Annals of Plastic Surgery最新文献

Background: Although the indications for the dangle protocol following lower extremity free flap reconstruction (LEFFR) are well established, significant heterogeneity in the postoperative day (POD) of protocol initiation is observed in clinical practice. This study aims to evaluate the outcomes associated with different initiation times of the dangle protocol following LEFFR.

Methods: A retrospective chart review included adult patients who underwent LEFFR at a level 1 trauma center from January 2016 to December 2022. Patients were grouped according to initiation of extremity dangling: early (POD 4-6) versus late (POD 7-8). The primary outcome was flap failure. Secondary outcomes were postoperative and dangle-related complications, including rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, wound dehiscence, infection, and pulmonary embolism.

Results: A total of 103 patients (mean age, 43.5 ± 14.5 years) were included: 46 in the early group and 57 in the late group. No significant difference in flap failure was observed between groups (4.3% vs 1.8%, P = 0.585). The early group displayed a significant reduction in average hospital LOS (21.5 vs 25 days, P = 0.010). The rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, infection, and pulmonary embolism did not differ significantly between groups.

Conclusion: Our results suggest that early initiation of the dangle protocol may decrease hospital LOS without adversely affecting flap outcomes. Future prospective studies are needed to provide additional evidence to determine the optimal timing of dangle protocol initiation.

Background: Traction neurectomy (TN) remains the standard of care for digital nerve management in partial and ray digital amputations but is associated with both neuroma formation and chronic postoperative pain. The purpose of this study is to evaluate if digital nerve coaptation (DNC) is associated with lower postoperative pain and complication rates compared to standard TN. We hypothesize that patients undergoing digital amputations with DNC will demonstrate lower postoperative complications, reduced rates of persistent pain, and fewer reoperations for nerve-related pain.

Materials and methods: A retrospective cohort study was conducted, analyzing 95 patients who underwent partial or ray amputation at a single institution from 2019 to 2024. Patients were stratified by nerve management technique: DNC (n = 26) vs TN (n = 69). Primary outcomes included postoperative pain scores and complication rates including neuroma formation, infection, wound dehiscence, persistent pain, and functional stiffness. Pain scores were assessed using the Neuropathic Pain Scale (NPS, 0-100) and a numerical pain rating scale (NPRS, 0-10). Of the 95 patients, 48 (TN = 33, DNC = 15) were successfully contacted for postoperative pain assessment. Statistical comparisons were made using independent t tests, Mann-Whitney U tests, and chi-square analyses, with significance set at P < 0.05.

Results: Patients with a digit amputation that underwent DNC experienced a lower percentage of complications compared to traction neurectomy (26.9% vs 55.1%, P = 0.030). Furthermore, although not statistically significant, patients undergoing DNC reported lower average NPS (36.1 vs 43.8, P = 0.263) and NPRS (3.79 vs 4.20, P = 0.590) scores compared to neurectomy alone. This trend of decreased pain scores reported by patients who received DNC was true regardless of whether the amputation was due to acute injury or other causes. Similarly, patients described reduced pain at all amputation levels except the middle phalanx.

Conclusions: These data indicate a positive observable outcome when comparing patients' postoperative pain and rate of complications with DNC vs TN at the time of amputation. Though a larger sample size is needed to solidify these results, these findings do suggest that DNC is a potentially superior alternative for nerve management in digital amputations, with the potential to improve long-term pain control and patient outcomes.

Background: Conventional facelift surgery may fail to adequately address submandibular gland ptosis (SMGP), prompting recommendations for partial gland resection. Alternatively, the extended SMAS technique involves a more extensive SMAS-platysma dissection, providing lower facial and neck rejuvenation while preserving the submandibular glands. This study aims to quantify the effect of the extended SMAS technique on SMGP.

Methods: This retrospective cohort study analyzed 53 patients who underwent extended SMAS facelift surgery over a 10-year period in the senior author's practice. Photographic analysis was used to quantify SMGP correction and cervicomental angle (CMA) improvement.

Results: All patients were available at a mean follow-up of 8.4 months (range: 1-34 months). Mean SMGP decreased from 8.9 mm preoperatively (range: 0-23 mm) to 0.1 mm postoperatively (range: 0-3.9 mm), with an average improvement of 8.01 mm (P < 0.001). The mean CMA improved from 152° (range: 100-180°) to 121° (range: 92-156°), with a mean change of 30.8° (P < 0.001). Two patients (3.8%) were dissatisfied, and 3 (5.7%) required office revisions.

Conclusion: The extended SMAS facelift technique effectively controls SMGP, nearly eliminating submandibular gland visibility on postoperative photographic analysis while enhancing neck angularity. This improvement may result from the thorough release of the cervical and parotid retaining ligaments as well as the platysma-auricular ligament. This level of SMAS-platysma flap mobilization may have a more effective sling-like effect on the contents of the digastric triangle, potentially obviating the need for submandibular gland resection.

Background: Lower trapezius myocutaneous flap (LTMF) is widely used for reconstructing head and neck defects. However, a single LTMF, even after pre-transfer tissue expansion, is often insufficient to cover defects involving the bilateral neck and chest wall. This study presents our experience with the use of bilateral pre-expanded LTMFs for repairing extensive cervicothoracic defects.

