Journal of plastic, reconstructive & aesthetic surgery : JPRAS最新文献

Background: The pectoralis major myocutaneous pedicled (PMMP) flap is still considered by many a workhorse flap in head and neck (H&N) reconstruction, despite free flap surgery advancing. The authors aimed to examine this claim and associated myths and controversies by analyzing literature trends and revealing the role of the PMMP flap in a well-established microsurgery center.

Methods: The senior author's reconstructive H&N practice between 1995 and 2022 was reviewed to describe and critically judge primary and secondary PMMP flap decisions to provide invaluable lessons learned and debunk common controversies related to complex H&N reconstruction. A literature review from 1978 to 2022 evaluated PMMP flap articles from plastic surgery and allied H&N specialties, with a deeper analysis on publications from 2010 onward.

Results: In 27 years of practice, the senior author performed 2871 major H&N reconstructions, including 27 PMMP flaps. Both primary (13/27) and secondary (14/27) PMMP flaps decreased over time. Indications shifted from external skin compromise (fistulae/metastases) to complex medical morbidity and high-risk neck status. Neck status was increasingly evaluated based on any previous violation, surgical or irradiative, rather than simply number of remaining vessels. A literature review revealed an ongoingly abundant and primary PMMP flap use, largely by non-plastic surgeons.

Conclusion: The PMMP flap can and should be reserved for complex, high-risk or free flap-exhausted cases. Thus, current indications deserve redefinition. Multidisciplinary collaboration in specialized centers with plastic surgeons is imperative to ensure appropriate reconstructive rational and protect patient outcomes, as changing reconstructive hands and starting anew risks reconstructive regression.

The restoration of nerve function after the injury might be complicated by the development of a disorganized fibrous mass-a neuroma. This results in sensory and/or motor deficits and pain that can be severely debilitating. Surgical excision of the painful neuroma may leave a gap, which can be bridged using autografts or allografts. The main objectives of this study were to obtain 1-year clinical results in patients who underwent excision and reconstruction of a painful neuroma in continuity using decellularized allografts after nerve lesions in the upper extremity. In a prospective cohort study, we evaluated 21 consecutive patients. The patients were evaluated for pain, motor, and sensory function of the hand as well as with patient-reported outcomes. The results showed meaningful sensory recovery in 47% (≥S3), persisting cold intolerance in 48%, disabling hypersensitivity in 48%, and new neuroma formation proximal to or within the allograft in 25% of patients, one year post-operatively. Q-DASH showed 52% of patients with poor results. Overall, 43% of the patients had persisting pain in rest and activity. Measuring muscle strength showed grip strength of 60% and a pinch of 58% of the strength measured in the uninjured hand, which was statistically significant. Even with the excision of a neuroma in continuity and reconstruction with human acellular nerve allograft, limited functional outcome, pain, cold intolerance, and hyperesthesia may persist in the treated patients. There is also the risk of new neuroma formation proximal to or within the allograft.

Background: This study aimed to investigate the risk factors affecting epineurectomy of the facial nerve trunk for facial synkinesis and use them to establish a prediction model to assess the recurrence of post-operative facial synkinesis.

Methods: A total of 68 patients with synkinesis after facial paralysis were enrolled in this study. They were randomized to the training and testing sets. All patients underwent standard surgical procedures and their clinical data were collected and analyzed. The condition of facial synkinesis was evaluated at 12 months after the operation. Univariable and multivariable logistic regression analysis was performed to identify independent risk factors and establish a model and related nomogram to predict the recurrence of post-operative facial synkinesis. Area under receiver operating characteristic curve (AUC) and calibration curves were employed to assess the predictive accuracy of the nomogram.

Results: Multivariate logistic regression analysis indicated that older age and higher preoperative score of synkinesis may be the potential factors for the recurrence of post-operative facial synkinesis at 12 months. The prediction model showed a good discrimination with mean AUC of 5-fold cross-validation of 0.781. The accuracy of the nomogram predicting the recurrence in the testing set reached 78.57%, respectively. Bias-corrected curve revealed a strong consistency between the actual observation and prediction.

Conclusion: The study illustrated that the proposed logistic regression model based on the age and preoperative score of synkinesis of 2 potential factors could be a promising tool to predict the recurrence of facial synkinesis after the surgery.

