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[This corrects the article DOI: 10.1016/j.jpra.2025.02.013.].
To describe the Open Book Abdominoplasty, a form of vertical abdominoplasty used in selected massive weight loss patients, and to evaluate clinical outcomes. A retrospective review was performed of all consecutive patients who underwent the Open Book Abdominoplasty between June 2021 and December 2024. All patients with a BMI under 35 were included in this study, with patient demographics, operative details, outcomes, and complications analysed. 53 patients were identified for this study, with 27 patients having a BMI below and 30, and 26 with a BMI between 30 and 34.9. The mean patient age was 40.5 years. The mean preoperative weight loss was 43.5 kg, with 39 patients achieving weight loss following bariatric surgery. Fourteen patients underwent Open Book Abdominoplasty alone, while 39 underwent combined procedures, including breast surgery (n=27), bra lipectomy (n=14), and belt lipectomy (n=7). The mean resection weight was 4.3 kg. The overall complication rate was 9.4%, including seroma (3.8%), haematoma (1.9%), and wound complications with delayed healing (3.8%). The Open Book Abdominoplasty is a vertical abdominoplasty technique incorporating a vertical scar for massive weight loss patients. It allows management of significant abdominal wall laxity and, when combined with adjunctive procedures, facilitates treatment of multidirectional circumferential torso excess with reproducible outcomes in appropriately selected patients.
The aging process of the face is characterized by dermal thinning, loss of elasticity, and wrinkle formation. Injection of autologous micrografts containing fibroblasts (Am-FBs) has emerged as a promising regenerative technique. This trial aims to assess the efficacy and safety of Am-FBs for facial rejuvenation. A randomized, open-label, controlled study was conducted. Forty patients presenting with mild to moderate dermal thinning, reduced elasticity, and wrinkles were divided into two groups: a study group (SG; n = 20) that received Am-FBs treatment and a control group (CG; n = 20) treated with a hyaluronic acid (HA)-based skin booster. Both groups received treatment at baseline (T0), at one month (T1), and at three months (T2). Clinical outcomes were evaluated at T1, T2, T3 (6 months), and T4 (12 months) through patient and physician evaluations, the Wrinkle Severity Rating Scale (WSRS), and objective skin elasticity metrics. In vitro evaluation of the Am-FBs and immunophenotypic characterization of the nucleated cell population contained in the Am-FBs suspension was performed. At T4, the SG showed significantly greater improvements in wrinkle depth, skin elasticity, and WSRS score than the CG (p < 0.01). The physician's evaluation showed scores ranging from 9 to 4 (p = 0.049), whereas patient self-assessments ranged from 9 to 5 (p = 0.039). Patient satisfaction was higher in the SG. The in vitro analysis documented 2.780.750 nucleated cells/ml in Am-FBs with a viability of 89.61% and immunophenotype: CD34%0.2, CD45%0.2, CD44%98.7, CD200%80.0, Cytokeratin 15%99.4. Am-FBs significantly improve signs of facial aging and present a safe option for skin rejuvenation.
Lower leg soft-tissue injuries in older adults are common. These injuries can be complicated by frailty, comorbidities, and impaired healing; however, there is limited high-quality evidence to guide optimal management. This study aimed to establish a consensus-driven research agenda for lower leg soft-tissue injuries in older adults using a modified Delphi approach. An international three-round modified Delphi study was conducted, with clinicians involved in the management of lower leg soft-tissue invited to participate. In Round 1, participants submitted open-text responses identifying challenges in assessment and management. These were thematically grouped and converted into research questions. In Rounds 2 and 3, these were rated by participants and ranked using predefined consensus criteria. In Round 1137 participants generated 498 research items, which were refined into 30 research questions across 6 domains. In Round 2142 respondents rated the importance of each question using a Likert scale, with a predefined consensus threshold, resulting in 8 questions meeting the criteria. In Round 3168 respondents ranked these questions to establish research priorities. The final consensus highlighted research priorities relating to decision making between operative and non-operative management, comparative effects on wound healing and mortality, influence of comorbidities, prevention of operative complications, the role of standardised assessment and care pathways, impact of mobility and nutrition and optimal dressing selection. The priorities identified highlight critical evidence gaps and provide a framework to inform future studies and the development of care pathways for this vulnerable patient population.
