搜索结果：Seminars in plastic surgery

Artificial intelligence (AI) and machine learning (ML) technologies are transforming reconstructive microsurgery through data-driven approaches that enhance precision and standardize clinical workflows. These innovations address long-standing challenges, including subjective assessment methodologies, operator-dependent decision-making, and inconsistent monitoring protocols across the perioperative continuum. Contemporary applications demonstrate remarkable capabilities in preoperative risk stratification, with ML algorithms achieving high predictive accuracy for complications such as flap loss and donor site morbidity. CNNs have revolutionized perforator localization, with advanced models achieving Dice coefficients of 91.87% in anatomical structure detection from CT angiography. Intraoperative assistance through AI-enhanced robotic platforms provides submillimeter precision and tremor filtration, particularly beneficial in supermicrosurgery involving vessels measuring 0.3- to 0.8-mm diameter. Postoperative monitoring represents a particularly promising domain, where AI-based image analysis systems achieve 98.4% accuracy in classifying flap perfusion status and detecting early vascular compromise. Automated platforms may enable continuous surveillance with reduced clinical workload while maintaining superior consistency compared with traditional subjective methods. Patient communication benefits from AI-driven visual simulation and large language models (LLMs) that generate personalized educational materials, enhancing informed consent processes. Critical implementation challenges include data quality, algorithmic bias, and inherent dataset imbalance, where complications represent rare but clinically crucial events. Future advancement requires explainable AI systems, multi-institutional collaboration, and comprehensive regulatory frameworks. When thoughtfully integrated, AI serves as a powerful augmentation tool that elevates microsurgical precision and outcomes while preserving the fundamental importance of surgical expertise and clinical judgment.

Lymphedema has traditionally been viewed as a localized disorder characterized by regional fluid accumulation and tissue swelling. However, emerging evidence challenges this paradigm, revealing that lower limb lymphedema induces significant systemic pathophysiological changes. This review synthesizes recent findings demonstrating that lymphedema triggers widespread oxidative stress, chronic inflammation, dysregulated gene expression in circulating monocytes, and contralateral limb muscle edema-even in the absence of clinical lymphedema in the unaffected limb. Furthermore, we examine the potential association between lymphedema and increased Alzheimer's disease (AD) risk through shared mechanisms involving oxidative stress and neuroinflammation. Lymphaticovenous anastomosis (LVA), a minimally invasive supermicrosurgical technique, has emerged as an effective intervention that not only reduces limb volume but also reverses many of these systemic alterations. Studies utilizing advanced imaging techniques, including magnetic resonance volumetry and diffusion tensor imaging, combined with comprehensive biomarker analyses, have documented post-LVA improvements in antioxidant capacity, reduction in oxidative stress markers, normalization of inflammatory cytokines, recovery of dysregulated gene expression patterns, and decreased muscle edema bilaterally. Additionally, preliminary data suggest LVA may reduce AD biomarkers, including tau protein and amyloid-beta levels, while increasing neuroprotective factors such as brain-derived neurotrophic factor. These findings fundamentally redefine lymphedema as a systemic condition with far-reaching metabolic and potentially neurodegenerative consequences, positioning LVA as a therapeutic intervention with benefits extending beyond local symptom control to systemic disease modification.

Lower-extremity nerve reconstruction, most commonly involving the lumbosacral plexus (LSP), sciatic nerve (including common peroneal and posterior tibial nerves), and the femoral nerve, remains one of the most demanding challenges in peripheral nerve surgery, with outcomes primarily determined by injury mechanism, anatomical level, and timing of reconstruction. Over the past 35 years (1987-2022), the Peripheral Nerve Team at the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan treated 3 patients with LSP injuries, 6 patients with femoral nerve injuries, and 35 patients with sciatic nerve injuries using different surgical techniques, including neurolysis, direct nerve repair, cable grafting, nerve transfer, vascularized nerve grafting, and adjunctive procedures such as functioning free muscle transplantation (FFMT) and tendon transfer. The corresponding surgeons included D.C-C.C., T.N-J.C., and J.C-Y.L. as the senior authors in this paper. Meaningful recovery clustered with early timing and tension-free nerve coaptation; in selected long-segment or scarred beds, well-constructed multistranded or vascularized grafts achieved useful function, yet the superiority of vascularized constructs was not uniform across cases. Delayed exploration and isolated neurolysis generally yielded limited improvement. Although functional recovery declined with increasing graft length, satisfactory results were observed in selected extensive reconstructions using multiple grafts appropriately and, when indicated, FFMT. These observations highlight the complexity of lower-extremity nerve reconstruction and the need for careful surgical planning and long-term follow-up to optimize outcomes after nerve reconstruction in the lower extremities.

