There are many ways that rehabilitation therapists, including occupational and physical therapists, treat nerve-related pain. Commonly used interventions include neurodynamic treatment, pain neuroscience education, desensitization, exercise, physical agent modalities, mirror box therapy, and Kinesio taping. Despite common practice and anecdotal support, it can be challenging to determine the appropriate intervention for each patient. In this article, each of these treatment approaches is discussed, including indicated pain phenotypes and diagnoses, timing, efficacy, mechanism, contraindications, and limitations.
A mangled upper extremity often involves injury to soft tissue, bone, nerves, and vessels and presents a unique challenge to hand surgeons. The complexity of such injuries requires a multidisciplinary approach to achieve an optimal functional outcome. After obtaining a thorough history and performing a secondary survey, initial management is built upon a strong understanding of the likelihood of limb salvage. Initiation of antibiotics upon presentation, timely and thorough surgical debridement, and early revascularization efforts should be pursued. The surgical team should create a long-term plan involving skeletal stabilization and soft tissue reconstruction along with postoperative rehabilitation and social support. This article reviews current concepts of upper extremity limb salvage and recommendations for surgical management of the mangled extremity.
Aim: Centrocentral anastomosis (CCA) can be applied in the treatment of painful neuromas, by connecting nerve ends or fascicles after neuroma resection, with or without an interposed nerve graft. While this technique was developed directly after the introduction of microsurgical techniques, it is currently not frequently applied in neuroma treatment.
Methods: In this article, the literature on CCA was systematically reviewed, both for clinical and experimental studies. Specific attention was paid to the different surgical techniques, potential applications, and pathophysiologic mechanisms that might explain how CCA can prevent neuroma formation.
Results: A total of 15 articles were found on this subject, 11 clinical and 4 experimental studies. In clinical studies, CCA was mostly applied for neuroma treatment following amputation of fingers and lower limbs. In experimental studies, different combinations of nerve connections and grafts were investigated in the rat sciatic nerve model. Pain reduction in the clinical studies overall was good to excellent, but only in two studies control groups were used. Results from experimental studies showed that the use of an interposed graft was beneficial by entrapment of axons inside the graft.
Conclusion: Although CCA has shown promising results for neuroma treatment, there are only a few case series to date, one cohort and one randomized study, and in the latter two, no graft was used. More research is needed to investigate the outcome of CCA, especially for the option of an interposed nerve graft. This investigation should involve comparisons with alternative techniques, utilization of standardized outcome measures, and, preferably, inclusion of longer follow-up periods.
As rates of oropharyngeal squamous cell cancer (OPSCC) increase and patients survive longer, the number of patients with recurrence will also increase. Surgery is the primary tool for the management of locoregional recurrence when feasible, and transoral robotic surgery (TORS) techniques are a useful adjunct in effectively managing these cases. Careful patient selection, surgical planning, a thoughtful reconstructive plan, and postoperative supportive therapy are crucial for adequate oncologic and functional outcomes.
Aim: Lymphedema is a progressive degenerative disease that can cause severe swelling and recurrent infections. Conservative and surgical treatments, such as lymphaticovenous anastomosis (LVA), are available; however, the optimal timing for LVA after the initiation of complex decongestive therapy (CDT) remains unclear. This study aimed to evaluate the effect of CDT duration prior to LVA on the treatment outcomes of upper extremity lymphedema.
Methods: Fifty patients with stage II upper extremity lymphedema who underwent LVA were retrospectively evaluated. Patients were divided into two groups based on the duration of CDT before LVA: < 6 months (early group) and > 6 months (non-early group). The primary outcome measures were percent excess volume (PEV) and reduction rate 12 months after LVA.
Results: The early group (CDT < 6 months) showed significantly better outcomes than the non-early group
Conclusions: Early indication for LVA (within 6 months of CDT initiation) resulted in better treatment outcomes for stage II upper extremity lymphedema. This study highlights the potential benefits of early surgical intervention for improving the prognosis of lymphedema.
Management of clinically negative necks (cN0) in oral cavity (OCSCC) and oropharyngeal (OPSCC) squamous cell carcinoma (SCC) has evolved over time. Historically, the clinically negative neck has been managed with elective neck dissection (END) or observation, but more recently sentinel lymph node biopsy (SLNB) has emerged as a technique to detect occult metastases. In this review, we will discuss the role of SLNB in early-stage OCSCC and in the management of OPSCC.
Autologous fat grafting is a commonly performed procedure for facial volume augmentation and rejuvenation. While overall complication rates in the literature are low, adverse events related to fat grafting can range from minor to systemic and severe. It is crucial that the surgeon be aware of these potential complications, counsel patients appropriately, and take the necessary steps to mitigate these risks. Local graft site complications include contour irregularity, over- or under-volumization, prolonged edema and ecchymosis, fat necrosis, granuloma formation, and infection. Similar complications can also be seen at the donor sites, including contour irregularity, prolonged induration or erythema, infection, and skin pigmentation changes. Finally, the most severe complications, resulting from fat embolism due to intravascular injection, can result in vision loss or stroke. In this review, risk factors for adverse events, surgical techniques to mitigate risk, and potential treatment options for complications of autologous fat grafting are reviewed.
Cervical spinal cord injury is a life-altering event that profoundly affects an individual’s upper extremity function. Nerve transfer surgeries have been shown to restore more natural movement and fine motor control in this population. At present, there is no consensus on how to evaluate the efficacy of these restorative surgeries. The purpose of this work was to perform a comprehensive review of the existing literature and describe the outcome measures used. We hypothesized that the assessments will be heterogeneous across studies and will incompletely capture the effect of nerve transfers on upper extremity motion in cervical spinal cord injury. A search strategy was designed and a review of multiple databases (Embase.com, Ovid-Medline All, and Scopus) yielded 481 articles; 26 unique studies met inclusion criteria and underwent analysis. Both manual muscle strength testing and video content were presented in the majority of studies. Outcome assessments including myometry, functional outcomes measures (such as the grasp and release test), patient-reported outcomes (including generic, extremity, and disease-specific types), and custom de novo questionnaires were used variably across studies. Future work should focus on standardizing outcomes measures in the field and developing and incorporating kinematic analysis to quantify the intricate, coordinated, and precise movement attained after nerve transfer surgery in the setting of cervical spinal cord injury.
The most common nerve compression in the upper extremity is that of carpal tunnel syndrome. Although generally recognized and treated, as much as a 20% failure rate is reported. Recent publications are indicating that one of the sources of persistent median nerve symptoms may be missed proximal median nerve entrapments, of which the lacertus fibrosus represents a principal cause of compression, and rarely other sites such as the flexor superficialis arch or pronator teres. Compression by the lacertus fibrosus is called lacertus syndrome, and as this is a clinically diagnosed entity, only rarely confirmed using electrodiagnostic or imaging studies, it is frequently overlooked. Clinicians regularly treating patients with carpal tunnel syndrome or patients with signs of median nerve neuropathy should be aware of the lacertus fibrosus as a possible compression site. In this review, we will define lacertus syndrome, describe its clinical manifestations and diagnosis, and demonstrate surgical techniques used to treat it.