A necessary component of postoperative care in gender-affirming vaginoplasty is the dilation of the neovaginal canal. Difficulty with dilation can cause patient pain and distress, often decreasing compliance and leading to partial or complete closure of the neovaginal canal. This study sought to evaluate the sociodemographic, operative, and comorbid characteristics that contribute to patient difficulty with neovaginal dilation. A retrospective review of patients undergoing gender-affirming vaginoplasty between June 2019 and July 2023 was carried out. The primary outcome was consistent dilation difficulty reported during the follow-up clinic visits for any reason. Univariate and multivariate analyses were used to compare characteristics and outcomes of each group. Statistical significance was set at p<0.05. In total, 614 patients were included in the study, 506 (82.5%) patients had no dilation difficulty and 108 (17.5%) had dilation difficulty. Medicare insurance status (p=0.007), unemployment (p<0.001), hyperlipidemia (p=0.019), HIV (p<0.001), psychiatric diagnosis besides gender dysphoria (p=0.048), and primary peritoneal vaginoplasty (p=0.019) were associated with postoperative dilation difficulty. Multiple logistic regression revealed higher odds of dilation difficulty in patients who are unemployed (OR 2.740, 95% CI 1.587-4.732, p<0.001), have HIV (OR 2.588, 95% CI 1.290-5.190, p=0.007), have a psychiatric diagnosis besides gender dysphoria (OR 1.606, 95% CI 1.001-2.577, p=0.049), or received a primary peritoneal graft (OR 3.202, 95% CI 1.212-8.460, p=0.019). The risk of postoperative dilation difficulty may be associated with multiple aspects of the care spectrum. Understanding these risks and continued encouragement of dilation is critical to optimizing patient outcomes and dilation success.

Lower limb injuries resulting from sports activities, industrial accidents, and traffic incidents represent a significant global healthcare challenge. These injuries often entail a high risk of complications, especially when fractures are associated with substantial soft tissue damage. Open fractures classified as Gustilo type II or III are particularly susceptible to complications such as fistula and osteomyelitis. Globally, millions of lower limb injuries are reported annually, leading to considerable morbidity and escalating healthcare costs. The standard treatment for shin ulcers with bone exposure involves the debridement of necrotic tissue, followed by coverage of the defect with well-vascularized tissue. Classical flaps are employed in certain cases; however, their applicability, along with techniques such as pedicled muscle flaps from the rectus abdominis or tensor fasciae latae muscles, depends on the extent and location of the injury. Classical flaps are employed in certain cases, but their applicability depends on the extent and location of the injury. Given these limitations, propeller flaps have emerged as highly effective alternatives for microsurgical reconstruction in lower limb recovery. The objective of our study was to delineate the anatomy and demonstrate the utility of propeller flaps based on the perforators of the posterior tibial artery. By providing detailed anatomical insights, we aimed to highlight the strategic advantages of propeller flaps in complex lower limb reconstruction cases.

Machine learning (ML) is a branch of artificial intelligence (AI) that enables computers to learn from data and discern patterns without direct instruction. This review explores cutting-edge developments in microsurgery through the lens of AI applications. By analyzing a wide range of studies, this paper highlights AI's transformative role in enhancing microsurgical techniques and decision-making processes. A systematic literature search was conducted using Ovid MEDLINE, Ovid Embase, Web of Science, and PubMed (2005-2023). Extensive data on ML model function and composition, as well as broader study characteristics, were collected from each study. Study quality was assessed across 7 methodological areas of AI research using an adapted methodological index of nonrandomized studies (MINORS) tool. Seventeen studies met the inclusion criteria. ML was used primarily for prognosis (35%), postoperative assessment (29%), and intraoperative assistance/robotic surgery (24%). Only 2 studies were conducted beyond phase 0 of AI research. Fourteen studies included a training group, but only one of these reported both validation and training sets. ML model performance was assessed most frequently using accuracy, specificity, and sensitivity. Scores for the adapted MINORS criteria ranged from 10 to 14 out of 14, with a median of 12. Through collation of all available preclinical and clinical trials, this review suggests the efficacy of ML for various microsurgical applications. Despite this, widespread adoption of this technology remains scarce, currently limited by methodological flaws of individual studies and structural barriers to disruptive technologies. However, with growing evidence supporting its use, microsurgeons should be receptive to implementing ML-incorporated technologies or may risk falling behind other specialties.

Objective: Autoimmune diseases are systemic conditions that can have negative effects on wound healing. The objective of the present study was to investigate the efficacy of combining bone marrow-derived mesenchymal stem cells (BM-MSCs), acellular dermal matrix (ADM), split-thickness skin graft (STSG), and negative-pressure wound therapy (NPWT) for treating patients with autoimmune diseases and chronic non-healing wounds.

