Annals of Plastic Surgery最新文献

Background: The anterolateral thigh (ALT) flap is widely used for head and neck reconstruction because of its versatility and reliable vascular supply. However, anatomical variability of ALT perforators complicates their consistent identification, which is critical for successful flap harvest. Conventional methods such as Doppler ultrasound often produce false-positive results, making perforator localization challenging. Indocyanine green (ICG) angiography enables real-time intraoperative visualization of vascular flow, but interpretation remains largely subjective. This study integrates artificial intelligence (AI) with ICG angiography to enhance perforator detection, hypothesizing that AI-assisted analysis improves mapping precision and sensitivity.

Methods: This prospective cohort study included 51 patients undergoing ALT flap surgery between February and October 2024. Intraoperative indocyanine green angiography (ICG-A) was performed to identify perforators, followed by grayscale analysis of angiography videos to quantify pixel intensity over time. Perforators were classified as septocutaneous or musculocutaneous and annotated using the Roboflow platform for AI model training. The YOLOv11 object detection algorithm was applied. Model performance was compared with Doppler ultrasound and subjective ICG interpretation in terms of sensitivity and positive predictive value (PPV), with corresponding 95% confidence intervals (CIs). Statistical analysis used the independent t test, with significance set at P < 0.05.

Results: A prototype AI model for ALT perforator detection was developed using ICG-A data. Sensitivity was highest with subjective ICG interpretation (78%; 95% CI, 68%-85%), followed by Doppler ultrasound (53%; 95% CI, 43%-62%) and AI-assisted ICG-A (45%; 95% CI, 26%-65%); PPVs were 28%, 29%, and 21%, respectively. Quantitative pixel analysis showed a mean inflow time of 36 seconds, maximal slope time of 45 seconds, and maximal intensity time of 64 seconds, with a mean maximal intensity of 110 grayscale units. No significant differences were found between musculocutaneous and septocutaneous perforators.

Conclusions: AI-assisted ICG angiography is an emerging tool with potential to support perforator mapping. Although the current AI model demonstrated limited sensitivity, its accuracy can be enhanced by expanding training datasets, integrating temporal fluorescence dynamics, and refining fluorescence-time curve analysis. Future advancements in AI-driven image processing may further optimize intraoperative perforator identification, ultimately improving surgical precision and patient outcomes.

Introduction: Free flap phalloplasty and genital reconstruction have advanced significantly since the first reported case in 1982. Commonly used flaps include the radial forearm, anterolateral thigh (ALT), and ulnar forearm. However, less attention has been given to recipient vessel selection, which is critical for surgical success. This study evaluates the descending branch of the lateral circumflex femoral artery (DLCFA) as a potential recipient artery. We reviewed its reliability, anatomical characteristics, and suitability relative to established recipient vessel systems, including the deep inferior epigastric artery (DIEA) and the femoral artery.

Methods: Cadaveric dissections were performed with thigh incision to expose the rectus femoris and vastus lateralis muscles, allowing identification and dissection of the DLCFA and its venae comitantes. The DLCFA was transposed toward the pubic region to simulate its use in genital reconstruction. The great saphenous vein (GSV) was also dissected and transposed as its potential for venous supercharging. Sensory nerves, including superior and median perforator branches, were noted for potential coaptation.

Results: The DLCFA was consistently present, was easily accessible, and could be transposed to the pubic region without significant risk to nearby structures. Compared to the DIEA and femoral artery, the DLCFA was more superficial and simpler to dissect. It allowed for end-to-end anastomosis, which is technically less complex than the end-to-side technique required for larger-caliber arteries. These features suggest reduced intraoperative difficulty and potential for fewer complications.

Discussion: The DLCFA presents several distinct advantages. Unlike the DIEA, its dissection avoids the intra-abdominal space, thereby reducing the risk of hernia formation or visceral injury. Although its caliber is smaller than that of the femoral artery, the DLCFA facilitates microsurgical handling and anastomosis. Its relatively superficial course, compatibility with venous supercharging via the GSV, and potential for sensory nerve coaptation further underscore its suitability as a recipient vessel in genital reconstruction.

