Increasing Nasal Tip Projection Using Structural Grafts: A Review of Outcomes.

OBJECTIVES: Nasal tip projection (NTP) is an important criterion when evaluating the result of rhinoplasties. Increasing NTP is essential for nasal function and visual aesthetics. Grafts such as columellar strut grafts (CSGs) and septal extension grafts (SEGs) are commonly used. We analyzed the safety and efficacy of the most commonly used grafts for increasing NTP during surgical rhinoplasty. METHODS: The authors reviewed all English-language articles in PubMed, Embase, and Web of Science between 2000 and 2020 that reported original outcomes on structural grafts used to increase NTP. We recorded and analyzed the following at 6 months postoperatively: NTP change, Goode ratio, nasolabial/columellar-labial angle, postoperative complications, and subjective patient assessments. A total of two structural grafts in 35 studies (21 CSG, 14 SEG) were included. RESULTS: Of the 2290 included patients, 1707 received CSGs (21 studies) and 583 received SEGs (14 studies). Overall NTP increased after using either graft. Subgroup analysis showed that more patients experienced postoperative complications after receiving SEGs (23.7%) than CSGs (9.7%). For patient satisfaction, three CSG studies found 83.3% of patients rated their satisfaction high, 12.1% moderate, and 4.5% not satisfied (n = 66). Most patients reported improvement in tip projection (97.0%), breathing (86.4%), and olfaction (83.3%). There was a significant increase in average patient satisfaction on the Visual Analog Scale (n = 39). CONCLUSIONS: Findings show that CSG and SEG grafts were safe and effective at increasing NTP. We suggest that CSG may be safer and more effective than SEG at increasing NTP in rhinoplasties. Further prospective studies may elucidate the mechanisms underlying the differences between CSGs and SEGs in patient safety and satisfaction when increasing NTP in surgical rhinoplasty.

Review of current and new drugs for the treatment of metabolic-associated fatty liver disease.

In the past 3 decades, metabolic-associated fatty liver disease (MAFLD) has emerged as a widespread liver condition, with its global prevalence on the rise. It ranks as a leading contributor to hepatocellular carcinoma (HCC) and necessitates liver transplantation. Under the multiple parallel hits model, the pathogenesis of MAFLD stems from various liver stressors, notably nutrient overload and sedentary lifestyles. While medical management for MAFLD is well-established, encompassing non-pharmaceutical and pharmaceutical interventions, determining the most effective pharmaceutical therapy has remained elusive. This review discusses diabetic medications for MAFLD treatment, emphasizing recent studies and emerging drugs while reviewing other nondiabetic agents. Emerging evidence suggests that combination therapies hold promise for resolving MAFLD and metabolic steatohepatitis (MASH) while managing side effects. Ongoing trials play a pivotal role in elucidating the effects of mono, dual, and triple receptor agonists in individuals with MASH. With the rising burden of MAFLD/MASH and its severe consequences, the need for effective treatments is more pressing than ever. This review provides a comprehensive overview of the current landscape of pharmaceutical interventions for MAFLD and MASH, shedding light on the potential of newer drugs especially diabetic medications and the importance of ongoing research in this field.

Iatrogenic Injuries in Manual and Mechanical Cardiopulmonary Resuscitation.

PURPOSE: Mechanical chest compression has been shown to be equivalent to manual chest compression in providing survival benefits to patients experiencing cardiac arrest. There has been a growing need for a contemporary review of iatrogenic injuries caused by mechanical in comparison with manual chest compression. Our study aims to analyze the studies that document significant life-threatening iatrogenic injuries caused by mechanical and manual chest compression. METHODS: A systematic review of PubMed and Embase was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All studies published after January 1st, 2000 were reviewed using inclusion/exclusion criteria and completed by May 2020. A total of 7202 patients enrolled in 15 studies were included in our meta-analysis. RESULTS: Significant life-threatening iatrogenic injuries had higher odds of occurring when mechanical chest compression was used compared to manual chest compression, especially for hemothorax and liver lacerations. Mechanical chest compression involves consistently deeper compression depths compared to manual chest compression, potentially resulting in more injuries. In the mechanical chest compression cohort, chest wall fractures had the highest incidence rate (55.7%), followed by sternal fracture (28.3%), lung injuries (3.7%), liver (1.0%), and diaphragm (.2%) lacerations. CONCLUSIONS: Mechanical chest compression was associated with more iatrogenic injuries as compared to manual chest compression. Further research is needed to define the appropriate application of mechanical in comparison with manual chest compression in different scenarios. Levels of provider training, different mechanical chest compression device types, patient demographics, and compression duration/depth may all play roles in influencing outcomes.

