screening and close longitudinal follow-up to identify and manage neurologic sequelae.

Introduction: Gender-affirming surgery (GAS) is a complex process that often requires multiple surgical operations and carries a complication risk that could be exacerbated by connective tissue disorders (CTDs). This study aims to investigate the association between CTD diagnosis and GAS outcomes.

Methods: Using the Merative MarketScan Research Databases, patients with gender dysphoria diagnoses who underwent GAS between 2007 and 2022 were identified. Among these, patients with diagnosed CTDs were identified. Demographics, comorbidities, and postoperative complications were recorded. Chi-squared, Shapiro-Wilk, Wilcoxon-Mann-Whitney, and multivariate logistic regression testing was used for statistical analysis.

Results: Of 7575 patients meeting criteria (mean age 29 ±10 years), 300 (4%) had CTD diagnoses. One or more postoperative complications were recorded in 9.8% of patients, without statistically significant difference between CTD and non-CTD patients. Additional simultaneous GAS procedures [odds ratio (OR) 2.02; P < 0.01], Elixhauser index scores of 3+ (OR 1.36; P = 0.010), and age >45 years (OR 1.47; P = 0.02) increased odds of experiencing complications following the index GAS procedure, while CTD diagnoses (P = 0.52) did not affect odds of experiencing complications. However, CTD diagnoses did elevate odds of readmission (OR 1.47; P = 0.046), as did multiple simultaneous GAS procedures (OR 2.66), Elixhauser index scores of 3+ (OR 3.72), and smoking (OR 2.18) (P < 0.01).

Conclusions: These findings suggest CTDs may impact some gender-affirming surgical outcomes, and careful preoperative evaluation and management of comorbidities is necessary to reduce the risk of complications and readmission in this population. Surgeons should continue to exercise caution when performing elective surgery on patients taking immunomodulatory medications.

Abstract: Simulation training has been growing in popularity, as a means to help supplement the training of surgical residents. The Newcastle Surgical Training Centre K-wiring course, a 1-day course designed for early-years surgical trainees, aims to teach essential skills in K-wire fixation for hand fractures. The course integrates lectures and hands-on practice with both simulated and cadaveric specimens, supported by a high faculty-to-delegate ratio. Despite minor limitations, such as the quality of initial hand simulators and the potential need for more radiographer support, the course provides substantial educational value and practical experience. Overall, authors found the Newcastle Surgical Training Centre K-wiring course to be a well-resourced and effective training opportunity for surgical trainees.

Abstract: The radial forearm free flap (RFFF) has emerged as a leading option for microvascular reconstruction of head and neck soft-tissue defects. Despite the favorable outcomes conferred by RFFFs, complications such as skin graft loss and tendon exposure can occur. We present the case of a 77-year-old man who underwent RFFF reconstruction after excision of squamous cell carcinoma from the head and neck. The patient subsequently developed flexor tenosynovitis, septic arthritis of the wrist, and osteomyelitis of several carpal bones as a direct result of partial skin graft loss and prolonged tendon exposure at the donor site. To the best of our knowledge, this is the first reported case of this specific complication. Review of the literature reveals the need for continued research into RFFF donor site complications to mitigate the incidence of significant morbidity.

Background: Among patients with critical limb ischemia and tissue loss, revascularization is an essential component for limb salvage. Local flaps of the foot and ankle remain a versatile tool in reconstructive limb salvage but is dependent on adequate arterial flow. In patients with arterial occlusive disease requiring revascularization, there is a lack of evidence in the current literature investigating on the necessity of direct arterial flow to the respective angiosome for local flaps reconstruction. Our study thereby compares the outcomes of direct (DR) and indirect (IR) revascularization for local flap success.

Methods: Patients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. IR was performed in patients where DR could not be performed. DR was defined as an intervention on the same pedicle used for the local flap. IR was defined as an intervention performed on a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, postoperative complications, and long-term outcomes were collected.

Results: A total of 33 patients underwent 43 local flap reconstruction with preoperative ER: 58.1% (n = 25) received DR and 41.2% (n = 18) received IR. Patients had a mean CCI of 6.7 ± 1.8, with a high prevalence of diabetes mellitus (93.9%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. In the immediate postoperative period (postoperative day 0 to 12), there were no significant differences in immediate flap success (DR: 100% vs IR: 88.9%, P = 0.169) or partial flap necrosis between (DR: 0.0% vs IR: 16.7%, P = 0.066). Rates of major complications from infection (DR: 28.2% vs IR: 22.2%, P = 0.736), ischemia (DR: 4.0% vs IR: 11.1%, P = 0.562), or dehiscence (DR: 8.0% vs IR: 16.7%, P = 0.634) requiring reoperation were similar between 2 groups. Overall limb salvage rate was 84.9%, and comparable between groups (DR: 78.6% vs IR: 89.5%, P = 0.628).