Empty nose syndrome (ENS) is an iatrogenic condition that results from traumatic injury, often overresection, of the turbinates during sinonasal surgery. The underlying etiology is not entirely understood but is thought to have multifactorial contributions including alterations in the native nasal airway anatomy, abnormal mucosal and neural healing, and decreased trigeminal sensitivity, among other possibilities and contributors. Patients typically present with an intense fixation on their sensations of nasal obstruction and congestion despite an anatomically patent airway on examination. Because many patients with ENS have been shown to have significant psychiatric comorbidities, multidisciplinary specialist care including psychiatry and pain services is essential. Diagnosis is often difficult due to the variability of presentation and severity of symptoms, but standard assessments exist including the empty nose syndrome 6-item questionnaire (ENS6Q) and cotton test. Patients can be initially managed with conservative measures through humidification, moisturization, and psychiatric testing/referral. Procedural approaches to improve the nasal airway include submucosal implantation of temporary, semi-permanent, and permanent materials. A realistic and empathetic approach to patient communication is necessary in order to help manage patients with ENS, and all plastic surgeons performing septorhinoplasty should be aware of the risk and treatment options of the disease.
Aim: This study isolates septal perforations due to nasal surgery for clinical analysis and their effect on bilateral mucosal flap repair.
Methods: This is a retrospective review of a single surgeon’s 20-year experience with endonasal perforation repair utilizing bilateral mucosal advancement flaps supported with an autologous tissue interposition graft. Patients with a minimum of 4-month postoperative follow-up were included in the study. Comparative analyses of repair failure rates and perforation size of failures between surgical and non-surgical etiologies were performed.
Results: Three hundred ninety-two patients met the criteria for inclusion in the study. The incidence of perforation and prior septal surgery was 40.6%. Overall repair closure in patients with a minimum of 4 months follow-up was 94.8%. Failures were noted in 5.7% of surgical and 4.7% of non-surgical perforation etiologies (P = 0.816). Mean differences in perforation length and height in failed repairs between non-surgical and surgical etiologies
Conclusion: Post-surgical nasal septal perforations can be repaired with a low rate of failure. However, this study found that the size of perforations in failed repairs was significantly smaller in patients with a history of septal surgery, suggesting that prior septal surgery increases the technical difficulty of a bilateral flap perforation repair.
Patients with breast cancer-related lymphedema (BCRL) commonly present with both debilitating upper extremity symptoms and the need for breast reconstruction. By combining autologous flaps with physiologic lymphatic surgery, postmastectomy patients with BCRL can obtain aesthetic breast reconstruction and lymphedema management in a single operation. Lymph node transfer to an area of lymphatic obstruction creates a healthy lymphatic bridge and restores physiologic flow. Early success and improved understanding of vascularized lymph node transfer (VLNT) physiology have led to the rapid development of numerous flap options and modalities. Several studies have shown the efficacy of combining autologous breast reconstruction with VLNT. Chimeric flaps using inguinal nodes, lateral thoracic nodes, or omentum aim to construct an aesthetic breast and improve lymphatic function. In this article, we will detail the surgical options that accomplish autologous breast reconstruction and restore the lymphatic network in a single operation.
Complications following amputation can be devastating for patients, including debilitating neuropathic pain, the inability to perform activities of daily living (ADLs) or gain meaningful employment. While prosthesis use allows patients to restore independence and reintegrate into daily activities, patients often abandon these devices. Despite the immense advancements in prosthetic technology, there is still a need for an interface that can provide a natural experience with accurate and reliable long-term control. The Regenerative Peripheral Nerve Interface (RPNI) is a simple surgical technique that offers real-time control of myoelectric prosthetic devices to restore extremity function. This stable, biological nerve interface successfully amplifies efferent motor action potentials, provides sensory feedback, and offers a more functional prosthetic device experience. Based on the principles of RPNI, novel surgical approaches have been developed to expand its applications and improve outcomes. This review article summarizes the utilization of the RPNI and its recent modifications of different neural interfaces in the setting of major limb amputation and musculoskeletal injuries.
As botulinum toxin is increasingly used cosmetically and medically, it is important to understand the differences between each formulation of this product. While the active molecule in each is a 150 kDa protein that prevents neurotransmitter release, there are currently five products FDA-approved for clinical use, with a sixth currently in its Phase 3 trial and a seventh applied under FDA review, each with different nontoxic accessory proteins and varying amounts of human serum albumin. These properties affect diffusion rates and storage methods, which are outlined in this review. Common complications and recommendations to avoid them are discussed.
An estimated 500,000 women were diagnosed with the debilitating breast cancer-related lymphedema (BCRL) in 2022. Lymphedema is not just fluid, but a complex disease characterized by low-grade inflammation, fat deposition, and fluid accumulation, severely affecting patients’ quality of life (QoL). The impact of surgical and adjuvant breast cancer treatment on BCRL has been investigated, and treatments have been modified to maintain a high cancer-free survival while addressing the late effects. In addition, the demand for breast reconstruction has increased in the last two decades, leaving a gap in the understanding of the association between BCRL and breast reconstruction. Early detection and treatment of BCRL is crucial in preventing advancement into an impairing chronic stage, making reliable diagnostic modalities necessary. This review is an updated overview of the various diagnostic tools and the established and evolving treatment approaches for BCRL, providing insight into the research findings published since 2017 on breast reconstruction and BCRL through a systematic literature search. Based on the reviewed literature, the authors could not conclude any sure causality between BCRL and breast reconstruction. Studies suggest that breast reconstruction contributes to lower BCRL rates, but prospective observational studies are recommended for future research.
Secondary rhinoplasty to address complications from initial surgical intervention is a technically challenging operation. Common aesthetic complications that plague patients after primary rhinoplasty include nasal tip asymmetries, bossae, and alar retraction. These adverse outcomes are usually a result of over-manipulation and/or over-excision of native cartilage and are especially prevalent in patients with thick lower lateral cartilages and thin nasal skin. Techniques to minimize tissue handling, maintain natural nasal anatomic support and structure, and soften sharp edges from cartilage grafts or incisions are all essential in the prevention of nasal tip irregularities. In addition to prevention, there are many operative and procedural interventions to correct tip asymmetries, bossae, and alar retraction. These interventional corrections include varying cartilage and/or fascial grafts, camouflaging of previously performed grafts, and repositioning of the alar cartilage.
The evolution of autologous breast reconstruction is marked by significant technological advancements aimed at enhancing surgical outcomes. This review explores the current limitations and inherent challenges in standard practices of autologous breast reconstruction and highlights the potential benefits of the latest technological innovations. It addresses key aspects that stand to gain from improvements in surgical training and perioperative patient care, with a particular focus on preoperative planning, intraoperative techniques, and postoperative monitoring. The transformative potential of these technologies is poised to significantly improve patient outcomes, optimize surgical efficiency, and advance surgical education.
The excessively short nose is a challenging dilemma in rhinoplasty. The variability in patient goals and nasal anatomy prevents a one-size-fits-all approach, yet a collection of commonly employed techniques may be considered when approaching an individual nose. This article discusses the common anatomical abnormalities associated with a short nose and reviews the existing literature on techniques to address these abnormalities and how they may be combined to create a unique surgical plan. Typically, correcting a short nose requires an increase in nasal length and projection, along with a decrease in rotation. Achieving this necessitates a complete release of the soft tissue and ligaments from all bony and cartilaginous attachments to allow for skin redraping, as the mucosa and/or soft tissue envelope often pose limitations. Commonly employed techniques include a septal extension graft, anterior septal reconstruction, lower lateral cartilage repositioning with grafting, tip grafts, and occasionally composite grafts.
