Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis.

OBJECTIVES: To evaluate the efficacy of pharmacological interventions for treating early-stage, pain predominant, adhesive capsulitis, also known as frozen shoulder. METHODS: We performed a systematic review in accordance with PRSIMA guidelines. Searches were conducted on PUBMED, EMBASE and Cochrane Central Register of Controlled Trials on the 24th of February 2022. Outcomes were shoulder pain, shoulder function and range of movement. Synthesis involved both qualitative analysis for all studies and pairwise meta-analyses followed by a network meta-analysis for randomised controlled trials (RCTs). RESULTS: A total of 3,252 articles were found, of which 31 met inclusion criteria, and 22 of these were RCTs. Intraarticular (IA) injection of corticosteroids (8 RCTS, 340 participants) and IA injection of platelet-rich plasma (PRP) (3 RCTs, 177 participants) showed benefit at 12 weeks compared with physical therapy in terms of shoulder pain and function, while oral non-steroidal anti-inflammatories (NSAIDs) (2 RCTs, 44 participants) and IA injection of hyaluronate (2 RCTs, 42 participants) did not show a benefit. Only IA PRP showed benefit over physical therapy for shoulder range of movement. CONCLUSION: These results shows that IA corticosteroids IA PRP injections are beneficial for early-stage frozen shoulder. These findings should be appraised with care considering the risk of bias, heterogeneity, and inconsistency of the included studies. We believe that research focused on early interventions for frozen shoulder could improve patient outcomes and lead to cost-savings derived from avoiding long-term disability. Further well-designed studies comparing with standardised physical therapy or placebo are required to improve evidence to guide management.

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise. OBJECTIVE: This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies. METHODS: This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias. RESULTS: Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention. DISCUSSION: This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments. CONCLUSION: HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II 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 .

Beyond Borders: A Global Microsurgery Training and Case Exposure Survey.

BACKGROUND: Microsurgery is essential in modern reconstructive surgery and plastic surgery training. Surgeon's proficiency and experience are crucial for effective microsurgical interventions. Despite anecdotal evidence of varying quality of microsurgery training globally, no empirical studies have investigated this. We conducted a global survey to investigate microsurgical training and clinical case exposure among plastic surgery trainees worldwide. METHODS: An online survey was conducted using a secure platform to gather information on microsurgical case exposure and training among plastic surgery trainees between August 2020 and April 2021. Participants provided consent and completed a 37-question survey across four themes: clinical caseload, surgical exposure to microsurgery, microsurgical simulation training exposure, and barriers and opportunities. RESULTS: A total of 202 responses were received, with most respondents in formal training programs (86.7%). The data highlighted regional variation in microsurgery case indications and flap types, with North America and Europe exhibiting the highest activity levels in microsurgery. Trainees in Asia have the highest cumulative practical exposure in microsurgery, followed by Australia and Oceania, and North America. Only 39.6% of respondents reported formal microsurgical simulation training, and almost one-third (29.7%) received no simulation training. Trainee access to practical experience is limited by several factors, including insufficient time and procedure complexity. Notably, practical experience was most commonly denied without reason being given. CONCLUSION: Our study highlights significant disparities in microsurgical training and exposure among plastic surgery trainees globally. Further research is needed to identify strategies for addressing these issues, given the growing demand for complex reconstructive microsurgery and its impact on health care inequalities.

The 'Flapbot'- a global perspective on the validity and usability of a flap monitoring chatbot.

BACKGROUND: The Flapbot chatbot assists in free flap monitoring, emphasising accessibility, user-friendliness, and global reliability. This study assesses Flapbot's worldwide validity and usability and uses qualitative analysis to identify areas for future enhancement. METHODS: Flapbot, built on Google's Dialogflow, was evaluated by international plastic surgeons. Invitations were sent to the International Lower Limb Reconstruction Collaborative (INTELLECT), International Confederation of Plastic Surgery Societies (ICOPLAST), and the International Microsurgery Club. Out of the 42 surgeons who agreed to participate 21 tested the Flapbot and completed an online survey on its validity and usability. The survey had 13 validity items and 10 usability items. Data analysis involved computing the Individual Content Validity Index (I-CVI) and Scale-wide Content Validity Index (S-CVI) for validity, and the System Usability Score (SUS) for usability. Thematic analysis distilled free text responses to identify key themes. RESULTS: Nine of thirteen items had an I-CVI over 0.78, denoting significant relevance. The S-CVI score stood at 0.82, indicating high relevance. The SUS score was 68, representing average usability. Themes highlighted issues with the current model, development suggestions, and surgeons' concerns regarding growing reliance on digital tools in healthcare. CONCLUSION: Flapbot is a promising digital aid for free flap monitoring. While it showcases notable validity and usability, improvements in functionality, usability, and accessibility are needed for broader global use.

