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Background: The association of vaginal laxity with female sexual function is clinically significant. Male sexual pleasure can also be affected by vaginal laxity., Objectives: The aim of this study was to investigate the effect of vaginoplasty on a cohort of women who underwent this procedure for indications of vaginal laxity/impaired sexual function. The sexual satisfaction of partners after vaginal tightening was also evaluated., Methods: Fifty women who underwent vaginoplasty and their male partners (n = 50) were included in the study. The State-Trait Anxiety Inventory (STAI) and the Female Sexual Function Index (FSFI) were administered to female patients 3 months before and after the treatment. In addition, the sexual function of male partners was assessed by the International Index of Erectile Function-5 (IIEF-5) 3 months before and after the treatment. A 5-question questionnaire inquiring about pleasure status, scored on a 4-point Likert scale, was administered to the male partners., Results: The posttreatment STAI-State and STAI-Trait scores of the female patients were statistically significantly lower than their pretreatment scores (52.5 vs 32, P < .001; 56 vs 44, P < .001, respectively). The posttreatment FSFI score of the female patients was significantly higher than their pretreatment score (19.2 vs 29.7, P < .001)., Conclusions: The results demonstrated a significant improvement in the sexual function of males and females, and additionally, a significant decrease in the indices of temporary anxiety levels and the inherent predisposition for anxiety disorders after vaginoplasty., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Autologous bone cranioplasty is associated with a high complication rate, particularly infections and bone resorption. Although there are studies on the incidence and risk factors for complications following autologous bone cranioplasty, the study design is typically limited to retrospective analysis with multiple statistical explorations in small cohorts from single centers. Thus, there is a need for systematic analysis of aggregated data to determine the rate and risk factors for cranioplasty complications., Objective: To determine the incidence and risk factors for complications after autologous bone cranioplasty., Methods: In this systemic review, we conducted a Medline, Embase, Cochrane, and Web of Science search: 11,172 papers were identified. Duplicates were removed and only articles on complications following autologous bone cranioplasty between the years 2000 and 2022 were included. After title, abstract, and article screening, 132 papers were included for further analysis., Results: In total, the 132 studies are based on 13,592 patients (14960 implants). One third of the studies include patients with less than 3 months of postoperative follow-up. Complication management (flap removal, revision without flap removal, and conservative treatment) of infection, bone resorption, and hematoma/seromas are not reported in 19-30% of the studies. In the studies with defined complications management, the overall complication rate is 7.6% (95% Confidence Interval (CI) [7.1-8.2]) for infection, 14.4% (95% CI [13.7-15.2]) for bone resorption with indication for reconstruction, and 5.8%, (95% CI 5.2-6.5) for hematoma/seromas. Factors such as younger age, an extended interval between craniectomy and cranioplasty, the use of a fragmented bone implant, a larger implant size, and shunt treatment are linked to an increased risk of postoperative bone resorption., Conclusion: The lack of consistent definitions of complications, variations in follow-up time, and small study cohorts limit the external validity of many studies. Overall, the rate of bone flap resorption that required reoperation is high, while the rate of infectious complications is comparable to synthetic implants. Thus, autologous bone should preferably be used in cases without strong risk factors for bone necrosis., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Purpose: Although blood loss in microsurgical reconstruction is rarely large enough to be life-threatening, preoperative anemia can be a particular issue in terms of postoperative morbidity, impaired wound healing, and compromised tissue viability. We seek to review the effect of preoperative hemoglobin (Hgb) levels on perioperative blood transfusion (PBT) requirements and complications to guide management of patients with preexisting anemia undergoing reconstruction., Methods: PubMed, Embase, and Scopus were queried for relevant articles. Inclusion criteria were as follows: original studies investigating outcomes and PBT requirements in flap-based reconstruction based on preoperative Hgb levels. Patient and study characteristics were analyzed using descriptive statistics. A meta-analysis was conducted to assess transfusion requirements across the included studies using Stata (version 18.0 Stata Corp, College Station, Texas, USA). The Fisher method was used to aggregate individual study p values into a single combined value to statistically assess the combined findings, where a p value of < 0.05 was set as statistically significant., Results: One thousand three hundred and eighty-nine studies were screened for title and abstract relevance, 14 of which met the inclusion criteria, including a total of 61,116 patients. Meta-analysis of the studies revealed a PBT requirement of 36.2% for anemic individuals, significantly higher than the 20.0% for those with normal preoperative Hgb levels (p < 0.001), with an average 4.9 versus 2.4 units of packed red blood cells being transfused (p < 0.001). The majority of studies concluded that preoperative anemia was associated with medical complications, such as myocardial infarction, stroke, and infection (p < 0.001). While six studies reported a significant relationship between low preoperative Hgb and flap morbidity (flap loss and partial flap necrosis), two studies found no correlation. The overall postoperative complication rate across the studies was 42.2% among patients with low preoperative Hgb levels, whereas the nonanemic group demonstrated a markedly lower rate of 13.9% (p < 0.001)., Conclusion: The existing evidence is strongly suggestive of increased PBT requirement in patients with anemia, highlighting the necessity for preoperative optimization of Hgb levels and intraoperative monitoring. While preliminary evidence demonstrates a relationship between anemia and medical complications, more research is warranted to characterize the specific association between preoperative Hgb levels and flap morbidity., (© 2024 Wiley Periodicals LLC.)

Background: The purpose of this meta-analysis was to compare the surgical outcomes of head and neck reconstruction via free flap surgery, with neck vessels versus superficial temporal vessels as recipient vessels., Methods: The PubMed, Embase, and Scopus databases were systematically searched via the following keywords: ("superficial temporal" OR "temporal") AND ("free flap" OR "free tissue transfer") AND ("head and neck" OR "face"). The following data were extracted: first author, publication year, flap type, reconstruction region, concordant vein graft, recipient vessel, and postoperative complications, including thrombosis, partial necrosis, and flap failure. The recipient vessels were divided into two groups: the superficial temporal artery (STA)/V group and the neck group., Results: Six hundred and thirty-five studies that met the inclusion criteria were included and reviewed systematically for a meta-analysis. Compared with the neck vessel group, the STA/V vessel group had a significantly greater risk of flap failure (odds ratio: 2.18; 95% CI: 1.32-3.60; p = 0.002), with low heterogeneity (p = 0.84; I 2  = 0%). However, there were no significant differences in the rates of thrombosis or partial necrosis., Conclusions: Compared with the use of neck vessels, the use of STA/V vessels as recipient vessels for head and neck reconstruction could increase the risk of total flap necrosis. Considering these findings, surgeons should exercise caution when selecting the STV as the recipient site, and as some authors have suggested, proximal dissection may be necessary during surgery., (© 2024 The Author(s). Microsurgery published by Wiley Periodicals LLC.)

