The latest medical research on Plastic Surgery

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Sub-Flap Use of Nano-Selenium Oxide Solution Enhances Skin Flap Viability in Rats: Study the Novel Role of mTOR and p-mTOR Expression.

Aesthetic Plastic Surgery

Nano-selenium oxide (NSeO) particles are highly noticeable due to their tissue-protective and antioxidant properties. For this purpose, the effect of NSeO was evaluated on skin flap survival and flap oxidative stress markers in rats. Also, another effect of NSeO was investigated on the expression of mTOR and p-mTOR.

Fifty rats were divided into five groups of ten. Skin flap size was 3×8 cm in all groups. Groups were: (1) Sham, (2) Flap Surgery group, (3) Flap Surgery + NSeO, (4) Flap Surgery + Rapamycin (mTOR inhibitor), (5) Flap Surgery + Rapamycin + NSeO. The flap necrosis rate was computed using the paper pattern method on day seven after surgery. After day seven, flap tissues were collected for histological evaluations. Then, malondialdehyde (MDA) content and superoxide dismutase (SOD) activity were measured. Furthermore, the expression levels of mTOR and p-mTOR were measured using the Western blot method.

Treatment with NSeO significantly reduced necrosis (P<0.05). It also resulted in a decrease in MDA level (P<0.05). Histologically, NSeO reduced inflammation and increased positive signs of tissue healing (epithelialization, neovascularization, fibroblast migration, and granulation tissue). NSeO increased SOD activity significantly (P<0.05), whereas, using rapamycin reversed these effects. Also, in all groups, mTOR changes were not significant. Additionally, p-mTOR expression was significantly reduced in groups that rapamycin was injected.

NSeO can reduce flap necrosis and enhance tissue healing in rats. So, it can potentially be used clinically to promote tissue repair significantly, and its effects are independent of the mTOR pathway.

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessment of an Artificial Intelligence Mandibular Osteotomy Design System: A Retrospective Study.

Aesthetic Plastic Surgery

In this study, an AI osteotomy software was developed to design the presurgical plan of mandibular angle osteotomy, which is followed by the comparison between the software-designed presurgical plan and the traditional manual presurgical plan, thus assessing the practicability of applying the AI osteotomy software in clinical practices.

(1) Develop an AI osteotomy software: design an algorithm based on convolutional neural networks capable of learning feature point and processing clustering segmentation; then, select 2296 cases of successful 3D mandibular angle osteotomy presurgical plans, followed by using those 2296 cases to train the deep learning algorithm; (2) compare the osteotomy presurgical plan of AI osteotomy software and that of manual: first step: randomly selecting 80 cases of typical female head 3D CTs, and designing those 80 cases by means of AI osteotomy software designing (group A) and manually designing (group B), respectively; second step: comparing several indexes of group A and those of group B, including the efficiency index (time from input original CT data to osteotomy presurgical plan output), the safety index (the minimum distance from the osteotomy plane to the mandibular canal), the symmetry indexes (bilateral difference of mandibular angle, mandibular ramus height and mandibular valgus angle) and aesthetic indexes (width ratio between middle and lower faces (M/L), mandibular angle and mandibular valgus angle).

The efficiency index: the design time of group A is 1.768 ± 0.768 min and that of group B is 26.108 ± 1.137 min, with P = 0.000; the safety index: The minimum distances from the osteotomy plane to the mandibular canal are 3.908 ± 0.361mm and 3.651 ± 0.437mm, p = 0.117 in groups A and B, respectively; The symmetry indexes: Bilateral differences of mandibular angle are 1.824 ± 1.834° and 1.567 ± 1.059° in groups A and B, respectively, with P = 0.278; bilateral differences of mandibular ramus height are 2.083 ± 1.263 and 2.965 ± 1.433, respectively, with P = 0.119 in groups A and B; Aesthetic indexes: M/L in groups A and B is 1.364 ± 0.074 and 1.371 ± 0.067, respectively, with P = 0.793; mandibular angles in groups A and B are 127.724 ± 5.800° and 127.242 ± 5.545°, respectively, with P = 0.681; Valgus angles in groups A and B are 11.474 ± 5.380 and 9.743 ± 4.620, respectively, with P = 0.273.

