RESUMO
BACKGROUND: The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes. OBJECTIVES: The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction. METHODS: An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection. RESULTS: Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days. CONCLUSIONS: Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area.
Assuntos
Inibidores da Liberação da Acetilcolina/administração & dosagem , Preenchedores Dérmicos/administração & dosagem , Imageamento Tridimensional/métodos , Rejuvenescimento , Ritidoplastia/métodos , Adulto , Idoso , Toxinas Botulínicas Tipo A/administração & dosagem , Terapia Combinada/métodos , Face/diagnóstico por imagem , Músculos Faciais/diagnóstico por imagem , Músculos Faciais/efeitos dos fármacos , Músculos Faciais/inervação , Músculos Faciais/fisiologia , Feminino , Humanos , Ácido Hialurônico/administração & dosagem , Injeções Subcutâneas , Pessoa de Meia-Idade , Satisfação do Paciente , Fotografação/métodos , Estudos Prospectivos , Envelhecimento da Pele/fisiologia , Resultado do TratamentoRESUMO
BACKGROUND: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Artroplastia do Joelho , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/cirurgia , Terapia de Salvação/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. METHODS: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. RESULTS: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. CONCLUSION: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.
Assuntos
Tecido Adiposo/transplante , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Expansão de Tecido/métodos , Feminino , Humanos , Mamoplastia/efeitos adversos , Mastectomia Segmentar , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Complicações Pós-Operatórias , Estudos Retrospectivos , Expansão de Tecido/efeitos adversos , Dispositivos para Expansão de TecidosRESUMO
BACKGROUND: Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting. STUDY DESIGN: A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated. RESULTS: Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67). CONCLUSIONS: We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.
Assuntos
Colectomia , Hérnia Incisional/epidemiologia , Modelos Estatísticos , Complicações Pós-Operatórias/epidemiologia , Estudos de Coortes , Atenção à Saúde/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de RiscoRESUMO
BACKGROUND: Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. METHODS: A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. RESULTS: Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). CONCLUSION: Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.
Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hérnia Incisional/prevenção & controle , Laparotomia/efeitos adversos , Telas Cirúrgicas , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Hérnia Incisional/etiologia , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Prevenção Primária/métodos , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Técnicas de Sutura , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
BACKGROUND: Few reports focus exclusively on microsurgical reconstruction of traumatic lower extremity defects in children. Hence, the authors felt it prudent to contribute to this area of clinical research. The authors hypothesized that reconstructive success would be comparable to success rates reported in adults, and that young age or concerns regarding vessel size or behavior do not negatively impact surgical outcome. METHODS: A retrospective review of microsurgical lower extremity reconstruction cases at two academic medical centers was performed. All pediatric patients who underwent microsurgical reconstruction of traumatic lower extremity defects between 1997 and 2012 were included for analysis. RESULTS: Forty flaps transferred in 40 patients with a mean age of 11.4 years (range, 1 to 17 years) were included for analysis. Muscle flaps were predominantly used [n = 23 (57.5 percent)]; however, there was a recent increase in use of fasciocutaneous flaps [n = 16 (40 percent)]. Postoperative complications were seen in 25 percent of patients, with a total flap loss rate of 5 percent. No donor-site complications were observed. The mean postoperative length of hospital stay was 12.9 days (range, 4 to 41 days), with patients returning to full weight-bearing after a mean of 2.6 months (range, 1 to 8 months). CONCLUSIONS: Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population is safe. Concerns related to patient age, vessel size, or vessel behavior (i.e., vasospasm) should not detract from offering free flap reconstruction, as they do not negatively impact outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.