Background: Bicanalicular and mono-canalicular stent intubations were developed for post-oncological lacrimal duct reconstruction; however, comparative analysis between the two surgical modalities is lacking. This study aimed to compare the surgical outcomes between the two types of stents at a single institution., Materials and Methods: Briefly, 75 eyes of 75 patients who underwent lacrimal reconstruction combined with lacrimal stent intubation were enrolled in this study and were divided into bicanalicular stent intubation and mono-canalicular stent intubation groups. The clinical characteristics, follow-up, and prognosis were compared between the two groups., Results: Bicanalicular and mono-canalicular stent intubations were performed in 36 eyes (36 patients; Group A) and 39 eyes (39 patients; Group B), respectively. The difference in stent duration between Groups A and B was statistically significant. Three eyes in Group A and one eye in Group B experienced postoperative stent prolapse. Two eyes in Group B showed punctum stenosis and one eye had punctal ectropion. Seven eyes in Group A had canalicular slitting. There were no statistically significant differences in the mean preoperative Munk scores between the two groups. There were no statistically significant differences in the mean Munk scores and mean VAS scores at 1 week postoperatively, before stent removal, and 3 months after stent removal between the two groups., Conclusion: Bicanalicular and mono-canalicular stent intubations were equally effective in ensuring lacrimal duct patency and in preventing postoperative epiphora. Appropriate cases and stent selection can reduce the incidence of postoperative complications., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Although plastic surgery procedures generally demonstrate less than 2% incidence of venous thromboembolism (VTE) outcomes, the post-COVID era data remain elusive. This study sought to elucidate the relationship between COVID-19 infection and the risk of VTE outcomes across plastic surgery procedures., Methods: Plastic surgery procedures were identified in the 2012-2022 National Surgical Quality Improvement Program databases. The outcomes of interest were the postoperative occurrence of VTE, defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), and postoperative complication. Propensity score matching was used to 1) compare overall rates of VTE between the pre-pandemic era and pandemic era cohorts and 2) compare rates of VTE and overall postoperative complications in cases with and without COVID-19 diagnosis in the years 2021-2022 (p < 0.05)., Results: Overall, 269,006 plastic surgery cases were identified, comprising general breast (76%) and trunk (9.4%) procedures. Non-breast free tissue transfer cases were associated with the highest rates of DVT (1.3%) and trunk procedures with the highest rates of PE (0.7%). After propensity score matching, the overall rate of VTE after the onset of the COVID-19 pandemic was not significantly different from the pre-pandemic era (p = 0.40). In a separately matched cohort, COVID-19 diagnosis did not significantly predict the risk for VTE (p = 0.48) but did significantly predict the risk for overall postoperative complications (p < 0.001)., Conclusions: Although COVID-19 diagnosis itself did not predict the risk of VTE in matched analysis, it significantly predicted the overall postoperative complications. Future studies may further investigate the effects of COVID-19 infection over longer periods of follow-up., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The optimal sequence of microvascular clamping during free flap transfer is yet to be established. Many surgeons are reluctant to perform temporary declamping and subsequent reclamping during microvascular anastomosis; however, we generally anastomose the artery first and temporarily declamp it before performing venous anastomosis to confirm arterial patency and ensure proper alignment of the flap veins. Herein, we aimed to retrospectively investigate the efficacy and safety of this temporary revascularization method in 126 patients who underwent microvascular head and neck reconstruction., Methods: A total of 127 free flaps were transferred, with the anterolateral thigh flap (49 flaps) being the most frequently used. The internal jugular vein was the most frequently used recipient vein and end-to-side anastomoses to it were performed in 112 patients., Results: Intraoperative reanastomosis was required because of arterial thrombosis in 5 cases (4.0%), arterial and venous thrombosis in 1 case (0.8%), injury to the flap artery distal to the anastomotic site in 1 case (0.8%), and venous twisting in 1 case (0.8%). Postoperatively, all the flaps survived without microvascular compromise., Conclusions: Vascular kinking or twisting of the vascular pedicle is a major cause of free flap failure. However, it is difficult to place empty vessels accurately during clamping. Nonetheless, temporary revascularization engorges the flap vein before venous anastomosis and minimizes the risk of venous kinking and twisting. According to our results, reclamping did not increase the risk of arterial thrombosis., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Predictors of outcomes in pediatric microtia surgery are not well understood within the current literature. A multi-institutional database study may reveal insights into these predictors., Objectives: To explore the predictors of 30-day complications, 30-day readmission, and postoperative length of stay (PLOS) in pediatric microtia patients undergoing autologous rib grafting., Methods: The Pediatric National Surgical Quality Improvement Program was queried for details on patients with microtia (ICD-9/10 744.23/Q17.2) who underwent autologous rib grafting (CPT 21230) between 2012-2021. Demographics, comorbidities, inpatient status, 30-day complications, PLOS, and 30-day readmissions were analyzed. Statistical analyses were performed to compare the preoperative characteristics with postoperative outcomes., Results: Overall, 667 patients met the inclusion criteria. Sixty-three (9.4%) had at least one complication, and 19 (2.9%) were readmitted. Univariate analysis showed that inpatient status (p = 0.011) and race (p = 0.023) were associated with higher complication rates. Multivariate analysis revealed that outpatient status was associated with significantly lower odds of complications (OR: 0.49, 95% CI [0.27, 0.87], p = 0.018), and developmental delay was associated with higher odds of 30-day readmission (OR: 2.80, 95% CI [1.05, 7.17], p = 0.036). Longer operative time was associated with older age (13.9% increase per five-year age increase, p < 0.001) and inpatient status (35.3% increase, p < 0.001). PLOS was shorter for outpatients (45.45% shorter, p < 0.001) and cases performed by plastic surgeons (14.2% shorter, p < 0.001)., Conclusion: Microtia reconstruction using autologous cartilage is a relatively safe procedure with low complication and readmission rates. Significant predictors of postoperative outcomes include inpatient status, race, developmental delay, and age. These findings highlight the importance of considering these factors in surgical planning and patient counseling., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: In transgender or non-binary patients (TGNB) with failed penile inversion vaginoplasty (PIV), peritoneal flap vaginoplasty (PFV) and intestinal segment vaginoplasty (ISV) facilitate restoration of neovaginal depth and sexual function. This study compared the outcomes of revision PFV and ISV in TGNB patients with failed PIV., Methods: TGNB patients who underwent secondary PFV or ISV from December 2018 to April 2023 were reviewed., Results: Twenty-one (5.8%) patients underwent secondary PFV and 24 (6.6%) underwent secondary ISV, due to vaginal stenosis (n = 45, 100.0%). Mean duration to first successful dilation and average vaginal depth were comparable between the groups. Seven (33.3%) PFV patients experienced short-term complications, including introital dehiscence (n = 2, 9.5%), vaginal stenosis (n = 2, 9.5%), vaginal bleeding (n = 2, 9.5%), and reoperation (n = 2, 9.5%). Nine (42.9%) experienced long-term complications, including urethrovaginal fistula formation (n = 2, 9.5%), hypergranulation (n = 2, 9.5%), vaginal stenosis (n = 7, 33.3%), and reoperation (n = 6, 28.6%). Ten (41.7%) ISV patients experienced short-term complications, including dehiscence (n = 4, 19.0%), ileus (n = 2, 8.3%), introital stenosis (n = 2, 9.5%), and reoperation due to vaginal bleeding (n = 2, 8.3%). Six (25.0%) experienced long-term complications, including introital stenosis (n = 3, 12.5%), mucosal prolapse (n = 2, 8.3%), and reoperation due to mucosal prolapse (n = 4, 16.7%). Secondary PFV had a higher rate of vaginal stenosis (p = 0.003). There were no cases of partial or full-thickness flap necrosis., Conclusion: Revision PFV and ISV represent viable techniques for addressing vaginal stenosis secondary to PIV. Although PFV and ISV had comparable rates of short-term complications, ISV demonstrated a lower incidence of recurrent vaginal stenosis, which may inform operative decision-making., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To explore the influencing factors of syncope in patients after plastic surgery, establish a syncope risk prediction model, and verify its accuracy., Methods: A total of 265 patients undergoing craniomaxillofacial surgery were included and divided into a syncope group and non-syncope group. Multivariate logistic regression analysis was used to screen for risk factors of syncope, and R language was used to establish a risk prediction nomogram of syncope in craniomaxillofacial surgery patients. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the fit of the model, and the receiver operating characteristic (ROC) curve was used to analyze the predictive value of the model., Results: Syncope occurred in 87 of 265 patients (32.8%), and no syncope occurred in 178 patients (67.8%). Multivariate logistic regression analysis revealed statistical differences in age, orthostatic heart rate, orthostatic diastolic blood pressure, syncope history, weight loss history, and medication history between the 2 groups (P < 0.05). A nomogram was constructed for predicting the risk of syncope after craniomaxillofacial surgery, and the Hosmer-Lemeshow goodness-of-fit test proved that the nomogram fitted well (P = 0.431). The results of ROC curve analysis showed that the alignment graph model had high prediction accuracy; the area under the curve was 0.886 (95% confidence interval, 0.8381-0.9332)., Conclusion: Evaluating the risk of syncope after craniomaxillofacial surgery is helpful and provides guidance for the formulation of preventive strategies., (Copyright © 2024. Published by Elsevier Ltd.)