Conclusion: The DLCFA represents a reliable, readily accessible, and anatomically favorable recipient vessel for free flap phalloplasty and pelvic reconstruction. Its utilization may decrease operative complexity and enhance surgical outcomes, supporting its consideration as a preferred recipient vessel in appropriate clinical contexts.

Introduction: Lower eyelid blepharoplasty is performed via transconjunctival and subciliary approaches. In the subciliary approach, we have compared 2 methods: biplanar flaps versus a composite flap, with the goal of improved short-term recovery.

Materials and methods: Preoperative and 6-day postoperative 2-dimensional patient photographs were reviewed from each patient assigned to 1 of the 2 groups. Two blinded surgeons who neither performed the procedure nor were aware of the technique used reviewed the postoperative pictures from each patient and scored the results based on the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) Questionnaire.

Results: Forty-one patients (82 eyes) underwent subciliary lower blepharoplasty in the stated time frame. The primary outcome of the modified SPREE survey showed that patients who underwent the composite technique had an average edema score of 1.06 (from a 1-4 increasing severity scale) compared to 1.52 scored on patients with the biplanar technique ( P < 0.00228). For ecchymosis, patients who underwent the composite technique had an average score of 0.25 (from a 0-3 increasing severity scale) compared to 0.60 scored on patients with the biplanar technique ( P < 0.04444).

Conclusions: Composite flaps were shown to have a statistically significant decreased Modified SPREE score compared to biplanar flaps.

Objective: While numerous tools exist for grip strength measurement, there is a lack of research for assessing the individual finger flexor strength. This study aimed to evaluate the test-retest reliability of measuring individual finger flexion strength in healthy adults using the smallest bulb of the Martin Vigorimeter (MV).

Methods: Grip strength of 100 adults without hand pathology was measured using the large bulb of the MV, while individual finger flexor strength was assessed using the small bulb. Measurements were repeated after 3 weeks to evaluate test-retest reliability. Contribution of each finger flexor was calculated and compared to the previously reported values obtained using specialized equipment or protocol.

Results: The MV showed excellent reliability for grip strength (intraclass correlation coefficient > 0.9) and good-to-excellent reliability for individual finger flexor strength (intraclass correlation coefficient = 0.805-0.914). The middle finger contributed the most (approximately 30%), followed by the index and ring fingers (25%-26%), which were comparable to values previously reported using specialized equipment or protocols. Normalized minimal detectable change values for finger flexor strength ranged from 9.7% to 14.2%.

Conclusions: These findings suggest that the smallest bulb of the MV is a reliable and accessible tool for measuring individual finger flexor strength in healthy adults, with results comparable to those obtained using specialized equipment or protocols.

Background: The bradykinin B2 receptor (B2R), a type of G protein-coupled receptor, exerts several beneficial biological effects on flaps. Accordingly, we investigated the role of the bradykinin B2R in the survival of perforator flaps.

Methods: In this study, a total of 50 male Sprague-Dawley rats were allocated equally into 2 groups: one receiving a bradykinin B2R blocker and the other serving as a control, with both groups undergoing flap procedures. Flap viability was assessed 7 days postoperatively by quantifying the surviving flap area. Blood perfusion within the flap was evaluated using laser Doppler imaging. The levels of Beclin-1, p62, and LC3-II/I were used to assess autophagy. The extent of flap angiogenesis was evaluated using immunohistochemistry and hematoxylin and eosin staining. Western blotting revealed the expression levels of vascular endothelial growth factor (VEGF) and the apoptotic index. Moreover, superoxide dismutase (SOD) activity and malondialdehyde (MDA) levels were used to evaluate oxidative stress. This study used a nitric oxide (NO) assay kit to determine NO production.

Results: The bradykinin B2R blocker group exhibited significantly reduced flap survival areas (blocker group: 64.7 ± 3.36%; control group: 85.6 ± 3.35%; P < 0.01), diminished blood perfusion (blocker group: 389.8 ± 7.92; control group: 491.8 ± 5.81; P < 0.05), and decreased neovascularization (blocker group: 20.13 ± 1.58; control group: 52.17 ± 1.49; P < 0.05). Compared to the control group, the bradykinin B2R blocker group also demonstrated lower SOD activity, NO content, and VEGF expression, and increased MDA levels (all P < 0.05). Rats treated with the bradykinin B2R blocker exhibited higher levels of autophagy and apoptosis than those observed in the control group.