In the landscape of breast reconstruction, autologous tissue procedures have provided viable alternatives, albeit restricted by donor site morbidity and patient-specific anatomical considerations, including donor tissue availability and surgical history. Amidst these challenges, a novel approach has emerged - the fat-augmented omentum-based construct for breast reconstruction. This comprehensive review endeavors to explore the historical evolution, anatomical considerations, surgical techniques, clinical outcomes, and future directions of the fat-augmented omentum-based approach in breast reconstruction. The omental fat-augmented free flap (O-FAFF) offers a promising choice for patients who might not be appropriate candidates for conventional autologous reconstruction methods due to low BMI, previous surgeries compromising traditional donor sites, or insufficient adipose tissue volume. Operative techniques for O-FAFF involve a coordinated team approach, with simultaneous mastectomy and laparoscopic omentectomy. The omentum is shaped within an acellular dermal matrix casing, allowing for precise control of reconstruction dimensions. In addition, utilizing the omentum with fat grafting effectively restores the natural breast volume. Clinical outcomes of O-FAFF reconstruction have shown promise, with patients reporting natural-looking and soft-feeling reconstructed breasts. However, challenges such as accurate tissue volume estimation and potential complications remain, highlighting the need for further research and refinement of the technique. Overall, O-FAFF represents a significant advancement in breast reconstruction, offering a promising alternative to traditional methods. Continued investigation and clinical experience will be instrumental in establishing O-FAFF as a standard of care, ultimately improving outcomes for a wide range of patients undergoing breast reconstruction.
Despite advancements in research and technology, breast cancer remains the second leading cause of cancer-related mortality affecting women worldwide. Radiation therapy is a widely recommended adjunct to surgery due to its significant role in reducing
The rhinoplasty surgeon will undoubtedly encounter a cosmetic patient who is persistently dissatisfied with their results, no matter the objective outcome achieved. This article seeks to describe risk factors for postoperative dissatisfaction and highlight effective management strategies for the “difficult patient.” A literature search was performed using PubMed and Embase databases during September and October of 2023 to identify articles that analyzed factors related to dissatisfaction in rhinoplasty. Forty unique references were identified. The majority of structural aesthetic complaints related to dissatisfaction after rhinoplasty were residual dorsal hump (20%) or persistent tip dissatisfaction (19%-37%). Demographic factors including younger age, male sex, self-referral, history of body dysmorphic disorder or abuse/neglect were risk factors for postoperative dissatisfaction. Ineffective patient-provider communication, litigation due to inadequate informed consent, and surgeon inattentiveness were contributing factors to postoperative dissatisfaction. Revision rhinoplasty rates ranged from 5%-15%, where most patients sought revision surgery due to the development of a new deformity or failure to correct the original deformity, with the greatest complaints at the nasal bridge and nasal tip. Validated
The gold standard for post-mastectomy autologous breast reconstruction is abdominally based free flaps. For patients with contraindications to abdominal free flap reconstruction, utilization of other donor sites should be considered. The profunda artery perforator flap has become a popular option for autologous reconstruction as it offers many advantages, including a long pedicle, muscle preservation, and easy soft tissue contouring. This review will provide an extensive outline of the history, anatomy, clinical indications, surgical techniques, and outcomes of the profunda artery perforator flap. It will also discuss appropriate preoperative imaging (CTA, MRA) and present a case of a patient who received a profunda artery perforator flap at our institution.
Aim: Postoperative administration of adjuvant therapy is associated with reduced breast cancer recurrence and mortality. Concerns have been raised that immediate reconstruction may lead to a delay in the administration of adjuvant therapy with the risk of compromising survival. This systematic review seeks to evaluate and discuss whether post-mastectomy immediate autologous microsurgical breast reconstruction affects the timely initiation of adjuvant chemotherapy and radiotherapy.
Methods: PubMed and EMBASE were searched to identify studies assessing the impact of immediate autologous microsurgical breast reconstruction on the timely initiation of adjuvant therapy.
Results: Seven studies comprising 267 patients treated with immediate autologous microsurgical reconstruction followed by adjuvant therapy and 2,622 patients treated with mastectomy-only followed by adjuvant therapy were included in this study. Reconstructed patients started adjuvant therapy later, with a mean difference ranging from 2 to 14 days. Adjuvant therapy was initiated after 4-10 weeks in most cases - regardless of reconstruction or not - and only few examples of delays of more than 12 weeks were recorded. Major postoperative complications were found to be associated with delay in the initiation of adjuvant therapy.
Conclusion: The literature generally agrees that delays in adjuvant therapy beyond 12 weeks after surgery are associated with increased breast cancer recurrence and mortality, but uniform data on the clinical effects of delays within this interval are lacking. The association between postoperative complications and delays in adjuvant therapy underlines the importance of careful patient selection, a multidisciplinary treatment approach, and other measures known to reduce the risk of complications.
Aim: The use of three-dimensionally printed (3DP), patient-specific models in autologous breast reconstruction is gaining popularity, namely for their benefits in surgical planning and ability to aid in aesthetic outcomes. Furthermore, 3DP patient-specific models serve as a safe alternative to intraoperative surgical training and act as a useful tool for visualizing the intramuscular course of deep inferior epigastric perforator vessels. Despite demonstrated usefulness in other surgical specialties and areas of plastic surgery, there remains a significant gap in the literature exploring specific perioperative, preoperative, and intraoperative uses as well as the educational advantages of 3DP in autologous breast reconstruction.
Methods: PubMed, MEDLINE, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched for all English language articles using specific MeSH terms (3dp OR 3D-print* OR three dimension* print*) AND (breast reconstruction). Only studies discussing the use of 3DP for surgical planning or as an educational tool in autologous breast reconstruction were included. Studies using 3DP as interventions or implants were excluded.
Results: A total of 168 articles were identified, 13 of which were selected for inclusion. Risk of bias was low for 8 articles and moderate for 5 articles. Seven (53.8%) articles discussed 3DP usage in preoperative planning. Most papers (12, 92.3%) focused on 3DP models as guides for intraoperative identification of anatomical landmarks and 3DP molds as tools to achieve desired breast volume, shape, and projection. Only 4 (30.7%) articles discussed patient outcomes. Of the 4 (30.7%) articles that discussed education, only one of these properly assessed trainees and faculty using pre- and post-intervention surveys.
Conclusion: The majority of 3DP research as an intraoperative guide and educational tool is concentrated outside of autologous breast reconstruction. Studies that do discuss this have found significantly higher success rates in dissecting true DIEP flaps when 3DP vascular modeling is used and can result in improved confidence and competence in surgical training for microsurgical anastomosis. Although 3DP has been shown to aid microsurgeons in preoperative planning, most research concentrates on the aid of this novel technology in dynamic, intraoperative decision making. Existing research has identified five 3DP breast molds, but studies have yet to compare these molds in a controlled setting to assess for superiority in feasibility and outcomes. There is little investigation into the usefulness of 3DP as an educational tool, and more research should be conducted as this methodology expands to cover more forms of autologous breast reconstruction.
