Cost and value of office-based facial plastic and reconstructive surgery procedures

Introduction:This chapter will provide an overview of factors affecting the cost of office-based procedures in Facial Plastics and Reconstructive Surgery(FPRS),and will discuss the value of office-based interventions.Material and Methods:An in-depth literature review was conducted using multiple primary and secondary sources.Literature from multiple disciplines was included in the review,including otolaryngology,anesthesiology,surgery,public health,and economics.Discussion/Conclusions:A wide variety of procedures can be performed in an FPRS office.Large upfront costs to the office include laser,electrocautery and surgical equipment.These investments will yield an initial negative cost margin until sufficient case volume is achieved.It is often in the best interest of the patient to perform a procedure in-office and avoid the facility and anesthesia fees associated with a surgical center or hospital.Costs and reimbursements vary greatly across regions and facilities.Additionally,overall cost depends on payer mix,procedures performed,and productivity of the practice.The scarcity of literature on this topic as it applies specifically to FPRS indicates that further research is needed to elucidate the value of common facial plastics procedures in an office-based setting.

First Reconstructive Plastic Surgery of the Perineum in a Hominin Pan paniscus (Bonobo) and Plea by a Plastic Surgeon for Surgery for the Benefit of All Hominins (Members of the Human Lineage)

We present, for the first time, the repair by plastic surgery procedures of a large loss of perineal substance in a bonobo (hominin Pan paniscus). A 20-year-old male bonobo living in captivity in the Lola Ya Bonobo Sanctuary in Kinshasa in the Democratic Republic of the Congo was attacked by another bonobo. It was a large perineal wound through which urine flowed, located between the penis and the testicles, taking part of the anterior and posterior urethra, the bladder, as well as the elements of the spermatic duct. To repair the large loss of perineal substance, a pedicled flap of scrotal skin was removed, and then turned over, cutaneous surface on the trench of the loss of bladder substance and the urethral lumen. The postoperative course was satisfactory with healing by the first intention of the surgical wound, despite the wild postoperative behavior of the patient (removal of the vesicourethral catheter and protective plaster). We observed in the short term an urethro-cutaneous fistula, left in natural healing. The reconstructive surgery procedures applied in humans can also be applied with satisfactory results in bonobos, a species in the process of extension and whose members are our closest cousins. The bonobo is genetically close to humans. Based on this first successful experience, we advocate for reconstructive plastic surgery for all hominins (members of the human lineage), if indicated.

2016至2020年《中华整形外科杂志》和Plastic and Reconstructive Surgery杂志皮瓣类论著文章发文情况简要对比研究

目的通过对比分析中、美两国2种整形外科领域权威期刊的皮瓣类论著文献, 寻找异同点, 探讨将来的研究方向。方法 2021年5月, 以"皮瓣"为关键词检索2016年1月至2020年12月《中华整形外科杂志》(CJPS)和Plastic and Reconstructive Surgery(PRS)杂志发表的文题或摘要内含有相关关键词的论著类文献。通过万方数据知识服务平台及中国知网检索、获取CJPS发表的相关文献, 通过PubMed数据库及Scopus数据库检索获取PRS杂志发表的相关文献。去除重复文献后, 阅读文题及摘要, 排除非皮瓣研究及非论著类文献。阅读全文并运用文献计量学方法, 对总发文量、皮瓣研究发文量、循证医学证据级别、作者国籍及机构分布、皮瓣类型、皮瓣应用及新技术应用等方面进行综合分析。结果 CJPS近5年总发文量为1 166篇, 244篇纳入研究;PRS杂志近5年总发文量为4 562篇, 268篇纳入研究。PRS杂志作者以美国学者居多, 中国学者发文总量位居第2位, 近5年内中国内地作者共发文21篇。CJPS发文以带蒂皮瓣研究居多, PRS杂志则以游离皮瓣为主;CJPS传统皮瓣发文量多于穿支皮瓣, PRS杂志则与之相反;CJPS发文以局部皮瓣、股前外侧皮瓣和腓动脉穿支皮瓣为主, 而PRS杂志以腹壁下动脉穿支皮瓣、腓骨骨瓣或骨皮瓣和股前外侧皮瓣等类型的皮瓣为主。CJPS报道的皮瓣主要用于修复缺损, 而PRS杂志报道的皮瓣则主要用于乳房再造等领域。此外, 两本杂志都报道了许多皮瓣外科领域的新技术和新方法, 如计算机辅助成像、吲哚菁绿成像技术、螺旋桨皮瓣、分叶皮瓣等, 已经得到了广泛应用。结论近5年, 我国的皮瓣研究整体处在国际领先水平, 具有一定的国际竞争力。但我国的研究局限于报道临床经验, 循证医学级别低, 与国际前沿研究尚有一定的差距。