Free tissue transfer has become the gold standard for reconstructing complex head and neck defects, achieving success rates exceeding 95% in experienced centers. Despite these advances, vascular compromise remains the leading cause of flap failure, most commonly occurring within the first 24 to 72 hours postoperatively. Early detection of arterial or venous thrombosis is therefore critical to maximize flap salvage and optimize patient outcomes. Conventional clinical monitoring, including assessing flap color, temperature, capillary refill, tissue turgor, and bleeding on pinprick, remains the cornerstone of postoperative surveillance due to its simplicity, noninvasiveness, and universal applicability. However, its accuracy depends heavily on clinical experience and is limited in cases such as buried or intraoral flaps where direct observation is restricted. To improve diagnostic sensitivity and objectivity, various adjunctive technologies have been introduced, including handheld and implantable Doppler ultrasonography, laser Doppler flowmetry, thermography, and near-infrared (indocyanine green) angiography. These modalities can provide quantitative or continuous perfusion data, facilitating earlier recognition of vascular compromise. Nonetheless, each technique carries limitations related to cost, invasiveness, and susceptibility to artifacts, and no single method has proven superior to clinical evaluation alone. Effective monitoring requires structured protocols, multidisciplinary coordination, and prompt surgical re-exploration when perfusion deficits are suspected. Integration of multimodal strategies tailored to flap type and patients offer the best balance between sensitivity and practicality. This paper aims to standardize monitoring algorithms, evaluate cost-effectiveness, and explore novel technologies such as artificial intelligence-assisted systems to further enhance early detection, improve flap salvage rates, and optimize reconstructive outcomes.

The orthoplastic approach to extremity reconstruction represents a paradigm shift in the management of complex limb injuries, integrating orthopedic and plastic surgery principles to optimize functional and aesthetic outcomes. This review examines the evolution of this approach, its hierarchical framework for addressing tissue defects, and the essential technical competencies required for successful implementation. Key components of orthoplastic extremity reconstruction are illustrated through current evidence focusing on soft tissue management with high free flap success rates, vascularized bone transfers utilizing fibula, iliac crest, and medial femoral condyle flaps, and advanced techniques for amputee reconstruction including regenerative peripheral nerve interfaces and targeted muscle reinnervation. Meta-analysis evidence demonstrates that the synergistic collaboration between orthopedic and plastic surgery specialties achieves significant reduction in infection rates, improved limb salvage rates, and decreased health care costs through reduced hospital stay and revision surgeries. This article emphasizes the importance of multidisciplinary collaboration, comprehensive preoperative planning, and technical expertise in achieving optimal results in complex extremity reconstruction while addressing recent advances in reconstructive microsurgery protocols.

Microsurgical free tissue transfer has become the standard for complex head and neck reconstruction. One of the most feared scenarios is the so-called "vessel-depleted neck" (VDN), in which prior surgery, irradiation, or multiple reconstructions are thought to preclude suitable recipient vessels. However, definitions of VDN remain inconsistent, and many patients are not truly "depleted." A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed and Web of Science were searched (1980-2025) using terms related to "vessel-depleted neck," "recipient vessels," and "head and neck reconstruction." Eligible studies included case series, cohorts, and case reports describing reconstructive strategies following prior neck dissection, irradiation, or multiple reconstructions. Fifty-six reports met the inclusion criteria. In addition, we contextualized these findings with the Chang Gung Memorial Hospital (CGMH) experience of >10,000 microvascular reconstructions. The review identified a spectrum of recipient vessel options and technical innovations. Common second-tier choices included the transverse cervical vessels, superficial temporal system, and contralateral cervical vessels. Less common strategies involved cephalic vein transposition, internal mammary vessels, thoracoacromial, or subclavian system. Techniques to overcome pedicle length constraints included vein grafts, Corlett loops, vascular bridge flaps (VBFs), and in situ pedicle lengthening. Local and regional flaps, such as the pectoralis major (PM) and supraclavicular flaps, provided salvage options when free flaps were not feasible. At CGMH, even after multiple reconstructions, ipsilateral vessels (transverse cervical, superior thyroid, facial artery) remained usable in most patients, with contralateral or vein graft use required in fewer than 20%. The concept of a "VDN" is often overstated and may serve as a psychological barrier to optimal reconstruction. Most patients retain viable recipient vessels, and free flaps remain achievable with careful planning and surgical expertise. We advocate reframing these cases as "vessel challenged necks," emphasizing technical demands rather than depletion, to improve decision-making and outcomes.