The purpose of this paper is to provide the author’s view on basic techniques to optimize burn wound healing. For burns that are partial thickness, the goal is to optimize re-epithelialization to reduce the chance of hypertrophic scarring. For deeper burns, there are principles that lead to better outcomes. For very small burns, such as on the hand, full-thickness skin grafts can be performed in the outpatient setting. For burns requiring split-thickness skin grafts, thicker grafts tend to contract less than thinner ones. Using wider skin grafts or breaking up straight seams with darts also leads to improved results. Choosing donor sites that either minimize scarring or can be hidden should also be considered. For the massive burn, one must still prioritize better grafts for more functional or cosmetic areas (face, hands). Early excision and coverage should reduce scarring. Despite the availability of newer technologies, simple strategies to treat the burn wound still lead to excellent results.
The purpose of this manuscript is to fully characterize modern approaches to robotic breast reconstruction. The authors review and describe preoperative planning, operative anatomy & techniques, and clinical outcomes regarding robotic breast reconstruction. In the modern era of robotic surgery, many of the beneficial outcomes in other surgical specialties also apply to breast reconstruction. When comparing outcomes between traditional and robotic latissimus flap reconstruction, a robotic approach is associated with a shorter hospital length of stay, lower postoperative opioid requirements, and higher patient satisfaction. For robotic DIEP flap reconstruction, outcomes from several studies also report favorable results with no flap losses, intraabdominal complications, or postoperative hernia/bulge. Although barriers exist regarding this technology, robotic latissimus and DIEP flap reconstruction can be safely learned and applied with thoughtful patient selection and preoperative planning. Robotic breast reconstruction facilitates a minimally invasive approach that decreases donor-site morbidity, length of stay, and opioid requirements, and even improves patient satisfaction.
The increasing adoption and widespread acceptance of negative pressure wound therapy (NPWT) have paralleled the expansion of its indications in clinical practice. The spectrum of indications for NPWT now extends to encompass soft tissue defects arising from trauma, infection, surgical wound care, and soft tissue grafting procedures. Recent advancements in NPWT devices have introduced various adjuncts, such as instillation of fluids or antibiotics into the wound. These additions empower surgeons to enhance the wound healing environment and contribute to combatting infections more effectively. This review delves into the latest literature addressing the proposed mechanisms underlying NPWT's action, its cost-effectiveness, its impact on patient quality of life, and the essential components necessary for its safe use. The review examines the evidence supporting NPWT's application in managing traumatic extremity injuries, controlling infections, and wound care. While NPWT generally exhibits a low complication rate, surgeons must remain aware of the potential risks linked to its utilization. Moreover, the review explores the widening scope of indications for NPWT, shedding light on prospective avenues for innovation and research in this field.
Hair restoration surgery is an increasingly common treatment for androgenetic alopecia and may also address other forms of non-scarring and scarring alopecia. To optimise surgical outcomes, it is crucial to consider key pre-surgical factors and avoid diagnostic pitfalls. This review summarises the diagnostic and differential diagnostic approaches to alopecias, as well as a checklist for holistic patient assessment before hair transplantation.
Amputation is a historically well-grounded procedure, but such a traumatic operation invites a litany of postoperative complications, such as the formation of agonizing neuromas. Developments in mitigating these complications include the clinically successful targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), which showcased the potential for utilizing peripheral nerves' regenerative capabilities to circumvent neuroma formation and isolate neural activity for control of a sophisticated prosthetic device. Nevertheless, these techniques only record the aforementioned neural activity from the reinnervated muscle, not the nerve itself, which may ultimately limit the degree of functionality they can restore to amputees. Alternatively, regenerative sieve electrodes are non-biological end targets for reinnervation that utilize their porous structure to isolate regenerating axons into discrete transient zones lined with stimulating and recording electrodes. Albeit more invasive, such direct contact with the once-damaged nerve opens the door for highly selective, bi-directional neural interfaces with the capacity to restore higher degrees of sensorimotor functionality to patients for enhanced rehabilitation outcomes. By expanding the definition of innervation to include non-biological targets, clinicians can make room for these advancements in neural interfacing to revolutionize patient care.
Microsurgical breast reconstruction has continued to evolve to improve outcomes and minimize complications. Dual-plane, conjoined and stacked flaps represent one aspect of this evolution in an effort to improve tissue perfusion and flap volume. Dual-plane flaps combine the superficial and deep circulation in abdominally-based free flaps to augment perfusion. Conjoined flaps use additional pedicles to supply multiple perforasomes combined in a single flap. Stacked flaps utilize separate flaps on individual pedicles to increase volume at a single recipient site. Multiple donor sites, pedicle configurations and recipient vessel choices have been described, primarily focusing on using the cranial and caudal internal mammary system as well as intra-flap anastomoses. Though more technically demanding, dual-plane, stacked and conjoined flaps allow for improvement in flap perfusion and volume, and are important tools for optimizing results in autologous breast reconstruction.
In the last few decades, the utilization of 3D printing has transcended its niche status to become an indispensable tool in medicine, and its ability to swiftly produce intricate geometries, coupled with its cost-effectiveness, has propelled its adoption across multiple surgical specialties, including plastic, abdominal, and orthopedic surgery. Notably, in plastic surgery, 3D printing has revolutionized several facets of patient care, spanning from the creation of anatomical models for surgical planning and medical education to the fabrication of custom implants and molds and the creation of surgical guides. This review delves into the expansive landscape of 3D printing applications within plastic surgery, examining the diverse modalities and materials employed. By leveraging advancements in printing processes and materials, surgeons are empowered to refine established techniques and develop novel solutions tailored to individual patient needs. As the technology continues to mature, its impact on plastic surgery is poised to deepen, promising further enhancements in surgical precision, patient care, and functional and aesthetic outcomes. This review underscores the transformative potential of 3D printing in shaping the future landscape of plastic surgery, driving continuous improvement and innovation in the field.
Correction of a crooked nose after primary rhinoplasty is a not uncommon and often complex problem encountered by facial plastic surgeons. Adequate and lasting correction of the deformity requires a thorough assessment of the anatomy contributing to the deviation, as well as the application of robust techniques to correct the problem at each subsite, which is reviewed in this article. Finally, risk factors for failure and common pitfalls are discussed.
Despite its technical complexity, the lumbar artery perforator (LAP) flap remains a valuable asset in the realm of autologous breast reconstruction, providing an option for patients who may not be suitable candidates for abdominal flaps. The LAP flap offers dimensions and volume suitable for recreating a natural breast shape, including a sloping upper pole and optimal projection in the lower third. Harvesting LAP flaps can also lead to simultaneous improvement in body contour by lifting the buttocks and narrowing the waist, following the principles of aesthetic body lift procedures.
