Annals of Plastic Surgery最新文献

Abstract: Burn injuries often require immediate assistance and specialized care for optimal management and outcomes. The emergence of accessible artificial intelligence technology has just recently started being applied to healthcare decision making and patient education. However, its role in clinical recommendations is still under scrutiny. This study aims to evaluate ChatGPT's outputs and the appropriateness of its responses to commonly asked questions regarding acute burn care when compared to the American Burn Association Guidelines. Twelve commonly asked questions were formulated by a fellowship-trained burn surgeon to address the American Burn Association's recommendations on burn injuries, management, and patient referral. These questions were prompted into ChatGPT, and each response was compared with the aforementioned guidelines, the gold standard for accurate and evidence-based burn care recommendations. Three burn surgeons independently evaluated the appropriateness and comprehensiveness of each ChatGPT response based on the guidelines according to the modified Global Quality Score scale. The average score for ChatGPT-generated responses was 4.56 ± 0.65, indicating the responses were exceptional quality with the most important topics covered and in high concordance with the guidelines. This initial comparison of ChatGPT-generated responses and the American Burn Association guidelines demonstrates that ChatGPT can accurately and comprehensibly describe appropriate treatment and management plans for acute burn injuries. We foresee that ChatGPT may play a role as a complementary tool in medical decision making and patient education, having a profound impact on clinical practice, research, and education.

Background: Hypoxia-inducible factor-1α (HIF-1α), regulated by prolyl hydroxylase, plays a central role in tissue adaptation to ischemia. This study investigates the impact of HIF-1α on angiogenesis in the Choke II zone of multiterritory perforator flaps.

Methods: Ninety male Wistar rats were allocated into 3 groups, with 30 rats in each group: the dimethyloxalylglycine (DMOG) group, the 3-(5-hydroxymethyl-2-furyl)-1-benzylindazole (YC-1) group, and the normal saline (NS) group. All rats underwent multiterritory perforator flap surgeries on their dorsal side. Subsequently, they received intraperitoneal injections of DMOG (40 mg/kg), YC-1 (10 mg/kg), and normal saline on postoperative days 1, 2, and 3, respectively. After treatment, angiogenesis in the Choke II zone of the flap on day 7 was observed through transillumination tests and lead oxide/gelatin x-ray angiography. Histological features were determined using hematoxylin and eosin staining, and the expression of HIF-1α and vascular endothelial growth factor (VEGF) in the Choke II region of the flap was assessed via immunohistochemistry and western blotting.

Results: Compared to the YC-1 and NS groups, the DMOG group exhibited significant angiogenesis, resulting in a denser vascular network in the Choke II zone of the flap. The DMOG group showed significantly higher microvessel density in the Choke II zone than the YC-1 and NS groups (7.10 ± 0.99 vs 24.30 ± 3.65; 14.30 ± 2.40 vs 24.30 ± 3.65, both P<0.05). Additionally, the DMOG group demonstrated higher expression of VEGF and HIF-1α in the flaps than the other groups (P < 0.05).

Conclusions: In summary, HIF-1α enhances the expression of VEGF, promoting angiogenesis in the Choke II zone of the multiterritory perforator flap, thus increasing the survival area.

Background: The lower lip is an important anatomical structure involved in daily activities such as eating, drinking, and speaking, as well as in facial expressions. Lower lip defects should be repaired to preserve lip function without disrupting the aesthetic harmony of the lips within the face. This goal is difficult for plastic surgeons because, for functional and aesthetic repair, it is necessary to replace the mucosa, muscle (especially contractile), and skin tissues present in the lip.

Methods: Subtotal lower lip repair was performed using an innervated depressor anguli oris muscle flap and a desepithelialized reverse superior labial artery flap in seven male patients with a mean age of 63 years. A depressor anguli oris muscle flap was used to repair the orbicularis oris muscle defect. The desepithelialized part of the reverse superior labial artery flap was used for mucosal defect repair, whereas the remaining part was used for skin defect repair. Patients were followed up for an average of 15 months. Patient lips, epithelialization, sensation, and sphincter function were clinically evaluated. Electromyography (EMG) was performed at 6 and 12 months to evaluate the function of the depressor anguli oris muscle flap.

