The Impact of COVID-19 on Plastic Surgery Residents Across the World: A Country-, Region-, and Income-level Analysis.

BACKGROUND: The COVID-19 pandemic has upended graduate medical education globally. We investigated the COVID-19 impact on learning inputs and expected learning outputs of plastic surgery residents across the world. METHODS: We administered an online survey capturing training inputs before and during the pandemic and retrieved residents' expected learning outputs compared with residents who completed their training before COVID. The questionnaire reached residents across the world through the mobilization of national and international societies of plastic surgeons. RESULTS: The analysis included 412 plastic surgery residents from 47 countries. The results revealed a 44% decline (ranging from - 79 to 10% across countries) and an 18% decline (ranging from - 76 to across 151% countries) in surgeries and seminars, respectively, per week. Moreover, 74% (ranging from 0 to 100% across countries) and 43% (ranging from 0 to 100% across countries) of residents expected a negative COVID-19 impact on their surgical skill and scientific knowledge, respectively. We found strong correlations only between corresponding input and output: surgeries scrubbed in with surgical skill (ρ = -0.511 with p < 0.001) and seminars attended with scientific knowledge (ρ = - 0.274 with p = 0.006). CONCLUSIONS: Our ranking of countries based on their COVID-19 impacts provides benchmarks for national strategies of learning recovery. Remedial measures that target surgical skill may be more needed than those targeting scientific knowledge. Our finding of limited substitutability of inputs in training suggests that it may be challenging to make up for lost operating room time with more seminars. Our results support the need for flexible training models and competency-based advancement. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Venous Thromboembolism (VTE) Prophylaxis After Abdominoplasty and Liposuction: A Review of the Literature.

BACKGROUND: The aim of this review article was to study recent articles and summarise the guidelines, indications, risks and benefits of using VTE prophylaxis in patients undergoing abdominoplasty and liposuction. METHODS: A search of PubMed was performed using selected keywords related to the topic. Based on the inclusion and exclusion criteria, a total of 25 articles were included in the review. RESULTS: Abdominoplasty has the highest occurrence of VTE among aesthetic procedures. A higher incidence of VTE was noted when abdominoplasty was combined with liposuction. Circumferential procedures, obesity and HRT (hormone replacement therapy) were found to be independent risk factors for VTE. The 2005 Caprini/Davison risk assessment model is the most appropriate model for risk stratification in plastic surgery patients. Newer oral anticoagulants hold promise. CONCLUSIONS: Preoperative risk stratification should be performed for all patients. Chemoprophylaxis should be considered in cases with a Caprini RAM score > 7 or in those with independent risk factors. Administering regional blocks for anaesthesia and avoiding full muscle paralysis help reduce the risk of VTE. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Helpful, albeit hazardous! Esophageal stem-cell injection in systemic sclerosis.

BACKGROUND: Over 90% of patients with systemic sclerosis suffer from gastroesophageal reflux. Esophageal motility disturbances are associated with a reduced life quality and may force interstitial lung disease progression. We wanted to determine whether we can improve gastroesophageal reflux in these patients by esophageal stem-cell injection. METHODS: We performed a pilot study including eights patients with systemic sclerosis and symptomatic gastroesophageal reflux. Sampling of adipose tissue was performed by an experienced plastic surgeon under local anesthesia. The collected fat was injected into the submucosa of the distal esophagus, each time 1 ml in all four quadrants starting 2, 4 and 6 cm proximal to the Z line (ending up to a total volume of 12 ml). Before the intervention, 3, 6 and finally 12 months after the procedure, patients answered the Gastroesophageal Reflux Disease Health-Related Quality of Life Questionnaire (GERD HRQL) and a high-resolution manometry was performed to quantify changes in motility function. RESULTS: All patients showed an improvement in the GERD HRQL score after the stem-cell injection and a lower dosage of proton-pump inhibitors. The manometric findings showed no change throughout the time. A serious adverse event occurred, as one patient developed multiple cerebellar embolic infarcts. CONCLUSION: Because of the favorable effect in all patients, a safe route for esophageal fat injection needs to be developed.

[Lipedema - basics and current hypothesis of pathomechanism]. / Lipödem ­ Grundlagen und aktuelle Thesen zum Pathomechanismus.

Lipoedema is a painful, chronic progressive disorder of adipose tissue, characterised by symmetrical swelling of the lower and/or upper limbs. Due to a lack of awareness, lipoedema is frequently misdiagnosed. However, accurate diagnosis and treatment are essential since they determine the patient's prognosis. There is no known causal therapy because the exact aetiology of the disease is not fully understood at this time. Familial aggregation is common, which suggests a genetic disorder. Since lipoedema is almost exclusively found in women and manifests around hormonal changes (puberty, pregnancy, menopause), oestrogen is believed to play a decisive role in its pathogenesis. This review aims to summarise the symptoms and clinical features of lipoedema, its differential diagnosis, treatment options, and current theories on the pathogenesis of lipoedema.

Aesthetic Refinements in Patients with Prominent Eyes.

The treatment of prominent eyes is still a challenging task. As well as the surgery, proper preoperative diagnosis differentiating between patients with and without Graves ophthalmopathy plays an important role. In functionally asymptomatic patients with Graves disease suffering from the aesthetic impairment of prominent eyes, the transpalpebral decompression by intraorbital fat removal technique has been proved to be reliable, effective, safe, and easily performed by a trained and experienced oculoplastic surgeon. This technique provides long-lasting results, leading to improvement not only in visual function but also in personal well-being and in the patient's social life, with a high benefit-to-risk ratio. The most powerful tool to treat the lower lid deformity and malar bags in patients without Graves disease is the subperiosteal midface lift. It shortens the lid-cheek junction and blends the retaining periorbital ligaments. Furthermore, it adds volume to the lower lid and gives a stable support. By the nature of the procedure, it also turns a negative into a positive vector. In experienced hands, Olivari's orbital decompression and Hester's midface lift are ideal options for the treatment of prominent eyes.

Simultaneous dermal matrix and autologous split-thickness skin graft transplantation in a porcine wound model: a three-dimensional histological analysis of revascularization.

Despite the popularity of a simultaneous application of dermal matrices and split-thickness skin grafts, scarce evidence exists about the process of revascularization involved. In this study, we aimed at analyzing the progression of revascularization by high-resolution episcopic microscopy (HREM) in a porcine excisional wound model. Following the surgical procedure creating 5 × 5 cm(2) full-thickness defects on the back, one area was covered with an autologous split-thickness skin graft alone (control group), the other with a collagen-elastin dermal matrix plus split-thickness skin graft (dermal matrix group). Two skin biopsies per each group and location were performed on day 5, 10, 15, and 28 postoperatively and separately processed for H&E as well as HREM. The dermal layer was thicker in the dermal matrix group vs. control on day 5 and 28. No differences were found for revascularization by conventional histology. In HREM, the dermal matrix did not appear to decelerate the revascularization process. The presence of the dermal matrix could be distinguished until day 15. By day 28, the structure of the dermal matrix could no longer be delineated and was replaced by autologous tissue. As assessed by conventional histology and confirmed by HREM, the revascularization process was comparable in both groups, notably with regard to the vertical ingrowth of sprouting vessels. The presented technique of HREM is a valuable addition for analyzing small vessel sprouting in dermal matrices in the future.

Onset and duration of effect of incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA in the treatment of glabellar frown lines: a randomized, double-blind study.

BACKGROUND: Three botulinum neurotoxin type A preparations (incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA) are widely approved in Europe and in the US for the treatment of glabellar frown lines. The purpose of this study was to determine and compare the time to onset and duration of treatment effect of incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA for the treatment of glabellar frown lines. SUBJECTS AND METHODS: Subjects aged 20-60 years with moderate to severe glabellar frown lines received one treatment of either 21 units (U) incobotulinumtoxinA, 21 U onabotulinumtoxinA, or 63 U abobotulinumtoxinA. Assessments were made over a period of 180 days. Onset of treatment effect was defined as the day that the observer noted a decrease in glabellar muscle activity compared with baseline photographs and videos. Duration of treatment effect was defined as the time until glabellar muscle action returned to the baseline level. Analyses were performed using a Weibull log(T) regression model. RESULTS: The study enrolled 180 subjects; 60 per group. For all three products, onset of treatment effect occurred earlier in female subjects compared to male subjects. For both sexes, a significantly earlier time to onset of treatment effect was seen for incobotulinumtoxinA compared to onabotulinumtoxinA and abobotulinumtoxinA; in female subjects these times were 3.02 days, 5.29 days, and 5.32 days, respectively. The duration of treatment effect was longer for incobotulinumtoxinA compared to onabotulinumtoxinA and abobotulinumtoxinA; for all products, treatment effect duration was longer in females than in males. Time to onset was not a predictor of treatment duration. CONCLUSION: IncobotulinumtoxinA demonstrated a more rapid onset and a longer duration of treatment effect than onabotulinumtoxinA (1:1 dose ratio) and abobotulinumtoxinA (1:3 dose ratio). Onset of effect was faster and duration of effect was longer in female subjects compared to male subjects.

No adverse affect after harvesting of free fibula osteoseptocutaneous flaps on gait function.

The aim of this study was to analyze gait function and muscular strength on donor site after harvesting of a vascularized fibula osteoseptocutaneous flap. Nine patients with a mean follow-up of 33 months (range, 7-59) and a mean resection length of the middle portion of the fibula of 18.0 cm (range, 14.0-23.0) underwent an instrumented three-dimensional gait analysis to evaluate gait function. Furthermore, CYBEX II extremity system was used for muscular strength measurements. Subjective muscle strength measurements were performed according to Kendall et al. and were classified according to the British Medical Research Council. Intraindividual comparison between the operated and the nonoperated leg revealed no significant differences for gait function parameters (cadence, velocity, and stride length, P > 1.00) and for muscular strength measurements for flexion (knee: P = 0.93, ankle: P = 0.54) and extension (knee: P = 0.97, ankle: P= 0.21), respectively. In conclusion, intraindividual comparison of the operated and nonoperated sides after harvesting of the middle portion of the fibula for gaining a free fibula osteoseptocutaneous flap has no adverse affect on gait function or muscular flexion and extension strength on donor site at a mean follow-up of 33 months.

The superior lateral genicular artery flap for soft-tissue reconstruction around the knee: clinical experience and review of the literature.

Soft-tissue reconstruction in the knee area needs thin, pliable, and tough skin. The availability of local soft tissue, which would meet the requirements best, is limited. This study is a retrospective analysis of our clinical experience with the superior lateral genicular artery (SLGA) flap for soft-tissue reconstruction around the knee, and a review of the relevant literature. Between 2000 and 2002, 6 SLGA flaps were elevated for reconstruction of defects around the knee in our institution. Indications for the SLGA flap were chronic ulcers after bursectomy of the prepatellar bursa, a pressure ulcer over the patella, and a defect after resection of a malignant fibrous histiocytoma on the anterolateral aspect of the distal thigh. There was no flap loss in any of our 6 patients. Three patients had partial tissue loss at the distal tip of the flap. Two of the 3 resulting wounds were effectively covered with split skin graft, the third one eventually healed with wound care. Primary donor site closure was possible in all cases. There were no late complications, either in the flap area or in the donor site region. We conclude that the SLGA flap is a good option for defect coverage around the knee, because of its fast and easy harvest and the very good aesthetic results.

The differential gene expression profiles of proximal and distal muscle groups are altered in pre-pathological dysferlin-deficient mice.

The selective pattern of muscle involvement is a key feature of muscular dystrophies. Dysferlinopathy is a good model for studying this process since it shows variable muscle involvement that can be highly selective even in individual patients. The transcriptomes of proximal and distal muscles from wildtype C57BL/10 and dysferlin deficient C57BL/10.SJL-Dysf mice at a prepathological stage were assessed using the Affymetrix oligonucleotide-microarray system. We detected significant variation in gene expression between proximal and distal muscle in wildtype mice. Dysferlin defiency, even in the absence of pathological changes, altered this proximal distal difference but with little specific overlap with previous microarray analyses of dysferlinopathy. In conclusion, proximal and distal muscle groups show distinct patterns of gene expression and respond differently to dysferlin deficiency. This has implications for the selection of muscles for future microarray analyses, and also offers new routes for investigating the selectivity of muscle involvement in muscular dystrophies.