Porocarcinoma in a palm reconstructed with a full thickness skin graft: A case report

BACKGROUND Porocarcinoma is a rare type of skin cancer that originates from sweat gland tumors.It is an aggressive malignant skin cancer that is difficult to diagnose clinically owing to its rarity and similarity to squamous cell carcinoma(SCC).CASE SUMMARY This case involved a 92-year-old woman,a farmer by profession,presented with an exophytic and verrucous mass on her left palm that had formed 2 years prior and caused chronic pain and frequent bleeding.Initially,the patient was diagnosed with SCC using a punch biopsy;however,a repeat biopsy with addi-tional immunohistochemical tests was performed for porocarcinoma.Ultimately,the patient was diagnosed with porocarcinoma and reconstruction was planned using a full-thickness skin graft.After treatment,the range of motion of the palm was preserved,and the aesthetic outcome was favorable.At 6 mo of follow-up,the patient was satisfied with the outcome.CONCLUSION Porocarcinoma is commonly misdiagnosed as SCC;therefore,clinicians should consider porocarcinomas when evaluating mass-like lesions on the hands.

Coronary Artery Complications after Right Ventricular Outflow Tract Reconstruction Surgery

Background:Mechanisms and clinical manifestations of coronary artery complications after right ventricular outflow tract reconstruction surgery are not well known.Methods:Patients who had coronary artery complications after pulmonary valve replacement or the Rastelli procedure at a single tertiary centre were retrospectively analysed.Results:Coronary artery complications were identified in 20 patients who underwent right ventricular outflow tract reconstruction surgery.The median age at diagnosis of coronary artery complication was 21 years(interquartile range:13–25 years).Mechanisms of coronary artery complications were compression by adjacent materials in 12 patients,dynamic compression of intramural course of coronary artery in two patients,and intraoperative injury in six patients.Congenital coronary artery anomalies were identified in 50%(10/20)of patients.Four patients presented with early postoperative haemodynamic instability.Fourteen patients showed late onset symptoms or signs of coronary insufficiency,including chest pain,ventricular dysfunction,or ventricular arrhythmias.Coronary artery stenosis was incidentally found on cardiac computed tomography angiography in two asymptomatic patients.Four patients underwent surgical interventions,and one patient underwent percutaneous coronary intervention for coronary stenosis.One patient with recurrent ventricular tachycardia required an implantable cardioverter-defibrillator.There were two deaths in patients with intraoperative coronary injury.Conclusion:Preoperative coronary evaluation and long-term follow-up for the development of coronary artery complications are required in patients undergoing right ventricular outflow tract reconstruction surgery to prevent ventricular dysfunction,arrhythmias,and death,especially among those with congenital coronary anomalies.

Surgical Outcomes Following Partial Breast Reconstruction with Chest Wall Perforator Flaps

Introduction: In the last two decades, chest wall perforator flaps (CWPF) have become a versatile tissue replacement technique for partial breast reconstruction following breast-conserving surgery (BCS) in well-selected cases. We present the surgical outcome of 81 patients with chest wall perforator flaps used for breast-conserving surgery. Methods: We recorded the outcomes of three oncoplastic breast surgeons who performed partial breast reconstruction with chest wall perforator flaps from 1st January 2018 to 30th June 2022 at Sherwood Forest Hospitals NHS Foundation Trust. Data were collected on patient demographics, including age, BMI, smoking status, bra size, previous treatments, type of CWPF procedure, tumor size (measured clinically, via imaging and histologically), biopsy results, specimen weight, margins involvement, re-operation rate, surgical site infection (SSI), flap loss, flap shrinkage, hematoma, and seroma rates. Results: A total of 81 patients were included in this study, with an average age of 55.7 years and a body mass index (BMI) of 26.7 kg/m2. The bra size varied between A to FF with A (7.4%), B (28.3%), C (38.2%), D (13.6%), DD (11.1%), and FF (1.2%). 14.8% of the patients had neoadjuvant chemotherapy (NACT). For 45 patients, LICAP (lateral intercostal artery perforator), 16 AICAP (anterior intercostal artery perforator), 13 MICAP (medial intercostal artery perforator), and for seven patients, LTAP (lateral thoracic artery perforator) flaps were used. The average tumor was measured at 15.75 mm clinically, 19.1 mm via imaging, and 19.6 mm histologically. Biopsy showed that 16% of the tumors were ductal carcinoma in situ (DCIS), and 84% were invasive. 16% of patients had involved margins, and re-excision was required in 10 patients, and completion mastectomy was performed in 2 patients. A thirty-day SSI rate was 6.2%, with flap-related complications, including flap loss and shrinkage, at 3.7% and 4.9%, respectively. In addition, 3.7% had a hematoma, and 17.3% had other complications. Conclusion: Partial breast reconstruction with perforator flaps is an excellent volume replacement technique in breast-conserving surgery with acceptable complications in well-selected cases.