Lymphedema is a chronic, debilitating condition characterized by impaired lymphatic drainage, tissue swelling, and fibrosis. Conventional treatments mainly focus on finding symptomatic solutions, rarely using tissue-engineered approaches of regenerative therapies. Tissue engineering approaches have emerged as promising strategies to restore lymphatic function by integrating molecular cues, cellular components, and biomaterial scaffolds. This review summarizes recent advances and challenges in lymphatic regeneration, focusing on (1) molecular regulation, including growth factors and chemical modulators; (2) cellular components with primary lymphatic endothelial cells (LECs), stem cells, fibroblasts, and macrophages; (3) biomaterials and engineering strategies, highlighting hydrogels, 3D scaffolds, and controlled delivery systems; and (4) preclinical and translational studies in different animal models. Finally, current and emerging strategies in clinical and plastic reconstructive surgery are discussed. Challenges such as cell survival, molecular specificity, and functional integration are highlighted, along with future directions for combinatorial approaches. This review provides a current framework for advancing tissue-engineered solutions and challenges for lymphedema and promoting translational success.

Compression neuropathies comprise a diverse spectrum of peripheral nerve disorders resulting from chronic mechanical insult within anatomically constrained fibro-osseous or myofascial tunnels. Although common entities such as carpal and cubital tunnel syndromes are well established, several less frequently addressed compression syndromes remain diagnostically and therapeutically controversial. This chapter reviews contemporary advances in the pathophysiology, diagnostic evaluation, and surgical management of select complex compression neuropathies, with specific focus on thoracic outlet syndrome (TOS), groin and pelvic neuropathies, and common peroneal nerve entrapment. TOS continues to generate debate regarding diagnostic criteria and operative indications; however, in carefully selected patients, supraclavicular decompression with first rib and scalene resection yields high rates of durable symptom relief. Neuropathic groin and pelvic pain syndromes-including ilioinguinal, genitofemoral, and pudendal neuropathies-require rigorous clinical assessment, exclusion of proximal pathology, and confirmatory diagnostic nerve blocks prior to intervention. Contemporary reconstructive strategies, including targeted muscle reinnervation and regenerative peripheral nerve interfaces, have expanded surgical options for refractory neuromas. Common peroneal nerve compression, including subclinical presentations preceding overt foot drop, underscores the importance of early recognition and timely decompression to mitigate irreversible axonal degeneration. Detailed patient selection, early and anatomically comprehensive decompression, and adherence to principles of peripheral nerve biology are essential to optimize functional outcomes in modern peripheral nerve surgery.

Combat ballistic injuries to the face present complex challenges for military medical personnel, often involving multiple traumas that require immediate intervention to preserve life and function. This review explores the mechanisms of ballistic trauma, highlighting the unique injury patterns seen in modern conflicts like those in Iraq, Afghanistan, Syria, and Ukraine. Advances in protective gear have altered injury profiles, increasing the incidence of head, neck, and facial injuries. Early evacuation and definitive care are critical, though prolonged field care settings may require adapted surgical techniques due to resource constraints. The goals of surgical management focus on restoring form and function, with treatment strategies influenced by the severity of injuries and available medical resources. This article also discusses the long-term complications, such as infections, nerve injuries, and posttraumatic stress disorder, emphasizing the need for a multidisciplinary approach. The evolving nature of combat injuries underscores the importance of continuous surgical innovation and timely intervention to improve outcomes for soldiers suffering from ballistic facial trauma.

Oncologic ablation in the head and neck region frequently results in the sacrifice of peripheral nerves and their target organs. This inevitably can compromise facial expression, ocular protection, oral competence, speech, swallowing, and cutaneous sensation, causing functional and aesthetic impairment. The application of principles from peripheral nerve surgery in these instances provides the opportunity to minimize these morbidities. For facial reanimation, targeted nerve transfers, cross-facial nerve grafting, and nuances for functioning free muscle transplantation are delineated to restore smile and spontaneous blink function. Dynamic tongue reconstruction is described for hypoglossal nerve innervated muscle flaps combined with conventional fasciocutaneous flaps for improved swallow function, bulk, and lining. Sensory reconstruction includes interposition and cross-face sural grafts to supraorbital/supratrochlear, infraorbital, lingual, and mental nerves, including corneal and lacrimal gland neurotization as potentially vision-saving procedures.