Methods: A retrospective study was conducted of patients who underwent bilateral pre-expanded LTMF reconstruction between March 2013 and August 2024. Patient demographics, defect features, flap characteristics, and surgical outcome were recorded to assess the efficacy and safety of the procedure.

Results: Ten patients underwent reconstruction of bilateral pre-expanded LTMF reconstruction. The median age was 18 years (range, 5-41 years). The median defect size was 222.5 cm2 on the left (range, 85-390 cm2) and 246 cm2 on the right (range, 80-490 cm2). Tissue expansion lasted 3.5-9.5 months. The median flap size was 420 cm2 on the left (range, 150-660 cm2) and 477 cm2 on the right (range, 260-645 cm2). Fourteen flaps were transferred through subcutaneous tunnels, while 6 were transferred through an open wound between donor and recipient sites in a propeller fashion. The donor sites were closed primarily in all patients. Complete flap survival was achieved in 9 patients, while 1 patient experienced flap tip necrosis.

Conclusions: Bilateral pre-expanded LTMFs represent a reliable reconstructive option for cervicothoracic defects, providing satisfactory functional and aesthetic outcomes.

Background: This study evaluates the postoperative functional and quality-of-life outcomes associated with using the free noninnervated latissimus dorsi muscle flap in combination with transversus abdominis release (TAR) and retrorectus mesh for massive ventral hernia repair (VHR).

Methods: Eighteen patients who underwent VHR were reviewed. Patients were contacted at least 2 years postoperatively and assessed using standardized patient-reported outcome measures (PROMs), including visual analog scale (VAS) for pain, Short-Form Health Survey (SF-12), Hernia-Related Quality-of-Life Survey (HerQLes), and Carolinas Comfort Scale (CCS). Data were analyzed using t tests and linear regression models.

Results: Comorbidities included diabetes (27.8%), chronic obstructive pulmonary disease (5.6%), smoking (5.6%), and immunosuppression (16.7%). The mean clinic follow-up was 8.9 months, with no flap failures or hernia recurrences. Medical complications occurred in 3 patients, and 5 patients (27.8%) experienced 8 surgical complications. Two patients died of unrelated causes. Of 16 survivors, 8 (50%) completed phone surveys at a mean follow-up of 36.8 months. Increasing age was positively correlated with Physical Component Summary-12 (PCS-12; 0.70, P < 0.05) and HerQLes scores (1.94, P < 0.05) but negatively with CCS scores (-2.40, P < 0.05). Larger abdominal wall defects were associated with lower PCS-12 (-2.31, P < 0.05) and HerQLes scores (-6.40, P < 0.05), whereas CCS scores increased with defect size (8.20, P < 0.05). Higher body mass index (BMI) was linked to lower Mental Component Summary-12 (MCS-12; -1.60, P < 0.05).

Conclusions: Free LD flap is effective for repair of massive ventral hernias. Age positively impacted quality-of-life scores, whereas higher BMI and larger defects negatively influenced outcomes.

Methods: A retrospective chart review of 2500 patients having undergone bilateral reduction mammoplasty at 5 institutions from 2010 to 2019 was performed to record pedicle selection, patient demographics, comorbidities, body mass index, patient measurements to determine patient selection for different pedicle techniques, and clinical outcomes associated with these techniques.

Results: A total of 1186 patients had inferior pedicle technique, 65 had superior pedicle technique, 807 had superomedial pedicle technique, 148 had free nipple graft, and the remainder were not specified. A total of 1899 reduction mammaplasties were closed with wise-pattern skin closure, and 189 were circumvertical. Demographics were similar across groups except for higher age ( P < 0.001), BMI ( P < 0.001), and ASA score ( P < 0.001) in the free nipple graft cohort. Superomedial pedicle was used most frequently with lower sternal notch to nipple (SNN) distance, whereas inferior pedicle was performed most frequently with higher SNN distance. Inferior pedicle was most commonly employed for obesity class I-III patients, and free nipple graft was only used for obese patients. On linear regression, superior pedicle reduction (coefficient = -195.2, P = 0.001) was significantly associated with lower resection weights, whereas free nipple grafting was associated with a higher resection weight (coefficient = 752.8, P < 0.001). On univariate analysis, inferior pedicle technique was associated with higher dehiscence, delayed wound healing, and overall complication rates than other techniques ( P < 0.001). Regression analysis demonstrated only age and BMI as independent risk factors for overall complications.

Conclusions: Inferior pedicle reduction remains the most popular pedicle design followed by superomedial pedicle, with wise-pattern closure the most common skin closure type. SNN distance was the most impactful physical exam metric used to choose pedicles. Inferior pedicle and free nipple graft were used most commonly for obese patients, whereas superior reduction was associated with lower resection weights and BMI. Inferior pedicle technique was associated with increased wound healing complications, yet regression analysis implicated only BMI and smoking as statistically significant in this regard. Superomedial technique performed well across different BMI classifications.