Non-surgical (liquid) rhinoplasty (LR) is a common and expanding cosmetic procedure. The use and safety of in-office injectables, as well as surgeon comfort, has led to substantial growth with the procedure. Knowledge of nasal structural and vascular anatomy, injectable filler properties and in situ behavior, and procedural technique are all required for the application of non-surgical rhinoplasty. There is consensus regarding common indications for the procedure, including dorsal augmentation, correction of post-surgical deformities, and improvement of nasal tip symmetry. However, there is substantial variability in filler usage, technique, and patient selection. As with surgical rhinoplasty, the risk of patient dissatisfaction with LR remains high. It is of utmost importance to consider the rise of non-surgeon providers performing these procedures. A thorough understanding of the risks, benefits, and proper patient selection are key for any facial plastic surgeon utilizing LR.
The lateral thigh perforator flap is an excellent alternative to the deep inferior epigastric artery perforator (DIEP) flap for patients with absolute or relative contraindications for a DIEP flap and adequate volume at the lateral thigh. Preoperative physical examination, preoperative markings, and radiological perforator mapping are essential for adequate surgical preparation. The flap is based on septocutaneous perforators of the lateral circumflex femoral artery, located in the posterior septum between the tensor fascia latae and the gluteus medius muscle. Being relatively stiff, septocutaneous perforators are sensitive to kinking and compression, which is important to keep in mind during flap inset. A donor nerve can be taken and coapted with the flap for sensate autologous breast reconstruction. For larger breast volumes, bipedicled, conjoined, or stacked flaps are viable options. Quilting sutures during donor site closure is crucial in risk reduction of seroma formation and wound dehiscence. Complication risks seem comparable to other free flap breast reconstructions, such as the DIEP flap, especially when applying the quilting sutures at the donor site. During postoperative control visits at the outpatient clinic, additional procedures will be discussed, which often consist of lipofilling in the pectoralis major muscle for increasing upper pole volume, liposuction of the non-operated lateral thigh for symmetry in unilateral cases, or dog-ear corrections at the donor site.
Three-dimensional (3D) printed models offer potential advantages over traditional teaching methods by providing realistic, tactile learning aids. The overall efficacy of 3D printing in plastic surgery education has not been previously systematically analysed. A review of PubMed, Web of Science, and Embase databases up to October 2023 identified studies using 3D printed models in plastic surgery education. Inclusion criteria were set to select before-after studies or studies comparing 3D printed models to traditional teaching methods. Outcome measures included Likert scales, Multiple choice quest tests or other scoring systems. 37 studies met the inclusion criteria. Learners demonstrated enhanced anatomical understanding and procedural knowledge after engaging with 3D models. The comparative studies included in the review further highlight the superiority of 3D models over traditional learning tools, with average increases in test scores and procedural confidence, quantified through Likert scales and multiple-choice questionnaires. Ultimately, the findings of this review suggest that 3D printing enhances learning, making educational experiences more interactive and effective than traditional methods. While costs, accessibility, and a lack of technical expertise may pose challenges, integrating 3D models into training could enhance plastic surgical education. High-quality randomized controlled trials are necessary to confirm these findings and standardise outcomes for broader applications.
Aim: In the field of burns and soft tissue reconstruction, skin substitutes have been successfully used for various indications. They allow for conservative treatment as well as temporal coverage through the improvement of wound bed conditions, pathogen control and the formation of new tissue. Fish skin grafts (FSGs) have gained rising attention as a new tool in the skin substitute market. This systematic review aims to provide an update on clinical studies investigating the effects of FSG on healing for the following indications: donor sites of split-thickness skin grafts, superficial and deep partial-thickness burns, full-thickness burns, combat wounds, and other acute wounds.
Methods: A systematic review of the peer-reviewed literature available as of January 2024 was conducted to examine the effects of FSG on wound healing of burn and complex trauma wounds, using the databases PubMed and Web of Science. Only clinical studies published in English were included.
Results: In total, 11 clinical studies were considered eligible and therefore included in the present review. According to the available data, the main advantages of the two commonly used types of FSGs (Kerecis® Omega3 Wound Matrix and Nile tilapia) are an acceleration of re-epithelialization time, a reduction in pain intensity and infection rates, as well as a reduction in the number of required dressing changes.
Conclusion: FSGs represent a safe and promising product for the management of donor sites, partial-thickness and full-thickness burns, as well as complex trauma wounds. However, there is a paucity of high-quality clinical evidence, especially randomized controlled trials. More research is needed to fully understand the product’s potential for wound healing and to create a more meaningful treatment algorithm.
Digital neuromas can be psychologically and functionally debilitating. While typically the result of penetrating traumatic injury, neuromas also stem from blunt trauma, chronic irritation, or prior inadequate repair. Abnormal axonal regeneration without an appropriate distal target following nerve injury results in the formation of end-neuromas, often leading to significant pain. Conservative management is centered around a combination of pharmacological interventions and therapeutic modalities. In the setting of failed conservative management, surgical intervention is employed with the goals of excising the neuroma and redirecting axonal growth into healthy tissue. This article focuses on painful digital neuromas and options for both nonoperative and operative management.
Autologous breast reconstruction has greatly evolved with the introduction of stacked deep inferior epigastric perforator (DIEP) flaps, providing a sophisticated option for patients with insufficient donor tissue or those requiring substantial breast mounds. This technique utilizes either conjoined/bipedicled or separate abdominal flaps to recreate the breast with natural-looking results and high satisfaction rates. Preoperative planning is critical, involving detailed vascular mapping to ensure successful outcomes. Despite the complexity of the procedure, the complication profile remains comparable to non-stacked methods, with a notable reduction in fat necrosis and no significant increase in overall risk. Similar to the DIEP flap, possible complications related to the stacked DIEP flap include donor-site morbidity such as abdominal bulge or hernia, and complications at the recipient site such as flap ischemia or fat necrosis. The stacked DIEP flap technique has improved the symmetry and volume matching of reconstructed breasts while maintaining abdominal integrity, marking a significant advancement in the field that aligns with the aesthetic aspirations of patients undergoing mastectomy.
Mycobacterium ulcerans (M Ulcerans) infection leads to the debilitating Buruli ulcer (BU), characterized by necrotizing skin and soft tissue lesions. Conventional treatment primarily focuses on an antibiotic regimen, but wound management remains paramount to patient recovery. This literature review aims to evaluate the efficacy and benefits of Vacuum Assisted Dressing (VAC) in the treatment and management of BU wounds. A systematic literature search was undertaken using databases such as PubMed, Cinahl, Cochrane database, Joanna Briggs Institute, Medline, Internurse, Nursing & Allied Health database, and Scopus search from January 1995 to December 2023. The key search terms included “Mycobacterium ulcerans”, OR “Buruli ulcer”, AND “vacuum assisted dressing”, “vacuum assisted therapy”, “Vacuum Assisted Dressing”, “negative pressure wound therapy”, and “Negative Pressure Wound Therapy (NPWT)”. The exclusion criteria were animal studies and studies not in the English language. The current literature emphasizes the importance of antibiotic treatment for BU and highlights the skin and soft tissue damage that results in open, infected wounds. However, there is a notable lack of quantitative data on the efficacy of NPWT for treating BU wounds. Early evidence indicates that NPWT might accelerate wound healing, decrease secondary infections, and enhance wound bed readiness for grafting or secondary healing. While more comprehensive quantitative studies are warranted, NPWT emerges as a promising adjunctive therapy in the holistic management of BU wounds, offering benefits that may improve patient outcomes and reduce morbidity.
