Annals of Plastic Surgery最新文献

Background: The circumflex scapular artery (CSA) flap system, consisting of scapular, parascapular, and chimeric flaps, is useful for pediatric reconstruction in many anatomical locations. The objectives of this case series are to offer insights into our decision-making process for selecting the CSA flap in particular pediatric reconstructive cases and to establish a framework for choosing a scapular or parascapular skin paddle. We also aim to emphasize important technical considerations of CSA flap utilization in pediatric patients.

Methods: Pediatric reconstruction with CSA flaps performed at our institution between 2006-2022 was retrospectively reviewed. Patient demographics, indications, flap characteristics, complications, and operative data were abstracted. Functional donor site morbidity was assessed through postoperative physical examinations. Unpaired t test analyzed scapular versus parascapular flap size.

Results: Eleven CSA flaps were successfully performed in 10 patients (6 scapular and 5 parascapular flaps). Patient ages ranged from 2 to 17 years. Scapular fasciocutaneous free flaps (n = 4) were performed in patients' ages 2-5 years for hand and forearm scar contractures. Two pedicled scapular flaps were performed for a single patient for bilateral axillary hidradenitis suppurativa. The 5 parascapular flaps were performed in patients' ages 2-14 years for calcaneus and forearm avulsion wounds and reconstruction after resection of hidradenitis suppurativa, nevus sebaceous, and Ewing sarcoma. In the sarcoma resection case, a chimeric flap with latissimus dorsi was employed. Average flap size was 101.6 ± 87.3 cm 2 (range: 18-300 cm 2 ). Parascapular flaps were significantly larger than scapular flaps (156.60 ± 105.84 cm 2 vs 55.83 ± 26.97 cm 2 , P = 0.0495). Overall, 3 complications occurred (27.3% of cases) including venous congestion (n = 2) and wound dehiscence (n = 1). There were no reported cases of compromised shoulder function at 1.9 ± 2.5-year follow-up. The successful reconstruction rate for scapular, parascapular, and chimeric flaps was 100%.

Conclusions: The CSA flap treated a wide variety of indications demonstrating the flap's attributes: large vessel caliber, wide arc of rotation, reliable vascular anatomy, minimal donor site morbidity, and ability to incorporate bone and muscle. Our cases also highlight important pediatric considerations such as vascular mismatch and limited scapular bone stock. We recommend selection of the parascapular over the scapular flap with reconstruction of larger, complex defects given its ability to be harvested with a large skin paddle.

Background: Both reconstructive outcomes and donor site deformities should be considered in forehead expander selection for resurfacing facial skin defects. Cranial bone deformity as well as bone resorption always cannot be completely normalized after tissue expander extraction. This study aimed to investigate the correlation between the degree of frontal deformity, the reconstruction outcomes, and the expander size.

Patients and methods: Cases of forehead tissue expansion performed from 2011 to 2020 with 50/80 mL sized expanders and 150/200 mL expanders were retrospectively reviewed and separated into 2 groups. Demographic and clinical data were collected. Two plastic surgeons (Y.Z. and L.L.) who were not involved in the operation process compared the patient's preoperative photos with their final follow-up photos. The Fisher exact, 2-sample t tests, and the Wilcoxon rank-sum test were performed in this study.

Results: Ultimately, 51 patients were included in the 50/80ml sized expander group, and 28 patients were included in the 150/200 mL expander group. Demographic data were collected and had no statistically significant differences between the 2 groups. There was no statistical difference in the frontal deformation rate between the 2 groups. The degree of frontal deformation was significantly different, and a large expander could significantly reduce the frontal deformation degree ( P < 0.05) and acquire a higher evaluation of the whole reconstruction outcomes ( P = 0.007).

Conclusions: The large-sized (150/200 mL) expander sited on the forehead was shown to have a slighter postoperative forehead change and better reconstruction effect. It is advisable to choose expanders with relatively larger sizes in the application of the forehead expand flap.

Background: The racial diversity portrayed in plastic and reconstructive surgery (PRS) media is an important indicator of an inclusive environment for potential patients. To evaluate the degree to which PRS websites demonstrate inclusivity, we assessed the racial composition of both patients and plastic surgeons depicted on the most visited academic and private PRS websites to determine the extent to which racial diversity is represented.

Methods: A cross-sectional study was conducted in September 2023. The 10 most visited websites in each state were identified. Sociodemographic characteristics including race and sex of patients and plastic surgeons, as well as the type of practice, were collected. Race was classified according to individuals' Fitzpatrick Phototypes into White and non-White. Differences in patient and surgeon representation were compared to the 2020 US Census and the 2020 ASPS demographics using χ 2 tests. Subgroup analyses were conducted to identify differences by type of practice and region.

