BACKGROUND: In lower-limb reconstruction using free fibular flaps, fibular hypertrophy is essential for achieving weight-bearing function. However, the effects of different fixation methods on hypertrophy and its long-te...BACKGROUND: In lower-limb reconstruction using free fibular flaps, fibular hypertrophy is essential for achieving weight-bearing function. However, the effects of different fixation methods on hypertrophy and its long-term progression remain unclear. METHODS: We retrospectively reviewed 51 patients who underwent free fibular flap transfer to the femur or tibia between 2003 and 2024. Fixation methods included external skeletal fixator (ESF), dynamic compression plate (DCP), locking compression plate (LCP), and others. Hypertrophy was evaluated as the ratio of fibular width on follow-up radiographs to that on the immediate postoperative radiograph. Long-term changes were assessed in patients with ≥2-year follow-up radiographs. RESULTS: ESF was used in 12, DCP in 28, LCP in 6, and others in 5 patients. Recipient sites were femur in 12 and tibia in 39 patients. At the last follow-up (mean 5.7 years), mean hypertrophy ratios were 1.08 (ESF), 1.48 (DCP), 1.69 (LCP), and 1.20 (others), with LCP showing the highest value. Multivariable mixed-effects linear regression analysis identified DCP as being significantly associated with greater hypertrophy compared with ESF (p = 0.011). Younger age was also significantly associated with greater hypertrophy. In 30 patients with ≥2 years of follow-up, hypertrophy progressed significantly beyond 2 years, with a greater increase in patients younger than 20 years. CONCLUSIONS: Plate fixation, particularly using LCPs, may represent an optimal fixation method for promoting hypertrophy. The continued progression of hypertrophy beyond 2 years, especially in younger patients, highlights the potential advantages of fibular flap transfer in pediatric lower-limb reconstruction.Level of Evidence: 3.
BACKGROUND: Facial feminization surgery (FFS) involves bony modifications of the forehead, chin, and mandible. Accurately estimating the millimeter-level bony modification required to achieve the desired aesthetic outcom...BACKGROUND: Facial feminization surgery (FFS) involves bony modifications of the forehead, chin, and mandible. Accurately estimating the millimeter-level bony modification required to achieve the desired aesthetic outcome remains a challenge. Presented is the first analysis comparing bone anatomic changes to perceived soft tissue changes in FFS. METHODS: Computed tomography (CT) scans were obtained pre- and postoperatively, while three-dimensional (3D) photographs were acquired preoperatively and ≥6 months postoperatively (N = 70). Cephalometric and anthropometric landmarks were used to calculate bony and soft tissue parameters. Correlations and soft tissue-to-bony change ratios were computed for five paired parameters across facial regions. Multivariable regression assessed body mass index (BMI), age at surgery, duration of hormone therapy, and local soft tissue thickness as predictors of the soft tissue response ratio. RESULTS: Significant correlations were observed between soft tissue and bony changes for all paired measures. In the gonial region, soft tissue reduction exceeded bony reduction (response ratio 1.85 [95% CI: 1.02-2.67]). Ratios were near 1:1 for forehead projection (0.98 [95% CI: 0.92-1.14]) and lower for the bossing angle (0.70 [95% CI: 0.51-0.89]), chin horizontal projection (0.83 [95% CI: 0.37-1.30]), and chin vertical projection (0.52 [95% CI: 0.03-1.01]). Variability in response ratios across regions paralleled differences in soft tissue thickness. Within regions, however, soft tissue thickness, BMI, age, and duration of hormone therapy were not significant predictors. CONCLUSIONS: Our findings suggest that the soft tissue response to bony change is region-specific and variable. Recognizing regional patterns may enhance surgical planning precision.
INTRODUCTION: Chronic postamputation pain, driven by residual limb pain (RLP) and phantom limb pain (PLP), is a major source of long-term disability after limb loss. The long-term effectiveness of targeted muscle reinner...INTRODUCTION: Chronic postamputation pain, driven by residual limb pain (RLP) and phantom limb pain (PLP), is a major source of long-term disability after limb loss. The long-term effectiveness of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), particularly compared with untreated patients, remains unclear. METHODS: A retrospective cohort study was performed at a single quaternary cancer center. Adult oncologic amputees who received TMR and/or RPNI were compared with a historic cohort without nerve reconstruction, with outcomes assessed at least 10 months after amputation. Long-term pain and controlled-substance use were evaluated using patient-reported measures (Numeric Pain Scale, PROMIS Pain Intensity, Interference, and Behavior) and prescription records for opioids, benzodiazepines or pregabalin, and gabapentin. RESULTS: Seventy-nine patients were analyzed (25 historic, 54 TMR/RPNI). At long-term follow-up, the TMR/RPNI cohort had significantly lower RLP (0.0 [0.0-2.0] vs. 2.0 [0.0-4.0], p = 0.017), PLP (0.0 [0.0-3.0] vs. 4.0 [2.0-5.0], p = 0.001), and PROMIS Pain Intensity (47.5 [36.3-58.5] vs. 54.8 [51.4-61.9], p = 0.040) and Behavior (56.9 [45.5-62.4] vs. 64.5 [59.8-68.5], p = 0.003) scores. Opioid (p = 0.022) and benzodiazepine or pregabalin (p = 0.017) use were significantly reduced, while gabapentin use was higher (p = 0.006), indicating a transition to non-opioid analgesia. CONCLUSION: This study provides the long-term comparison of oncologic amputees with and without TMR/RPNI and demonstrates durable reductions in pain and opioid dependence more than 10 months after amputation. Physiologic nerve reconstruction offers sustained benefit and supports improved survivorship and safer analgesic practices in oncologic amputation care.
LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Classify vascular anomalies as either proliferative tumors or structural malformations using the current International Society for t...LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Classify vascular anomalies as either proliferative tumors or structural malformations using the current International Society for the Study of Vascular Anomalies biological framework. 2. Identify key molecular pathways and somatic mutations that serve as targets for modern medical therapies. 3. Differentiate between high-flow and slow-flow malformations based on hemodynamic characteristics observed in Doppler ultrasound and magnetic resonance imaging. 4. Summarize the indications, mechanisms of action, and potential adverse effects of primary pharmacologic agents, including propranolol and sirolimus. 5. Formulate a multidisciplinary management plan that integrates medical, laser, and surgical modalities tailored to specific anomaly subtypes. SUMMARY: Vascular anomalies encompass a heterogeneous group of disorders, from simple birthmarks to complex, life-threatening lesions. Effective management is predicated on the International Society for the Study of Vascular Anomalies classification, which provides a biological framework for differentiating proliferative vascular tumors from structural vascular malformations. In this article, the authors synthesize current knowledge on the epidemiology, clinical presentation, and pathophysiology of these conditions, including significant advances in molecular genetics that have identified key driver mutations in signaling pathways, such as PI3K/AKT/mTOR and RAS/MAPK. This understanding has not only refined diagnosis but also ushered in an era of targeted medical therapies. The present article outlines a systematic approach to diagnosis, combining clinical acumen with essential imaging modalities and strategic genetic testing. Current management strategies for vascular anomalies include observation, medical therapy (eg, propranolol and sirolimus), laser treatment, endovascular interventions, and resection. Given the complexity of these conditions and their multisystemic nature, a coordinated, multidisciplinary team approach is essential for optimizing patient outcomes.