Conclusions: DR and IR achieve similar rates of limb salvage and flap success after local flap reconstruction. A multidisciplinary vasculo-plastic approach that incorporates preoperative arteriogram and revascularization should be utilized for this highly comorbid patient population to achieve optimal success and limb salvage.

Abstract: Indocyanine green (ICG) is a water-soluble green substance that is detectable through infrared cameras and emits greenish light. Approved for medical use in the 1950s, ICG has gained prominence as a real-time visualization tool. Widely recognized as a generally safe substance, ICG is applied in diverse fields. Despite its prevalent use without significant safety concerns, we report a case of anaphylactic shock due to ICG to reflect on its potential risk.A 46-year-old woman with phyllodes tumor of the breast came to our clinic. She had no significant medical history except dog hair allergy. She underwent nipple-sparing mastectomy, and we planned reconstruction with a deep inferior epigastric perforator free flap. Intraoperatively, we injected ICG to visualize the perfusion area of the abdominal flap. Immediately after injection, her blood pressure dropped to 39/32 from 124/66. Anaphylaxis management included injection of epinephrine, norepinephrine, and steroid. With proper management, her vital signs recovered to normal ranges and the operation proceeded. After discharge, the patient developed no flap-related or internal medical complications.Despite the widely known safety of ICG, it carries a risk of life-threatening adverse effects. Surgeons should be aware that, although rare, these events can occur in their operations.

Background: While there is mounting evidence that closed suction drains are not necessary, there is a paucity of literature to demonstrate that drains are harmful after breast reduction. The purpose of this study was to investigate the effect of drains on postoperative seroma, hematoma, and infection, as well as elucidate any risk factors that may be implicated in the development of these complications.

Methods: A retrospective cohort study was conducted of all reduction mammaplasty procedures at our university medical center between 2010-2020. Pedicle type, skin incision, drain utilization, breast excision mass, sternal notch to nipple distance, and inframammary fold to nipple distance were analyzed with postoperative outcomes including hematoma, seroma, infection, dehiscence, nipple necrosis, and fat necrosis.

Results: This study included 944 female patients undergoing reduction mammaplasty. Median age was 39.0 years, median body mass index was 31.9 kg/m2, and median breast mass resected was 742 grams per side. Drain utilization did not significantly reduce postoperative hematoma (P = 0.196), seroma (P = 0.185), nipple necrosis (P = 0.511), or fat necrosis (P = 0.113), but drain utilization significantly increased postoperative surgical site infection (P = 0.011). Patients with breast mass removed over 1500 g had significantly higher risk of hematoma (P = 0.002), fat necrosis (P < 0.001), and nipple necrosis (P < 0.001) compared to patients with less than 1500 g removed. In patients with greater than 1500 g resected, drain utilization did not significantly decrease risk of hematoma (P = 0.086) or seroma (P = 0.497).

Conclusions: Breast reduction greater than 1500 g per side significantly increased risk of hematoma, nipple necrosis, and fat necrosis. Drain utilization did not demonstrate any advantageous effects, rather it increased risk of infection. Future multicenter study will be needed to confirm these findings across different patient referral networks and practice patterns.

Background: Red breast syndrome (RBS) has been noted in past literature as a possible complication of implant-based breast reconstruction (IBBR) with the use of acellular dermal matrices (ADMs). Since its first appearance in 2009, RBS has drawn growing medical attention with reported incidence ranging from 7%-9%. There has been a noted decrease in the emergence of RBS despite its inclusion among the analyzed complications in a number of studies. This systematic review aims to evaluate the trend in reported RBS incidence over time and appropriately determine an accurate incidence of RBS from reported literature since the emergence of the phenomena.

Methods: A systematic literature review was performed in July 2023 that analyzed the incidence of RBS among retrospective cohort studies on complication rates of IBBR with ADM. Patient demographics, RBS incidence rates, and all-cause complications were captured. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and Methodological Index for Nonrandomized Studies criteria was used to assess study quality.

Results: From 2009 to 2023, a total of 48 studies (n = 6251) met inclusion criteria of which 35 studies from 2017 to 2023 were not already included in a prior systematic review (n = 5246). The mean incidence of RBS in the unreported studies was 2.88% with a weighted mean of 3.22%. Analysis of the trend in RBS over time shows an increasing reported incidence rate from 2009 with a peak in incidence between 2016 and 2017, followed by a steady decline through 2022. Twenty-six of the studies were published from 2016 to 2019.

Conclusions: The incidence of RBS among prior studies and systematic reviews has fluctuated significantly since its initial emergence in 2009. Reported incidence rates have been on the decline since 2018 with a true weighted incidence of 3.22% from analysis of recent reported studies. Potential causes for the decline in incidence include practice changes in ADM preparation, changes in the ADM brand used for IBBR, and improved categorization of RBS compared to cellulitis/infection. Despite more robust criteria for diagnosis, no consensus for management has yet been established.