With high efficiency, as well as safety, symmetry and aesthetics equivalent to those of a manual design, the AI osteotomy software designing can be used as an alternative method for manual osteotomy designing.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Shakespearean Dilemma in Breast Augmentation: to Use Drains or not? a Systematic Review : Drains in Breast Augmentation.

Aesthetic Plastic Surgery

Breast augmentation is one of the most commonly requested and performed plastic surgery procedures. In order to prevent early postoperative complications such as seroma or hematoma, surgical drains could be useful. The aim is to perform a systematic review of the literature on the use of surgical drains in primary breast augmentation.

This review was performed following the PRISMA guidelines. PubMed, SCOPUS, Web of Science and Cochrane Library databases were queried in search of clinical studies describing the use of surgical drains in women undergoing primary breast augmentation with implants and documenting seroma and/or hematoma formation rate and/or infection rate.

Initial search identified 2596 studies, and 162 were found relevant. Full-text review and application of our inclusion criteria to all retrieved papers produced 38 articles that met inclusion criteria. Among the included studies, 16 papers reported the use of surgical drains in breast augmentation, while in the remaining 22 articles drains were not used. Only 5 studies specifically investigated the role and effectiveness of surgical drains in augmentation mammaplasty and its possible relationship with complication rate such as seroma, hematoma or infection.

Despite similar complication rates emerged from the analyzed articles, because of the heterogeneity of the studies, we were not able to demonstrate specifically whether drain use affects the rate of early postoperative complications such as seroma, hematoma and infection. Additional randomized controlled trials are strongly advocated in order to provide the necessary scientific evidence.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Effect of Lipofilling and Platelet-Rich Plasma on Patients with Moderate-Severe Vulvar Lichen Sclerosus who were Non-Responders to Topical Clobetasol Propionate: A Randomized Pilot Study.

Aesthetic Plastic Surgery

The first-line treatment for vulvar lichen sclerosus (VLS) is 3 months of topical corticosteroid therapy. However, limited evidence is available concerning the use of fat grafting and platelet-rich plasma as a second-line treatment for patients who do not respond to first-line treatment.

This prospective single-center randomized pilot trial included 20 patients with a clinical and histological diagnosis of moderate to severe VLS. The patients in the treatment group (TG) received two infiltrations (at 3-month intervals) of nanofat mixed with platelet-rich plasma (PRP) into the vulvar area, while the control group (CG) received standard topical corticosteroid therapy. Fat was aspirated from the medial thigh or lower abdomen regions. Microfat was obtained after centrifugation and was emulsified to obtain a nanofat suspension. Treatment efficacy was determined by measuring changes in the vulvar skin elasticity, histopathology, and clinical signs, symptoms, and patient quality of life at after 1 year.

A total of 19 patients were finally assessed (9 TG and 10 CG). At the end of the study (1 year), there had been no significant improvement in vulvar skin elasticity. However, patients in the TG showed a significant improvement in their symptoms (itching, pain, burning, and dyspareunia) and clinical signs (cervical erosions, fissures, stenosis, and leukoderma). Analysis of skin biopsies revealed a significant decrease in all inflammatory cell types in the TG. No adverse events related to the autologous treatment were recorded.

Compared with topical corticosteroids, two infiltrations delivered 3 months apart decreased the inflammation of the vulva and improved most of the clinical signs and symptoms associated with VLS. Nonetheless, no improvement in vulvar skin elasticity was derived from the autologous treatment.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nasolabial Sulcus Rejuvenation: Paranasal Augmentation Using a Folded Dermal Graft.

Aesthetic Plastic Surgery

Nasolabial sulcus rejuvenation is steadily gaining popularity among Asians. Though many treatment options using synthetic grafts and autografts have been introduced, none of them has yet been accepted as an ideal technique. This study describes the operative procedure and evidence-based clinical outcomes of paranasal augmentation using dermal grafts.

From March 2015 to August 2019, 56 patients underwent paranasal augmentation. The dermal graft, harvested from the buttock, was folded into 4 to 6 layers and inserted into the supraperiosteal pocket through a gingivobuccal incision. Ultrasonographic evaluation was performed at postoperative months 1, 6, 12, and 18 to appraise the change in the thickness of the graft.