Gender-affirming mastectomy (GAM) most commonly uses the double-incision technique, producing prominent transverse chest scars. Although effective, these scars are highly visible and may influence postoperative aesthetic satisfaction. Incision orientation is typically determined by the surgeon, yet little is known about which patterns patients find favorable. This study evaluated patient preferences for double incision orientations to inform preoperative discussions. A cross-sectional survey was distributed to individuals with a history of or considering GAM. Participants ranked connected and non-connected incision patterns from most to least aesthetically pleasing. Rankings were converted to weighted preference scores using the Borda count method. The Friedman test, with post hoc Wilcoxon signed-rank tests and Bonferroni correction, assessed preference differences. 104 responses were analyzed. Participants were primarily 20-29 (49%) or 30-39 years old (28%), identified as transgender men (66%) or non-binary (31%), and mostly underwent GAM (85%). Friedman testing demonstrated significant differences among incision types (p < 0.001). Curved incisions were most strongly preferred across connected and non-connected designs (all p < 0.001). In non-connected designs, curved incisions received the highest weighted score (460), ranked first by 66% of participants, followed by angular incisions (345). In connected designs, curved incisions again ranked highest (451; 65% first-choice), followed by inverted V incisions (298). Large V and inverse-diagonal patterns were least favored. Patients considering double-incision GAM show varied scar orientation preferences, with curved incisions following the natural pectoralis contour most favored. Discussing scar orientation may support more informed preoperative discussions and shared decision-making when multiple surgical options are feasible.
Autologous fat transfer has gained recognition as total breast reconstruction. Application remains constrained by unpredictable fat graft survival. Donor site selection may influence fat survival, but evidence remains inconsistent and consensus is lacking. This systematic review evaluated the impact of donor site selection on fat graft survival following autologous fat transfer to the breast. MEDLINE, Cochrane Library, Embase, and Scopus were searched up to October 27, 2025. Eligible studies included randomized controlled trials and cohort studies reporting donor site and graft survival. Risk of bias was assessed using ROBINS-I V2. Meta-analyses were conducted using a random-effects model. Seven studies comprising 291 patients were included. Fat was harvested from the abdomen (n=211) or thighs (n=80). No study specifically addressed total breast reconstruction. Pooled mean graft survival was 56.04% (95% CI, 41.57-70.51; I2 = 99.8%) at 12 months postoperatively for the abdomen and 34.13% (95% CI, 30.51-37.76; I2 = 15.2%) at 6 months postoperatively for the thighs. All studies had a serious or critical risk of bias. Although fat graft survival in autologous fat transfer to the breast appears higher when fat is harvested from the abdomen compared to the thighs, these findings should be interpreted with caution. Due to low-quality evidence, time bias and substantial study heterogeneity, no donor site can be recommended based on fat graft survival alone. High-quality, standardized research is needed to clarify the role of donor site in graft survival as such evidence could guide surgical decision-making and improve outcomes in total breast reconstruction.
Pseudomonas aeruginosa (PA) is isolated in up to 12% of post-operative head and neck cancer patients, capable of surgical site tissue invasion triggering acute inflammation, thrombus formation, and localized microcirculatory collapse. This may result in flap failure and delay post-operative radiotherapy due to extended hospital stays. This report reviews literature on acetic acid washouts as adjunctive treatment for post-surgical PA infection and presents a single-centre case series. A systematic review protocol was registered with PROSPERO, and a comprehensive literature search on acetic acid use in PA infection was conducted. A retrospective single-centre review of head and neck patients undergoing ablative and reconstructive surgery with microvascular free tissue transfer (2020-2023) was performed. Patients with clinical and biochemical evidence of PA infection received 2-3 daily bedside washouts with 0.05% acetic acid for 7-14 days, alongside intravenous antibiotics. Six patients with post-operative PA infection were identified. Acetic acid washouts were administered for 1-2 weeks alongside IV antibiotics based on susceptibility testing. Four patients required return to theatre (mean days post-op=20.5; range=5-44). Post-operative inpatient stays ranged from 9 to 38 days. No flap failures or metal-work removals occurred. Our literature search found no comparable studies. Acetic acid is an easily available, non-toxic, inexpensive topical agent, with bedside washout courses costing £28-£84 per patient. This modest expense is outweighed by the substantial health and psychological benefits of avoiding flap failure. Its low side effect profile supports its use in managing PA-infected surgical sites post-operatively in head and neck cases.