Background: People with diabetic foot ulcers (DFUs) are at risk of major amputation, which is associated with a high mortality rate (exceeding 50% at 5 years) and reduced quality of life. The authors hypothesized that flap reconstruction of DFUs improves patient outcomes in comparison with standard treatment modalities, including major amputation., Methods: MEDLINE, Embase, the Cochrane Library, and gray literature were searched on February 9, 2022. Comparative and single-arm studies reporting outcomes of DFUs treated with local, regional, or free flaps that included function, limb loss, mortality rates, and flap failure rates were included. Risk of bias was assessed, and meta-analysis of proportions was performed., Results: A total of 3878 records were retrieved, of which 45 met the inclusion criteria, including the records of 1681 patients who underwent flap reconstruction of DFUs. Free flaps were most commonly performed ( n = 1257 [72%]). Only one study used a verified functional outcome measure. At 12 months, the mortality rate was 6.35% (95% CI, 3.89% to 10.20%), the limb loss rate was 11.39% (95% CI, 7.02% to 17.96%), and the free flap failure rate was 9.95% (95% CI, 8.19% to 12.05%). All studies were at high risk of bias. A comparative meta-analysis of interventions was not performed because of study method and outcome heterogeneity., Conclusions: There is short-term evidence that flap reconstruction (including microsurgical transfer) has low mortality, limb loss, and flap failure rates. However, there are limited high-quality comparative studies, and uncertainty remains regarding the outcome of DFU flap reconstruction in comparison to other treatments., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction., Methods: The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs)., Results: The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence., Conclusions: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state., Methods: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022., Results: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period., Conclusion: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications., Level of Evidence: 4 Laryngoscope, 134:4521-4526, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Shoulder function after spinal nerve grafting in pan-brachial plexus injuries (pan-BPI) is not well described. The authors evaluated shoulder abduction (ABD) and external rotation (ER) after spinal nerve grafting to the suprascapular nerve, axillary nerve, or posterior division of the upper trunk and determined patient characteristics, injury severity and characteristics, and nerve graft factors that influenced outcomes., Methods: A total of 362 patients undergoing pan-BPI reconstruction and spinal nerve grafting for shoulder reanimation in a single institution between 2001 and 2018 were reviewed. Patient demographics, Injury Severity Score (ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into 3 groups based on recovery of shoulder function: no return, ABD only, and ABD and ER., Results: A total of 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. Seventeen (41.5%) had no return of shoulder function, 14 (34.1%) had ABD alone, and 10 (24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger (18.6 ± 5.56 years), had lower body mass index (22.4 ± 4.0), and had a lower ISS (10.5 ± 6.24; P = 0.003). Multivariable analysis found that with increasing age (OR, 0.786; 95% CI, 0.576, 0.941) and ISS (OR, 0.820; 95% CI, 0.606, 0.979), odds for return of ABD and ER decreased significantly., Conclusions: In pan-BPI, 24.4% of patients demonstrated return of both ABD and ER after spinal nerve grafting to suprascapular nerve and either axillary nerve or posterior division of the upper trunk. Age, body mass index, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, body mass index, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation., Clinical Question/level of Evidence: Risk, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Various surgical methods have been developed for treating velopharyngeal insufficiency (VPI); however, the choice of surgical treatment is controversial. The pharyngeal flap, which is commonly used, has a high success rate but frequently leads to airway complications. Furlow double-opposing Z-plasty (DOZ) does not deform the velopharyngeal port; therefore, it is expected to show good speech outcomes while reducing airway complications if an appropriate indication is noted. This study aimed to identify indications for DOZ in cases of VPI after palatoplasty., Methods: Nonsyndromic patients who underwent palatoplasty were prospectively followed from 2008 to 2016, and those diagnosed with VPI were treated with DOZ. Preoperative facial computed tomography (CT) and postoperative nasometric assessment results were examined. Surgical indication was set based on a 30% threshold value for postoperative nasalance., Results: Comparing the preoperative CT measurements of both groups, high need ratio (NR), wide width of the nasopharynx (WNP), and long velopharyngeal depth (VPD) were contributing factors to VPI occurrence ( P < 0.05). Analyzing preoperative CT and postoperative speech evaluation results, a linear relationship was observed between preoperative NR, WNP, and VPD and postoperative nasalance. In cases where NR was less than 0.81, WNP was less than 27.64 mm, and VPD was less than 20.34 mm, DOZ showed favorable outcomes ( P < 0.05)., Conclusions: Preoperative CT evaluation should be performed in patients with VPI. When WNP, VPD, and NR values are small, DOZ can achieve sufficient correction of VPI and reduce the risk of airway complications. In cases where the indication range is exceeded, the pharyngeal flap is considered., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: This study updates the authors' institutional experience with modified Furlow palatoplasty, evaluating speech outcomes and incidence of secondary speech surgery throughout development and at skeletal maturity., Methods: Nonsyndromic patients undergoing primary modified Furlow palatoplasty between 1985 and 2005 with postoperative speech evaluations were reviewed retrospectively. Secondary speech surgery and Pittsburgh Weighted Speech Scale (PWSS) scores before secondary speech or orthognathic operations were assessed in the groups aged 5 to 7 years, 8 to 11 years, 12 to 14 years, and older than 15 years and analyzed by Veau cleft type., Results: A total of 551 patients with 895 total speech assessments were analyzed. Of 364 patients followed up to age 15 years or older, 19.8% underwent secondary speech surgery. Speech assessment of patients aged 15 years or older without prior secondary speech surgery showed competent velopharyngeal mechanisms in 77% of patients. PWSS nasal emission scores were worse in the 5- to 7-year age range ( P = 0.02), whereas resonance scores remained stable throughout development ( P = 0.2). Patients with Veau type I or II clefts had worse overall PWSS classifications in the groups aged 5 to 7 years and 8 to 11 years ( P = 0.01 and P = 0.03), with greater odds of secondary speech surgery relative to those with Veau type III (OR, 2.9; P < 0.001) or IV clefts (OR, 3.6; P = 0.001)., Conclusions: Most patients undergoing primary modified Furlow palatoplasty do not require secondary speech surgery and achieve socially acceptable speech at skeletal maturity. However, Veau type I and II clefts are associated with increased risk for early velopharyngeal dysfunction and secondary speech surgery. The incidence of secondary speech surgery was 19.8%, an increase from our previously reported rate of 8%., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: There is no optimal reconstruction technique after proximal gastrectomy. The esophagogastrostomy (EG) is a rather simple procedure technically, but the incidences of reflux esophagitis and anastomotic stricture are higher. While the double-tract reconstruction (DTR) can lessen postoperative reflux esophagitis, it is technically complex with a long operation time. The purpose of this study was to evaluate the quality of life (QoL) and short-term outcomes of the two reconstruction techniques., Methods: We retrospectively collected consecutive patients with upper-third gastric adenocarcinoma and adenocarcinoma of the esophagogastric junction (AEG) at our center between 2019 June and 2023 May. Patients who underwent laparoscopic proximal gastrectomy (LPG) with EG or DTR were included in this study. A comparison was made between the clinical and pathological characteristics of patients and their surgical parameters, postoperative complications, and its 1-year QoL in two groups. The QoL of the two groups was assessed by Visick grading, the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-STO22 scales at 1 year after operation. The nutritional status of the two groups was evaluated by BMI, hemoglobin and serum albumin., Results: AII the qualified patients were divided EG group (n = 63) and DTR group (n = 93). Compared to the DTR group, the blood loss volume of EG group was more (p = 0.001). There were no significant differences in operation duration, number of lymph nodes dissected, and postoperative length of stay between the two groups(p > 0.05). No statistical differences were observed in terms of the incidence of early complications and Clavien-Dindo classification as well(p > 0.05). After one year, the Visick grade of the DTR group was better than EG group (p = 0.040). The multivariable logistic regression analysis showed the only independent risk factor for reflux esophagitis was the reconstruction method. According to the EORTC QLQ-C30 questionnaire, patients in the DTR group had a better global health status(p = 0.001) and complained less about nausea and vomiting(p = 0.033), and appetite loss (p = 0.022). Patients in the DTR group complained less about reflux (p = 0.030) based on the EORTC QLQ-STO22 questionnaire. The multiple linear regression analysis revealed that the reconstruction method, reflux esophagitis and age had a linear relationship with the global health status score. Regarding nutritional status, BMI of the two groups both decreased 1 year after operation, and BMI decline value of the DTR group was lower than EG group (p = 0.001). There is no statistically significant difference between the two groups as for postoperative change in hemoglobin and serum albumin., Conclusion: Our findings suggest that it is possible for skilled surgeons to achieve minimal blood loss volume without significantly increasing operation duration when performing DRT, which does not raise risk. In terms of anti-reflux, postoperative QoL and BMI maintenance, 1-year postoperative follow-up outcomes reveal the DTR is superior to EG, which deserve further research and promotion., (© 2024. The Author(s).)

