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\"This book provides a complete history of plastic surgery, a description of the modern techniques and choices available, and an overview of the controversies surrounding the choice to voluntarily change your physical appearance\"--Provided by publisher.

Abstract BACKGROUND The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes. OBJECTIVE To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD. METHODS Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay. RESULTS Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups. CONCLUSION Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice Graphical Abstract Graphical Abstract

The use of transvaginal mesh and biological graft material in prolapse surgery is controversial and has led to a number of enquiries into their safety and efficacy. Existing trials of these augmentations are individually too small to be conclusive. We aimed to compare the outcomes of prolapse repair involving either synthetic mesh inlays or biological grafts against standard repair in women. We did two pragmatic, parallel-group, multicentre, randomised controlled trials for our study (PROSPECT [PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trials]) in 35 centres (a mix of secondary and tertiary referral hospitals) in the UK. We recruited women undergoing primary transvaginal anterior or posterior compartment prolapse surgery by 65 gynaecological surgeons in these centres. We randomly assigned participants by a remote web-based randomisation system to one of the two trials: comparing standard (native tissue) repair alone with standard repair augmented with either synthetic mesh (the mesh trial) or biological graft (the graft trial). We assigned women (1:1:1 or 1:1) within three strata: assigned to one of the three treatment options, comparison of standard repair with mesh, and comparison of standard repair with graft. Participants, ward staff, and outcome assessors were masked to randomisation where possible; masking was obviously not possible for the surgeon. Follow-up was for 2 years after the surgery; the primary outcomes, measured at 1 year and 2 years, were participant-reported prolapse symptoms (i.e. the Pelvic Organ Prolapse Symptom Score [POP-SS]) and condition-specific (ie, prolapse-related) quality-of-life scores, analysed in the modified intention-to-treat population. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN60695184. Between Jan 8, 2010, and Aug 30, 2013, we randomly allocated 1352 women to treatment, of whom 1348 were included in the analysis. 865 women were included in the mesh trial (430 to standard repair alone, 435 to mesh augmentation) and 735 were included in the graft trial (367 to standard repair alone, 368 to graft augmentation). Because the analyses were carried out separately for each trial (mesh trial and graft trial) some women in the standard repair arm assigned to all treatment options were included in the standard repair group of both trials. 23 of these women did not receive any surgery (15 in the mesh trial, 13 in the graft trial; five were included in both trials) and were included in the baseline analyses only. Mean POP-SS at 1 year did not differ substantially between comparisons (standard 5·4 [SD 5·5] vs mesh 5·5 [5·1], mean difference 0·00, 95% CI −0·70 to 0·71; p=0·99; standard 5·5 [SD 5·6] vs graft 5·6 [5·6]; mean difference −0·15, −0·93 to 0·63; p=0·71). Mean prolapse-related quality-of-life scores also did not differ between groups at 1 year (standard 2·0 [SD 2·7] vs mesh 2·2 [2·7], mean difference 0·13, 95% CI −0·25 to 0·51; p=0·50; standard 2·2 [SD 2·8] vs graft 2·4 [2·9]; mean difference 0·13, −0·30 to 0·56; p=0·54). Mean POP-SS at 2 years were: standard 4·9 (SD 5·1) versus mesh 5·3 (5·1), mean difference 0·32, 95% CI −0·39 to 1·03; p=0·37; standard 4·9 (SD 5·1) versus graft 5·5 (5·7); mean difference 0·32, −0·48 to 1·12; p=0·43. Prolapse-related quality-of-life scores at 2 years were: standard 1·9 (SD 2·5) versus mesh 2·2 (2·6), mean difference 0·15, 95% CI −0·23 to 0·54; p=0·44; standard 2·0 (2·5) versus graft 2·2 (2·8); mean difference 0·10, −0·33 to 0·52; p=0·66. Serious adverse events such as infection, urinary retention, or dyspareunia or other pain, excluding mesh complications, occurred with similar frequency in the groups over 1 year (mesh trial: 31/430 [7%] with standard repair vs 34/435 [8%] with mesh, risk ratio [RR] 1·08, 95% CI 0·68 to 1·72; p=0·73; graft trial: 23/367 [6%] with standard repair vs 36/368 [10%] with graft, RR 1·57, 0·95 to 2·59; p=0·08). The cumulative number of women with a mesh complication over 2 years in women actually exposed to synthetic mesh was 51 (12%) of 434. Augmentation of a vaginal repair with mesh or graft material did not improve women's outcomes in terms of effectiveness, quality of life, adverse effects, or any other outcome in the short term, but more than one in ten women had a mesh complication. Therefore, follow-up is vital to identify any longer-term potential benefits and serious adverse effects of mesh or graft reinforcement in vaginal prolapse surgery. UK National Institute of Health Research.