Facial palsy, characterized by the partial or complete paralysis of facial muscles, poses significant challenges to individuals' quality of life due to its functional and psychological impacts. Botulinum toxin (botulinum toxin) injections have emerged as a promising therapeutic option for managing facial palsy, but the extent of their efficacy across various etiologies and the duration of treatment effects warrant further investigation. This study aims to systematically assess the efficacy of botulinum toxin injections in treating facial palsy, including subjective assessments, long-term follow-up, and evaluation of adverse effects. A systematic review following the PRISMA Guidelines was conducted by searching four major databases: PubMed, Cochrane, Scopus, and Embase. A total of 394 randomized controlled trials (RCTs) published between 2013 and 2024 were initially identified for screening. After applying the inclusion and exclusion criteria, 20 studies were selected for detailed analysis in this review. The analysis revealed a significant improvement in facial symmetry, reduction in spasticity, and enhancement of functional outcomes following botulinum toxin injections for facial palsy. Subjective assessments indicated patient satisfaction, with sustained treatment effects observed during long-term follow-up. Adverse effects were generally mild and transient. Botulinum toxin injections demonstrate promising efficacy in treating facial palsy, offering improvements in facial symmetry and functional outcomes. Long-term follow-up confirms sustained treatment effects, while adverse effects remain manageable. This study underscores the potential of botulinum toxin therapy as a valuable intervention for individuals with facial palsy.
The application of silicone sheets to surgical wounds is currently recommended for hypertrophic scar and keloid prophylaxis after closure of surgical incisions. The use of other types of tapes that differ in cost and biomechanical properties has been reported, although a formal synthesis on this topic within recent years has yet to be undertaken. MEDLINE, Embase and Cochrane were comprehensively searched between January 2000 - December 2025, following the PRISMA guidelines. Included studies evaluated cosmetic outcomes of adult patients (≥18 years) undergoing surgical wound taping following primary wound closure. Randomised controlled trials, comparative cohort studies, and case series (n≥5) were eligible. In the 14 included studies, microporous tapes and Steri-Strips were most popular, encompassing 217 and 159 patients respectively. Cosmetic outcomes were assessed at a mean of 5.13 months (range 21 days to 12 months), using heterogeneous tools including SCAR-Q, Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale, and Visual Analogue Scales. The application of tapes after primary closure showed significant improvements in scar cosmesis compared to patients without any interventions (n=75), with some evidence suggesting that more inexpensive paper tapes produce clinically similar results to gold-standard silicone sheets. Surgical wound taping using adhesives other than silicone sheets appears to be an effective strategy for improving scar cosmesis. Further randomised controlled trials studies using a consistently layered primary closure methods and directly comparing different types of tapes including silicone sheets using longer follow up and standardised reporting outcomes are needed.
A precise understanding of perforator anatomy and the corresponding cutaneous perfusion is essential for the design of perforator flaps in reconstructive surgery. Although large-animal models such as the sheep more closely reproduce human vascular dimensions than rodents, data integrating systematic anatomical mapping with functional perfusion assessment in this model are scarce. A systematic review (PRISMA 2020) was conducted in PubMed, Cochrane Central and Scopus to identify ovine studies investigating perforator anatomy and/or vascular injection techniques. Methodological quality was assessed with the MINORS tool. In parallel, an anatomical study was performed on seven adult ewes (Ovis aries). Five vessels were dissected on each side (10 vessels per animal, 70 perforators in total): the deep circumflex iliac (DCI), medial tarsal (MT), cranial tibial (CT), superior epigastric (SE) and thoracodorsal (TD). Perforator coordinates were recorded using a standardized orthogonal reference system based on reproducible anatomical landmarks. Pedicle length and vessel diameter were measured. A reproducible India-ink injection protocol was used to map the cutaneous territory perfused by each pedicle, quantified by digital planimetry (ImageJ). The systematic review yielded eight heterogeneous studies, none of which combined perforator mapping with India-ink-based perfusion assessment in a sheep model (mean MINORS score 11.25 ± 3.01). The anatomical study identified five reproducible dominant pedicles with consistent spatial organization. Mean pedicle lengths ranged from 7.25 ± 1.57 cm (SE) to 17.43 ± 2.23 cm (TD). Mean perfused cutaneous areas ranged from 188 ± 36 cm² (CT) to 650 ± 84 cm² (DCI). This study provides the first combined anatomical and functional characterization of cutaneous perforators in the ovine model. The standardized mapping framework, quantitative vascular measurements and reproducible India-ink perfusion protocol provide a reproducible experimental framework for experimental research in perforator flap surgery and microsurgical training.
