Annals of Plastic Surgery最新文献

Abstract: Breasts hold multifaceted significance in modern society, encompassing elements of motherhood, sexuality, and female identity. Diseases of the breast can thus result in uniquely complex decision making, particularly in the case of malignancy when mastectomy is indicated. Patient narratives reveal the profound impact of breast loss on self-perception, femininity, and community belonging. Although post-mastectomy breast reconstruction is empirically well supported, intersecting societal pressures and surgeon biases may challenge the autonomy of patients deciding on reconstructive options.This article critically examines various factors involved in decision-making in breast reconstruction following mastectomy, highlighting the significance of patient autonomy. We excavate the historical, sociocultural, and economic influences that may have tilted the current balance in favor of breast reconstruction. While considering the benefits of this shift, we examine the potential existing biases that may influence patient decisions. We emphasize that autonomy is a central ethical consideration in navigating complex reconstructive decisions and promoting patient-centered care. We hope that our work will contribute to a broader discussion on the value placed on breasts and reinforce the agency breast cancer survivors have in decision making.

Abstract: Interdigitating dendritic cell sarcoma (IDCS) is a rare malignancy with a poor prognosis, and currently, there lacks a standardized treatment protocol. IDCS can be challenging diagnostically given its immunophenotypic overlap with other malignancies such as melanoma. We describe a 52-year-old woman presenting with a left cervical mass. Following workup and MDT discussion, she underwent a unilateral modified radical neck dissection and superficial parotidectomy. On histopathological examination, despite some morphological and immunohistochemical overlap with melanoma, IDCS was confidently diagnosed. There have been few cases of IDCS in the head and neck published since the most recent pooled analysis. This case adds to the current literature, highlights unique diagnostic findings, and explores its overlap with melanoma. More data are required regarding treatment outcomes and follow-up for cases of IDCS. Increased reporting such as this case will facilitate future analyses to guide management of this rare malignancy.

Background: The diagnosis and management of velopharyngeal dysfunction (VPD) is a particularly challenging part of the cleft care timeline, particularly in resource-limited settings. Although machine learning (ML) models offer promising results as screening tools, their real-world clinical viability has yet to be reliably demonstrated. This study aims to systematically compare the capability of several ML models to detect VPD in nonstandardized conditions to simulate real-world clinical testing.

Methods: Eighty-two patients were enrolled under standardized acoustic conditions and partitioned into an in-domain 60-subject training set and a 22-subject test set. For the out-of-domain test set, audio samples were obtained from publicly available Internet sources. A total of 131 case samples (70 control, 61 case) were obtained from multiple publicly available sources. Recording scenarios were highly variable, nonstandardized and largely not described, thereby introducing extreme heterogeneity.

Results: On the hold-out testing dataset, multiple deep learning models, particularly those using Whisper and HuBERT features, achieved near-perfect performance, with the Whisper/Support Vector Machine (SVM) pipeline reaching 100% accuracy and a 1.0 macro F1-score. The traditional MFCC baseline model also performed exceptionally well, achieving 99.2% accuracy and a 0.95 macro F1-score. Cross-domain generalization testing on the out-of-domain dataset demonstrated severe performance degradation. State-of-the-art deep learning models failed to generalize. The simpler baseline MFCC/SVM pipeline proved to be the most robust in real-world simulation, achieving an accuracy of 64.1% and a macro F1-score of 0.61.

Conclusion: The results of this study demonstrate that pretrained ML models can achieve near-perfect VPD detection in highly standardized acoustic environments. However, models are highly susceptible to domain shift caused by variations in recording devices and acoustic environments. Out-of-domain testing results were mediocre but suggest that real-world clinical detection of VPD by ML models is feasible. These results shed light on the difficulties of real-world model generalization and emphasize that for clinically deployable diagnostic tools, cross-domain robustness is as important as, if not more important than, achieving maximal accuracy on a benchmark dataset. The development of a software-based screening tool has the power to improve VPD screening, particularly in low- and middle-income countries.

Abstract: Unilateral cleft lip (UCL) repair has evolved significantly over the past decades. In certain areas of the world, barriers such as limited surgical expertise, lack of equipment, and restricted access to general anesthesia make cleft care challenging. Simplified, reliable, reproducible, and time-tested techniques are essential to ensure equitable outcomes and reduce the need for revision surgeries. With over 4 decades of refinement, the technique described in this chapter incorporates key maneuvers that yield consistent results. It is easy to teach and applicable to all cleft severities, including wide clefts, and across healthcare settings. This technique empowers providers and promotes long-term, sustainable primary UCL repair through reproducibility, accessibility, and durability. Key maneuvers described in this chapter include the following: (1) simplified and effective surgical markings, (2) the Hamdan Sliding V-Cheiloplasty for appropriate orbicularis muscle repair, and (3) the cartilage-sparing rhinoplasty, using an alar base flap and suspending suture (ABFSS), double interdomal sutures, transverse crural and alar crease transfixion sutures, and soft triangle suspending sutures.

Background: Craniosynostosis, characterized by premature fusion of cranial sutures, can impede childhood development. This study compares outcomes between open cranial vault remodeling and endoscopic strip craniectomy with helmet therapy in children with isolated craniosynostosis of the sagittal, metopic, coronal, and lambdoid sutures.

Methods: Retrospectively, 89 patients treated over 13 years were analyzed; 44 underwent endoscopic repair, and 45 underwent open surgery. Key operative variables including intraoperative blood loss, operative time, transfusion rates, and hospital stay were analyzed. Neurodevelopment was assessed at multiple postoperative intervals.