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.

Recently, venous couplers have been routinely employed for free flap surgery. Its use is justified considering the large number of backlog cases as well as for surgeon and patient benefit. However, venous thrombosis remains a worrisome problem in the use of venous couplers. Although the efficacy of venous couplers has been found to be equal to that of hand-sewn anastomosis, comparison of single versus double venous coupler anastomosis has not been reported. A prospective randomized study carried between 2020 and 2024 included 154 patients who underwent maxillofacial free flap reconstruction; these patients were divided into two groups based on the number of venous coupler anastomoses performed. (Single MACD, n = 82 vs. Double MACD, n = 72). Data were evaluated for demographics, perioperative details, vascular thrombosis, flap complications and flap loss. There were no significant differences regarding comorbidities or ASA status between the two groups. Overall, there was no significant difference regarding the rate of venous thrombosis (1 MACD: 2.44% versus 2 MACD: 2.78%, p > 0.05) or flap loss (1 MACD: 1.22% versus 2 MACD: 1.39%, p > 0.05). As our overall survivability rate was more than 97% in each group, it can be concluded that flap survivability is not dependent on the number of venous coupler anastomoses and that it would be safe to proceed with single venous coupler anastomosis with close flap monitoring. Various other factors, such as improper technique, intimal injury, hematoma and pedicle compression, may play more prominent roles in flap survivability.

Vascularised iliac flaps (VIFs) are widely used for the reconstruction of jawbone defects; however, postoperative donor-site complications, such as gait disturbances, with an incidence of 13.9–50%, significantly impede patient recovery. Despite this, evidence-based rehabilitation protocols specific to VIFs remain lacking. Existing rehabilitation guidelines for hip surgeries are unsuitable owing to differences in surgical mechanisms. This study employed the Delphi method, engaging 20 multidisciplinary experts (oral and maxillofacial surgery: 5; orthopaedics: 7; rehabilitation: 6; nursing: 2). Through three rounds of anonymous consultations, and by integrating literature evidence with postoperative mobility assessments, we developed a phased, individualised progressive functional training (PFT) protocol featuring dynamic evaluation, coordinated activation of abdominal and hip muscle groups, and safe exercise strategies during head and neck immobilisation, while overcoming conventional hip rehabilitation limitations (e.g., restrictions on flexion < 90°, and bans on squatting or cross-legged sitting). PFT is structured into six progressive phases, with exercise intensity tailored to assessment outcomes. A single-centre randomised controlled trial (n = 62) demonstrated that PFT significantly accelerated lower limb functional recovery, improved hip mobility and balance, reduced donor-site pain, and enhanced quality of life (University of Washington Quality of Life questionnaire: F (1,60) = 17.262, P  < 0.001), without increasing the risk of flap vascular compromise or iliac hematoma. The limitations of the study include the single-centre design and lack of cross-cultural validation. Future multicentre studies are required to enhance adaptability. This study establishes a foundational yet effective framework for post-VIF rehabilitation, guiding clinical practice and research advancements.