With the rapid development of 3D printing (3DP) technology in both educational and perioperative settings, a thorough evaluation of the latest literature is warranted. This semi-systematic review explores the current educational, clinical, and rehabilitative applications of 3DP technology in hand surgery. In educational settings, student and trainee education improved with the use of inexpensive, accessible models for anatomy and surgical simulation, demonstrating an enhanced understanding of spatial relationships and increased confidence in surgical skills. Patient education and consent can be improved with the use of patient-specific models. Studies showed that patient-specific models led to higher patient comprehension and satisfaction during the consenting process. Patient-specific models also offer more comprehensive preoperative planning, and cutting guides facilitate more precise surgical techniques. Clinical outcomes indicated reduced operative times and radiation exposure, along with improved surgical accuracy. Additionally, 3DP enables the creation of cost-effective implants that precisely conform to each patient's anatomy. For rehabilitative purposes, 3DP can make splints that have the potential to reduce costs and improve compliance. Preliminary data indicated higher patient comfort and improved functional outcomes with 3D-printed splints. Overall, the current literature is mixed on the benefits of 3DP in hand surgery; however, many studies show promising results. As 3DP becomes more streamlined and the equipment becomes less expensive, its applications will continue to expand, and future research will be needed. Future studies should focus on long-term clinical outcomes and cost-effectiveness to fully ascertain the efficacy and value of 3DP in hand surgery.
Aim: Despite the significant increase in the proportion of graduating female physicians in recent decades, gender representation in surgical training remains imbalanced. The initial rise in female interest in plastic surgery has reached a plateau. Gender bias, affecting women’s confidence and opportunities, negatively impacts training and career prospects. This study aims to quantify and analyze disparities in surgical training opportunities, workplace treatment, and career advancement among male and female plastic surgery residents in Italy.
Methods: Our study involved all Italian plastic surgery residents contacted between February and March 2024. A 21-item survey assessed professional, surgical, and personal aspects, focusing on gender gap differences. Responses were expressed in percentages and compared utilizing the Fisher Exact test.
Results: A total of 551 surveys were distributed to Italian plastic surgery residents, with 46 responses each among women and men. Gender disparities persisted in workplace treatment, with more women reporting discrimination. Significant differences were identified in treatment inequality by hospital personnel and patients, the occurrence of inappropriate comments in the workplace, inquiries regarding work-life balance and career advancement opportunities, an augmented gender gap in surgical vs. clinical programs, and the perception of a negative impact of gender on surgical training.
Conclusion: In conclusion, our study emphasizes the pervasive gender inequality in plastic surgery training, urging action against systemic biases hindering female surgeons’ progress. Gender equity efforts should combat discrimination, promote work-life balance, and foster inclusive training environments. Addressing these issues can create a field that empowers all surgeons to thrive.
Aim: The purpose of this study was to analyze fat grafting with platelet-rich plasma (PRP) in the context of volume replacement and scar hypertrophy improvement in a variety of different cases.
Methods: A retrospective review was conducted on 40 patients who underwent a total of 50 fat grafting with PRP procedures by a single surgeon between October 2019 and October 2022. Fat was generally harvested from the abdomen, thighs, or flanks using an enclosed power-assisted system or Toomey syringes with 3.0 or 3.7 mm cannulas. The fat with PRP was grafted into various sites using a 0.9 mm Tulip single port injection cannula for faces/small defects. Of the 50 cases reviewed, the injection sites were as follows: 20 cases of injections into scars (hypertrophic scars, burn/trauma scars, and scars from hidradenitis suppurativa), 15 injections to the face [to replenish volume lost by aging and two cases for human immunodeficiency virus (HIV) facial atrophy], 6 injections to the breasts, 4 injections to keloids, 4 injections to buttocks, and 1 case of injection to the nose.
Results: Overall, for all sites, the average amount of fat harvested was 360 mL, and the average amount of fat with PRP grafted was 96 mL. Of the face grafts, the average amount of fat grafted was 20 mL. The overall complication rate in our cohort was 2%, occurring only in one patient who developed cellulitis after fat grafting to the breast. There were no cases of embolization. The patients showed excellent improvement in volume and significant cosmetic improvement of scars.
Conclusion: Patients who underwent autologous fat grafting with PRP had favorable volume replacement and improvement in scarring deformity following the procedure. Fat grafting with PRP was found to be a safe and reliable technique to address various volume and skin concerns.
Breast cancer is a leading cause of cancer in women worldwide. With increased public awareness of routine breast cancer screening, the incidence of mastectomy and, therefore, breast reconstruction continues to increase year over year. Value-based healthcare has become a universal priority in medical systems. A systematic review of the literature was performed in March 2024 across four electronic databases (PubMed, Embase, Google Scholar, and MEDLINE) and in accordance with the PRISMA guidelines. Screening was performed at two levels (title/abstract and full text screening) by two independent reviewers. Data items extracted included: year, authors, country, study size, duration, strategy implemented, main aims, area of application, study design and methodology, outcomes, relevant statistical analysis, and follow-up. Eleven articles were identified that met all inclusion criteria. Six were retrospective reviews and five were prospective cohort studies. The efficiency models implemented included Lean Six Sigma, the Four Disciplines of Execution, and process mapping and analysis. Emphasizing efficiency is pivotal in delivering outstanding breast reconstruction services and enhancing the overall patient journey.
Aim: Current microsurgical procedures are limited by the physiological tremor and dexterity of the surgeon. The MicroSurgical Assistant (MUSA, Microsure), the world’s first robotic platform for (super)microsurgery can aid in resolving issues encountered during microsurgery. This study presents an overview of the operating times and Structured Assessment of Microsurgery Skills (SAMS) scores to assess the duration and quality of microsurgical anastomoses for three microsurgical procedures currently performed using the MUSA.
Methods: This study integrates data from one ongoing randomized controlled trial focusing on robotic-assisted lymphaticovenous anastomosis, along with findings from two separate prospective pilot studies concerning digital nerve repair and free tissue transplantation. SAMS scores and time needed per anastomosis were used to evaluate the quality and learning curve of the MUSA-assisted procedures.
Results: Thirty-five robotic-assisted procedures were analyzed, including 18 lymphaticovenous anastomoses, 9 digital nerve repairs, and 8 free tissue transplantations. All procedures showed a trend of a decrease in the time needed to perform the procedure. Moreover, the mean overall SAMS scores for all three procedures were rated above ‘satisfactory’, with all procedures demonstrating a consistent trend of increasing SAMS scores over time.
Conclusion: The evaluation of anastomosis’ quality in the initial cohorts of patients undergoing robotic-assisted microsurgery using MUSA indicates satisfying outcomes across all three types of procedures. The reduction in anastomosis time and the improvement in SAMS scores imply an ongoing learning process among the operating surgeons. Subsequent reports are expected to provide information on reaching a plateau phase in procedural efficiency.
Free flap autologous breast reconstruction is becoming more and more common for post-mastectomy reconstruction. Abdominally-based tissue flaps are the first choice for many reconstructive breast microsurgeons, but not all patients are candidates, whether due to their leaner habitus or a history of prior abdominal surgery. The gluteal donor site in many patients can provide adequate soft tissue for autologous breast reconstruction, even in lean patients, with a scar that remains well-hidden. This review presents an overview of the superior gluteal artery perforator (SGAP) flap as an invaluable tool for autologous breast reconstruction.