Purpose: Tibial tubercle osteotomy (TTO) is often employed for certain patellofemoral instability (PFI) cases, though its indications and effectiveness are not widely accepted. This systematic review gathers recent studies comparing isolated medial patellofemoral ligament reconstruction (iMPFLR) to MPFLR combined with TTO in managing PFI and to offer recommendations for clinicians when selecting TTO. This review proposes that MPFLR combined with TTO is superior to iMPFLR and that the combined procedure does not increase the incidence of postoperative complications., Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020), extensive searches were performed on August 20, 2024, across PubMed/Medline, Embase, and Cochrane databases to locate relevant studies. Data on research protocols, participant characteristics (including epidemiological and radiographic features), functional scores, and complications were collected and examined. A meta-analysis was conducted to compare the outcomes between the two surgical techniques., Results: This systematic review analyzed 10 studies involving 715 participants, divided into a control group (which underwent iMPFLR) and an experimental group (which underwent MPFLR combined with TTO). In the control group, the incidence of severe trochlear dysplasia before surgery was 68.3% (95% CI [67.3-69.3%]), and the mean preoperative tibial tubercle to trochlear groove distance (TT-TG) was 16.1 mm (95% CI [15.8-16.3]). In the experimental group, both were respectively 79.1% (95% CI [77.5-80.7]) and 20.2 mm (95% CI [20.0-20.4]). Eight studies (80%) reported postoperative Kujala scores, with an average score of 85.1 (95% CI [84.4-85.9]) for the control group and 85.4 (95% CI [84.9-85.9]) for the experimental group (I²=22.7%). Four studies (40%) reported postoperative Lysholm scores, with an average score of 89.4 (95% CI [88.9-89.9]) for the control group and 89.1 (95% CI [89.0-89.3]) for the experimental group (I²=0%). The mean surgical failure rate for the control group was 5.1% (95% CI [4.7-5.6%]), compared to 3.2% (95% CI [3.0-3.4%]) for the experimental group, with an odds ratio (OR) of 2.18 (95% CI [1.05-4.53], I²=0%, p = 0.738). The rate of secondary surgeries in the control group was 1.9% (95% CI [1.6-2.2]), while in the experimental group it was 10.7% (95% CI [9.4-12.1]), with an OR of 0.12 (95% CI [0.03-0.54], I²=63.1%, p = 0.028)., Conclusion: The combination of MPFLR and TTO for treating PFI yields knee joint function comparable to that achieved with MPFLR alone. The approach does not elevate the failure rate of the surgery or the incidence of other adverse events. However, the combined approach may prolong the postoperative rehabilitation process and typically requires removal of internal fixation devices, resulting in a higher rate of secondary surgeries., (© 2024. The Author(s).)

Background: Chest wall tumors are uncommon. The surgical objective is local disease control and the relief of symptoms. Due to the heterogeneity of cases, the great variety of reconstructions, size of resection, and clinical and surgical outcomes are still uncertain., Methods: Patients were submitted to sternectomies for tumors between 1997 and 2019. Oncological, and surgical characteristics were taken into consideration. The outcomes were related to the size of resection and classified into local and systemic complications. The authors used univariate and multivariate analyses to determine predictors of complications. Survival analysis and Kaplan-Meier curves were obtained., Results: Thirty resections were performed due to metastatic disease. Partial sternectomy was accomplished in 48.8 %, followed by subtotal in 40 %. Primary closure using Pectoralis major was performed in 48.8 %, and Latissimus dorsi in 35.5 %. Polypropylene mesh was used in 86.6 % of reconstructions. The prosthesis removal was necessary in 6.66 %. Respiratory failure was evidenced in 6.66 %. The resection area was a predictor of local and systemic complications (p = 0.0029; p = 0.0004 respectively) in univariate analysis. However, the size of resection was the only predictor of systemic complications regarding multivariate analysis (p = 0.014, 95 % CI 1.00‒1.07)., Conclusion: The size of the resection was related to systemic complications, and the mesh reconstruction resulted in a low percentage of prosthesis removal and respiratory failure. This suggests a high resistance to local issues and a low respiratory failure rate., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Various surgical techniques have been devised for the surgical cosmetic enhancement of female outer genitalia. The selection of an optimal method should be based on satisfaction rates and safety; however, comprehensive, contemporary systematic assessment of these factors has been limited in the literature., Objectives: Our aim was to conduct a comprehensive systematic review and meta-analysis to evaluate the overall satisfaction rates and risk factors associated with various labiaplasty techniques and tools., Methods: The authors performed a systematic literature search in 3 medical databases: PubMed, Elsevier, and Cochrane (Central) with the closing date of October 2023. Original articles with quantitative satisfaction rates and frequencies of the most common complications (hematoma, dehiscence, swelling, bleeding, and infection) were included., Results: Systematic search provided a total of 3954 records. After selection and review of the articles, 86 eligible, peer-reviewed studies were identified, of which 53 provided quantitative data. High overall satisfaction rate was found for all methods (proportion [prop] 94%; confidence interval [CI] 93%-95%), with highest satisfaction for deepithelialization (prop 97%; CI, 85%-99%). Complications were generally rare, with elevated incidences for some techniques (wedge resection: dehiscence, prop, 8%, CI 5%-13%; and composite reduction: swelling, prop 13%, CI 2%-54%). Scalpel technique had significantly higher incidence of complications than laser, namely for bleeding, swelling, and hematoma., Conclusions: Labiaplasty can be considered a generally effective approach to outer female genitalia beautification, with low associated risks. Surgeons must tailor their approach to the patients' needs and anatomy to achieve maximal satisfaction, given the differences in the frequency of complications for each method., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Artificial intelligence (AI) techniques are showing significant potential in the medical field. The rapid advancement in artificial intelligence methods suggests their soon-to-be essential role in physicians' practices., Objectives: In this study, we sought to assess and compare the readability, clarity, and precision of medical knowledge responses provided by 3 large language models (LLMs) and informed consent forms for 14 common aesthetic surgical procedures, as prepared by the American Society of Plastic Surgeons (ASPS)., Methods: The efficacy, readability, and accuracy of 3 leading LLMs, ChatGPT-4 (OpenAI, San Francisco, CA), Gemini (Google, Mountain View, CA), and Copilot (Microsoft, Redmond, WA), was systematically evaluated with 14 different prompts related to the risks of 14 common aesthetic procedures. Alongside these LLM responses, risk sections from the informed consent forms for these procedures, provided by the ASPS, were also reviewed., Results: The risk factor segments of the combined general and specific operation consent forms were rated highest for medical knowledge accuracy (P < .05). Regarding readability and clarity, the procedure-specific informed consent forms, including LLMs, scored highest scores (P < .05). However, these same forms received the lowest score for medical knowledge accuracy (P < .05). Interestingly, surgeons preferred patient-facing materials created by ChatGPT-4, citing superior accuracy and medical information compared to other AI tools., Conclusions: Physicians prefer patient-facing materials created by ChatGPT-4 over other AI tools due to their precise and comprehensive medical knowledge. Importantly, adherence to the strong recommendation of ASPS for signing both the procedure-specific and the general informed consent forms can avoid potential future complications and ethical concerns, thereby ensuring patients receive adequate information., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background and Objectives : The deltopectoral (DP) flap represents a reconstructive option for the head and neck. It is a fasciocutaneous flap raised from the anterior chest wall below the clavicle. Its role partially declined with the arise of free flaps. However, it still remains a valid option in patients that could not undergo a reconstruction with free flaps. The aim of this retrospective study was to evaluate the role of the DP flap in head and neck reconstruction, with a focus on surgical outcomes and complications. Materials and Methods : Thirty-one patients who underwent head and neck reconstruction with DP flap were included in the study. The delayed technique was not used in any procedure to harvest the flap beyond the deltopectoral groove. The patients' characteristics, the recipient site, the closure of the donor site, and the flap-related complications were recorded. Results : The median time to autonomization of DP flap was 23 days. Postoperative complications were observed in 10 subjects (32.3%). A partial necrosis was seen in five patients (16.1%), while a complete necrosis developed only in one case (3.2%). The diabetes mellitus was the only parameter associated with postoperative complications. In particular, the percentage of necrosis in subjects with or without diabetes was 66.7% and 8.0%, respectively. Conclusions : The DP has a wide range of applications in head and neck reconstruction, and a low complication rate can be observed. The delayed technique does not necessarily need to be applied, and the flap can be extended beyond the deltopectoral groove when necessary. However, patients with diabetes mellitus have a higher risk of postoperative necrosis of the distal portion of the flap.

