Annals of Plastic Surgery最新文献

Purpose: Open access publishing models are common in plastic surgery. We aim to quantify the financial investment required to support open access publishing for plastic surgery students during both medical school and residency training.

Methods: Peer-reviewed PubMed journal articles from plastic and reconstructive surgery-related journals published by current PGY-2 through PGY-6 integrated plastic surgery residents were divided into publications during medical school and publications during. Article-processing charges (APCs) for analyzed articles were collected online. Subgroup analyses by institutional NIH funding were conducted.

Results: A total of 2904 unique publications published by 606 PGY-2-PGY-6 integrated plastic surgery residents during medical school and 1109 publications from 245 PGY-5 and PGY-6 residents during residency were extracted. For medical school publications, each individual had a median (interquartile range [IQR]) of 4 (2-7) publications; 20.4% of their publications had a mandatory APC with a mean (SD) APC of $2140 (727) per project. The percent APC increased over time (correlation = 0.09). For residency publications, each student had a median (IQR) of 3 (2-7) publications; 23.6% of each resident's publications required an APC, with an average APC of $2140 ± $765 (mean ± SD) per project. Publications affiliated with a top 25 NIH-funded medical institution had a lower rate of open access publishing with an APC (17.8% vs 22.9%) but higher average impact factor (1.86 vs 2.03).

Conclusions: Students publishing in plastic surgery journals require financial investment for open access fees. Institutions should ensure that they have adequate resources to support trainee publishing.

Background: The anterolateral thigh free flap is widely utilized for reconstructing complex wounds. Despite considerable advances in free flap procedures, partial flap loss remains a challenge, particularly with larger perforator flaps. This study explored the outcomes of bipedicle anterolateral thigh free flap procedures by comparing single-pedicle free flaps in cases involving larger flaps.

Methods: This retrospective study included 70 patients who underwent procedures (N = 72) involving extremely large anterolateral thigh free flaps (≥240 cm 2 in area and >30 cm in length) at our hospital between January 2020 and December 2024. Patient characteristics and medical records were comprehensively reviewed, focusing on variables such as age, sex, flap size, surgical technique, perioperative characteristics, and postoperative outcomes.

Results: A comparison of patient demographics revealed no statistically significant differences across the entire group. A total of 8 bipedicle anterolateral thigh free flap reconstruction procedures were performed. No flap complications were observed in patients undergoing bipedicle free flap reconstruction; this outcome differed significantly from that noted in patients undergoing single-pedicle free flap reconstruction ( P = 0.0215). Besides, no significant between-procedure difference was observed in ischemic time, operative time, or donor site complications.

Conclusions: The bipedicle anterolateral thigh free flap procedure appears to be a reliable approach for reconstructing extensive soft tissue defects with a single, substantial flap.

Introduction: Extensive keloids represent a major therapeutic challenge due to their high propensity for recurrence and their functional, aesthetic, and psychological impact. Surgical excision alone is associated with a high recurrence rate ranging from 40% to 100%. The use of a dermal regeneration matrix after excision, in combination with intralesional corticosteroid injections, has emerged as a promising alternative. This combined approach may improve healing quality and reduce recurrence, particularly in large or complex lesions. The objective of this study was to evaluate the effectiveness of this multimodal treatment protocol.

Methods: We conducted a retrospective study of extensive keloids treated between 2015 and 2023. All lesions were completely excised and covered with a dermal matrix, followed by secondary intention healing or split-thickness skin grafting. Monthly triamcinolone injections were administered postoperatively. The primary outcome measure was the absence or significant reduction of recurrence at the end of the follow-up period.

Results: In a cohort of 66 keloids with a median follow-up of 4.15 years, this combined therapeutic approach achieved a 65% success rate. Keloids covered with both dermal matrix and skin grafting had a significantly reduced risk of recurrence ( P < 0.01). However, donor site keloid formation occurred in 20% of cases.