Autologous fat grafting is routinely used in plastic and reconstructive surgery to improve contour deformities and appearance. However, retention of fat over time is inconsistent and unpredictable. Cell-assisted lipostransfer (CAL), the practice of using stem cell-containing portions of adipose to enrich fat grafts, has been found to be a promising area of research to increase not only the retention of volume but also increase collagen production, enhance angiogenesis, and direct the overall repair, remodeling, and regeneration of the recipient site. CAL, therefore, has a multitude of clinical applications, ranging from oncologic reconstruction following radiation to facial rejuvenation, among others. In this paper, we provide a comprehensive review of the current state of cell-supplemented fat transfer and discuss our understanding of cellular interactions in enriched fat grafts, techniques to improve the viability of fat, clinical translation of CAL, regulatory oversight, and future directions.
Aim: Hyaluronic acid (HA) is extensively used in injectable skin quality products due to its documented role in skin rejuvenation. The rapid in vivo degradation of HA by the enzyme hyaluronidase necessitates the development of advanced formulations to ensure the efficacy and longevity of the treatments. In this context, a novel 2.6% high molecular weight HA (H-HA)/3.2% sorbitol composition has been introduced, featuring stabilization through hydrogen bonds rather than traditional crosslinking.
Methods: The stabilized composition was evaluated through two in vitro enzymatic degradation tests. In the first test, the efficiency on the gel degradation was followed by rheology and compared with two crosslinked HA products available on the market. In the second test, the effect on the gel structure of a less diluted hyaluronidase dose was followed by rheological and cohesivity measurements.
Results:In vitro study demonstrates that, before its complete degradation into a liquid-like state, the stabilized composition exhibits high elasticity and cohesivity during the enzymatic degradation process, surpassing traditional crosslinked HA products.
Conclusion: The stabilization provided by the sorbitol in the stabilized composition effectively enhances product properties and protects them during gel degradation. These attributes indicate significant potential for improved clinical outcomes in skin quality treatments.
Aim: Informed consent for paediatric facial reanimation requires effective patient/parent education and involvement in a shared decision-making (SDM) process to help set their expectations and understanding from the outset. No article in the current literature has systematically reviewed the available tools for facilitating effective patient/parent education and the validity of informed consent in the context of paediatric facial reanimation.
Methods: A systematic literature review was undertaken, following the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. MEDLINE via PubMed, Embase and Cochrane Library were searched and the results screened and reviewed in accordance with pre-defined inclusion and exclusion criteria.
Results: The initial search yielded 478 articles, of which only 4 fulfilled the study’s inclusion criteria. One cohort study evaluated qualitative feedback from patients and their relatives participating in a family education and support day for paediatric facial palsy, while another article from the same group reviewed the readability of online education resources. The remaining two articles represented educational reviews focusing on treatment and patient education based on expert opinion without providing original outcome data.
Conclusion: There is a paucity of evidence regarding patient/parent education to support the informed consent process for children undergoing paediatric facial reanimation. There remains a need for further resources and platforms to be developed that may support children and their parents in engaging in a SDM process, setting appropriate expectations, and providing valid informed consent for their surgery.
Introduction: Targeted muscle reinnervation (TMR) is increasingly common in the care of major limb amputation to limit amputation-related pain. This review aims to elucidate how chronic pain states and length of delay prior to TMR affect its success and outcomes.
Methods: Manuscripts were collected from three databases. Articles were first screened and excluded based on exclusion criteria. The remaining manuscripts were independently reviewed to determine inclusion. Article and patient demographics, as well as pain outcomes, were extracted. Data were analyzed based on pain condition, amputation vs. neuroma, and time from amputation/injury to surgery.
Results: The literature search yielded 723 articles, with 41 meeting the inclusion criteria. Twenty-one articles included patients with residual limb pain (RLP) and phantom limb pain (PLP), including 14 on amputation and 6 on neuroma excision. Five articles included cancer-related amputation. Complex Regional Pain Syndrome (CRPS) was discussed in 3 articles, ischemia or infection in 2 articles, and neurofibromatosis 1 in 1 article. Twenty-two articles described TMR at the time of amputation.
Conclusions: TMR is effective at preventing neuroma formation and limiting pain when performed at the time of amputation. Delayed patients had a greater improvement in RLP but less of an improvement in PLP, when assessed against immediate TMR patients who were compared to non-TMR standard amputees. In the presence of chronic pain states, such as CRPS, there is also improved analgesia. However, current clinical data are limited, indicating a need for further research into the use of TMR for chronic pain management.
Aim: Beta-adrenergic receptor blockers are conventionally used for the treatment of hypertension, tachycardia, and glaucoma. Research has shown that beta-blockers can accelerate wound epithelialization. In this study, we tested the efficacy of the beta-blocker timolol in an ovine model of grafted full-thickness burn wound healing, which closely mimics clinical scenarios.
Methods: Six full-thickness burn wounds were created on the sheep’s posterior surface. Twenty-four hours later, eschars were excised and meshed skin was grafted (Day0). The wounds in the treatment group received topical application of timolol. Blood flow was measured using a blood perfusion imager. Cardiovascular hemodynamics and blood glucose levels were recorded daily. The epithelialization rate on Day 14 was determined by planimetric assay and analyzed by paired t-test. The days that the epithelialization rate exceeded 85%, 90%, and 95% were analyzed by survival analysis. To assess the potential influence of TGFβ, epithelial-mesenchymal transition (EMT), or myofibroblast activation (MFA) on wound healing, the RNA abundance of gene products related to these pathways was measured by reverse transcription and quantitative polymerase chain reaction (RT-qPCR).
Results: The epithelialization rate on Day 14 was significantly higher in the treatment group. The days that the epithelialization rate exceeded 85%, 90%, and 95% were significantly shorter in the treatment group. There was no significant difference in wound blood flow or RNA abundance related to TGFβ, EMT, or MFA-related pathways among the groups at any time point.
Conclusion: The results demonstrate that the beta-blocker timolol accelerates epithelialization of mesh skin grafted full-thickness burn wounds through a mechanism other than improving wound blood flow.
Dermal grafting (DG) has emerged as an innovative technique in plastic and reconstructive surgery, offering several advantages over traditional skin grafting methods. This review provides an in-depth exploration of DG, highlighting its applications, benefits, and future directions. The historical evolution of skin grafting is discussed, tracing the development of DG as a novel approach to address the limitations of conventional techniques.
The review focuses on four key advantages of DG: (1) accelerated healing of donor sites; (2) improved aesthetic outcomes at recipient sites due to the elastic nature of dermal grafts; (3) increased graft availability by effectively at least doubling the amount of graft material obtained from a single donor site; and (4) utility in scar revision and reconstruction procedures, particularly in areas with restrictive scarring or contractures.
Recent advancements, such as the development of a multiblade dermatome, have addressed the technical challenges associated with DG harvesting, potentially broadening the clinical adoption of this technique. Preliminary results from studies utilizing this new device have demonstrated its feasibility in producing dual grafts (split-thickness skin graft and dermal graft) concurrently, simplifying the surgical procedure.