No major complications, including foreign body sensation and graft extrusion, occurred. The average dermal thickness was 10.31 mm at postoperative month 1 and 6.30 mm, 5.21 mm, and 5.17 mm at postoperative months 6, 12 and 18, respectively. The average absorption rates were 38.72%, 49.36%, and 49.92% at postoperative months 6, 12, and 18, respectively.

Paranasal augmentation using a folded dermal graft serves as a useful method to rejuvenate the midface with durable and aesthetically satisfactory outcomes. By virtue of biocompatibility, complications occurred rarely compared with the artificial implants.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Immediate Lipo-Filling as a Novel Technique for Volume Replacement in Oncoplastic Breast Conservative Surgery.

Aesthetic Plastic Surgery

We aimed to evaluate the feasibility of immediate lipofilling as a volume replacement technique in breast conservative surgery (BCS) in terms of the volume of fat graft resorption after radiotherapy, patient satisfaction, and oncological safety.

This was a prospective study that included female patients with breast cancer, with small- or medium-sized breasts. The patients underwent BCS followed by lipofilling into the deformed areas away from the tumor site that resulted from direct closure of the tumor cavity. They were followed up for early and late postoperative complications, including recurrence. Volumetric computed tomography was performed before and after radiotherapy to determine percentage fat resorption. Postoperative patient satisfaction was assessed using the Kyungpook National University Hospital Breast Reconstruction Satisfaction Questionnaire.

The study included 54 female patients with a mean age of 47.57 ± 9.26 years. The mean follow-up period was 31.02 ± 4.47 months. Local recurrence was observed in three patients (5.56%). The volume reduction of the injected fat graft ranged from 10.15% to 55.67%, with a mean of 29.27 ± 10.06%. Fifty-two patients (96.30%) reported postoperative satisfaction, and nine of them expressed satisfaction only after a second lipofilling session.

Immediate lipofilling as a volume replacement technique in BCS is a safe and simple technique without major complications. It has a locoregional recurrence rate similar to BCS alone, with an acceptable fat resorption percentage and high postoperative patient satisfaction.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Search for the Ideal Female Breast: A Nationally Representative United-States-Census Study.

Aesthetic Plastic Surgery

Many studies have started to search for the perfect aesthetic breast in order to create a pars-pro-toto for reconstruction, but especially for aesthetic surgery. To date, no representative study with anatomically accurate models was performed.

In an online based United-States-census-representative survey with 1049 participants, questions regarding the preferred breast were asked utilizing lifelike morphed 3D-generated female models for the first time. Attributes such as breast pole ratio, areola size, breast direction and projection were asked.

The results show that, contrary to what has been claimed in previous studies, an upper-pole-to-lower-pole ratio of 55:45 is preferred by both female and male participants. When it comes to breast size, on the other hand, there are clear gender-specific differences. While women opted for a cup size around B, the men preferred larger cup sizes. Moreover, the smallest depicted areola size of 30 mm was favored among all groups in the survey.

Most publications used rather detrimental models for their surveys. We therefore opted for computer-generated 3D models and varied their naturalness. This enabled us to ensure a more aesthetic and accurate illustration and thus obtained more comparable and reliable results paired with the representation of the US-population. Taken together this study unveiled unexpected insights into the population favored breast attributes that might change operative planning in breast surgery.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

A Proposed Classification and Treatment Algorithm for Rectus Diastasis: A Prospective Study.

Aesthetic Plastic Surgery

This study presents a classification system and treatment method to correct Rectus diastasis (RD) during abdominoplasty.

One hundred and sixty seven patients undergoing abdominoplasty were enrolled between April 2014 and January 2018. Forty-three patients did not present with RD and were excluded from the analysis. Mean age was 40.32 years, mean BMI was 23.84, and minimum follow-up was 24 months. A four-type (A: mild 2-3cm, B: moderate 3-5cm, C: severe 5-7cm, and D: very severe 7-9cm) classification system is described. A different treatment method is performed in each category using continuous and interrupted absorbable sutures. Postoperatively patients filled up a questionnaire that involved the level of pain, the postoperative day they performed specific indoor/outdoor activities, and the evaluation of the aesthetic result.