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations., (© Crown copyright 2024.)

Introduction: Lower extremity (LE) reconstruction in the elderly population presents a multifaceted challenge, primarily due to age-related degenerative changes, comorbidities, and functional decline. Elderly individuals often encounter conditions such as osteoarthritis, osteoporosis, and cardiovascular and peripheral artery disease (PAD), which can severely compromise the structural integrity and function of the lower limbs. As such, we aim to assess postoperative complications and functional recovery following LE reconstruction in elderly patients., Methods: Patients ≥ 18 years who underwent post-traumatic LE reconstruction with flap reconstruction at a Level 1 trauma center between 2007 and 2022 were included. Patient demographics, flap/wound characteristics, complications, and ambulation for the elderly (≥ 60 years old) and the control (< 60 years old) cohorts were recorded. The primary outcome was final ambulation status, modeled with logistic regression. Secondary outcomes included postoperative complications., Results: The mean ages of the control (n = 374) and elderly (n = 49) groups were 37.4 ± 12.6 and 65.8 ± 5.1 years, respectively. Elderly patients more frequently required amputation after flap surgery (p = 0.002). There was no significant difference between the two cohorts in preoperative ambulation status (p = 0.053). Postoperatively, 22.4% of elderly patients were independently ambulatory at final follow-up, compared to 49.5% of patients < 60. Of the elderly, 14.3% could ambulate with an assistance device (cane, walker, etc.), compared to 26.5% in the control group. A wheelchair was required for 46.9% of elderly patients, significantly higher than the 22.7% of those < 60 years of age (p < 0.001). Multivariate regression confirmed an association between older age and nonambulatory final status (p = 0.033)., Conclusion: LE reconstruction can likely be performed safely in patients 60 years of age or older. However, older age is independently associated with significantly worse postoperative ambulation. Preoperative assessment, including gait and muscle strength, and early initiation of postoperative rehabilitation can potentially improve ambulation in elderly individuals undergoing LE reconstruction., (© 2024 Wiley Periodicals LLC.)

Introduction and Hypothesis: To assess the outcomes of mid-urethral sling (MUS) procedures for urodynamic stress incontinence (USI) following extensive pelvic reconstructive surgery (PRS) and identify risk factors for persistent USI (P-USI)., Methods: This retrospective study analyzed 84 women who underwent a staged approach to MUS for USI after PRS for advanced pelvic organ prolapse (Pelvic Organ Prolapse Quantification III and IV). The primary outcome was objective cure rate, defined by negative urine leakage on urodynamic study and a 1-h pad test weight of < 2 g. Subjective cure rate was through a negative response to question 3 of UDI-6., Results: The overall objective cure rate was 81.0%. The highest cure rate was observed in de novo USI (MUS-D; 89.7%) compared with women with persistent USD (MUS-P). Patients with overt SUI exhibited lower cure rates than those with occult SUI. Predictive factors for persistent USI were lower pre-operative maximum urethral closure pressure (MUCP; p = 0.031) and higher BMI in the MUS-P group than in the MUS-D group (p = 0.008). Subjective improvement was noted, especially in the MUS-D group, with a subjective cure rate of 78.6%. Those with MUS-D reported a higher impact on patient well-being post-surgery. No complications were observed after MUS surgery at follow-up., Conclusions: Overt USI, low MUCP and high BMI are independent predictors of persistent USI after a staged MUS approach after pelvic reconstructive surgery., (© 2024. The International Urogynecological Association.)

Background: With the growing popularity of the use of free flaps, surgeons may frequently encounter situations necessitating the performance of multiple free flap surgeries in a single day. Given its prolonged duration and technical complexity, concerns remain regarding their safety. This study investigated whether a single surgeon conducting multiple free flap surgeries in a day heightens the risk of complications., Methods: Patients who underwent free flap-based reconstruction from March 2002 to May 2023 were reviewed and categorized into 3 groups: one flap per day (Group 1), multiple flaps per day on the same patient (Group 2), and multiple flaps per day on different patients (Group 3). Outcomes, particularly perfusion-related complications (PRCs), were compared., Results: In total, 1910 cases were analyzed: 1570 in Group 1, 126 in Group 2, and 214 in Group 3. Over time, the proportion of cases in Group 3 increased. Group 3 had fewer breast reconstruction cases but more lower extremity reconstructions, with a higher prevalence of chronic wounds. Although the rates of PRCs varied among groups, multivariable analysis exhibited no association of performing multiple flaps in a day with their occurrence, regardless of breast or nonbreast reconstruction. The rate of arterial insufficiency was significantly higher in group 3 compared with group 1 after adjusting for other variables., Conclusions: Performing multiple free flaps in a single day may not significantly increase the risks of overall PRCs. However, there appears to be a higher incidence of arterial insufficiency, emphasizing the need for careful planning and precise execution of procedures., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Complications following head and neck microvascular free tissue transfer (MFTT) are common. Less is known about when they occur., Method: Retrospective study of patients with primary or recurrent head and neck cancer undergoing MFTT reconstruction at a tertiary care institution. MFTT reconstructions with inpatient postoperative complications were included. The Kruskal-Wallis test was used to compare median postoperative day (POD) onset of complication by flap type., Results: Of 1090 patients undergoing MFTT reconstruction, 126 (11.6%) patients experienced inpatient complications including fibula (n = 35), anterolateral thigh (n = 60), or radial forearm (n = 31) MFTTs. POD onset was shortest for surgical site hematoma (median = 1 [IQR 1-5]), and longest for donor site infection (median = 11.5 [IQR 8-15]). There was no significant difference between flap types and POD onset of complications (p > 0.05)., Conclusion: Hematoma formation and flap failure occur earliest during hospitalization, while dehiscence, infection, and fistula occur later. There is no difference in complication timing between flap types., (© 2024 Wiley Periodicals LLC.)