The review also explores future directions in DG, including further refinements to the multiblade dermatome, and clinical trials to validate long-term benefits.
Overall, this review highlights the significant advantages of DG and its potential in advancements of plastic and reconstructive surgery, ultimately improving patient outcomes and quality of life.
Hyaluronic acid (HA) dermal fillers are extensively used for facial volume enhancement. Despite their widespread use, HA fillers are prone to degradation due to various factors, including enzymatic activity, pH changes, ultrasound exposure, temperature variations, oxidative stress, and ultraviolet (UV) radiation. To mitigate these issues, manufacturers have developed cross-linking techniques to improve the stability of HA fillers. Energy-based devices (EBDs) are increasingly utilized for purposes such as skin tightening, collagen stimulation, and fat reduction. However, the interaction between EBDs and HA fillers is complex and requires further investigation. Recent research has examined the effects of EBDs on HA fillers, yielding mixed results. Some studies suggest that early EBD treatment may lead to the degradation of HA fillers, while others find no significant impact. The timing between filler injection and EBD treatment appears to be crucial, with delayed treatment potentially reducing the risk of degradation. Histological examinations have demonstrated that the interactions between EBDs and HA fillers are intricate, influenced by factors such as the location of the filler and the timing of the treatment. The relationship between EBDs and HA fillers is multifaceted and affected by numerous variables, including the type of EBD, energy levels, filler characteristics, and the timing of the treatment. Further research involving diverse participant groups, various types of HA fillers, and different EBD technologies is necessary to develop comprehensive guidelines for optimal treatment intervals.
The introduction of generative artificial intelligence (AI) has revolutionized healthcare and education. These AI systems, trained on vast datasets using advanced machine learning (ML) techniques and large language models (LLMs), can generate text, images, and videos, offering new avenues for enhancing surgical education. Their ability to produce interactive learning resources, procedural guidance, and feedback post-virtual simulations makes them valuable in educating surgical trainees. However, technical challenges such as data quality issues, inaccuracies, and uncertainties around model interpretability remain barriers to widespread adoption. This review explores the integration of generative AI into surgical training, assessing its potential to enhance learning and teaching methodologies. While generative AI has demonstrated promise for improving surgical education, its integration must be approached cautiously, ensuring AI input is balanced with traditional supervision and mentorship from experienced surgeons. Given that generative AI models are not yet suitable as standalone tools, a blended learning approach that integrates AI capabilities with conventional educational strategies should be adopted. The review also addresses limitations and challenges, emphasizing the need for more robust research on different AI models and their applications across various surgical subspecialties. The lack of standardized frameworks and tools to assess the quality of AI outputs in surgical education necessitates rigorous oversight to ensure accuracy and reliability in training settings. By evaluating the current state of generative AI in surgical education, this narrative review highlights the potential for future innovation and research, encouraging ongoing exploration of AI in enhancing surgical education and training.
The integration of artificial intelligence (AI) into plastic surgery is transforming the field by enhancing precision in preoperative planning, diagnostic accuracy, intraoperative assistance, and postoperative care. AI encompasses machine learning, natural language processing, computer vision, and artificial neural networks, each offering unique advancements to surgical practice. This narrative review explores the ethical challenges of AI in plastic surgery, addressing concerns such as data protection, algorithmic bias, transparency, accountability, and informed consent. A comprehensive search adhering to PRISMA guidelines identified 63 studies, with 15 selected for in-depth analysis. Findings indicate significant ethical issues: data privacy needs stringent cybersecurity, biases in AI models must be mitigated, and transparency in AI decision making is essential. The review emphasizes the necessity for updated Health Insurance Portability and Accountability Act (HIPAA) regulations, robust validation mechanisms, and the development of explainable AI models. It also highlights the need for an independent regulatory body to oversee AI integration, ensuring ethical standards and protecting patient welfare. Although AI presents promising benefits, its successful application in plastic surgery hinges on addressing these ethical challenges comprehensively.
Delayed pedicled flaps are a reliable reconstructive tool for limb salvage. Determining the optimal timing for pedicle division is critical for surgical success and minimizing complications. Assessment of optimal timing has traditionally relied on arbitrary timing or subjective measures. This study explores the use of indocyanine green (ICG) angiography in the office setting as an objective guide for timing the delayed pedicled flap pedicle division, aiming to improve surgical outcomes and resource efficiency. In the outpatient setting, ICG is administered intravenously while the flap pedicle is under tourniquet control. If the distal flap opacifies with the tourniquet still applied, appropriate revascularization has occurred, and the pedicle may be safely divided. We present the example of a 47-year-old male with multiple previous flap reconstructions who eventually required a reverse sural artery flap. Initial intraoperative ICG imaging on postoperative day (POD) 23 revealed insufficient perfusion, prompting the postponement of pedicle division. Subsequent office-based imaging on POD 47 revealed a persistent lack of neovascularization. Adequate vascularization was demonstrated on POD 81, enabling successful pedicle division in the operating room on POD 121 without complications. ICG fluorescent angiography can guide the timing of division for delayed pedicled flaps. We recommend its use in the outpatient setting to decrease unnecessary operating room usage and anesthetic events and reduce the risk of wound healing complications from early pedicle division.
This article presents a comprehensive strategy for both the prevention and treatment of neuropathic pain at the radial forearm (RF) donor site. This strategy is presented within the framework of RF phalloplasty, based on the senior author’s practice and the premise that of all RF reconstructions, phalloplasty holds the greatest potential for postoperative neuropathic pain due to flap size and the inherent division of multiple antebrachial cutaneous nerves to provide for flap sensation. This proposed protocol offers a thorough care pathway that integrates techniques in peripheral nerve surgery with perioperative clinical strategies to prevent and treat neuropathic pain. Specific technical recommendations for the prevention and treatment of postoperative neuromas, compression neuropathies, and hyperalgesia of each peripheral nerve involved in RF phalloplasty flap harvest are proposed. These strategies can be adapted and applied to RF flaps utilized in other reconstructive areas.
In autologous breast reconstruction, the deep inferior epigastric perforator (DIEP) flap is the most commonly used. For patients undergoing unilateral breast reconstruction who desire augmentation of the contralateral breast but wish to avoid using implants, augmentation of the contralateral breast using DIEP flaps is a reliable option. Preoperative evaluation requires assessing the patient’s desired outcome and the amount of abdominal tissue available. CT angiography (CTA) helps facilitate the evaluation of abdominal perforator anatomy and the estimation of flap volumes for simultaneous reconstruction and contralateral augmentation. Flap design takes into consideration the perforators needed for a large flap for the primary reconstruction and the length of the pedicle needed to access contralateral recipient vessels for a smaller flap for augmentation. One set of recipient vessels [internal mammary artery (IMA)/internal mammary vein (IMV)] are used with antegrade anastomoses performed for primary reconstruction flaps and retrograde anastomoses for flaps used in augmentation. Augmentation flaps can be completely buried or include a skin paddle for monitoring. Subsequent secondary procedures are often needed to achieve the desired final breast shape and symmetry. Overall, patients who have undergone unilateral autologous breast reconstruction with simultaneous contralateral autologous augmentation report high levels of satisfaction postoperatively.