Background: Reduction mammaplasty is an effective treatment for symptomatic macromastia but is associated with postoperative complications, such as hematoma, seroma, and infection. Tranexamic acid (TXA) has been shown to reduce blood loss and hematoma formation across surgical specialties, whereas the efficacy of adjunctive topical agents like Arista, a microporous polysaccharide hemostat, remains uncertain in breast surgery. This study evaluates whether combining TXA with Arista confers additional benefit in reducing postoperative complications following reduction mammaplasty.

Methods: A retrospective cohort study was conducted on patients undergoing bilateral reduction mammaplasty at a single institution from January 1, 2020, to April 1, 2025. Patients were divided into 3 groups: those receiving both IV TXA and topical Arista (n = 120), TXA alone (n = 133), and neither agent (control, n = 211). The primary outcome was hematoma incidence, stratified into major (requiring reoperation) and minor. Secondary outcomes included seroma, infection, and delayed wound healing. Statistical analyses included ANOVA and chi-squared tests with significance set at P < 0.05.

Results: A total of 464 patients were included in this study; 120 consecutive breast reduction patients received both Arista and TXA, 133 patients received TXA only, and 211 controls received neither. Combined use of TXA and Arista resulted in the lowest total hematoma rate (2.5%), compared to TXA alone (3.8%) and control (10.0%; P < 0.05). Major hematoma rates were significantly reduced in both treatment groups compared to control but did not differ significantly between TXA (2.3%) and TXA + Arista (1.7%). Infection rates were lowest in the combination group (0.8%) versus TXA alone (6.8%) and control (2.8%; P < 0.05). Delayed wound healing was also reduced with combined treatment (1.7%) compared to TXA alone (16.5%) and control (11.4%; P < 0.0005). Seroma rates and estimated blood loss showed no significant differences across groups.

Conclusions: IV TXA significantly reduces postoperative hematoma rates following reduction mammaplasty, with the addition of Arista providing a modest incremental benefit. Although TXA remains the primary agent for hematoma prophylaxis, Arista may be selectively useful in patients contraindicated for TXA. Further prospective studies are warranted.

Background: Neurogenic thoracic outlet syndrome (nTOS) results from compression of the brachial plexus and can lead to debilitating symptoms such as pain, paresthesia, and motor weakness. This study aimed to compare outcomes between patients undergoing rib-sparing scalenectomy (RSS) and those receiving first rib resection (FRR).

Methods: The TrinetX Collaborative Network was queried for patients who underwent surgical treatment of nTOS. Adult patients with a diagnosis of nTOS who underwent either RSS or FRR between 2013 and 2025 were included. Patients were identified using Current Procedural Terminology codes and matched 1:1 via propensity score matching based on age, sex, and comorbidities. One-year outcomes including postoperative hand pain, hematoma, and reintervention rates were compared using risk differences, odds ratios, and Kaplan-Meier analysis.

Results: There were a total of 5359 patients meeting the inclusion criteria, with 4352 (81.2%) patients in the FRR cohort and 1007 (18.8%) patients in the RSS cohort. After matching, 973 patients were included in each group. The incidence rates of postoperative pain (3.7% FRR vs 3.2% RSS) and hematoma (1.85% vs 2.05%) were similar between groups (P > 0.05). Reintervention rates were also comparable for both FRR (7.8%) and RSS (7.6%). Kaplan-Meier analysis showed no significant difference in 1-year reintervention-free survival (FRR: 89.4% vs RSS: 89.5%, P > 0.05).

Conclusion: In this large, matched cohort, rib-sparing scalenectomy and first rib resection yielded comparable 1-year outcomes for nTOS. Given the similar complication and reintervention rates, RSS may serve as an effective, less invasive alternative to FRR in select patients.

Abstract: Plastic and reconstructive surgeons must stay current on the care of facial palsy. The time constraints of a busy surgical schedule may prevent them from continuing their professional development. Due to limited learning opportunities or a shortage of experts, surgeons in resource-poor or low-income locations may be unable to provide their patients with the latest procedures. Our webinar masterclass series brought together a distinguished faculty of facial palsy surgeons from around the world to address knowledge gaps in facial palsy management. Doctors and other healthcare workers who treat facial palsy may benefit from this. Our educational theories included experiential learning, connectivism, and constructivism to improve the experience.The 3-session series, publicized on social media and surgical networks, attracted 1338 participants from 42 countries. Live sessions with international experts involved active debates on surgical procedures, patient care strategies, and emerging technologies. All interested colleagues received free world-class surgical education from this multinational collaboration. After careful discussion and postwebinar feedback, we concluded the following: (1) Global collaboration enhances surgical knowledge and skills, (2) accessibility for equitable education, (3) real-time debates for evidence-based decision-making, and (4) a multidisciplinary approach for optimal patient outcomes, and (5) it embraces telemedicine to shape patient care and education. This webinar series showcases the innovative power of virtual education for facial palsy surgery, bringing together experts in one place for the first time. Sharing worldwide expertise in reconstructive plastic surgery can enhance surgical standards, improve patient outcomes, and increase access to education. We strongly recommend using this paradigm to improve surgical training availability and creativity in future initiatives.