Interest in shoulder aesthetics has increased, with emphasis on clavicular definition and balanced shoulder contour. Minimally invasive approaches combining hyaluronic acid fillers and botulinum toxin type A (BoNT-A, Letibo, Hugel, Korea) have been proposed to address both structural and muscular components. This technical note describes three patients who underwent combined acromial and clavicular filler injections with BoNT-A administered to the upper trapezius and deltoid regions for shoulder contour refinement. Filler volume was individualized according to baseline shoulder slope, clavicular/acromial projection deficiency, soft-tissue thickness, and the degree of asymmetry, with total volumes of 10, 12, and 15 cc. BoNT-A was administered as 25 units distributed across five anatomically defined injection points. Outcomes were assessed by standardized clinical photography, clinical follow-up, patient-reported satisfaction, and adverse-event grading using the Common Terminology Criteria for Adverse Events framework. All three patients demonstrated visible, qualitative improvement in shoulder contour, including enhanced clavicular definition and reduced trapezius prominence. Patient-reported satisfaction was favorable in all cases. No major complications were observed. Minor adverse events, including transient swelling and discomfort, were classified as mild CTCAE grade 1 events and resolved without intervention. This three-case technical note illustrates a feasible anatomy-guided multimodal approach for shoulder contour refinement. Because of the very small sample size, lack of a control group, and predominantly qualitative outcome assessment, these observations should not be interpreted as evidence of efficacy, safety, or generalizability. Larger controlled studies with standardized morphometric measurements, validated patient-reported outcome instruments, and longer follow-up are required.
We report a 63-year-old female with Factor V Leiden deficiency who underwent a left delayed DIEP flap reconstruction with contralateral symmetrising breast reduction following mastectomy. Hypercoagulable disorders are theorised to increase flap failure risk. Current evidence and operative guidance are limited. A focused review of the literature is provided.
Peripheral nerve injury (PNI) represents a challenging frontier for the many surgical specialties dealing with these injuries. Improved surgical techniques and understanding have resulted in improvements in patient care, but a mastery of the processes of nerve regeneration and repair have proved elusive. This review intends to outline the changes at the neuromuscular junction in response to denervation injury. By reviewing the current literature, we aim to solidify the understanding of these morphological changes and identify future areas of research need. A literature search of PubMed, Embase and Web of Science including studies up to 22nd December 2023 was carried out. Search terms related to the motor endplate or neuromuscular junction, nerve degeneration, peripheral nerve injury and nerve regeneration. Three researchers independently performed screening of potentially relevant studies, using Covidence (Melbourne, Australia), a review workflow platform facilitating blinded reviewing. Results are reported in accordance with the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. We identified 3595 records in the initial search, with no additional articles identified through backward and forward citation tracking. 350 full-text reports were assessed for eligibility. Ultimately, 118 studies were included for data extraction. The mechanisms of degeneration and regeneration at the NMJ summarized within provide multiple opportunities for ongoing research. Terminal Schwann cells and the constituents of the post synaptic apparatus may be able to be induced to survive for longer, or to be replenished to levels facilitating functional recovery from greater periods of denervation.