Objective: Compare full-thickness skin grafts versus split-thickness skin grafts in scalp reconstruction., Study Design: Retrospective chart review of patients who underwent scalp reconstruction with skin grafts performed at a single institution from 2011 to 2016., Methods: χ 2 or Fisher exact tests were used to compare graft integration and complication rates. The effects of graft type, defect type, graft size, and patient comorbidities on the likelihood of graft success and complications were analyzed using multivariate logistic regression., Results: A hundred and twenty-five full-thickness and 93 split-thickness grafts were performed in 200 patients, including 68 defects (31.2%) with exposed calvarium. Full-thickness grafts required fewer average reconstructions (P = 0.002). A 92.8% of full-thickness grafts had complete graft integration compared with 78.5% of split-thickness grafts (P = 0.002). This difference was more evident in defects with exposed calvarium (87.2% vs. 47.6%, P ≤ 0.001). Despite higher rates of minor debridement, full-thickness grafts had less postoperative bone exposure and wound breakdown than split-thickness grafts on intact pericranium and exposed calvarium defects. Preoperative radiation, immunosuppression, and increased graft sizes were significant predictors of graft outcomes., Conclusions: Skin grafts, especially full-thickness, provide a versatile, reliable, and simple approach for reconstructing medium to large scalp defects in the appropriate patient. Even on defects with bare calvarium, full-thickness grafts can succeed when a vascularized recipient bed is prepared. Defects with exposed bone, larger graft sizes, preoperative radiation, and immunosuppression may result in decreased graft take and increased complications., Level of Evidence: 3b., Competing Interests: Declaration of Competing Interest None of the contributing authors have any financial disclosures or conflicts of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Objectives: Complex head and neck defects involving composite defects can be reconstructed using chimeric flaps or multiple flaps with separate anastomoses. Limited comparisons exist between chimeric and multiple flap reconstructions. We compare outcomes between chimeric and multiple flap reconstructions in oral cavity reconstruction., Data Sources: PubMed (NLM), Embase (Elsevier), Web of Science (Clarivate Analytics), and Cochrane CENTRAL (Wiley)., Methods: A systematic review was conducted, including English articles reporting outcomes of oral cavity reconstruction with either chimeric flaps or multiple flaps. Data extraction included patient characteristics, flap type, and outcomes such as flap survival, partial flap loss, operating room time, hospital length of stay, and postoperative complications., Results: Forty-seven articles comprising 1435 patients were included. Notably, 552 patients underwent multiple flaps, while 883 received chimeric flaps. Meta-analysis revealed no statistically significant difference in flap survival between chimeric and multiple flap patients (98% vs. 99%, p = 0.198). Multiple flap patients had higher rates of operating room take-backs for anastomotic issues and longer hospital stays compared with chimeric flap patients. There were no significant differences in partial flap failure, resumption of diet and speech, need for subsequent flaps, fistula formation, or general complications., Conclusion: This large-scale meta-analysis demonstrates equivalent flap survival between chimeric and multiple flaps in the reconstruction of composite oral cavity defects. Both approaches appear to be safe and acceptable, with comparable outcomes in terms of diet and speech resumption, rates of fistulization, and general postoperative complications. Multiple flap patients had higher rates of operating room take-backs and longer hospital stays., Level of Evidence: NA Laryngoscope, 134:4196-4202, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

We report a very rare case of delayed necrosis of the reconstructed colon 6 months after esophagectomy.A 67-year-old male patient had undergone esophagectomy with gastric tube reconstruction for esophageal cancer in 2014. Subsequently, total gastrectomy and ileo-colon reconstruction via a retrosternal route was performed for gastric tube cancer in 2022. Six months later, he suffered acute chest pain and came to our hospital. Contrast-enhanced CT showed severe dilation of the reconstructed colon with poor enhancement of the wall opposite mesentery, without arterial obstruction. Endoscopy showed no ischemic changes in the esophago-ileum anastomosis; however, mucosal color change to black was observed in the reconstructed colon. We diagnosed ischemic colitis of the reconstructed colon and started conservative treatment; however, 18 days later, he developed a right pyothorax due to perforation of the reconstructed colon. We performed necrosed colectomy with right chest drainage and cervical esophageal fistula was made. Histopathological examination revealed mucosal detachment, thinning of the muscularis propria, and ghost-like appearance of crypt. If necrosis of the reconstructed colon is suspected in the late postoperative period, endoscopic findings of the colonic mucosa may be useful in determining surgical treatment, even in the absence of arterial blood flow obstruction., (© 2024. Japanese Society of Gastroenterology.)

Objective: To present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP)., Materials and Methods: A single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an "auxiliary" DVIU. The primary outcome was 3-year stricture recurrence-free survival (SRFS)., Results: BMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The 3-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, 3-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients., Conclusion: We present 2 techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Comparative data on free flap outcomes for elbow defect reconstruction are still lacking. This study aimed to compare complication rates of free muscle flaps (MFs) versus cutaneous flaps (CFs) for posterior elbow reconstruction., Methods: In a single-center retrospective analysis, patients who underwent posterior elbow reconstruction with free MFs and CFs from 2000 to 2021 were analyzed. Retrospective chart review included patient demographics, operative details, and post-operative complications. Outcomes of interest that were compared included microvascular complications, partial or total flap necroses, wound dehiscence, hematoma or flap infection, and donor-site complications., Results: Sixty-six free flaps (CFs: n = 42; MFs: n = 24) were included, with a trend over time toward using CFs (64%). MFs were used for larger defects (CF: 175 ± 82 vs. MF: 212 ± 146 cm 2 ; p = 0.13). Outcome analysis revealed an equal distribution of microvascular complications (10% vs. 13%; p = 0.7), partial flap necrosis (7% vs. 8%; p > 0.9), wound dehiscence (7% vs. 4%; p > 0.9), evacuation of hematoma (10% vs. 4%; p = 0.7), and infection (0% vs. 4%; p = 0.4). Total flap necrosis requiring additional flap surgery was necessary in one CF (2%) and in no MF (0%) (p > 0.9)., Conclusion: Surgical outcomes, flap necrosis rates, and microsurgical complications did not differ between CFs and MFs. Both flap types are safe and effective options. The free anterolateral thigh and latissimus dorsi flaps represent indispensable workhorses for the reconstruction of extensive elbow defects., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Fresh autologous cranial bone graft has traditionally been regarded as the ideal cranioplasty material; however, long-term comparisons of outcomes with modern alloplastic materials are absent in the literature. The authors evaluated complications and failures among cranioplasties performed with fresh, heterotopic, cranial bone graft versus 3 common alloplastic materials., Methods: Random-effects meta-analyses of logit-transformed proportions were performed on studies published between 1971 and 2021 to evaluate complications and failures of cranioplasties performed with fresh, autologous, heterotopic cranial bone; polyetheretherketone (PEEK); polymethylmethacrylate (PMMA); or titanium with a mean follow-up of 12 months or more. Generalized mixed model meta-regressions were performed to account for heterogeneity and to evaluate the contributions of moderators to outcomes variables., Results: A total of 1490 patients (mean age, 33.9 ± 10.8 years) were included. Pooled, all-cause complications were 6.2% for fresh, heterotopic, autologous cranial bone (95% CI, 2.1% to 17.0%; I2 = 55.0; P = 0.02), 18.5% for PEEK (95% CI, 14.0% to 24.0%; I2 = 0.0%; P = 0.58), 26.1% for titanium (95% CI, 18.7% to 35.1%; I2 = 60.6%; P < 0.01), and 28.4% for PMMA (95% CI, 12.9% to 51.5%; I2 = 88.5%; P < 0.01). Pooled all-cause failures were 2.2% for fresh autologous cranial bone (95% CI, 0.4% to 10.6%; I2 = 0.0%; P = 0.45), 6.3% for PEEK (95% CI, 3.2% to 12.3%; I2 = 15.5%; P = 0.31), 11.4% for titanium (95% CI, 6.7% to 18.8%; I2 = 60.8%; P < 0.01), and 12.7% for PMMA (95% CI, 6.9% to 22.0%; I2 = 64.8%; P < 0.01). Meta-regression models indicated that each alloplastic subtype significantly and independently predicted higher complications, whereas titanium and PMMA were significant predictors for all-cause failures compared with autologous bone. All 3 subtypes were predictive of higher cranioplasty failures secondary to infection compared with autologous bone., Conclusion: Cranioplasties performed with fresh, autologous, heterotopic cranial bone grafts resulted in lower complication and failure rates compared with alloplastic materials., (Copyright © 2023 by the American Society of Plastic Surgeons.)