Breast Implant Illness: Treatment Using Total Capsulectomy and Implant Removal.

Background: Breast implant illness (BII) is extramammary systemic symptoms that are caused by breast implants. The emergence of this controversial topic has spurred patients with breast implants who are experiencing these symptoms to seek implant removal, hoping to feel better. This article presents novel outcomes and suggestions for plastic surgeons in managing BII using total capsulectomy and breast implant removal. Methods: In this retrospective cohort study conducted between 2016 and 2020, medical records of all patients undergoing breast implant removal were reviewed. Inclusion criteria consisted of all patients with history of breast implant placement presenting with mastodynia and capsular contracture on physical examination. Patients with history of implant-based reconstruction following mastectomy and patients who underwent implant exchange were excluded. All patients underwent bilateral implant removal and total capsulectomies. Results: A total of 200 patients who fulfilled the inclusion criteria were identified. Average age was 45.5 (range: 29-73) years and average body mass index was 26.28 (range: 19-36.8), with an average follow-up time of 5 months postoperatively. Of patients with a presentation of BII, 96% reported improved or complete resolution of their systemic symptoms after implant removal and total capsulectomy. A positive microbial culture was found in 68.5% of patients, and all culture-positive patients reported improvement post-treatment. The most common organisms found were Propionibacterium acnes (49.6%). There were no associations between implant characteristics and rate of positive microbiology findings. Conclusions: Our study shows that implant removal with capsulectomy drastically improves BII symptoms. Further large prospective cohort studies are needed to better understand this entity.

Surgical Lymphedema Treatment: A Meta-Analysis and Recommendations.

Background: Lymphedema is a common complication of lymph node surgery; however, evidence on diagnosing, monitoring, and treating the condition is sparse. This meta-analysis evaluates the outcomes of common surgical treatments of lymphedema and provides suggestions for future research directions. Methods: A review of PubMed and Embase was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. All English-language studies published through June 1, 2020, were included. We excluded nonsurgical interventions, literature reviews, letters, commentaries, nonhuman or cadaver studies, and studies with inadequate sample size (N < 20). Results: A total of 583 cases from 15 studies in patients with lymphedema met our inclusion criteria for our 1-arm meta-analysis: 387 upper extremity treatments and 196 lower extremity treatments. The volume reduction rates of lymphedema for upper extremity and lower extremity treatments were 38.0% [95% confidence interval (CI), 25.9%-50.2%] and 49.5% (95% CI, 32.6%-66.3%), respectively. The most common postoperative complications were cellulitis, reported in 4.5% of patients (95% CI, 0.9%-10.6%), and seromas, reported in 4.6% (95% CI, 0%-17.8%) of patients. Average quality of life measures across all studies improved by 52.2% (95% CI, 25.1%-79.2%) for patients who underwent upper extremity treatment. Conclusions: Surgical management of lymphedema shows great promise. Our data suggest that adopting a standardized system of limb measurement and disease staging can increase effectiveness of treatment outcomes.

What Attributes Make United States Plastic Surgery Programs Desirable? Perspectives from Medical Students and Residents.

Background: Plastic surgery is a competitive specialty that attracts many qualified applicants. This study provides results of a survey conducted to identify the attributes that make integrated and independent plastic surgery residency programs in the United States most desirable. Medical students' preferences for virtual events during the 2020 to 2021 Match cycle were also investigated. Methods: An anonymous 7-question survey was deployed to plastic surgery residency program directors to forward to medical students and current residents during the 2021 to 2022 National Resident Matching Program cycle. Demographics and ranking of program attributes were collected in the survey, and data analysis consisted of both qualitative and quantitative results. Results: A total of 50 survey respondents from 28% of plastic surgery residency programs was received. The happiness and well-being of residents and training at their preferred geographical location were identified as the most desirable qualities of a program (P < 0.05). However, 82% of respondents opposed mandatory research (P = 0.002). There was a statistically significant larger proportion of students that highly valued faculty responsiveness to feedback over perceived program ranking (P < 0.05). In the context of COVID-19, virtual meet and greets, as well as resident happy hours, were rated most desirable (n = 35, 70%), followed by social media outreach (n = 23, 46%). Conclusions: Resident happiness and well-being, followed by preferred geographical location, were the most favorable program attributes. Plastic surgery residency programs may seek to better integrate these preferences within their curricula, as well as showcase them on social media, to attract high-quality applicants and optimize the training experience for matched residents.

The Use of Arteriovenous Bundle Interposition Grafts in Microsurgical Reconstruction: A Systematic Review of the Literature.