Standardising the management of open extremity fractures: a scoping review of national guidelines.

INTRODUCTION: Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS: A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS: Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION: Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.

Augmented Reality-Assisted Design of Local Flaps: A New Practical and Educational Tool in the Field of Plastic Surgery.

ABSTRACT: Augmented reality (AR) is a new and promising technology that has been incorporated into several aspects of our everyday life, including surgery. Examples of its application throughout various fields of surgery, although most of them are in experimental stage, have already been demonstrated and published. In this article, we describe the utilization of AR to design effectively and accurately surgical flap markings just with the help of an AR-compatible mobile phone and a low-cost application. We believe that, due to its ease of use, AR will play a pivotal role to the education and the training in the field of plastic surgery and burns, and other surgical specialties alike.

The Newcastle Microsurgery Fellowship: A Truly Multidisciplinary Training Experience.

ABSTRACT: The Newcastle upon Tyne Hospitals NHS Foundation Trust Plastic Surgery Department offers a 12-month, intense and comprehensive fellowship covering almost every aspect of reconstructive microsurgery. Across its 2 sites at The Royal Victoria Infirmary and Freeman Hospital, over 175 free flaps are performed every year, spanning the breadth of head and neck oncology, sarcoma, facial palsy, and breast and limb reconstruction. The appointed fellow is expected to be involved in at least 90 microsurgical cases, plus a reasonable number of complex nonfree flap reconstructions. An overview of this hands-on microsurgery fellowship is hereby presented based on the experience of 2 recent fellows.

Evaluation of Research Opportunities and Limitations for Plastic Surgery Residents: An International Survey.

BACKGROUND: Conducting research during specialty training provides an opportunity to develop critical thinking and leadership skills along with a better understanding of the scientific literature. However, trainees often find it difficult to undertake research, in the context of labor-intensive surgical training. The aim of this study is to evaluate the research output and limitations of plastic surgery residents in different countries. METHODS: An international cross-sectional study involving plastic surgery trainees and recent postgraduates from Brazil, Chile, Germany, and the United Kingdom was conducted. A survey inquiring into academic productivity, limitations to conducting research, and working-hours patterns was distributed among eligible participants. RESULTS: From September to December 2019, 106 surveys were retrieved. Most respondents declared having participated in at least 1 project that resulted in a presentation or publication during their training (90.6% in national presentations, 68% international presentations, 67% in national publications, and 66% international publications). Having completed a previous research fellowship was associated with a statistically higher academic output (P < 0.05). Seventy-nine percent of respondents felt that their participation in research activities would have been greater if limiting factors had been addressed, including lack of time (72.5%) and insufficient supervision and mentoring (55%). CONCLUSIONS: Optimizing plastic surgery trainees' participation in scientific research is beneficial both for residents and their mentors. Research fellowships can provide an opportunity for academically oriented trainees to further develop their research skills. Protected time and adequate mentoring can help not only to increase residents' research output, but also to recruit the next generation of academic plastic surgeons.

Mind the Gap: a Competency-Based Scoping Review of Aesthetic and Reconstructive Reported Simulation Training Models.

BACKGROUND: Simulation training has become an integral part of plastic surgery postgraduate curricula. It facilitates the acquisition of skills in a safe environment that can be later transferred to real-life settings. A variety of models have been described covering some aspects of the specialty better than others. The aim of this study was to identify and classify all the previously reported plastic surgery simulation models and the possible gaps having the Accreditation Council for Graduate Medical Education (ACGME) list of competencies as a guide. METHODS: Through a Delphi process, the complete list of ACGME minimum requirements for certification was analyzed to identify domains amenable for simulation training. A systematic search was conducted in Pubmed looking for all previously reported simulation models in plastic surgery. Predefined inclusion and exclusion criteria and parallel blind review were used to identify eligible models. RESULTS: A total of 81 ACGME competencies were identified. Following a 3-round Delphi process, consensus was reached on 19 reconstructive and 15 aesthetic surgery domains suitable for simulation training. 1667 articles were initially retrieved from Pubmed, of which 66 articles were eligible for inclusion. Descriptive (65%), quasi-experimental (24%) and experimental studies (11%) were found. For the 34 identified ACGME competencies, there were simulation models described for 58.8% of these, mostly covering reconstructive surgery (84.2%) while for aesthetic surgery it was 13.3%. CONCLUSIONS: This scoping review has identified that there are still gaps in ACGME competencies that could benefit from new simulation training models, especially in those related to aesthetic surgery. 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 .

Monitoring Breast Reconstruction Flaps Using Near-Infrared Spectroscopy Tissue Oximetry.