Atrophic acne scars result from impaired dermal repair following inflammation of the pilosebaceous unit, leading to collagen degradation, dermal atrophy, and tethering by fibrotic strands. Conventional subcision mechanically releases these adhesions but provides limited biologic stimulation for dermal remodeling. Carbon dioxide (CO₂) gas subcision has emerged as a hybrid mechanical-biologic modality that integrates fibrotic release with CO₂ -induced vasodilation, microcirculatory enhancement, and fibroblast activation. To describe the clinical use and short-term outcomes of CO₂ gas subcision for atrophic acne scars and explore its potential as a minimally invasive hybrid treatment. CO₂ device (Trifill Pro, South Korea) and PDLLA (Juvelook, VAIM Inc., South Korea) was used in the study. A temperature-regulated medical-grade CO₂ system delivered controlled intradermal gas through a 30-gauge needle. Short CO₂ bursts were administered into the deep dermal or upper subcutaneous plane to detach fibrotic bands while inducing hypercapnia-associated biologic responses. Five patients with atrophic acne scars underwent a single session. Follow-up at weeks 2 and 4 included standardized photography, clinical assessment of scar depth and contour, and patient-reported satisfaction using a 0-10 Visual Analogue Scale (VAS). Five patients completed follow-up at 4 weeks. All patients demonstrated qualitative improvement in scar depth and contour on clinical assessment. Mean patient satisfaction score (VAS) was high (range 7-9). No serious adverse events were observed. Mild transient erythema and edema resolved spontaneously within hours. Due to the small sample size and short follow-up, results are descriptive rather than statistically powered. CO₂ gas subcision appears to be a feasible and well-tolerated minimally invasive technique combining mechanical fibrotic release with biologic stimulation. This pilot case series suggests short-term improvement in atrophic acne scars; however, larger controlled studies with longer follow-up are required to confirm efficacy and durability. VBlinded manuscript without author contact information.
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Poland Syndrome (PS) is a rare congenital condition characterized by unilateral pectoralis major hypoplasia or aplasia, often with associated anterior axillary fold deficiency. Conventional reconstructive options carry inherent limitations including donor-site morbidity and unpredictable volume retention. This report describes the first use of an Achilles tendon allograft to reconstruct the anterior axillary fold in a PS patient with prior silicone implant placement. A 48-year-old male presented with persistent anterior axillary fold deficiency following prior left pectoralis major reconstruction with a silicone implant. Reconstruction was performed using an Achilles tendon allograft secured to the proximal humerus via suture anchors and to the implant capsule through a tendon-osseous repair technique adapted from pectoralis major rupture surgery. At four-year follow-up, the patient maintained full shoulder range of motion, durable anterior axillary fold contour, and satisfactory cosmetic outcome, with no graft failure, implant displacement, or animation deformity. Achilles tendon allograft implantation offers a novel, less invasive reconstructive option for anterior axillary fold restoration in PS, avoiding donor-site morbidity while providing durable structural support.
Intramuscular fat grafting has emerged as a transformative technique in aesthetic surgery, particularly within modern body contouring procedures where high-definition contouring and selective volume enhancement are desired. While subcutaneous fat grafting remains a foundational approach, intramuscular injection has been suggested to provide superior definition, projection, and dynamic contouring in selected anatomical regions. Nevertheless, its clinical adoption remains controversial due to ongoing concerns regarding safety, variable fat retention, and inconsistent reporting of complications. A structured literature search was conducted in PubMed, ScienceDirect, and the Cochrane Library using database-specific combinations of intramuscular- and fat grafting-related terms, yielding 495 reports. Ultimately, 45 studies met the inclusion criteria and were retrieved. Analysis focused on safety, fat retention, and clinical outcomes. The included studies suggested favorable aesthetic outcomes and generally positive reported satisfaction across selected facial, truncal, and extremity applications, although outcome reporting was heterogeneous and often non-standardized. While animal models present conflicting retention data, clinical series have described acceptable volume persistence in selected settings. Safety appeared to be strongly region-dependent. While intramuscular gluteal injection remains associated with a prohibitive embolic risk, non-gluteal ultrasound-guided applications reported low rates of major complications in the reviewed literature, although the available evidence remains limited. In conclusion, this review summarizes reported intramuscular fat grafting techniques and synthesizes the available evidence on outcomes and region-specific safety considerations. Future studies must focus on comparing this approach to subcutaneous grafting in larger cohorts.