Conclusion: According to our research, the bradykinin B2R protects multiterritory perforator flaps through diverse molecular pathways, which involve inhibiting apoptosis, combating oxidation, modulating autophagy, and fostering angiogenesis to improve the blood supply to the flap.

Background: Digital nerve injuries are the most prevalent form of peripheral nerve injuries. We aimed to conduct a systematic review and Bayesian network meta-analysis to determine the optimal technique for sensory restoration in patients undergoing digital nerve repair.

Methods: An electronic search was conducted from inception to September 2025. Thirteen studies were included comparing neurorrhaphy, allograft, autograft, and conduit. Outcomes analyzed included static 2-point discrimination (S2PD) and moving 2-point discrimination (M2PD), presented as mean difference (MD) with 95% confidence intervals (CIs) or as surface under the cumulative ranking curve (SUCRA) scores and mean rank estimates. Sensitivity analyses were also performed by excluding neurorrhaphy. A P value <0.05 was considered statistically significant.

Results: The pooled analysis demonstrated that allograft was the best technique for S2PD (SUCRA: 70.39, mean rank: 1.89), whereas neurorrhaphy ranked highest for M2PD (SUCRA: 70.71, mean rank: 1.88). Traditional meta-analysis also confirmed allograft's superiority for S2PD (MD = -1.44, 95% CI: -2.57 to -0.32; P = 0.01) and neurorrhaphy for M2PD (MD = -0.50, 95% CI: -0.87 to -0.13; P = 0.007). However, sensitivity analyses excluding neurorrhaphy demonstrated that allograft also ranked highest for M2PD (SUCRA: 69.91, mean rank: 1.60). Conduit repair was significantly worse than other techniques for both outcomes (S2PD : P = 0.002; M2PD : P = 0.004).

Conclusion: These findings highlight allograft as the most effective techniques for optimizing sensory recovery in digital nerve injuries, especially in cases where neurorrhaphy is not feasible.

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.

Background: Many surgeons have adopted chemoprophylaxis in an effort to reduce VTE risk. However, the efficacy of routine anticoagulation has been challenged. Whether chemoprophylaxis raises the risk of bleeding has been the subject of debate. This review was undertaken to evaluate the efficacy of this method and the bleeding risk.

Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the literature was reviewed for publications reporting series of at least 100 abdominoplasties published from 2012 to 2025. The incidences of VTE and hematomas were tabulated. The quality of evidence was evaluated using Methodological Index for Non-Randomized Studies (MINORS) scores.

Results: Twenty-four publications were identified, comprising 9502 patients. All studies were retrospective, with data heterogeneity. Seventeen studies (71%) routinely used chemoprophylaxis. The overall VTE risk was 0.3% in studies using chemoprophylaxis versus 0.5% in studies not using anticoagulation (difference not significant). The hematoma rate was 4.7% for anticoagulated patients versus 0.6% for nonanticoagulated patients. The difference was highly significant (P = 0). Blood transfusions were more likely in patients receiving chemoprophylaxis (P < 0.05). Only 1 study incorporated routine Doppler ultrasound screening. Most studies (15/24, 63%) reported using sequential compression devices (SCDs). The overall VTE risk among pooled patients treated with SCDs was 0.9% versus 0.5% for patients treated without SCDs. The difference was significant (P = 0.04).

Discussion: Some plastic surgeons have been wary of off-label chemoprophylaxis in plastic surgery patients, concerned about its efficacy and the potential for increased bleeding. The data do not show a significant treatment benefit in abdominoplasty patients. The evidence of an increased bleeding risk appears conclusive. The unexpected finding of more, not less, VTEs among patients treated with SCDs challenges the efficacy of this common practice. Ultrasound screening allows early detection of clinical and subclinical VTEs, and anticoagulation of affected patients.

Conclusions: No significant benefit derives from off-label chemoprophylaxis for VTE reduction in abdominoplasty patients. The risk of bleeding is significantly increased. SCDs appear to be of no benefit. An alternative method, using ultrasound screening, total intravenous anesthesia, and no chemoprophylaxis is safe and effective.

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.