Penile revascularization--contemporary update

Contemporary therapies for erectile dysfunction are generally targeted towards older men and universally engage pharmacological and/ or device related treatment options. Penile revascularization, using microvascular arterial bypass surgical techniques, is a non-pharmacological, non-device-related, and reconstructive surgical strategy for men with erectile dysfunction that was first described by Dr Vaclav Michal in 1973.

Keystone design perforator island flap in facial defect reconstruction

Facial defect coverage is a common subject in the field of reconstructive surgery.There are many methods for facial defect reconstruction,and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement.Among various options for facial reconstruction,the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture,which is consistent with the ideal goal of reconstruction(replacement of like-with-like).Keystone design perforator island flap(KDPIF),devised by Behan in 2003,has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity,robust vascular supply,and reproducibility.Several studies have reported KDPIF reconstruction of facial defects,such as large parotid defects,small-to-moderate nasal defects,and eyelid defects.However,KDPIF has been used relatively less in facial defects than in other body regions,such as the trunk and extremities.The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF,modifications,physiology,mechanism of flap movement,consideration of facial relaxed skin tension lines and aesthetics,surgical techniques,clinical applications,and precautions for successful execution of KDPIF reconstruction.

The robot-assisted ureteral reconstruction in adult:A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology,the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches.This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones,and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems.However,with the potential benefits of minimal invasiveness,several pioneering reports have been published on robotic surgery in urology.By reviewing the literature on this topic,we aimed to summarize the techniques,considerations,and consistent findings regarding robotic ureteral reconstruction in adults.Robotic applications for ureteral surgery have been primarily reported for pediatric urology,especially in the context of relieving a congenital obstruction in the ureteral pelvic junction.However,contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant,iatrogenic,and traumatic conditions,which generally occur in adult patients.Nevertheless,the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population;thus,qualified prospective trials are needed for wider acceptance.However,contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction,even in the absence of haptic feedback,which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

Endoscopic transnasal canaliculorhinostomy for refractory common canalicular obstruction with an unidentifiable lacrimal sac

AIM:To describe the role of endoscopic transnasal canaliculorhinostomy(ETC)in refractory common canalicular obstruction(CCO)associated with an absent or unidentifiable lacrimal sac.METHODS:The records of patients with refractory CCO who underwent ETC at the Eye Hospital of Wenzhou Medical University from October 2007 to December 2016 were retrospectively reviewed.RESULTS:Fifty-six patients(56 eyes)with refractory CCO were recruited into the study.Eight patients were excluded due to the presence of a residual lacrimal sac or failure to complete the follow-up duration.The anatomic and functional success rates were both 85.4%(41/48)at a mean follow-up of 18.6 mo.Five cases failed as a result of ostial synechia and two failed because of ostial obstruction by granulation.Postoperative complications included mild nasal bleeding in 5 cases,dried nasal feeling in 8 cases,and olfactory dysfunction in 4 cases.CONCLUSION:Although being surgically challenging,ETC has comparable findings to its external approach counterpart or conjunctivodacryocystorhinostomy(CDCR)with Jones tube.And it may prove to be a novel alternate surgical technique for patients with refractory CCO without identifiable lacrimal sac.