Conclusion: This combined approach offers an effective solution for extensive keloids. Skin grafting appears to reduce the risk of recurrence but carries a nonnegligible risk of keloid formation at the donor site. Randomized prospective studies are needed to further validate these findings and optimize patient selection.

Learning objectives: After studying this article, the participant should be able to (1) understand the nonsurgical and surgical techniques and advancements in the management of pediatric head and neck cancers, (2) describe the common management strategies used in pediatric head and neck cancers, and (3) Understand therapies to target head and neck cancers within pediatric patient populations.

Summary: Pediatric head and neck cancer management is complex and often requires a multidisciplinary approach. Management goals aim to deliver a multimodal treatment approach that integrates surgery with concurrent medical management through adjuvant and/or neoadjuvant chemotherapy and/or radiation therapy. Patients in remission should be monitored closely for recurrence or long-term treatment complications. Harmonizing a multidisciplinary approach between pediatric oncologists, hematologists, radiologists, pathologists, and surgeons is a priority. This review discusses advances in management strategies used for common pediatric head and neck malignancies, with a focus on surgical and medical techniques as well as treatment complications that can arise.

Abstract: Gross breast asymmetry, characterized by significant differences in size or shape between breasts, poses both psychological and surgical challenges. Achieving optimal symmetry requires a tailored approach that balances patient preferences with surgical precision. This study evaluates a sequential strategy for managing breast asymmetry through a combination of augmentation and reduction techniques, enhanced by Crisalix 3D imaging software (version 2) for preoperative planning. Three patients presenting with varying degrees of breast asymmetry were included, each undergoing individualized surgical correction based on their specific anatomical characteristics. Preoperative planning involved 3D software simulation to determine implant sizes corresponding to patients' desired postoperative appearance, alongside external sizers to validate volume projections. Outcomes were assessed through clinical and photographic evaluations, a 5-point Likert scale for satisfaction, and complication rates. Across all cases, high satisfaction scores (average 4.7/5) were achieved, with notable improvements in symmetry. Minor scar hypertrophy was observed in one patient, which improved with silicone gel application. The integration of 3D imaging software significantly enhanced preoperative decision making and patient communication, allowing for more precise implant selection and improved prediction of post-operative outcomes. The sequential approach proved advantageous by providing a clean surgical field, reducing infection risks, and offering a stable reference for tissue removal during contralateral procedures. This approach also facilitated preoperative discussions with patients regarding their desired breast size, allowing informed decision making aligned with their preferences. A carefully planned sequential strategy, augmented by advanced imaging technology, offers a logical, patient-centered method for correcting breast asymmetry, minimizing complications and optimizing outcomes. Future studies integrating advanced imaging and planning tools may further enhance surgical precision and patient satisfaction.

Background: Endoscopic suturectomy is increasingly favored over open cranial vault reconstruction for coronal synostosis patients due to decreased morbidity. However, ensuring an accurate craniectomy is challenging due to anatomical changes inherent to coronal synostosis. Given the improved intraoperative efficiency and postoperative outcomes previously seen with the use of virtual surgical planning (VSP) in traditional open craniosynostosis correction, we sought to utilize VSP to optimize the endoscopic correction of coronal craniosynostosis.

Methods: Patients who underwent endoscopic-assisted suturectomy for unicoronal or bicoronal craniosynostosis from 2020 to 2024 were retrospectively reviewed. In one cohort, a surface marking guide was developed with VSP to facilitate percutaneous tattooing of the periosteum. These marks were then followed to confirm craniectomy completion after subgaleal exposure. The VSP- and non-VSP-guided cohorts were compared for patient demographics, estimated blood loss, operative time, and length of stay.