Results: We analyzed a total of 2,752 patients from 462 websites belonging to 930 plastic surgeons. PRS websites were predominantly from private practices (93%). Regarding patient representation, 92.6% were female, 7.4% were male, 87.6% were White, and 12.4% were non-White. The surgeon population on the studied webpages was 75.1% male, 92.1% White, and 7.8% non-White. Statistically significant differences were found in the patient population when compared to the 2020 national ( P < 0.001) and regional ( P < 0.001) US Census demographics and the 2020 ASPS Statistics Report ( P < 0.001). Although minority representation was significantly higher on academic websites compared to private practice (22.9% vs. 12.1%; P = 0.007), both were significantly lower than the percentage of minority patients undergoing PRS.

Conclusions: This study illuminates racial disparities in the representation of racial groups among patients and plastic surgeons in the most frequented plastic surgery websites. Moreover, it underscores the imperative to bolster racial diversity within the digital content of both private and academic PRS websites. Greater racial representation can foster a more inclusive perception of the plastic surgery field, which may potentially broaden access to care and enrich the professional landscape.

Background: Distal phalangeal and interphalangeal joint injuries are common, and confer a significant burden to the individual, healthcare system and society. Operative intervention (when required) may involve retrograde trans-articular Kirschner wire (K-wire) fixation. Safe wire passage through the center of the distal interphalangeal joint (DIPJ) and associated phalanges is key in maintaining alignment and reducing complications. There is little evidence to guide optimal wire entry point and passage.

Purpose: The aim of this study was to determine soft tissue and radiographic landmarks to guide optimal trans-articular k-wire placement at the DIPJ.

Methods: A retrospective cohort study was conducted at a single institute, with 100 uninjured lateral phalangeal radiographs with a clear sagittal projection assessed by 3 independent assessors. Each assessor drew a line of ideal insertion, traversing the isthmus of the middle and distal phalanges, and the midline of the DIPJ, with soft tissue and bony parameters identified.

Results: The mean distance from the dorsal aspect of the nail plate to the line of ideal insertion was 3.86 mm, with a disparity between sexes noted. The distance from the dorsum of the soft tissue to the line of ideal insertion was expressed as a proportion of the total soft tissue diameter-the line of ideal insertion traversed approximately 40% of total width at the DIPJ and DIPJ soft tissue crease.

Discussion: The results suggest that a simple 'rule of fours' can be utilized to allow expedient and optimal passage. The entry point should be midline in the coronal plane, approximately 4 mm volar to the dorsal surface of the nail plate and aimed at a point 40% volar to the dorsal aspect of the soft tissue envelope at the level of the DIPJ crease. These guidelines are easily replicable and conveyable; additionally, they can guide insertion in the absence of fluoroscopy.

Background: Hand form and function play a vital role in daily living, and even minor trauma can significantly impair quality of life. There is a current paucity of data regarding hand burn patient and injury characteristics, particularly in urban areas in the United States. As the field of hand surgery expands, a demographic understanding of patients with severe injury potentially requiring surgical management is imperative. The aim of this study was to define the epidemiological characteristics of burn injuries involving the hand that were admitted to a large New York City burn center.

Methods: A retrospective review of the electronic health record was conducted to identify all patients admitted to our burn center with burn injury involving the hand from August 2020 to December 2023. Patient demographics, injury etiology and characteristics, and hospital course details were recorded and analyzed.

Results: We identified 96 admitted patients with 140 hand burn injuries, with a patient median age of 38 years. Female patients presented to the hospital significantly later after initial injury than male patients and were more likely to suffer from flame-related injury. The median length of stay for initial admission was 17.5 days, with longer length of stay associated with hypertension comorbidity. Patients experiencing homelessness demonstrated higher rates of psychiatric disorder, substance use, and current smoking. Length of follow-up was positively correlated with estimated household income. Compared to the general city population, the patient cohort was made up of a lower percentage of "White alone" and "Asian alone" race categories and higher percentage of persons experiencing homelessness.

Conclusions: We report the clinical and social characteristics of burn patients with hand involvement admitted to a large urban burn center. Hand burn injuries have distinct risk factors and morbidity implications, and consideration for higher-risk groups is imperative for optimal prevention, acute management, and long-term support.

Background: Feminizing top surgery, or mammaplasty augmentation, has multiple variables that surgeons can adjust to work synergistically with patient anatomy including plane of implant placement, pocket size, and inframammary fold (IMF) location. In the gender diverse population receiving this procedure to reduce symptoms of gender dysphoria, surgeons should be aware of differing anatomy and surgical approaches for feminizing top surgery.

Methods: A retrospective chart review was conducted using our institution's electronic health record between December 2019 and May 2023 with a minimum follow up period of 12 months. Inclusion criteria included transgender women, nonbinary patients, and all patients who did not identify as cis-gender women and who underwent feminizing top surgery. Demographic data including age, race, ethnicity, and gender were collected. Complication rates were recorded for hematoma, infection, seroma, wound dehiscence, hypertrophic scar, minor contour abnormalities, implant asymmetry, and revision surgery.