Heterologous Bovine Tunica Albuginea Graft Conserved in Honey as Abdominal Wall Reinforcement in Rats

Complex abdominal wall defects might be challenging for human and veterinary surgeons worldwide. Defects from trauma or congenital causes may lead to hernias development. The introduction of meshes to reinforce hernia repairs has improved surgical outcomes and several synthetic and biologic materials have been used. In this context, biomaterial prosthesis seems to be a satisfactory solution when managing great abdominal wall defects. The aim of the current study is to evaluate the bovine tunica albuginea (BTA) preserved in honey as graft material for rats’ abdominal wall reinforcement in incisional herniorrhaphy surgery as well as its viability, cicatrization and integration into the host tissue. Wistar rats were assigned to two main groups: 1) animals (n = 20) underwent median longitudinal laparotomy followed by laparorraphy with suture of the bovine tunica albuginea (BTA) graft as abdominal wall reinforcement;and 2) animals (n = 20) underwent only laparotomy and subsequent laparorrhaphy. Rats were clinically evaluated until euthanasia at post-surgical day 7, 14, 21 and 28. Necropsy and histopathological analysis of abdominal wall fragments were performed to compare groups and subgroups findings. BTA promoted abundant fibrosis, providing resistance and low postoperative complication rates. Besides, animals did not show rejection signs to the implant. In conclusion, BTA preserved in honey is an affordable, easy collection and handling biomaterial for graft, demanding simple surgical implantation technique for abdominal wall repair in rats.

The Preauricular Sinus:A Novel Approach for Complete Bilateral Excision via a Modified Face-Lift Incision

Objectives/Hypothesis: To present a novel technique based on the combination of aesthetic and reconstructive techniques for the radical and safe excision of preauricular sinus along with minimal cosmetic impairing. Study Design: Case report, description of surgical method and brief overview of the literature. Methods: In a patient with bilateral preauricular sinus, we used a modified face-lift incision and SMAS-fixation instead of solely excising the sinus with skin ellipse. Results: Total removal of the bilateral fistulous systems could be achieved, along with a very aesthetically pleasing result. Conclusions: The surgical approach shown here allows a radical excision with only minimal aesthetic impairment using a shortened facelift-incision and SMAS-fixation.

Functional nasal surgery in the office-based setting

Objective:Nasal obstruction is a very common problem often addressed by functional nasal surgery.Increasingly,these procedures are being performed in the office setting secondary to decreased down time,cost,and obviation of general anesthesia.Our goal with this review is to discuss how to appropriately select patients for office-based procedures,what procedures may be considered,and current outcomes with in-office functional nasal surgery.Data Sources:PubMed,Scopus,Google Scholar.Methods:Research databases were searched for articles discussing techniques for performing functional nasal surgery in an office setting,and outcomes of various in-office functional nasal procedures.Results:Studies found and included in this review discuss many aspects of office-based functional nasal surgery,including practical points on patient selection and office set-up,what procedures can safely be performed,and outcomes of different techniques to address specific problems.Broadly,procedures amenable to performance in the office address the internal and external nasal valves,the nasal septum,and the inferior turbinates.Conclusion:A wide range of techniques to aaddress the nasal valves,septum,and inferior turbinates can be performed in a safe and effective manner without the need for an operative suite.

Primary Closure of Infected Wound Infested by Fly Larvae—Case Report in Dog

One of the most common aggravating factors of wounds is the myiasis. Flies lay their eggs on the wound, they hatch and release a larval form of the dipteran, which feeds on host tissues leading to necrosis and large production of exudate, thus, it is an extremely pleasant environment to bacterial multiplication. The aim of this study was to describe the case of a dog that displayed an infested larvae ulcerated tumor in the ocular region. Successful results were obtained when performing surgical treatment of the wound with healing by primary closure. The 13-year-old female dog, 30 kg, was brought to the Veterinary Clinic of Ingá University Center, Maringá-PR, Brazil, with the main complaint of an ulcerated left ocular tumor. The owner could not tell when the problem had started. After the patient’s physical and laboratory evaluation, which were within normal parameters, enucleation was scheduled for tumor removal. On the day of surgery, the owner reported large mucopurulent secretion and foul odor at the site. The patient was taken for the larvae removal surgical procedure and later enucleation. The wound was debrided and washed with physiological solution, and then tarsorrhaphy was performed and a Penrose drain was applied. The animal returned 15 days later with the wound fully healed. As a conclusion with the current report, the primary closure treatment with the use of drain after intense debridement of a fly larvae infected wound can be a good alternative, especially when it is aimed at faster healing.