Endoscopic thoracic sympathectomy, while effective for palmar hyperhidrosis, results in devastating compensatory sweating and autonomic dysfunction affecting >80% of patients. We present our institutional evolution of robotic-assisted sympathetic trunk reconstruction (STR) for post-sympathectomy complications. Our prospective series of 23 patients underwent robotic STR with free nerve grafting (mean follow-up: 2 years). Six-month outcomes demonstrated significant improvement: Chest severity 9.4&#x2009;&#xb1;&#x2009;0.9 to 6.0&#x2009;&#xb1;&#x2009;2.4 ( p &#x2009;<&#x2009;0.001), back severity 9.3&#x2009;&#xb1;&#x2009;0.8 to 6.1&#x2009;&#xb1;&#x2009;2.6 ( p &#x2009;<&#x2009;0.001), with sustained gains at 2 years. To minimize donor site morbidity, we progressively transitioned to free intercostal nerve autografts, followed by vascularized intercostal nerve (vICN) grafting beginning January 2025. Vascularized grafts maintained immediate perfusion, enabling continuous Schwann cell proliferation and accelerated recovery. A propensity score-matched analysis of vICN versus free intercostal grafts achieved 100% technical success with no vascular complications. Six-month vICN recipients demonstrated continuous improvement without temporary worsening observed in controls. Recently, single-port robotic systems substantially reduced postoperative chest wall morbidity. These innovations demonstrate that precisely executed microsurgical technique, enabled by robotic precision and interdisciplinary expertise, offers viable treatment for carefully selected patients with intolerable post-sympathectomy complications.

Vascular anomalies consist of a wide range of diagnoses relating to abnormal vasculature. These lesions can affect a variety of anatomical structures, requiring the expertise of numerous specialists. Over the past few decades, the formation of multidisciplinary vascular anomalies clinics has allowed patients to meet multiple providers within the same clinic visit, leading to improved communication between patients and providers. Furthermore, diagnostic and treatment plans are discussed in multidisciplinary conferences allowing for enhanced diagnostic accuracy and more comprehensive management plans. The purpose of this article is to provide an overview of the multidisciplinary management of vascular anomalies, including descriptions of key team members, multidisciplinary clinics, and benefits and challenges of providing multidisciplinary care.

Without early diagnosis and intervention, brachial plexus birth injuries (BPBIs) can result in permanent upper extremity debilitation. Previously, BPBI was treated by single-specialty surgeons; however, given the complexity of the injury, BPBIs necessitate multidisciplinary team care. Common specialists involved within brachial plexus injury clinics include radiologists, physical medicine and rehabilitation physicians, occupational therapists, nerve surgeons, and shoulder surgeons. Care plans are meticulously designed by all team members, and depending on injury severity and clinical course, patients may undergo treatment including range-of-motion exercises, splinting, botulinum toxin injections, nerve surgery, or shoulder surgery. The objective of this article is to highlight and discuss key providers within BPBI clinics and describe the BPBI experience here at Texas Children's Hospital.

Deep inferior epigastric perforator (DIEP) flap has become a standard of care in autologous breast reconstruction, offering reliable aesthetic outcomes and minimized donor site morbidity. Despite its advantages, substantial variability in perforator anatomy and intramuscular course presents technical challenges, and detailed knowledge, meticulous preoperative planning, and precise microsurgical techniques are the key to success. Advances in preoperative imaging, particularly computed tomography angiography (CTA), have enhanced perforator selection and flap design, improving operative efficiency and safety. DIEP flap reconstruction is applicable across a wide range of clinical scenarios, including immediate and delayed reconstruction, patients requiring or receiving irradiation, and those with low body mass index (BMI) or prior abdominal surgeries. Emerging innovations, including robotic-assisted flap harvest, image-guided navigation, and sensory neurotization, aim to further reduce donor site morbidity and improve functional and aesthetic outcomes. This review summarizes the anatomical foundations, surgical strategies, perioperative care, postoperative outcomes, and evolving techniques in effective DIEP flap breast reconstruction.

The free fibula flap has transformed mandibular reconstruction, evolving from simply for bone defect reconstruction to including immediate dental rehabilitation and from a staged to a simultaneous procedure. This paper chronicles the progression from delayed implant placement to the modern-day single-stage "jaw in a day" (JIAD) procedure, enabled by advances in CAD/CAM (computer aided design/computer aided manufacturing) technology, virtual surgical planning, and digital prosthesis. Pioneering work contributing to fibula-jaw reconstruction and rehabilitation from Chang Gung Memorial Hospital is also highlighted. The anatomical study of the fibula osteoseptocutaneous flap makes its clinical application also possible when simultaneous skin/mucosal coverage is needed. The early and vast experience of secondary and primary dental implantation has allowed us to develop and advocate for the "jaw during admission" after several initial attempts at JIAD reconstruction. In this approach, the dental prosthesis is delayed to the day before discharge from the hospital after confirming the success of the transferred fibula. It not only avoids an unnecessary step in complicated fibula flap transfer procedures, but in case of failure, it also mitigates logistical and technical challenges of prosthesis conversion, while maintaining the benefits of immediate dental implant restoration. This review also examines current evidence surrounding implant success, complications like osteoradionecrosis, and outcomes in malignant versus benign cases.