Results: Seventeen patients were included who underwent 12 unilateral and 5 bilateral suturectomies. Eight patients (4 unicoronal and 4 bicoronal) compared to 9 patients (8 unicoronal and 1 bicoronal) were in the VSP and non-VSP cohorts, respectively. Overall EBL for unilateral cases was 12.1 ± 7.5 mL. Patients who underwent VSP had equivalent EBL to the non-VSP cohort (10.0 ± 1.0 mL vs 13.1 ± 19.2 mL, P = 0.53). For bilateral cases, EBL for the VSP cohort was 28.8 ± 30.9 mL compared to 50 mL for the one bilateral non-VSP guided case. Patients who had VSP guidance had significantly reduced operative time for unilateral cases (63±17 vs 81± 20 minutes, P < 0.01). For bilateral cases, VSP guidance was 78 ± 26 minutes compared to 118 minutes for the one bilateral case with non-VSP guidance.

Conclusions: Using VSP to assist endoscopic coronal suturectomy reduces operative time, which may reflect a decreased reliance on intraoperative assessment and increased fidelity of neosuture placement.

Introduction: The applications of artificial intelligence (AI) in plastic surgery have grown considerably in recent years. As large patient datasets become more accessible, surgeons are increasingly leveraging machine learning (ML), a subset of AI, to predict patient outcomes and guide surgical decision-making. This review evaluates the relative performance of ML prediction models in breast reconstruction.

Methods: A systematic review was conducted utilizing PubMed, Scopus, and EMBASE according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies using ML to predict patient outcomes in breast reconstruction were included. The type of ML model and the specific outcome measures were reported. Performance of the models was reported as area under the receiver operating characteristic curve and compared using descriptive statistics, multivariate linear regression, and random-effects meta-regression in RStudio.

Results: Our search yielded 1025 citations, of which 24 were assessed for eligibility. Fourteen studies met the inclusion criteria and were sought for data extraction. There were 19 ML models and 11,013 patients assessed across 92 testing conditions. Models were trained on varying patient demographics, comorbidities, and operative characteristics, whereas outcomes assessed included various surgical complications or patient satisfaction using BREAST-Q. The median area under the receiver operating characteristic curve of all models was 0.71 (interquartile range = 0.16). When adjusting for the number of patients, number of predictors, ML model category, and outcome of interest, models predicting BREAST-Q performed higher with skin necrosis used as the reference outcome (β = 0.13, P < 0.01). After adjusting for number of patients and predictors, models that employed strategies to mitigate class imbalance were associated with higher model discrimination (β = 0.038; 95% CI, 0.002-0.075; P = 0.041).

Conclusion: Machine learning applications for risk prediction and surgical planning are growing rapidly. The models evaluated in this review demonstrated the ability to predict a variety of outcomes, with models predicting BREAST-Q, various surgical outcomes, and those reporting class imbalance methods leading to higher model discrimination. Notably, covariate adjustment and study heterogeneity may have impacted these associations. As ML models are increasingly integrated into plastic surgery practice, standardized reporting practices are essential to promote reproducibility and cross-study comparison.

Background: Dual-nerve neurotization of deep inferior epigastric perforator (DIEP) flaps may enhance postmastectomy reinnervation, but the early timeline and regional patterns of tactile and thermal recovery remain incompletely defined.

Methods: We conducted a prospective, single-institution study (January 2024-September 2025) of women undergoing immediate dual-neurotized DIEP flap breast reconstruction. Anterior and lateral intercostal branches (T3/T4) were coapted to medial and lateral flap donor nerves (T10-T12). Objective sensory testing was performed preoperatively and at 3, 6, and 9 months. Tactile thresholds were normalized to each breast's baseline and reported as percent recovery. Thermal perception (hot 52°C; cold 12°C) was analyzed as regional accuracy. All analyses were performed within-breast.

Results: Twenty-three patients (43 breasts) were included. Composite tactile recovery increased from 44.9% ± 29.2% at 3 months to 55.5% ± 27.0% at 6 months and 64.2% ± 24.8% at 9 months (all P < 0.001). Regional recovery followed a superomedial pattern. By 9 months, outer-superior (85.6%) and outer-medial (85.9%) regions were not different from baseline (P > 0.05), whereas the NAC (46.0%) and inferior regions (41%-65%) remained reduced (P < 0.001). Thermal recovery improved over time. Cold accuracy increased to 48% ± 20% by 9 months (P < 0.001), with only the superior region approaching baseline (P > 0.05). Hot accuracy recovered more robustly (9 months: 67% ± 28%; P < 0.001), with superior, medial, and inferior regions reaching baseline equivalence (P > 0.05).