Results: All the reverse superior labial artery flaps survived without any loss. Trapdoor deformity developed in the flaps of two patients. The desepithelialized parts of the flaps were completely epithelialized (covered with mucosa) by approximately 6th week. In the EMG controls of the patients at 6 months, the depressor anguli oris muscle was contractible. Sensation regained in the operated lip during the follow-up period.

Conclusions: The combination of an innervated depressor anguli oris muscle flap and a desepithelialized reverse superior labial artery flap is an important surgical option for the functional and aesthetic repair of subtotal lower lip defects.

Abstract: To minimize confusion in description of the clinical examination of the patient with migraine/headaches and implement peripheral nerve concepts into the surgical approach to treating the patient with migraines, the historical origin of the phrase "trigger point" is explored. The symptoms of migraine/headache are due to stimulation of the cranial/peripheral nerve being interpreted as due to stimulation of the meningeal innervation. Use of the phrase "extraction of trigger points" is discouraged in favor of either neurolysis of a compressed nerve or resection of a neuroma, depending upon the peripheral nerve pathology.

Purpose: The Area Deprivation Index (ADI) is a validated quantifiable measure of neighborhood disadvantage and social determinants of health (SDoH). Higher percentiles in ADI correlate with the most disadvantaged neighborhoods: lower income, lower education, and less access to transportation. Using ADI, we aimed to investigate the impact of SDoH on bilateral breast reduction (BBR) complication rates.

Methods: A retrospective study of BBR patients from 2015 to 2021 was conducted. Patient addresses were matched to ADI percentiles and grouped into most (top 80% ADI) and least disadvantaged. Multivariable regressions were used to compare postoperative treatment between groups and adjust for confounders.

Results: In total, 568 patients were analyzed and 47% were high ADI. Time-to-event analysis revealed a 155% (β = 2.55; CI, 1.87-3.48; P < 0.001) increase in time to presentation for treatment of wound-related complications among higher-deprivation patients compared to their lower-deprivation counterparts. This difference in time to presentation equated to approximately 3 days overall when comparing higher to lower deprivation patients; however, this difference between the groups increased to 12 days when comparing those who experienced wound-related complications beyond day 30.

Conclusions: High deprivation was associated with increased delays to treatment after complications. More research is needed to determine the factors that impact postoperative courses among high ADI patients.

Introduction: Detection of critical colonization is gaining importance in wound management, but its pathophysiology remains unclear. We previously clarified that a dysbiotic wound microbiota differing from skin commensal microbiota may be involved in critical colonization and that such wounds contain fewer Forkhead box protein P3 (FOXP3)-positive cells in the tissue. However, it is not clear whether FOXP3-positive cells contribute to the development of critical colonization. Here, we examined whether inhibition of FOXP3-positive cell could induce critical colonization when the commensal microbiota was present in the wounds.

Methods: Sprague-Dawley rats were administered FK506 or vehicle to inhibit differentiation into FOXP3-positive cells. Full-thickness wounds were made on the dorsal skin and inoculated with bacterial solution (dysbiosis group) or Luria-Bertani medium (commensal group). A bacterial solution was prepared by anaerobically culturing bacteria from the skin of donor rats on an artificial dermis in Luria-Bertani medium for 72 hours. Tissues were collected on day 4 postwounding for histological evaluation.

Results: After microbiota transplantation, excessive inflammation occurred in the FK506 + commensal group. In contrast, wounds with transplanted dysbiotic microbiota showed the same level of neutrophil infiltration, regardless of FK506 administration. Furthermore, the wound area was larger in the FK506 + commensal group than in the vehicle + commensal group on day 4 postwounding ( P = 0.01). This area was also significantly larger in both the vehicle + dysbiosis ( P = 0.01) and FK506 + dysbiosis groups ( P = 0.03) than in the vehicle + commensal group.

Conclusions: This study has shown that dysbiosis may be at least related to developing critical colonization, and the results suggest that FOXP3-positive cells are involved in this process. Our study may contribute to establishing new interventions that prevent critical colonization by correcting wound microbiota.

Background: Tissue expansion is a well-established technique for soft tissue reconstruction in the pediatric population. We present a case series of this technique to create a safe pocket for baclofen pump insertion to minimize risk of complications including pump migration, extrusion, wound dehiscence and infection.

Methods: A case series of 3 pediatric patients undergoing tissue expansion prior to baclofen pump insertion at a single center in Melbourne. The expansion procedure was performed by senior surgeon N Low in all cases, and patients followed up 6 months after expander-pump exchange. The study was conducted over a 4-year period 2019 to 2023.