The potential benefits to surgical outcomes of intraoperative and/or same-day computed tomography (CT) during isolated orbital fracture reconstruction are debatable, and previous research on this topic is limited by small sample size. This retrospective IBM MarketScan Commercial and Medicare Supplemental research database study examined patients undergoing isolated orbital reconstruction from January 1, 2012 to December 31, 2018, to assess whether same-day CT affected postoperative outcomes. The average age of the 5,023 participants was 37 (standard deviation [SD]: 16) years and 63% were males. The data revealed that 16.2% (815 of 5,023) patients underwent a same-day CT. Those who underwent a same-day CT scan exhibited reduced odds of postoperative enophthalmos (adjusted odds ratio [aOR]: 0.269; 95% confidence interval [CI]: 0.167-0.433) and diplopia (aOR: 0.670; 95% CI: 0.495-906). Interestingly, these patients also displayed a higher rate of revision surgeries (aOR: 2.721; 95% CI: 1.893-3.912). In summary, while same-day CT scans diminish certain postoperative complications of orbital fracture repair, they are also associated with an increased likelihood of subsequent surgical revision., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Immediate lymphatic reconstruction (ILR) has been proposed to decrease lymphedema rates. The primary aim of our study was to determine whether ILR decreased the incidence of lymphedema in patients undergoing axillary lymph node dissection (ALND)., Methods: We conducted a two-site pragmatic study of ALND with or without ILR, employing surgeon-level cohort assignment, based on breast surgeons' preferred standard practice. Lymphedema was assessed by limb volume measurements, patient self-reporting, provider documentation, and International Classification of Diseases, Tenth Revision (ICD-10) codes., Results: Overall, 230 patients with breast cancer were enrolled; on an intention-to-treat basis, 99 underwent ALND and 131 underwent ALND with ILR. Of the 131 patients preoperatively planned for ILR, 115 (87.8%) underwent ILR; 72 (62.6%) were performed by one breast surgical oncologist and 43 (37.4%) by fellowship-trained microvascular plastic surgeons. ILR was associated with an increased risk of lymphedema when defined as ≥10% limb volume change on univariable analysis, but not on multivariable analysis, after propensity score adjustment. We did not find a statistically significant difference in limb volume measurements between the two cohorts when including subclinical lymphedema (≥5% inter-limb volume change), nor did we see a difference in grade between the two cohorts on an intent-to-treat or treatment received basis. For all patients, considering ascertainment strategies of patient self-reporting, provider documentation, and ICD-10 codes, as a single binary outcome measure, there was no significant difference in lymphedema rates between those undergoing ILR or not., Conclusion: We found no significant difference in lymphedema rates between patients undergoing ALND with or without ILR., (© 2024. Society of Surgical Oncology.)

Introduction: The opioid epidemic response led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use non-steroidal anti-inflammatory drugs (NSAIDs) for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized., Objective: ptUsing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3 mg/dL or increase in creatinine ≥1.5x baseline or urine output <0.5 mL/kg/hr for 6 h), we hypothesized there would be a difference in the incidence of postoperative AKI between patients who did and did not receive NSAIDs following surgery., Study Design: Patients 2-18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine output were retrospectively reviewed. Chronic kidney disease (CKD) stage was calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 11 characteristics with patients undergoing similar surgeries who did not receive NSAIDs. The primary outcome was incidence of AKI within 48 h of surgery., Results: The unmatched cohorts included 243 patients. Propensity matching identified 166 patients in the NSAID arm and 41 in the no NSAID arm. 26 patients with CKD stage 2-3 were included. There was no significant difference in the incidence of postoperative AKI based on any KDIGO criteria (17.1% no NSAID versus 16.3% NSAID, p = 0.87). Median postoperative opioids fell from 0.88 mg/kg in the no NSAID arm to 0.37 mg/kg morphine equivalents in the NSAID arm, although this was not statistically significant. Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p = 0.32). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.7% with versus 17.9% without CKD)., Discussion: There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction, excluding those with advanced CKD., Conclusion: These results support that postoperative NSAIDs were an unlikely source of AKI. However, AKI remained a risk following these surgeries, regardless of NSAID use, likely owing to underlying disease, longer operations, and fluid shifts., Competing Interests: Conflicts of interest No conflicts of interest to report., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Surgical site infection (SSI) is the most consistently reported complication of cranioplasty. No material showed a categorical superiority in the incidence of infection. Porous polyethylene (PE) is considered a low risk material regarding SSI. However, the literature data are very limited. Thus, our objective was to verify the assumed low incidence of SSI after PE cranioplasty in patients at high risk of SSI. The primary objective was the infection rate, while secondary objectives were implant exposure, revision and cosmetic results., Method: Patients who underwent three-dimensional (3D) personalized PE cranioplasty in the period 2014-2023 were evaluated prospectively. Only patients with an increased risk of SSI, and a satisfactory clinical conditions were included in the study., Results: Thirty procedures were performed in 30 patients. Cranioplasty was performed 23 times after hemispheric decompressive craniectomy, five times after limited size craniotomy and two times after bifrontal decompressive craniectomy. Risk factors for the development of infection were 18 previous SSIs, 16 previous repeated revision surgeries, four intraoperatively opened frontal sinuses and two times radiotherapy. Neither infection nor implant exposure was detected in any patient. All patients were satisfied with the aesthetic result. In two cases, a revision was performed due to postoperative epidural hematoma., Conclusions: Three-dimensional personalized PE cranioplasty is associated with an extremely low incidence of SSI even in high-risk patients. However, our conclusions can only be confirmed in larger studies., (© 2024. The Author(s).)

Objective: The reimplantation of autologous bone grafts after decompressive craniectomy (DC) is still up for debate. The objective of this study was to analyze the surgical revision rate for autologous cranioplasties in our center, aiming to identify predictors for procedure-related-complications., Methods: A retrospective single-center study was conducted for adult patients who underwent autologous cranioplasty after DC. The primary endpoint was the complication rate in terms of surgical revision and removal of the bone graft: infection, new onset seizures, dislocation, haemorrhage, osteolysis, wound dehiscence and cerebrospinal fluid (CSF) fistula. Demographic data, medical records, surgical reports and imaging studies were analysed and risk factors for complications were evaluated., Results: 169 consecutive patients were included. The median interval between DC and cranioplasty was 84 days. Mean age was 51 ± 12.4 years. 26 patients (15.3%) had revision surgery for following reasons. n = 9 implant dislocations (5.3%), n = 7 osteolysis (3.6%), n = 6 infections (3.6%), n = 5 had re-bleedings (3%), n = 5 wound dehiscences (3%), and n = 2 CSF fistulas (1.2%). 18 patients developed new seizures (10.7%). Bi- and multivariate analysis revealed three independent risk factors, simultaneous ventriculo-peritoneal (VP) shunting increased the risk for material dislocation (p < 0.001); large bone grafts (> 193.5 cm 2 ) increased the risk for osteolysis (p = 0.001) and bifrontal cranioplasties were associated with higher risk for infections (p = 0.04)., Conclusion: The complication rates in our study were comparable to previously reported data for autologous or artificial cranioplasties. As osteolysis was correlated to larger bone grafts, a synthetic alternative should be considered in selected cases., (© 2024. The Author(s).)