Conclusions: Dual-neurotization yields progressive tactile and thermal recovery within 9 months, most pronounced in the superior and medial breast, establishing early benchmarks for sensory outcomes after dual-neurotized DIEP reconstruction.

Introduction: A chest wall defect after resection of a recurrent desmoid tumor of the right breast was reconstructed with a TRAM flap over a Gore-Tex graft. The tumor had involved 2 ribs, and the wide resection included 5 ribs with a portion of the lateral sternum.

Methods: After the wide resection to effectively manage this aggressive, invasive lesion from the anterior chest of a 42-year-old woman, a 2-mm Gore-Tex graft was directly sewn in place to bridge the defect. A TRAM flap based on the left rectus abdominis muscle was delivered to the right chest to close the defect.

Results: The TRAM flap was initially well perfused and adequately reconstructed the chest wall defect. A clinical exam 6 hours after surgery found the flap pink, warm, and healthy. Within 18 hours of surgery, venous congestion of the distal TRAM flap was observed. Because of scarring from previous chest surgery and tightness of the flap, flap adjustment or advancement was not possible. Leech therapy was employed over 4 days. Twenty-six leeches alleviated the venous congestion and produced a persistent oozing that facilitated blood flow and oxygen delivery through hemodilution. The hospital had no established protocol for leech therapy, so there was resistance from the medical and nursing staff. The leeches were kept in the author's home refrigerator and personally driven to the hospital for each application over the 4 days. The leech therapy salvaged the congested flap, and the reconstruction successfully protected the heart and lungs.

Discussion: Radical resection of a desmoid tumor was the preferred management in 1993. The application of leeches to a myo-cutaneous flap was a novel approach. The leech therapy proved effective in reducing congestion and salvaging the TRAM flap reconstruction. Hemodilution was induced, which helped with tissue perfusion. Chest reconstruction continued in stages and included a solid silicone pectoralis implant inserted to add a rigid, more protective cover of the heart and lungs. Breast reconstruction with bilateral silicone gel implants produced a result acceptable to the patient. The desmoid tumor has not recurred.

Background: Endoscopic strip craniectomy represents an alternative to open cranial vault remodeling for repair of craniosynostosis. In addition to individual sociodemographic factors, hospital-level variables may affect the reception of such endoscopic procedures. This study incorporates a large national database to identify hospital-level and regional determinants of endoscopic repair for nonsyndromic craniosynostosis.

Methods: Open cranial vault remodeling and endoscopic strip craniectomy surgeries were identified in the 2016-2022 National Inpatient Sample. Admissions were characterized by hospital-level factors, such as hospital census division, bed size, ownership, and annual overall plastic surgery institutional volume. A multivariable logistic regression model was used to evaluate independent predictors of endoscopic repair ( P < 0.05).

Results: The final cohort comprised 12,785 nonsyndromic craniosynostosis repairs, 600 (4.7%) of which were endoscopic strip craniectomy procedures. Public hospital ownership was associated with lower odds of endoscopic repair compared to private nonprofit ownership (odds ratio [OR]: 0.30, 95% confidence interval [CI]: 0.21-0.43). Higher institutional plastic surgery volume also conferred higher odds (OR: 1.34, 95% CI: 1.25-1.43 per 100 cases). When compared to the Pacific region, all census divisions except the Mid-Atlantic (OR: 1.04, 95% CI: 0.72-1.51) and Mountain (OR: 0.84, 95% CI: 0.54-1.32) regions were associated with higher odds of endoscopic repair ( P < 0.05).

Conclusions: Multiple hospital-level factors, including hospital census division, ownership, and case volume, are associated with receipt of endoscopic strip craniectomy. This may reflect the impact of both state-specific insurance coverage and institutional experience on reception of endoscopic repair for nonsyndromic craniosynostosis.