Body contouring procedures have become increasingly common to meet the growing demand for aesthetic surgery, particularly in the context of bariatrics. Massive weight loss (MWL) patients are complex and often require extensive management of comorbidities, malnutrition status, physical debilitation, and psychological sequelae. Patient optimization prior to body contouring surgery in addition to strict postoperative maintenance are crucial to achieve favorable and sustainable outcomes. Surgical candidates should be screened thoroughly, and in the MWL patient population specifically, multidisciplinary care is needed for proper evaluation and support. Notable specialists that routinely contribute in MWL and body contouring patient care include plastic surgeons, bariatric surgeons, primary care physicians, dieticians, endocrinologists, mental health providers, and physical therapists. This article details essential roles within the multidisciplinary approach to body contouring surgery and MWL patients and reviews critical pre-, intra-, and postoperative aspects of care.

Multidisciplinary clinics (MDC) are a mainstay in medical and surgical management of complex diseases in the adult and pediatric populations. Due to increasingly complicated multimodal treatment plans and difficulties coordinating care, MDCs emerged to simplify care administration for patients and providers while optimizing outcomes. Multidisciplinary care is delivered in a variety of ways; however, the most common setups are concurrent and sequential clinics. With proper personnel and infrastructure organization, MDCs are beneficial to patients, providers, and institutions both clinically and financially. This introductory article will describe a brief history of MDCs, different models of operation, and known clinical and financial gains.

Microsurgical toe-to-hand transfer has revolutionized the reconstruction of missing thumbs and fingers, either from trauma or congenital etiologies, since its introduction in the late 1960s. The subsequent developments by global pioneers have made it a reliable surgical procedure with good functional and aesthetic results, yet acceptable donor site morbidities. This review article aims to highlight some significant concepts, surgical skills, and reconstruction strategies developed at Chang Gung Memorial Hospital over the past four decades, which are pivotal to the current landscape of toe-to-hand transfers practice. Avoiding unnecessary shortening of bone, joint, neurovascular bundle, tendon, and pulley in the amputation stump at the initial emergency management, provision of adequate coverage, and several other factors are essential for good results. Retrograde dissection of the vascular pedicle facilitates a quick and safe toe harvest for less experienced surgeons. Developing a modified great toe and lesser toe wrap-around flap, trimmed great toe, and combined second and third toes allows for optimal thumb and finger reconstruction even for challenging metacarpal hands. Both preservation of the proximal 1&#x2009;cm of proximal phalanx in the remaining great toe and inclusion of a smaller skin flap from the foot, especially in combined second and third toes transfer for primary wound closure, can ensure minimal donor site morbidities.

Total laryngopharyngectomy for advanced hypopharyngeal and laryngeal cancers results in complex defects that compromise both swallowing and phonation. Restoration of these functions is critical for quality of life, yet reconstructive options present unique challenges. This study evaluates the outcomes of free ileocolon flaps and J-designed anterolateral thigh (J-ALT) flaps for simultaneous reconstruction of the pharyngoesophagus and voice conduit in patients undergoing total laryngopharyngectomy. Between 1988 and 2025, 231 patients underwent ileocolon flap reconstruction, and from 2014 to 2025, 124 patients underwent J-ALT flap reconstruction. Technical refinements, including plication of the ileocecal valve and precise flap inset, were implemented to optimize swallowing and phonation. In the ileocolon cohort, overall flap survival was 97%, with low rates of fistula and anastomotic complications; 78% of patients achieved good swallowing function, and 64% demonstrated satisfactory speech outcomes. The J-ALT flap demonstrated comparable swallowing outcomes, with 97% of patients resuming oral intake and 50% achieving fluent speech through the neophonation tube. Both techniques avoided the complications associated with tracheoesophageal prostheses, including obstruction, infection, and mechanical failure. These findings highlight that meticulous surgical planning and a multidisciplinary approach can achieve reliable long-term restoration of alimentary and vocal function. Both ileocolon and J-ALT flaps represent viable reconstructive options for patients with a favorable life expectancy.