Free flap reconstruction is a common procedure with success rates greater than 99%. However, vascular complications may occur, resulting in flap failure. For this reason, early detection of vascular compromise is crucial for flap salvage. Vascular complications may be detected early by monitoring tissue oximetry parameter changes using near-infrared spectroscopy (NIRS). This method of noninvasive monitoring can evaluate changes in flap oxygenation levels caused by arterial and venous thrombosis before surgical reexploration. The goal of this study was to assess the validity of using NIRS oximetry for monitoring free flaps. We conducted a prospective cohort observational study of 10 patients undergoing breast reconstruction. We used the INVOS 7100 cerebral oximetry monitoring system (Medtronic, Dublin, Ireland) to provide 24-hr continuous postoperative monitoring of flap perfusion and compared the data with clinical assessment findings. The median patient age was 57 years (range = 41-61 years). Patients underwent immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flap surgery (n = 4), delayed reconstruction with DIEP flap surgery (n = 4), transverse upper gracilis flap surgery (n = 1), and latissimus dorsi flap with lipofilling (n = 1). We successfully monitored all 10 flaps for 24 hr postoperatively. The overall flap survival rate was 100%. Findings of clinical examination, Doppler studies, and surgical outcome were consistent with NIRS monitoring. In conclusion, NIRS tissue oximetry could potentially provide a noninvasive method for effective postoperative monitoring of free flaps.

Microsurgical Training Opportunities at the Queen Victoria Hospital: A Retrospective Review of 848 Free Flaps for Breast Reconstruction.

Becoming a competent microsurgeon requires training in a variety of skills and competences. However, instructing the next generation of microsurgeons seems to be a challenging task, considering the current trend to reduce training hours along with increased patient expectations. To evaluate the microsurgical training opportunities at the Queen Victoria Hospital, we conducted a retrospective review of the last 3 and a half years, to identify the opportunities given to trainees during breast reconstruction cases. We also surveyed the microsurgical fellows who worked in our unit during the same period. A total of 848 free flaps were performed between November 2015 and May 2019 for 699 patients undergoing breast reconstruction, with a flap failure rate of 0.47%. For unilateral cases, more than half of the flaps were raised by trainees: 39% by fellows and 12% by specialist registrars. For bilateral breast and bipedicled reconstructions, these figures were 44% and 2%, respectively. A total of 1835 microvascular anastomoses were performed, of which 33% were done by fellows and 17% by specialist registrars, with the remaining 50% being done by consultants. Six of 8 fellows who worked in our unit during the studied period replied to our survey. All of them were pleased with their training experience, and the majority of them progressed to a consultant post after their fellowship. We consider that a standardized surgical approach, along with a high-volume caseload, allows delivering an outstanding training experience while maintaining low complications rates.

Avoiding a Second Wave of Medical Errors: The Importance of Human Factors in the Context of a Pandemic.

The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimize the impact of human error in these circumstances. We hereby present a case study illustrating the application of human factors in the difficult times we are going through at present.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 .

The Versatility of the Superficial Circumflex Iliac Artery Perforator Flap: A Single Surgeon's 16-Year Experience for Limb Reconstruction and a Systematic Review.

BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap is a versatile option of free tissue transfer for small to large defects. In this study, we examine the advantages of the SCIP flap, its cadaveric anatomy, and clinical subtypes. METHODS: Ten cadavers were dissected and the corresponding pedicles of the SCIP and groin flaps were identified. A retrospective review of 20 clinical cases of free SCIP flap reconstruction was undertaken. The indication for reconstruction, flap dimensions, and survival were analyzed. A systematic literature review was conducted including articles that have previously reported the use of the SCIP flap. RESULTS: The SCIP pedicle was present in all our cadaveric dissections. The starting point of its pedicle ranged from 1.5 to 4.5 cm along the superficial circumflex iliac artery. The median diameter of the perforator and its concomitant vein was 1mm (range 0.8-2 mm). A cutaneous vein (1.3-2.3 mm) could be included in the flap if the concomitant vein was too small. Twenty consecutive patients had free SCIP flaps between 2002 and 2018. The indications were for finger defects (n = 8), thumb reconstruction (n = 1), lower limb compound fractures (n = 3), iatrogenic wounds (n = 2), upper limb large defects (n = 2), and scar contractures (n = 4). Flap dimensions ranged from 2 × 4 cm to 14 × 25cm, and the longest pedicle was 8cm. All flaps survived. The systematic literature review identified 34 previous reports using the SCIP flaps, most of these published by Asian units. CONCLUSION: The SCIP flap is useful for reconstruction throughout the body due to its ease of dissection, thinness, adjustable pedicle length, and flap dimension ranging from tiny to large, as well as the feasibility of raising a compound flap incorporating an adipofascial or vascularized bone component if necessary.This is a level of evidence therapeutic IV study.