Background Patients undergoing perineal defect reconstruction with the internal pudendal artery perforator (IPAP) flap traditionally face 5 days of postoperative bed rest (BR) to minimize surgical risks. However, prolonged BR can exacerbate postoperative physiologic changes such as increased fatigue, reduced body mass, and declining lung function, while also leading to complications such as pneumonia, delirium, deep vein thrombosis, and pressure injuries. This study assessed the effectiveness, feasibility, and safety of an adapted early mobilization (EM) program for these patients. Methods This prospective, randomized, controlled clinical study involved 51 patients assigned to adapted EM ( n  = 25) or BR ( n  = 26). Whereas EM included core exercises, orthostasis training, gait training, muscle strengthening, and aerobic exercises after surgery, BR followed standard bed rest protocols. The primary outcome was independent ambulation for 3 m on postoperative day 5. The secondary outcomes included 6-min walk test (6MWT) distances on days 5 and 30, hospital length of stay, healing time, postoperative complications, fatigue prevalence, and quality of life. Results On day 5, EM improved ambulation significantly compared with BR (68.0% vs 38.5%; P  = 0.035) and achieved greater 6MWT distances on days 5 (108.78 vs 47.73 m; P  = 0.041) and 30 (243.8 vs 166.29 m; P  = 0.018). The EM patients were discharged earlier (66.7% by day 10 vs 33.3% of the BR patients; P  = 0.043), with comparable healing times ( P  = 0.06) and postoperative complication rates (68% vs 80.8%; P  = 0.296). Fatigue prevalence and quality of life did not differ significantly between the two groups. Conclusion Early mobilization after IPAP flap reconstruction is safe and feasible, promoting early ambulation and recovery and facilitating earlier discharge without increasing complications.

To evaluate the clinical efficacy, advantages, and disadvantages of the modified Shiraki procedure and the transverse pedicled island flap phalloplasty in treating severe concealed penis in children. This study included seventy children with severe concealed penis treated at Yulin First People’s Hospital from June 2021 to January 2024. They were randomly assigned to either the observation group ( n  = 35), undergoing the modified Shiraki procedure, or the control group ( n  = 35), receiving the transverse pedicled island flap phalloplasty. We assessed average operation time, intraoperative blood loss, penile elongation, time until resolution of penile prepuce edema, flap infection or necrosis, penile erectile pain, prepuce skin redundancy, penile retraction, and overall penile appearance score six months postoperatively. The observation group showed significantly better average operative time and intraoperative blood loss compared to the control group ( p  < 0.05). The time for foreskin edema to regress was longer in the observation group ( p  < 0.05). No significant differences were noted in penile lengthening between groups ( p  > 0.05). The observation group had seven cases of refractory inner prepuce plate swelling and skin redundancy post-operation; two of these cases required secondary surgery, and without skin flap infection or necrosis. The control group reported one case of postoperative hemorrhage and four cases of infection and necrosis of the transferred flap, all resolved after prolonged dressing changes, with one case requiring surgical correction for scar contracture on the side of the penis. Neither group experienced penile erectile pain or retraction. Total complications and reoperations were similar between the groups. No significant difference in the overall penile appearance score was observed between the two groups six months post-surgery ( p  > 0.05). Both the modified Shiraki procedure and the transverse pedicled island flap phalloplasty are effective for treating severe concealed penis in children. The former is characterized by shorter, simpler operations, while the latter offers better cosmetic outcomes despite its complexity.

Cranioplasty (CP), a surgical procedure that restores cranial integrity and potentially enhances neurological outcomes, is commonly performed following decompressive craniectomy for various reasons. However, there is considerable controversy and variation regarding the optimal timing for cranioplasty, particularly concerning its impact on neurological functional outcomes. This paper outlines the protocol for a multicenter, non-randomized controlled trial designed to investigate whether the timing of cranioplasty influences neurological outcomes. This study will be conducted from June 2025 to June 2026 across multiple clinical centers in China, targeting the enrollment of at least 500 adults aged 18-65 years with skull defects larger than 25 cm². Participants will be divided based on the timing of their cranioplasty relative to decompressive craniectomy into two groups: early (within 3 months post-decompression) and late (after 3 months). The primary outcome, assessed through the Barthel Index, will measure functional recovery 6 months post-surgery, with secondary outcomes including mortality, quality of life, cognitive performance and complication rates. This non-randomized clinical trial focuses on the neurological outcomes associated with different timings of cranioplasty. It is anticipated that the findings will contribute valuable insights and support more informed clinical decisions regarding the timing of cranioplasty. By comparing early and late cranioplasty, the trial aims to clarify how timing affects recovery and overall neurological improvement post-surgery. Trial Registration: ChiCTR2400094619.

Purpose To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up. Methods Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes. Results Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p  = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p  = 0.014). Clinically both groups had significant improvements, but no differences were found between groups. Conclusion Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint. Level of evidence Level I.