Results: The endoscopic group experienced significant perioperative advantages with lower mean intraoperative blood loss (58.84 mL vs. 107.61 mL, P < 0.001), reduced operative time (96 minutes vs. 244 minutes, P < 0.001), shorter hospital stays (2.67 days vs. 4.07 days, P < 0.001), and reduced opioid prescription rates (40.9% vs. 71.1%; P = 0.004) compared to the open group. Overall developmental delay rates were similar (29.3% vs. 20.9%, P = 0.378). However, those with isolated coronal synostosis (OR, 4.81, P = 0.057) and isolated metopic synostosis (OR, 16.73; P = 0.005) had increased odds of developmental delay compared to those with sagittal synostosis. Endoscopic intervention (OR, 11.32; P = 0.044), each additional month of age at surgery (OR, 1.25; P = 0.026), and drain placement (OR, 12.59; P = 0.018) were each independently and significantly associated with greater odds of delay.

Conclusions: Endoscopic repair may offer perioperative benefits yet may be an independent predictor of postoperative developmental delay alongside age and drain placement.

Background: Recurrent carpal tunnel syndrome is a challenging surgical problem. Revision carpal tunnel release with vascularized flap coverage is indicated when scarring around the median nerve is believed to be the culprit for recurrence. Synovial flap coverage at the time of neurolysis is a described technique, but long-term results have not been reported. Our aim is to evaluate and present long-term outcomes (>1 year) of patients with recurrent carpal tunnel syndrome treated with carpal tunnel release and synovial flap coverage.

Methods: A retrospective review identified 17 patients who underwent revision carpal tunnel release combined with synovial flap coverage performed by the senior author over a 10-year time frame. Patient demographics and preoperative symptoms were collected. All patients were contacted via telephone. Fourteen patients completed follow-up surveys including the QuickDASH and Boston Carpal Tunnel Questionnaire (BCTQ). Data were analyzed using a Fisher exact test with a significance set to a P value <0.05.

Results: Of the 14 survey participants, 10 had good outcomes based on a BCTQ score <2 (71.43%), and 11 had good outcomes based on a QuickDASH score ≤34 (78.57%). All patients considered the surgery successful, and 13 would elect to undergo the surgery again. No patients required an additional release. No specific patient characteristics or preoperative symptoms were associated with a poor outcome. There were no major complications.

Conclusion: Revision carpal tunnel release with synovial flap coverage demonstrated good long-term patient-reported outcomes. This is a reliable, effective treatment option for this challenging condition.

Background: Xylazine is a veterinary sedative that is added to illicit fentanyl to prolong its euphoric effects. When injected subcutaneously, xylazine causes large, necrotic wounds. In 2023, the White House designated fentanyl adulterated with xylazine as an emerging US public health threat. To date, the optimal surgical management of xylazine-associated wounds is not well understood.

Methods: A total of 66 inpatient plastic and orthopedic surgery consultations for xylazine-associated wounds at an academic center in the northeast United States between 2018 and 2023 were reviewed. Following IRB exemption, charts were identified through report generation in Epic Systems. Categorical variables were compared using Fisher's exact test with significance set at P < 0.05. A treatment algorithm was developed.

Results: Wounds were located on the arm/forearm (54.5%), lower extremity (47.0%), hand (33.3%), neck (7.6%), chest (3.0%), and abdomen (1.5%). 69.7% presented with a chronic wound (>3 months). 20.0% presented with exposed bone. 65.2% presented with acute infection: 47.0% cellulitis, 24.2% osteomyelitis, 22.7% abscess, and 9.1% sepsis. One patient (1.5%) presented with an NSTI and was debrided urgently. Management included local wound care alone (45.5%), surgical debridement alone (22.7%), skin grafting (19.7%), skin substitute (10.6%), local tissue rearrangement (3.0%), free flap (3.0%), and amputation (9.1%). 72.7% continued to inject after initial treatment, 13.6% stopped injecting, and 13.6% were lost to follow-up. By study completion, 25.8% fully healed their wound, and 27.3% partially healed. 13.0% (3/23) of patients treated with wound care fully healed, compared to 21.4% (3/14) of those treated with debridement alone (P = 0.65). Among those who continued to inject, 20.4% (9/44) fully healed, compared to 75.0% (6/8) of those who stopped injecting (P = 0.005). Reconstructive procedures were successful in 50% (7/14).

Conclusions: Xylazine-associated wounds occur on all parts of the body. Substance use rehabilitation is associated with healing. Local wound care is effective for chronic, noninfected wounds. A staged reconstructive approach is preferred once the patient is optimized. An algorithm for multidisciplinary management is beneficial for standardizing care.

Abstract: Anterior palatal fistulae (APFs) present a considerable challenge following cleft palate repair, particularly when involving the alveolus and the anterior half of the hard palate. These defects are notoriously difficult to close due to limited local tissue availability, scarring, restricted flap mobility, and altered vascularity, all contributing to high recurrence rates. This study evaluates the effectiveness of the buccal sulcus myomucosal flap (BSMF) as a practical and reliable option for APF closure. A retrospective review of 132 patients treated between January 2021 and December 2023 was conducted. All patients underwent nasal layer closure with turn-in flaps, followed by measurement of the residual defect and harvest of a BSMF of appropriate size. Of the cohort, 59 patients (44.7%) presented with primary fistulae while 73 (55.3%) had recurrent defects. The overall recurrence rate following repair was 10.4%, with similar rates observed in primary and recurrent cases. The technique consistently achieved tension-free closure even in large anterior defects extending into the alveolus, with minimal donor site morbidity. Its technical simplicity and cost-effectiveness further enhance its applicability, particularly in resource-constrained and high-volume settings. The BSMF offers a reproducible, effective solution for managing anterior palatal fistulae and warrants broader consideration in cleft care algorithms.