Results: We suffered 2 minor complications with the tissue expansion process including cellulitis and pump deflation. Neither complication precluded further tissue expansion nor led to premature removal of the expander. All patients proceeded to safely complete expander-pump exchange. One patient suffered a small (6 mL) abdominal seroma associated with pump insertion, which required no intervention. All patients have had a successful outcome 6 months after pump insertion.

Conclusions: We describe a reliable and reproducible approach in creating a safe abdominal wall pocket to better accommodate baclofen pump insertion. Our series has overcome the imbalance between device size and abdominal wall pocket, now offering an alternative approach to achieve the safe delivery of intrathecal baclofen in the pediatric population.

Background: This study aimed to identify patient preferences and outcomes of chest masculinization surgery in patients identifying as nonbinary versus transgender (trans-) males.

Methods: Patients who underwent chest masculinization (2003-2022) were included. Demographics, medical comorbidities, surgical approaches, complications, secondary procedures, and BODY-Q chest module survey responses were compared between cohorts.

Results: Three hundred two patients were included. Thirteen percent identified as nonbinary and 87% as trans-male. The most common surgical approach in both groups was double incision with free nipple-areola graft (63% vs 71%, P = 0.33). Nonbinary patients more frequently opted for double incision without free nipple areola graft compared to trans-male patients (18% vs 2.7%, P < 0.001). Other unique surgical requests of nonbinary patients included nipple areola preservation and small breast mound preservation (5.2%) and balance between losing bulk and achieving a more androgynous appearance (5.3%). The survey response rate was 31% (93/302). Both groups reported improved quality of life postoperatively ( P = 0.16). Three nonbinary patients elected not to keep their nipple-areola complexes ( P = 0.005). Trans-male patients were more likely to report having a male chest as very important for their gender identity (82% vs 95%, P = 0.043). Nonbinary patients were less likely to prefer small nipples (82% vs 95%, P = 0.033) and 18% stated that they preferred no nipples (vs 2.7% trans-male patients, P < 0.001).

Conclusions: Nonbinary patients have distinct surgical preferences regarding nipple-areola complexes. Chest masculinization planning can differ for this group of patients compared to their trans-male counterparts.

Introduction: Wide-awake and office-based hand surgeries are increasingly common. The association of these techniques with postoperative pain and pain control has garnered recent attention. A prior study demonstrated that office-based trigger finger release (TFR) were associated with decreased perioperative opioid prescriptions compared to those performed in the operating room. The current study provides an in-depth analysis of the association between surgical setting and perioperative opioid prescriptions for wide-awake TFR.

Methods: Patients undergoing TFR between 2010 and 2021 were identified in PearlDiver, a national administrative claims database. Exclusion criteria were age <18 years, <6 months of preoperative data, <1 month of postoperative data, bilateral TFR, and concomitant hand surgery. To identify wide-awake cases, patients with procedural codes for general anesthesia, monitored anesthesia care, sedation and regional blocks were excluded. Patients were stratified by surgical setting (office or operating room), then matched based on age, sex, Elixhauser Comorbidity Index score, and geographic region. Patients with prior opioid prescriptions, opioid dependence, opioid abuse, substance use disorder, chronic back/neck pain, generalized anxiety, and major depression were identified. Perioperative opioid prescriptions (those filled within 7 days before or 30 days after surgery) were characterized.

Results: There were 16,604 matched wide-awake TFR patients in each cohort. In the cohort of office-based patients, 4,993 (30%) filled a prescription for perioperative opioids, in contrast to 8,763 (53%) patients who underwent surgery in the operating room. This disparity was statistically significant in both univariate and multivariate analyses. Univariate analysis indicated that office-based surgeries were linked to lower morphine milligram equivalents (MME) in opioid prescriptions than those performed in operating rooms (median of 140 vs 150, respectively). However, multivariate analysis demonstrated that opioid prescriptions for office-based surgeries were actually associated with greater MME.

Conclusions: Patients undergoing office-based TFR were less likely to fill perioperative opioid prescriptions but were prescribed opioids with greater MME. In wide-awake TFR, it appears that a disparity may exist in patient and provider beliefs about postoperative pain control. Future patient- and provider-level investigations may produce insights into perceptions of postoperative pain and pain control, which may be useful for reducing opioid prescriptions across surgical settings.