Partial auricular reconstruction surgery for facial skin cancer

Auricular defects resulting from excision of cutaneous malignancies pose a challenge to the reconstructive surgeon due to the complex anatomy,convexities,and concavities of the ear.A surgeon must be familiar with analyzing defects of the ear and understand the variety of reconstructive options available with the goals of restoring function,re-establishing anatomic units,and achieving aesthetic balance.This review summarizes current methods for reconstruction of partial auricular defects resulting from neoplasm.A brief overview of ear anatomy and aesthetic relationships is also provided.Techniques for the reconstruction are classified by anatomic region:upper-third,middle-third,and lower-third defects.

New considerations regarding pelvic organ prolapse treatment in China

Pelvic organ prolapse （POP） is non-fatal conditions which can markedly affect a patient’s quality of life. Multiple recently developed pelvic reconstructive surgeries have led to a recent expansion in China. In this study, we would like to discuss various aspects of the evaluation and management of POP and raise the question of what is sufficient evidence for the adoption of innovative treatments for POP.

Free tissue transfer for lower extremity trauma in the pediatric patient

Aim:The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described.Factors include microsurgeon inexperience,inadequate center resources,and fear of historically described poor surgical outcomes.The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects.Methods:A systematic review of the literature was conducted through the online databases PubMed,Embase,and Web of Science,examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric(aged 18 and younger)lower extremity following traumatic etiology since 2005.Outcomes included flap failure,return to the operating room,and functional status,where available.Results:Seven studies were deemed appropriate for inclusion,with a total of 243 flaps included.Motor vehicle and motorcycle accidents were greater than 75%of total etiology.Most defects involved the foot or ankle(65.1%).In total,perforator flaps compromised the majority of flaps(54%),with the most common being the anterolateral thigh,the scapular/parascapular,and deep inferior epigastric flaps.Less common perforators included the groin flap,tensor fascia lata,radial forearm,lateral arm,and thoracodorsal perforator flap.Muscle-based flaps were less common(46%),with the latissimus dorsi and rectus muscle flaps composing the majority.The most commonly used recipient vessel was the anterior tibialis(49.5%)and posterior tibialis vessels(45.3%).Most studies performed reconstruction within 7-10 days of presentation.There was a cumulative 6.5%flap failure rate.Conclusion:Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes.Recent trends indicate increasing usage of perforator flaps.This study shows that based on existing data,free flap utilization for pediatric patients is an adequate modality for repair,and may warrant greater consideration moving forward.

Soft-tissue management and reconstruction of lower-extremity trauma

Soft-tissue management and subsequent salvage of the lower extremity following trauma has long presented difficult challenges to the plastic surgeon.Trauma to the lower extremity can produce long-term sequelae consisting of psychological trauma,functional deficits,and increased costs to the healthcare system.Avoiding incorrect management is important,and is compounded by the fact that few guidelines exist on appropriate treatment and patient counseling.This study aims to describe the authors’experience at a large limb salvage center in order to further delineate management strategies.

Use of preoperative ultrasound in designing the true pectoralis major myocutaneous island flap

Background Traditional techniques used for harvesting the pectoralis major myocutaneous （PMMC） flap have accompanying disadvantages,such as the necessity for an upper chest skin incision,the bulkiness of myocutaneous tissue at the pedicle of the flap,and the risk of total or partial necrosis of flap tissue.The aim of this study was to develop a safe and fast method for preparing PMMC island flaps using preoperative ultrasonography for vessel detection.Methods Forty-one PMMC island flaps were used for one-stage reconstruction of head and neck defects,including 21 cases in the treatment group and 20 cases in the control group.In the treatment group,ultrasonography was used to mark out the course of the thoracic branches of the thoracoacromial artery and the lower end of this artery perforating from the fascia into the muscles,as well as the largest perforating branch of the fourth or fifth internal mammary artery entering the PMMC flap.A line,from the lower end of the thoracic branch to the largest perforating branch of the fourth or fifth internal mammary artery,was drawn to determine the axis of the PMMC flap.In the control group,PMMC island flaps were designed according to conventional methods without using ultrasonography.Results According to the ultrasonic marks,the distance from lower end of thoracic branch to the midpoint of the margin of the inferior clavicular was （5.1±1.2） cm.The time from designing to transferring the island flap was significantly shorter in the treatment group （（51.0±10.5） minutes） compared with the control group （（78.0±13.9） minutes,P 〈0.01）.The rate of partial necrosis was 4.7% （1/21） in the treatment group and 35.0% （7/20） in the control group.There was one case of flap failure in the control group due to vascular injury during vascular pedicle dissection.Conclusion Preoperative vessel detection by ultrasonography facilitates easy and safe harvesting of the true PMMC island flap.