Methods: Thirty-four patients with autoimmune diseases and non-healing chronic wounds of the lower extremities between 2012 and 2023 were included in the study. Among these, 18 patients had Behçet's disease, 8 patients had polyarteritis nodosa, and 8 patients had systemic lupus erythematosus. All patients underwent split-thickness skin grafting in external centers. The wounds were debrided, and BM-MSCs concentrate was injected into the wound base. A suitable ADM was applied to the wound. STSG were adapted onto the ADM. The grafts were closed with NPWT.

Results: Patients were followed-up for an average of 1.2 years. No necrosis was observed at the wound sites of the post-operative patients. During long-term follow-up, no wounds were observed at the same sites.

Conclusion: Although autoimmune diseases fall within the scope of rheumatology, the treatment of chronic non-healing wounds that accompany such diseases requires a multidisciplinary approach. We demonstrated that the combined use of BM-MSCs, ADM, STSG, and NPWT presents an effective approach in the healing of these types of wounds.

Background: Partial extensor tendon lacerations of the hand and forearm are common. There is a lack of evidence to guide their management and it is also unclear at what threshold surgeons would consider repair necessary. This study aimed to identify national surgical management of partial extensor tendon lacerations of the hand and forearm (zones 2-8) and assess surgeons' willingness to randomise in a future trial.

Methods: A 34-item online survey was developed by the steering group and, via a trainee-led collaborative model, was disseminated to plastic and orthopaedic surgeons in the UK. Summary data were calculated for each survey item, and the variations between zones and specialties were explored using linear regression.

Results: 142 complete responses were recorded (response rate 71%). On average, respondents said that 46% tendon division was the maximum they would manage in clinical practice without surgical repair. There was no significant difference in this percentage between zones or surgical specialties. Importantly, the majority (83%) of surgeons would be willing to randomise patients in a clinical trial to repair versus no-repair, within 29%-61% tendon division, demonstrating clinical equipoise.

Conclusions: There is significant variation in UK practice regarding the surgical management of partial extensor tendon lacerations of the hand and forearm and clinical equipoise exists regarding the decision to repair or not. A definitive randomised trial is warranted to identify the optimum management of this common injury.

Introduction: There is growing interest in understanding chest sensory function due to the significant morbidity associated with impaired sensation following nerve injury. While the baseline quantitative sensory and pain thresholds in female and male patients have been studied in various other anatomic areas, there is little knowledge on quantitative sensation at the chest as well as the presence of possible gender differences. Therefore, this study aimed to conduct a comprehensive quantitative sensory analysis to determine if female and male chests feel the same.

Methods: A total of 100 chests in 50 subjects (25 females and 25 males) were evaluated. Quantitative sensory testing (QST) was performed on the nipple areola complex (NAC) and surrounding chest skin and included mechanical detection using Semmes-Weinstein monofilaments, two-point discrimination, vibration detection, pin prick, cold detection, warm detection, heat pain and pressure pain thresholds.

Results: Male chests were significantly more sensitive to mechanical detection, two-point discrimination, vibration, pin prick as well as cold and warm detection at both the NAC and chest as compared to female chests (p<0.05). Females had significantly lower sensory thresholds to heat pain and pressure pain detection at both the NAC and chest as compared to males (p<0.05).

Conclusion: The quantitative sensory functions of female and male chests are significantly different. This knowledge helps to better understand baseline sensory functions at the chest and the awareness of gender differences in this anatomic area.

Chemodenervation with botulinum A toxin and neuromuscular retraining therapy are commonly performed as first-line treatments for postparalytic facial nerve syndrome (PFS). However, their effects are temporary, and side effects typically develop. Currently available selective neurectomy approaches are limited by variations in the anatomy of the peripheral branches of the facial nerve and the ability to reduce perioral synkinesis, but not periocular synkinesis. We devised a novel selective midfacial neurectomy for PFS that considers anatomical characteristics and is effective for both periocular and perioral synkinesis. In our approach, the facial flap was elevated subcutaneously, and facial nerve branches were identified at the anterior margin of the parotid gland. Using intraoperative nerve stimulation, the thin cranial zygomatic branches that innervate the lateral portion of the orbicularis oculi muscle and the buccal branches that innervate the orbicularis oris muscle independently were preserved. The thick caudal zygomatic branch and its communicating branch with the cranial buccal branches, which simultaneously and strongly contract both the periocular and perioral mimetic muscles, especially around the medial upper and lower eyelids, were selectively excised. From March 2021 to September 2022, selective midfacial neurectomy was performed in five patients with House-Brackman (HB) grade III-IV unilateral facial paralysis. With respect to the synkinesis score and palpebral fissure width ratio, statistically significant improvements were observed between the preoperative and 18-month postoperative values. Selective midfacial neurectomy is effective in treating patients with postparalytic facial nerve syndrome.