No statistically significant differences were observed between the four RD types regarding pain, complications, and return to specific activities. All types of RD had the same low rate complication profile. The seroma rate was 0.81%. The infection rate was 0.81%, and the thromboembolism and the pneumonic embolism rate was 0%. After 2-6 years of follow-up no clinical recurrence of rectus diastasis was observed. All reoperations (14.52%) were performed due to scar deformities. Mean pain score levels were very low (<1.5) and within a week most patients returned to specific indoor and outdoor activities. Most patients were extremely satisfied with the results.

In this article, we present an updated classification system and treatment protocol to provide surgeons a safe and standardized method that produces high-quality aesthetic results.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Use of Autologous and Cadaveric Grafts in Rhinoplasty: A Survey Study.

Aesthetic Plastic Surgery

Both autologous and cadaveric grafts are often used during rhinoplasty to create volume and provide support. Despite discussion in the literature comparing the efficacy, cost-effectiveness, and complication rates between grafting options, it remains unclear which is the superior choice when considering availability, donor site morbidity, and cost. There is a little description of the current use of these materials amongst facial plastic surgeons.

A 12 question survey was created, and IRB approval was obtained. The survey was distributed to practicing members of the AAFPRS via their membership listserv.

178 respondents completed the survey for an overall response rate of 17.5%. The most common rhinoplasty graft types used by respondents were autologous septal cartilage (96.6%), autologous auricular grafts (93.8%), autologous rib graft (ARG) (75.8%), and cadaveric rib graft (CRG) (56.7%). Patient comorbidities and performing more than 50 rhinoplasties per year were positively correlated with use of CRG grafts and concerns about complications and cost were negatively correlated.

While autologous septal and auricular cartilage remain the most common graft choices amongst surveyed facial plastic surgeons, a majority utilize cadaveric rib grafts in their practice. Patient comorbidities, surgery volume, concerns about graft complications, and cost were the chief factors associated with use of cadaveric grafts amongst survey respondents.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Biologic vs Synthetic Mesh for Single-stage Repair of Contaminated Ventral Hernias: A Randomized Clinical Trial.

JAMA Surgery

Biologic mesh is widely used for reinforcing contaminated ventral hernia repairs; however, it is expensive and has been associated with high rates of long-term hernia recurrence. Synthetic mesh is a lower-cost alternative but its efficacy has not been rigorously studied in individuals with contaminated hernias.

To determine whether synthetic mesh results in superior reduction in risk of hernia recurrence compared with biologic mesh during the single-stage repair of clean-contaminated and contaminated ventral hernias.

This multicenter, single-blinded randomized clinical trial was conducted from December 2012 to April 2019 with a follow-up duration of 2 years. The trial was completed at 5 academic medical centers in the US with specialized units for abdominal wall reconstruction. A total of 253 adult patients with clean-contaminated or contaminated ventral hernias were enrolled in this trial. Follow-up was completed in April 2021.

Retromuscular synthetic or biologic mesh at the time of fascial closure.

The primary outcome was the superiority of synthetic mesh vs biologic mesh at reducing risk of hernia recurrence at 2 years based on intent-to-treat analysis. Secondary outcomes included mesh safety, defined as the rate of surgical site occurrence requiring a procedural intervention, and 30-day hospital direct costs and prosthetic costs.

A total of 253 patients (median [IQR] age, 64 [55-70] years; 117 [46%] male) were randomized (126 to synthetic mesh and 127 to biologic mesh) and the follow-up rate was 92% at 2 years. Compared with biologic mesh, synthetic mesh significantly reduced the risk of hernia recurrence (hazard ratio, 0.31; 95% CI, 0.23-0.42; P < .001). The overall intent-to-treat hernia recurrence risk at 2 years was 13% (33 of 253 patients). Recurrence risk with biologic mesh was 20.5% (26 of 127 patients) and with synthetic mesh was 5.6% (7 of 126 patients), with an absolute risk reduction of 14.9% with the use of synthetic mesh (95% CI, -23.8% to -6.1%; P = .001). There was no significant difference in overall 2-year risk of surgical site occurrence requiring a procedural intervention between the groups (odds ratio, 1.22; 95% CI, 0.60-2.44; P = .58). Median (IQR) 30-day hospital direct costs were significantly greater in the biologic group vs the synthetic group ($44 936 [$35 877-$52 656] vs $17 289 [$14 643-$22 901], respectively; P < .001). There was also a significant difference in the price of the prosthetic device between the 2 groups (median [IQR] cost biologic, $21 539 [$20 285-$23 332] vs synthetic, $105 [$105-$118]; P < .001).