Microvascular reconstruction frequently requires anastomosis outside of the zone of injury for successful reconstruction. Multiple options exist for pedicle lengthening including vein grafts, arteriovenous loops, and arteriovenous bundle interposition grafts. The authors performed a systematic review of arteriovenous bundle interposition grafts to elucidate indications and outcomes of arteriovenous grafts in microvascular reconstruction. A systematic review of the literature was performed using targeted keywords. Data extraction was performed by two independent authors, and descriptive statistics were used to analyze pooled data. Forty-four patients underwent pedicle lengthening with an arteriovenous graft from the descending branch of the lateral circumflex femoral artery. Most common indications for flap reconstruction were malignancy ( n = 12), trauma ( n = 7), and diabetic ulceration ( n = 4). The most commonly used free flap was the anterolateral thigh flap ( n = 18). There were five complications, with one resulting in flap loss. Arteriovenous bundle interposition grafts are a viable option for pedicle lengthening when free flap distant anastomosis is required. The descending branch of the lateral circumflex femoral artery may be used for a variety of defects and can be used in conjunction with fasciocutaneous, osteocutaneous, muscle, and chimeric free flaps.

Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis.

BACKGROUND: Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS: A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS: A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS: Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.

How Does Insurance Status Correlate With Trauma Mechanisms and Outcomes? A Retrospective Study at a Level 1 Trauma Center.

OBJECTIVE: Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors. METHODS: A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05. RESULTS: 738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% (P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls. CONCLUSION: Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.

Going virtual: effectiveness of virtual opportunities in engaging applicants for plastic surgery residencies.

Purpose: During the COVID-19 pandemic, virtual events led by residency programs have eased deficits formed by the lack of in-person opportunities. Despite their anecdotal success, there is yet a study on their utility and value, as perceived by attendees. Therefore, we sought to investigate engagement rates of virtual opportunity posts via Instagram, equipping residency programs with recommendations for future virtual event planning. Methods: The 40 PRS residency programs with the highest number of followers on Instagram were inspected for posts regarding virtual opportunities. The virtual opportunities were classified by type, medium, and intended audience. The number of opportunities within each classification was analyzed, along with the like/comment to follower ratios, and compared via ANOVA tests. Results: A total of 141 virtual opportunities were evaluated, with the most events occurring in August (21.6%). The highest engagement rates occurred in May and June, with the most common virtual opportunity being meet and greets with residents (39.2%). The most prevalent medium for virtual events was Zoom, used in 84.7% of events. The intended audience was frequently medical students (80.6%), with a significant difference in engagement between audience groups (p < 0.05). Conclusion: The pandemic has disrupted the status quo of resident recruitment. In light of these findings, residency programs should consider instilling virtual opportunities for medical students as a standard practice. Peak times to broadcast events are May or June due to higher engagement. To address attendee burnout, programs should limit events to familiar ones, such as Zoom meet and greets with residents.

New Injury Severity Score and Trauma Injury Severity Score are superior in predicting trauma mortality.

BACKGROUND: Trauma scores are used to give clinicians appropriate quantitative context in making decisions. Studies show that anatomical trauma scores predicted intensive care unit admission better, while physiological trauma scores predicted mortality better. We hypothesize that trauma scores have a hierarchy of efficacies at predicting mortality and operative decision making. METHODS: We performed a retrospective analysis of our trauma patient database at a level 1 trauma center from 2016 to 2020 and calculated the following trauma scores: Glasgow Coma Scale, Revised Trauma Score, Trauma Injury Severity Score, Injury Severity Score, Shock Index, and New Trauma Injury Severity Score (NISS). Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of trauma scores for predicting mortality. RESULTS: A total of 738 patients were included (mean ± SD age, 35.7 ± 15.6 years). Area under the curve (AUC) results from the DeLong test showed that NISS predicted mortality the best compared with other trauma scores. New Trauma Injury Severity Score was superior in predicting mortality for penetrating trauma (AUC, 0.86 ± 0.02; p < 0.001) compared with blunt trauma (AUC, 0.73 ± 0.04; p < 0.001). Trauma Injury Severity Score was the best predictor of mortality for patients with gunshot wounds (AUC, 0.83; 95% confidence interval [CI], 0.73-0.92; p < 0.001), motor vehicle accidents (AUC, 0.80; 95% CI, 0.61-1.00; p = 0.01), and falls (AUC, 0.73; 95% CI, 0.61-0.85; p = 0.007). CONCLUSION: New Trauma Injury Severity Score was the best scoring index for predicting mortality in trauma patients, especially for penetrating trauma. Clinicians should consider incorporating other trauma scores, especially NISS and Trauma Injury Severity Score, in determining injury severity and the likelihood of mortality. These scores can help physicians determine the best course of action in patient management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; level IV.