Background: Bleeding during first sexual intercourse represents a significant sociocultural concern with potential implications for some couples., Objectives: The aim of this study was to introduce a novel modification to temporary and permanent hymenoplasty and evaluate both the objective and subjective success of defined techniques by assessing surgical outcomes and patient satisfaction with either temporary or permanent hymenoplasty procedures., Methods: A retrospective study of 246 patients was conducted between 2015 and 2023. Various parameters, including age, sexual history, pregnancies, BMI, and bleeding satisfaction, were assessed. Pain at first intercourse was rated on a visual analog scale (VAS)., Results: The age at the time of operation was significantly lower in patients undergoing permanent hymenoplasty compared with those undergoing temporary hymenoplasty (24.0 years [interquartile range (IQR), 22.0-26.0 years] vs 27.0 years [IQR, 26.0-29.0 years]; P < .001). Patients undergoing permanent hymenoplasty reported significantly lower VAS scores at first sexual intercourse compared with those undergoing temporary hymenoplasty (4.0 [IQR, 2.0-5.0] vs 7.0 [IQR, 6.0-7.0]; P < .001]. Satisfaction rates were high in both groups, with all temporary hymenoplasty patients satisfied with duration of bleeding compared with 78.6% (110/140) of permanent hymenoplasty patients (P < .001)., Conclusions: This study introduces a novel modified temporary and permanent hymenoplasty technique to the literature and provides the first video documentation for both temporary and permanent hymenoplasty procedures. Both hymenoplasty techniques are effective and reliable. However, temporary hymenoplasty is associated with a higher bleeding rate than permanent hymenoplasty, despite resulting in higher VAS scores., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background and Objectives: The radial forearm free flap (RFFF) is the most commonly used flap for head and neck reconstruction. However, complications at the donor site are its major drawbacks. We aimed to identify the patient comorbidities and factors that predict donor site complications after RFFF. Materials and Methods: A retrospective chart review of consecutive patients who underwent RFFF reconstruction for head and neck cancer between 2015 and 2022 was performed. Demographic variables, clinical processes, and postoperative complications were assessed. All variables were analyzed using univariate and multivariate analyses. Results: Sixty-seven patients underwent RFFF reconstruction, and all received a split-thickness skin graft at the donor site. Twenty-five patients experienced delayed skin graft healing, whereas nine experienced sensory changes at the donor site. Hypertension and age had statistically significant negative effects on wound healing. The incidence of hand swelling was related to graft size, and the occurrence of paresthesia was significantly higher in diabetic patients and significantly lower in those with acellular dermal matrix (ADM). Conclusions: Patients with hypertension had a higher risk of prolonged wound healing after RFFF than their normotensive patients. Clinicians should pay particular attention to wound healing strategies in patients with hypertension. Additionally, better neuropathy care is recommended to achieve sensory recovery after RFFF in patients with diabetes. Using a skin graft with ADM could be a method to alleviate neurological symptoms.

Background: In free jejunum transfer, knowing the ischemic tolerance time of the jejunum is crucial. It helps determine the need for reharvesting if an unexpected situation prolongs the ischemic time. The current ischemic tolerance time in humans is unknown. We investigated the relationship between ischemic time and postoperative complications in head and neck cancer patients who underwent free jejunum transfer., Methods: The study included 76 patients with available medical records out of 103 patients who underwent free jejunum transfer between 2009 and 2023. The association between the surgical procedure, including ischemic time, and patient's background, and flap engraftment, stenosis of the intestinal anastomosis, the swallowing function, and other complications was investigated., Results: The ischemic time for jejunal flaps ranged from 1 h 24 min to 6 h, with a mean of 197 ± 55.5 min. In 72 patients, the jejunum was successfully engrafted, but vascular occlusion occurred in another four patients. In three of these patients, jejunal necrosis occurred, and there was no specific trend in ischemic time. Stenosis of the intestinal anastomosis occurred in 17 cases (22%), with ischemic time (≥3 h) and age (≥75 years) being significant factors for stenosis (ischemic time: 30% vs. 10%, p = 0.048, age: 50% vs. 15%, p < 0.01). No significant correlations were observed with other complications or the swallowing function., Conclusion: There was no specific trend between ischemic time and jejunal survival rate, indicating that an ischemic time within 6 h may not have affected engraftment. Although we have recently performed intestinal anastomosis prior to vascular anastomosis, the choice of surgical technique should be adapted to the patient's age and background., (© 2024 Wiley Periodicals LLC.)

Background: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction., Methods: A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories., Results: A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years., Conclusions: BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery., (© 2024 Wiley Periodicals LLC.)

Cerebrospinal fluid (CSF) leakage is a common complication associated with endoscopic endonasal skull-base surgery (EESBS). Postoperative mobilization-associated postural changes are considered to cause CSF leakage. However, no study has demonstrated a robust relationship between postural changes and CSF leakage. We used upright computed tomography (CT) to clarify the effects of postural changes on the reconstructed skull base (RSB) after EESBS. Thirty patients who underwent EESBS at our institution were prospectively included, and their upright and supine CTs were compared to measure morphological changes in the RSB. Patient clinical data were also collected from medical charts and surgical videos, and their relationships with morphological changes were assessed. In upright CTs, the RSB shifted intracranially by 0.94 (0.0-2.9) mm on average. This shift was larger in cases with lesions extending to the sphenoid sinus, dural defects, intraoperative pulsation of the RSB, and large bone windows. The direction of the change was opposite to intuitive movement driven by gravity because of reduced intracranial pressure in the sitting position. Thus, these shifts can be directly associated with postoperative CSF leakage caused by reconstruction material displacement. Skull-base reconstruction and postoperative postural management accounting for these morphological changes may be necessary for preventing CSF leakage., (© 2024. The Author(s).)

Background: Evidence has shown increased morbidity and mortality for patients with COVID-19 infection within 7 weeks of surgery. However, no studies have specifically investigated the effects of COVID-19 in microsurgical outcomes. This study evaluated thrombotic and overall complications after free tissue transfer for a variety of indications in patients with and without previous COVID-19 infection., Methods: A retrospective cohort study was performed in adult patients with or without a history of COVID-19 infection who underwent microsurgical reconstruction between 2017 and 2022. Patients with a history of COVID-19 infection were matched to controls based on age, gender, race, body mass index, history of diabetes, coronary artery disease, hypertension, Caprini score, tobacco use, and flap indication., Results: From 2017 to 2022, 35 patients had a documented history of COVID-19. Matched case analysis determined a 4.8 times increased odds ratio of postoperative complications in the COVID-19 group compared with controls (p = 0.002). Significantly, more patients with COVID-19 experienced total or partial flap loss and anastomotic issues (COVID-19: 7/35, Control: 0/35; p < 0.001). There was no significant difference in incidence of VTE (COVID-19: 1/35, Control: 0/35; p = 0.493). Of note, 62.9% of the COVID-19 group were discharged on anticoagulants (versus 14.3% in the control group [p < 0.001])., Conclusion: COVID-19 has dire, long-lasting effects on virtually every organ system, chief among them, the microcirculation. Further studies are needed to fully determine the extent and influence of COVID-19 on complex procedures such as free tissue transfer and how to optimize the screening, workup, and postoperative care to guard against the associated thrombotic consequences., (© 2024 Wiley Periodicals LLC.)

Background: With the increasing legalization and popularity of marijuana, it is frequently and sometimes unintentionally combined with nicotine-containing products. As a consequence, patients may fail to accurately report usage during preoperative examinations or remain unaware of the inclusion of nicotine. This poses a challenge for clinicians in identifying preoperative nicotine exposure. This study aimed to establish normative data on the use of marijuana and nicotine in plastic surgery patients and correlate it with urine nicotine and cotinine levels., Methods: All consecutive patients presenting to the authors' clinic seeking elective procedures were identified. Patients were surveyed on marijuana and nicotine use, and provided a urine sample for analysis. The survey responses, urine results, surgical treatments, and clinical outcomes were followed up prospectively., Results: A total of 135 patients completed the survey and were categorized as nonusers (50%), active nicotine users (19%), active marijuana users (7%), active users of both (13%), or past users (11%). Marijuana users who denied nicotine use showed significantly elevated nicotine and cotinine levels compared with nonusers (average nicotine level, 23.1 ± 13.5 ng/mL [P = 0.00007]; average cotinine level, 221.2 ± 141.8 ng/mL [P = 0.0002]). Fewer than a third of active marijuana or nicotine users reported active use of these products during clinical encounters. There was no difference in urine levels, reported use, or other patient characteristics in patients with and without postoperative complications., Conclusion: This is the first descriptive study to document elevated urine nicotine levels in self-reported marijuana users in an urban, diverse patient population seeking elective plastic surgery procedures., (Copyright © 2023 by the American Society of Plastic Surgeons.)