Synthetic mesh demonstrated superior 2-year hernia recurrence risk compared with biologic mesh in patients undergoing single-stage repair of contaminated ventral hernias, and both meshes demonstrated similar safety profiles. The price of biologic mesh was over 200 times that of synthetic mesh for these outcomes.

ClinicalTrials.gov Identifier: NCT02451176.

Association Between Hospital Perioperative Quality and Long-term Survival After Noncardiac Surgery.

JAMA Surgery

There is known variation in perioperative mortality rates across hospitals. However, the extent to which this variation is associated with hospital-level differences in longer-term survival has not been characterized.

To evaluate the association between hospital perioperative quality and long-term survival after noncardiac surgery.

This national cohort study included 654 093 US veterans who underwent noncardiac surgery at 98 hospitals using data from the Veterans Affairs Surgical Quality Improvement Program from January 1, 2011, to December 31, 2016. Data were analyzed between January 1 and November 1, 2021.

Hospitals were stratified separately into quintiles of reliability-adjusted failure to rescue (FTR) and mortality rates. Patients were further categorized as having a complicated or uncomplicated postoperative course.

The association between hospital FTR or mortality performance quintile (with quintile 1 representing low FTR or mortality and quintile 5 representing very high FTR or mortality) and overall risk of death was evaluated separately using multivariable shared frailty modeling among patients with a complicated and uncomplicated postoperative course.

For the overall cohort of 654 093 patients, the mean (SD) age was 61.1 (13.2) years; 597 515 (91.4%) were men and 56 578 (8.7%) were women; 111 077 (17.0%) were Black, 5953 (0.9%) were Native American, 467 969 (71.5%) were White, 42 219 (6.5%) were missing a racial category, and 26 875 (4.1%) were of another race; and 37 538 (5.7%) were Hispanic. Hospital-level 5-year survival for patients with a complicated course ranged from 42.7% (95% CI, 38.1%-46.9%) to 82.4% (95% CI, 59.0%-93.2%) and from 76.2% (95% CI, 74.4%-78.0%) to 95.2% (95% CI, 92.5%-97.7%) for patients with an uncomplicated course. Overall, 47 (48.0%) and 83 (84.7%) of 98 hospitals were either in the same or within 1 performance quintile for FTR and mortality, respectively. Among patients who had a postoperative complication, there was a dose-dependent association between care at hospitals with higher FTR rates and risk of death (compared with quintile 1: quintile 2 hazard ratio [HR], 1.05 [95% CI, 0.99-1.12]; quintile 3 HR, 1.17 [95% CI, 1.10-1.26]; quintile 4 HR, 1.30 [95% CI, 1.22-1.38]; and quintile 5 HR, 1.34 [95% CI, 1.22-1.43]). Similarly, increasing hospital FTR rates were associated with increasing risk of death among patients without complications (compared with quintile 1: quintile 2 HR, 1.07 [95% CI, 1.01-1.14]; quintile 3 HR, 1.10 [95% CI, 1.04-1.16]; quintile 4 HR, 1.15 [95% CI, 1.09-1.21]; and quintile 5 HR, 1.10 [95% CI, 1.05-1.19]). These findings were similar across hospital mortality quintiles for patients with complicated and uncomplicated courses.

The findings of this cohort study suggest that the structures, processes, and systems of care that underlie the association between FTR and worse short-term outcomes may also have an influence on long-term survival through a pathway other than rescue from complications. A better understanding of these differences could lead to strategies that address variation in both perioperative and longer-term outcomes.

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases.

Plastic and Reconstructive Surgery

Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions.

Therapeutic, IV.

Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months).

This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations area valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions.