Preferred Nasolabial Angle in Rhinoplasty: A Cross-Sectional Analysis.

BACKGROUND: The perception of an ideal nose is influenced by a variety of factors, with demographic characteristics playing a significant role in what is considered an ideal nose. The nasolabial angle (NLA) is considered one of the defining features shaping the nose. OBJECTIVES: In this study we set out to capture the perception of the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations. METHODS: An online questionnaire-based cross-sectional study was conducted to investigate the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations (n = 197). Participants were patients attending outpatient clinics, plastic surgery residents, and medical students. The questionnaire included demographics and the perception of respondents of the ideal NLA for each gender: male (85°, 90°, 95°, 100°, 110°) and females (95°, 100°, 110°, 115°). RESULTS: The majority of respondents were female (81.2%), ages between 20 and 39 (84.3%). The mean and standard deviation of ideal NLA choices in both male and female models were 97.1 ± 6.39 and 109.5 ± 5.32, respectively. The ideal male NLA choices were found to correlate significantly with age (P = .044) and work status (P = .019). In choosing the ideal female NLA, age was a significant factor (P = .012). CONCLUSIONS: Identifying the ideal NLA is essential to establishing aesthetic goals for patient and surgeon alike. It is important to understand the effects of demographics on the choice of the ideal NLA, which ultimately influences the planning and outcome of the rhinoplasty procedure.

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review.

BACKGROUND: Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery. METHODS: A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type. RESULTS: Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery. CONCLUSIONS: Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Methodological Quality of Open Access Compared to Traditional Journal Publications in the Plastic Surgery Literature.

BACKGROUND: The methodological quality of open access studies has long been questioned due to increasing popularity and accessibility. The objective of this study is to compare the methodological quality of open access versus traditional journal publications in the plastic surgery literature. METHODS: Four traditional plastic surgery journals with their sister open access journals were chosen. For each of the eight journals, 10 articles were randomly selected for inclusion. Methodological quality was examined using validated instruments. Publication descriptors were compared to methodological quality values using ANOVA. Logistic regression was used to compare quality scores between open access and traditional journals. RESULTS: There was a wide distribution of levels of evidence, with a quarter being level one. Regression of non-randomized studies indicated a significantly higher proportion of traditional journal articles were of high methodological quality (89.6%) when compared to open access journals (55.6%; p < 0.05). This difference persisted in three quarter of the sister journal groups. No publication descriptions were associated with methodological quality. CONCLUSIONS: Methodological quality scores were higher among traditional access journals. Higher degrees of peer review may be necessary to ensure appropriate methodological quality in open access plastic surgery publications. 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 www.springer.com/00266 .

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis.

BACKGROUND: Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate. METHODS: A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates. RESULTS: Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality. CONCLUSION: The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction.

BACKGROUND: Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. METHODS: A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. RESULTS: Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. CONCLUSIONS: Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

Hand Rejuvenation: A Systematic Review of Techniques, Outcomes, and Complications.

BACKGROUND: Hand rejuvenation is an increasingly popular cosmetic procedure for hand atrophy and aging. The objective of this study is to systematically evaluate the techniques, outcomes, and complications of surgical hand rejuvenation. METHODS: A systematic review was undertaken using a computerized search. Publication descriptors, methodological details, techniques, outcomes, and complications were extracted. Articles were assessed using the MINORS and Cochrane instruments. RESULTS: Thirty-one studies were included. Most studies were published in the last five years (51.6 percent) and were prospective case series (35.5 percent). The mean age of patients was 56 (range 21-82), while the mean sample size was 47 (range 10-220). The most commonly examined interventions were Radiesse (32.2 percent) and fat grafting (32.2 percent). Major complications were not observed in any study, while minor complications such as edema and pain were temporary. Injection techniques varied, however, the proximal to distal fanning technique and using a cannula was associated with a lower risk of complications. Both Radiesse and fat grafting had robust long-term esthetic outcomes. CONCLUSIONS: Hand rejuvenation is a safe and efficacious surgical intervention to reduce dorsal hand atrophy. Further studies are needed to compare the long-term outcomes of common interventions. 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 .

A Systematic Review of Feeding Interventions for Infants with Cleft Palate.

OBJECTIVE: Various devices and techniques have been proposed to reduce feeding difficulties experienced by infants with cleft palate. The aim of this review is to identify and assess the scope and quality of evidence for these interventions. METHODS: A systematic review of published literature evaluating feeding interventions for infants with cleft palate (with or without cleft lip) from database inception to 2021 was conducted using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using a methodological index for nonrandomized studies, Cochrane, or a measurement tool to assess systematic reviews 2 instruments, according to study type. RESULTS: Fourteen studies met inclusion criteria, with the majority (71%) of studies consisting of second-level evidence. Included interventions were specialty bottles (21%), alternative feeding delivery systems (14%), obturators (14%), and educational programs (14%). Specialty bottles and palatal obturators did not appear to offer any substantial growth advantages compared to traditional bottles or no intervention, respectively. Designated education programs for the mothers of infants with clefts had a positive impact on infant growth. CONCLUSIONS: Overall evidence evaluating feeding interventions for infants with cleft palate was moderate to low. While it does not appear that specialized feeding delivery systems or palatal obturators significantly improve growth in infants with clefts compared to children without cleft conditions, education programs do appear to be beneficial.

Patient survival following renal transplantation in Indigenous populations: A systematic review.

BACKGROUND: Inequities in health care predispose Indigenous populations to poor health outcomes. The objective of this study was to examine patient survival and other post-transplant outcomes of kidney transplantation among Indigenous patients compared with non-Indigenous populations. METHODS: A systematic review of MEDLINE, EMBASE, and Google Scholar was undertaken from inception to September 30, 2019, using a computerized search. Publication descriptors and methodological and statistical details were extracted. Articles were assessed using the methodological index for non-randomized studies (MINORS) scale. RESULTS: Twelve studies were included. All studies were retrospective and published between 2004 and 2018. Mean Indigenous patient age was 40 (range: 8-76), while non-Indigenous was 41 (range: 6-74). Mean sample size for Indigenous populations was 398 (range: 24-1459), while for non-Indigenous patients was 1102 (range: 53-7555). Eight studies examined indigenous populations in Australia, two in Canada, one in the United States, and one in New Zealand. All studies were considered of high methodological quality and clinically homogenous. Results indicated that patient survival, graft survival, and delayed graft function were significantly reduced among Indigenous populations compared with non-Indigenous populations. CONCLUSIONS: Post-transplant outcomes among various Indigenous populations are significantly worse compared with non-Indigenous populations. The reasons for poor outcomes are likely multifactorial. Improved standardized reporting of transplant outcomes of Indigenous patients is necessary to better inform healthcare services and improve clinical outcomes.

The effect of talc particles on phagocytes in co-culture with ovarian cancer cells.

Talc and titanium dioxide are naturally occurring water-insoluble mined products usually available in the form of particulate matter. This study was prompted by epidemiological observations suggesting that perineal use of talc powder is associated with increased risk of ovarian cancer, particularly in a milieu with higher estrogen. We aimed to test the effects of talc vs. control particles on the ability of prototypical macrophage cell lines to curb the growth of ovarian cancer cells in culture in the presence of estrogen. We found that murine ovarian surface epithelial cells (MOSEC), a prototype of certain forms of ovarian cancer, were present in larger numbers after co-culture with macrophages treated to a combination of talc and estradiol than to either agent alone or vehicle. Control particles (titanium dioxide, concentrated urban air particulates or diesel exhaust particles) did not have this effect. Co-exposure of macrophages to talc and estradiol has led to increased production of reactive oxygen species and changes in expression of macrophage genes pertinent in cancer development and immunosurveillance. These findings suggest that in vitro exposure to talc, particularly in a high-estrogen environment, may compromise immunosurveillance functions of macrophages and prompt further studies to elucidate this mechanism.

Prevention of Autologous Costal Cartilage Graft Warping in Secondary Rhinoplasty.

BACKGROUND: Autogenous costal cartilage grafts (ACCG) are frequently used in secondary rhinoplasty; however, these grafts tend to warp. The objective of this study is to systematically evaluate current interventions to prevent warping of ACCGs and to assess long-term outcomes with their use. METHODS: A systematic review was undertaken using a computerized search. Eligible articles assessed adult patients undergoing secondary rhinoplasty with ACCGs. Interventions to reduce warping were examined. Publication descriptors were extracted, heterogeneity was examined, and methodological quality of articles was assessed. RESULTS: Eighteen studies were included. Most studies were published after 2010 (83.3%), assessed a single intervention (83.3%), and were of levels of evidence III and IV. Mean patient age was 30 (range 5-95 years) and studies included a mean of 64 cases (range 9-357). Nine of the 15 non-comparative studies were considered of high methodological quality, while all 3 comparative studies were considered high quality. Secondary rhinoplasties which did not describe a method to address warping showed increased rates of warping compared to counter balancing techniques, chimeric grafts, titanium microplating, Kirschner wire and suture usage, irradiation, and various carving techniques. Rates of warping remained low with no major complications with the use of a variety of approaches. CONCLUSIONS: ACCG warping during secondary rhinoplasty can be alleviated with a variety of techniques with no clear difference in outcomes between approaches. Plastic surgeons may consider adopting one of the various techniques described in order to reduce warping, maximize aesthetic outcomes and patient satisfaction.

Branches From the "SEAD": Sustained and Feasible Expansion of the Surgical Exploration and Discovery Program.

PROBLEM: A predicted shortage of surgeons and attrition among surgical residents has highlighted the need to attract well-suited medical students to surgical specialties. Literature suggests that early exposure may increase interest by addressing misconceptions and allowing students more time to make an informed career decision. APPROACH: The Surgical Exploration and Discovery (SEAD) program was created in 2012 with the goal of providing medical students with comprehensive and multifaceted exposure to surgical specialties to develop their knowledge and skills, and in turn positively influence their interest in pursuing a surgical career. The purpose of this innovation report is to describe the challenges, successes, and evolution of the SEAD program. OUTCOMES: Since its inception, SEAD has expanded to include 5 North American institutions and has educated nearly 400 participants in 5 y. Through a replication strategy, SEAD has maintained its basic curriculum, while accommodating the constraints and innovative approaches unique to each institution. Short-term results have demonstrated improved knowledge of curricular objectives, student perception of significant value of the program, and the generation of interest in a career in surgery. CONCLUSIONS: Future directions include the evaluation of long-term impact on pursuing a career in surgery and continuing further expansion using the current replication model, while maintaining a high-quality surgical education program.

Cross sectional analysis of student-led surgical societies in fostering medical student interest in Canada.

BACKGROUND: The objective of this study was to examine how surgery interest groups (SIGs) across Canada function and influence medical students' interest in surgical careers. METHODS: Two unique surveys were distributed using a cross sectional design. The first was sent to SIG executives and the second to SIG members enrolled at a Canadian medical school in the 2016/17 academic year. The prior focused on the types of events hosted, SIG structure/ supports, and barriers/ plans for improvement. The second questionnaire focused on student experience, involvement, and suggestions for improvement. RESULTS: SIG executives became involved in SIG through classmates and colleagues (8/17, 47%). Their roles focused on organizing events (17/17, 100%), facilitating student contact with resident/surgeons (17/17, 100%), and organizing funding (13/17, 76%). Surgical skills events were among the most successful and well received by students (15/17, 88%). Major barriers faced by SIG executives during their tenure included time conflicts with other interest groups (13/17, 76%), lack of funding (8/17, 47%), and difficulty booking spaces for events (8,17, 47%). SIGs were found to facilitate improvement in basic surgical skills (µ = 3.89/5 ± 0.70) in a comfortable environment (µ = 4.02/5, ±0.6), but were not helpful with final block examinations (µ = 2.98/5, ±0.80). Members indicated that more skills sessions, panel discussion and shadowing opportunities would be beneficial additions. Overall, members felt that SIGs increased their interest in surgical careers (µ = 3.50/5, ±0.79). CONCLUSION: Canadian SIGs not only play a critical role in early exposure, but may provide a foundation to contribute to student success in surgery.

Regional differences in aortic valve replacements: Atlantic Canadian experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is evolving rapidly and is increasingly being adopted in the treatment of aortic valve disease. The goal of this study was to examine regional differences in surgical aortic valve replacement (SAVR) and TAVI across Atlantic Canada. METHODS: We identified all patients who underwent SAVR or TAVI between Jan. 1, 2010, and Dec. 31, 2014, in New Brunswick, Nova Scotia and Newfoundland and Labrador. Data obtained included patient demographic characteristics and surgical procedure details. We performed univariate descriptive analyses and calculated crude and age- and sex-adjusted incidence rates. RESULTS: A total of 3042 patients underwent SAVR or TAVI during the study period, 1491 in Nova Scotia, 1042 in New Brunswick and 509 in Newfoundland and Labrador. Patient demographic characteristics were similar across regions. A much higher proportion of patients in Newfoundland and Labrador (43.6%) than in Nova Scotia (4.2%) or New Brunswick (13.6%) received a mechanical versus a bioprosthetic valve. Rates of TAVI increased over the study period, with New Brunswick adopting their program before Nova Scotia (144 v. 74 procedures). Adjusted rates of all AVR procedures remained stable in Nova Scotia (40-50 per 100 000 people). Adjusted rates were lower in New Brunswick and Newfoundland and Labrador than in Nova Scotia; they increased slowly in New Brunswick over the study period. CONCLUSION: Despite geographical proximity and similar patient demographic characteristics, there existed regional differences in the management of aortic valve disease within Atlantic Canada. Further study is required to determine whether the observed differences in age- and sex-adjusted rates of AVR may be explained by geographical disease-related differences, varying practice patterns or barriers in access to care.

CONTEXTE: Le remplacement valvulaire aortique par cathéter, une méthode en pleine évolution, est de plus en plus utilisé pour le traitement des valvulopathies aortiques. Cette étude visait à examiner les différences régionales quant au remplacement valvulaire aortique par cathéter ou par chirurgie dans les provinces de l'Atlantique. MÉTHODES: Nous avons recensé tous les patients ayant subi un remplacement valvulaire aortique entre le 1er janvier 2010 et le 31 décembre 2014 au Nouveau-Brunswick, en Nouvelle-Écosse et à Terre-Neuve-et-Labrador. Nous avons recueilli des données sur les caractéristiques démographiques des patients et les interventions chirurgicales, puis nous avons réalisé une analyse descriptive univariée et avons calculé les taux d'incidence bruts et corrigés selon l'âge et le sexe. RÉSULTATS: En tout, 3042 patients ont subi un remplacement valvulaire aortique par cathéter ou par chirurgie pendant la période à l'étude : 1491 en Nouvelle-Écosse, 1042 au Nouveau-Brunswick et 509 à Terre-Neuve-et-Labrador. Les caractéristiques démographiques des patients étaient semblables d'une région à l'autre. La proportion des patients recevant une prothèse mécanique plutôt qu'une bioprothèse était beaucoup plus élevée à Terre-Neuve-et-Labrador (43,6 %) qu'en Nouvelle-Écosse (4,2 %) ou au Nouveau-Brunswick (13,6 %). Les taux de remplacement par cathéter ont augmenté au cours de la période à l'étude; le Nouveau-Brunswick a adopté un programme à ce sujet avant la Nouvelle-Écosse (144 c. 74 interventions). Les taux corrigés pour tous les remplacements étaient stables en Nouvelle-Écosse (40-50 par 100 000 habitants); ils étaient plus faibles au Nouveau-Brunswick et à Terre-Neuve-et-Labrador, mais ont augmenté lentement au Nouveau-Brunswick pendant la période à l'étude. CONCLUSION: Malgré la proximité géographique des provinces de l'Atlantique et les caractéristiques démographiques semblables des patients, il existait des différences dans la prise en charge des valvulopathies aortiques. D'autres études seront nécessaires pour déterminer si les variations dans les taux de remplacement corrigés selon l'âge et le sexe pourraient s'expliquer par des différences géographiques dans le nombre de cas, des différences dans les pratiques ou des obstacles à l'accès aux soins.

Transgenerational transmission of asthma risk after exposure to environmental particles during pregnancy.

Exposure to environmental particles during pregnancy increases asthma susceptibility of the offspring. We tested the hypothesis that this transmission continues to F2 and F3 generations and occurs via epigenetic mechanisms. We compared allergic susceptibility of three generations of BALB/c offspring after a single maternal exposure during pregnancy to diesel exhaust particles or concentrated urban air particles. After pregnant dams received intranasal instillations of particle suspensions or control, their F1, F2, and F3 offspring were tested in a low-dose ovalbumin protocol for sensitivity to allergic asthma. We found that the elevated susceptibility after maternal exposure to particles during pregnancy persists into F2 and, with lesser magnitude, into F3 generations. This was evident from elevated eosinophil counts in bronchoalveolar lavage (BAL) fluid, histopathological changes of allergic airway disease, and increased BAL levels of IL-5 and IL-13. We have previously shown that dendritic cells (DCs) can mediate transmission of risk upon adoptive transfer. Therefore, we used an enhanced reduced representation bisulfite sequencing protocol to quantify DNA methylation in DCs from each generation. Distinct methylation changes were identified in F1, F2, and F3 DCs. The subset of altered loci shared across the three generations were not linked to known allergy genes or pathways but included a number of genes linked to chromatin modification, suggesting potential interaction with other epigenetic mechanisms (e.g., histone modifications). The data indicate that pregnancy airway exposure to diesel exhaust particles (DEP) triggers a transgenerationally transmitted asthma susceptibility and suggests a mechanistic role for epigenetic alterations in DCs in this process.

Supervisor Autonomy and Considerate Leadership Style are Associated with Supervisors' Likelihood to Accommodate Back Injured Workers.

PURPOSE: To determine the association between supervisors' leadership style and autonomy and supervisors' likelihood of supporting job accommodations for back-injured workers. METHODS: A cross-sectional study of supervisors from Canadian and US employers was conducted using a web-based, self-report questionnaire that included a case vignette of a back-injured worker. Autonomy and two dimensions of leadership style (considerate and initiating structure) were included as exposures. The outcome, supervisors' likeliness to support job accommodation, was measured with the Job Accommodation Scale (JAS). We conducted univariate analyses of all variables and bivariate analyses of the JAS score with each exposure and potential confounding factor. We used multivariable generalized linear models to control for confounding factors. RESULTS: A total of 796 supervisors participated. Considerate leadership style (ß = .012; 95% CI .009-.016) and autonomy (ß = .066; 95% CI .025-.11) were positively associated with supervisors' likelihood to accommodate after adjusting for appropriate confounding factors. An initiating structure leadership style was not significantly associated with supervisors' likelihood to accommodate (ß = .0018; 95% CI -.0026 to .0061) after adjusting for appropriate confounders. CONCLUSIONS: Autonomy and a considerate leadership style were positively associated with supervisors' likelihood to accommodate a back-injured worker. Providing supervisors with more autonomy over decisions of accommodation and developing their considerate leadership style may aid in increasing work accommodation for back-injured workers and preventing prolonged work disability.