Results: Our surgeons' subfascial approach, which uses 2 equations to calculate dissection pocket dimensions and determine placement of pocket and incision based on desired implant base diameter and projection, was performed on 140 gender-diverse patients and resulted in a hematoma rate of 4.29%, an infection rate of 2.86%, and a seroma rate of 1.42% with good cosmetic outcomes, as evidenced by our low rates of minor contour abnormalities (5.71%) and implant asymmetry (1.43%). Only 5 patients (3.57%) required revision surgery.

Conclusions: Bilateral breast augmentation with round implants in a subfascial plane using a concealed IMF incision following equations to determine the dissection pocket size and new IMF position and incision position is a reproducible technique that results in good aesthetic outcomes and minimizes complications.

Background: Use of intraoperative computer-assisted navigation (iCAN) has been well-established in otolaryngology and neurosurgery; however, its use in surgical management of facial fractures is yet to be reported on a large scale. This study aimed to review the existing literature to determine the outcomes, limitations, risks, and benefits of iCAN use in facial fracture management.

Methods: A systematic review of iCAN use in craniomaxillofacial fracture surgery was performed by 2 authors in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on 3 databases, PubMed, Cochrane Library, and Embase, using the search terms "navigation," "intraoperative," and "brain lab" in combination with "facial fractures" or "facial reconstruction." Study type, demographics, fracture characteristics, surgery characteristics, iCAN devices, intraoperative fracture fixation accuracy, postoperative outcomes, complications, navigation limitations, and risks and benefits were analyzed.

Results: There were 909 studies identified in the initial search, of which 42 were chosen for final use. iCAN use was most commonly reported in unilateral (57.1%) and complex (50%) facial fracture cases. Surgical accuracy ranged from 0.7 to 4 mm and postoperative discrepancy ranged from 0.05 to 8 mm. Benefits included improved intraoperative surgical accuracy (95.2%), improved postoperative surgical discrepancy (52.4%), and decreased total surgical time (35.7%). Limitations reported with iCAN device use included operative technical difficulties (23.8%) and persistent systematic errors during device registration (21.4%). None of the studies discussed cost analysis or risks compared to conventional fixation methods.

Conclusions: Advancements in and increasing familiarity with iCAN technology have preliminarily shown favorable surgical outcomes in facial fracture fixation, which include improved operative accuracy and discrepancy and decreased surgical time.

Background: Repair of the abdominal fascia at the time of abdominoplasty is a valuable method to improve the contour of the abdomen. However, this maneuver has been linked to an increased risk of venous thromboembolism (VTE). This review was undertaken to evaluate the evidence.

Methods: An electronic literature review was conducted to identify publications on the subject of abdominal fascial repair during abdominoplasty and VTE risk. Key words included abdominoplasty, fascial plication, intra-abdominal pressure, and venous thrombosis.

Results: Three large clinical studies were identified. One retrospective study using matched comparisons reported nearly identical VTE rates for patients treated with and without abdominal fascial plication (1.5% vs 1.7%). Another retrospective study reported significantly more VTEs (2.3%) in abdominoplasty patients undergoing fascial repair compared with panniculectomy patients who did not undergo fascial plication (0.36%). The author also recommended a modified Caprini score, adding fascial repair as a risk factor. Only 1 prospective study reported a large number of consecutive plastic surgery outpatients evaluated with Doppler ultrasound. This group included 188 abdominoplasty patients, all treated with fascial plication and without muscle paralysis. Only 1 VTE was diagnosed on the day after abdominoplasty (0.5%).

Discussion: Retrospective studies are susceptible to confounders and confirmation bias. Caprini scores do not have a scientific foundation. Chemoprophylaxis increases the risk of bleeding without reducing the risk of VTE.

Conclusions: The best available evidence supports performing a fascial repair. An effective and safe alternative to Caprini scores and chemoprophylaxis is avoidance of muscle paralysis and early detection of VTEs using ultrasound screening.

Background: Abdominal wall reconstruction (AWR) is a treatment option for structural defects of the abdominal wall. The most frequently cited publications related to AWR have not been quantitatively or qualitatively assessed. This bibliometric analysis characterizes and assesses the most frequently cited AWR publications, to identify trends, gaps, and guide future efforts for the international research community.

Methods: The 100 most cited publications in AWR were identified on Web of Science, across all available journal years (from May 1964 to December 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence-Based Medicine levels of evidence (LOE) of each study were also assessed.

Results: The 100 most cited publications in AWR were cited by a total of 9674 publications. Citations per publication ranged from 43 to 414 (mean 96.7 ± 52.48). Most publications were LOE 3 (n = 60), representative of the large number of retrospective cohort studies. The number of publications for LOE 5, 4, 3, 2, and 1 was 21, 2, 60, 2, and 12, respectively. The main content focus was surgical technique in 44 publications followed by outcomes in 38 publications. Patient-reported outcome measures were used in 3 publications, and no publications reported validated esthetic outcome measures.

Conclusions: Overall, 3 was the LOE for most frequently cited AWR publications, with more publications below LOE 3 than above LOE 3. Validated outcome measures and patient-reported outcome measures were infrequently incorporated in the studies evaluated.