Reduction mammaplasty is a common procedure to relieve symptoms of macromastia. Amid the ongoing opioid crisis, improving postoperative pain control with judicious opioid prescribing practices has become a clinical priority. Liposomal bupivacaine (LB; Exparel) is a long-acting local anesthetic that may reduce opioid requirements, though evidence supporting its use in breast reduction is limited. This study evaluated the efficacy of LB in reducing postoperative pain following reduction mammaplasty. In this prospective, single-blind, breast-split controlled trial, 32 adult female patients undergoing bilateral reduction mammaplasty were enrolled at a single academic center after IRB approval. Each breast received standard bupivacaine (SB; 0.25% bupivacaine hydrochloride); one side was randomly assigned to receive additional LB. Pain scores were recorded using the Numerical Pain Rating Scale (0-10) twice daily on postoperative days (POD) 1 through 3. Pain scores between sides were analyzed using paired t-tests and Wilcoxon signed-rank tests. The average patient age was 45.4 years (SD 14.4), with a mean BMI of 29.5 kg/m² (SD 4.3). No patients were lost to follow-up. Pain scores were lower on the LB side during POD1 and POD2. The greatest difference was noted on POD1 AM, with a mean reduction of -0.8 and median difference of -1 (p = 0.012). By POD3, pain scores equalized between sides. No adverse events or complications were observed. LB provided a modest reduction in pain scores during the first two postoperative days compared to standard bupivacaine. A more robust, adequately powered study is necessary to confirm the findings.
The demand for secondary rhytidectomies is increasing. These procedures are technically more demanding than primary surgery due to postsurgical anatomical changes, presenting unique challenges and risks. The objective of this systematic review is to define these challenges, describe common surgical principles, and summarize the reported outcomes and complications of secondary rhytidectomies. A literature search was conducted on PubMed and Scopus using particular keywords. Inclusion criteria included randomized controlled trials, observational studies, comparative studies, case series and case reports that reported the surgical outcomes of secondary rhytidectomies. Fourteen articles were included in this systematic review, encompassing 737 patients. Presentation was approximately 9-12 years after primary surgery. The most consistent intraoperative finding was altered anatomy, including a thinner, more delicate superficial musculoaponeurotic system (SMAS), fibrosis, and scarred tissue planes. Reported complication rates in cohort studies ranged from 2.0 % to 21.1 %. The most common complications were hematoma and temporary facial nerve injury, with rates of the latter reaching as high as 11.9 % in some series. Other reported adverse events included seroma, minor skin slough, and delayed healing. A secondary rhytidectomy presents distinct intraoperative challenges stemming from altered anatomy. Despite this increased complexity, the existing literature suggests that overall complication rates are comparable to those of primary facelifts.
Sickle cell trait (SCT) is considered a benign carrier state. Though not associated with vaso-occlusive crises of sickle cell disease (SCD), physiological stress like hypoxia, hypothermia, and sympathetic activation experienced during surgery can lead to sickling in patients with SCT. Some reports suggest that perioperative sickling may lead to thrombosis or flap loss. In the context of microsurgery, SCT is assumed to pose less risk than SCD due to lower hemoglobin S (HbS) levels. This study aims to characterize microsurgical outcomes in patients with SCT. We identified a series of patients with confirmed SCT who underwent microsurgical free flap reconstruction at one institution. Patient demographics, flap type, perioperative factors, postoperative complications, and overall flap survival were analyzed. Six free flaps were identified in five patients with sickle cell trait, including 4 DIEP flaps, 1 ALT flap, and 1 RFFF. All flaps survived with an average follow-up of 9.5 months. Four of six flaps (67%) experienced postoperative complications, including seroma (n = 1), donor site hematoma (n = 2), and wound dehiscence (n = 1). One patient developed venous thrombosis on postoperative day 1 requiring re-anastomosis. All but one maintained normothermia and adequate oxygenation. Preoperative hemoglobin averaged 11.1 g/dL, decreasing to 9.2 g/dL postoperatively, without transfusion. Despite concern for sickling events, this series of patients with SCT appear to tolerate free flap reconstruction. Even with transient intraoperative hypoxia and hypothermia, flap viability was preserved. Larger studies are needed to define microsurgical risk in SCT patients, particularly in relation to HbS levels and comorbidities.