Three-Dimensional Printing in Surgical Education: An Updated Systematic Review of the Literature.

INTRODUCTION: Three-dimensional printing (3DP) is being integrated into surgical practice at a significant pace, from preprocedural planning to procedure simulation. 3DP is especially useful in surgical education, where printed models are highly accurate and customizable. The aim of this study was to evaluate how 3DP is being integrated most recently into surgical residency training. METHODS: We performed a structured literature search of the OVID/MEDLINE, EMBASE, and PUBMED databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles published from 2016 to 2023 that met predefined inclusion and exclusion criteria were included. Data extracted included surgical subspecialty using 3DP, application of 3DP, and any reported satisfaction measures of trainees. A thorough analysis of pooled data was performed to evaluate satisfaction rates among studies. RESULTS: A total of 85 studies were included. The median number of participants was 18 (interquartile range 10-27). Fourteen surgical disciplines were represented, with ear, nose, and throat/otolaryngology having the highest recorded utilization of 3DP models among residents and medical students (22.0%), followed by neurosurgery (14.0%) and urology (12.0%). 3DP models were created most frequently to model soft tissue (35.3%), bone (24.7%), vessel (14.1%), mixed (16.4%), or whole organs (6.66%) (Fig.1). Feedback from trainees was overwhelmingly positive regarding the fidelity of the models and their support for integration into their training programs. Among trainees, the combined satisfaction rate with their use in the curriculum was 95% (95% confidence interval, 0.92-0.97), and the satisfaction rate with the model fidelity was 90% (95% confidence interval, 0.86-0.94). CONCLUSIONS: There is wide variation in the surgical specialties utilizing 3DP models in training. These models are effective in increasing trainee comfort with both common and rare scenarios and are associated with a high degree of resident support and satisfaction. Plastic surgery programs may benefit from the integration of this technology, potentially strengthening future surgical curricula. Objective evaluations of their pedagogic effects on residents are areas of future research.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

From Case Reports to Molecular Insight: Examining the Outcomes and Underlying Mechanisms of Squamous Cell Carcinoma in Breast Implant Patients-A Systematic Review.

There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.

Incidental Bystander or Essential Culprit: A Systematic Review of Bacterial Significance in the Pathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct subtype of T-cell non-Hodgkin lymphoma that arises in the context of prolonged exposure to textured breast implants. The intent of this manuscript is to explore whether the bacterial presence in biofilms on these implants is a mere incidental finding or plays a pivotal role in the pathogenesis of BIA-ALCL. Our goal is to delineate the extent of bacterial involvement, offering insights into potential underlying mechanisms, and establishing future research priorities aimed at resolving the remaining uncertainties surrounding this complex association. A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. The electronic search identified 442 publications. After evaluation, six studies from 2015 to 2021 were included, encompassing 201 female patients aged 23 to 75. The diagnosis span post-implantation ranged from 53 to 135.6 months. Studies consistently found bacteria near breast implants in both BIA-ALCL cases and controls, with varied microbial findings. Both BIA-ALCL cases and controls exhibited the presence of specific bacteria, including Pseudomonas aeruginosa, Klebsiella oxytoca, Staphylococcus aureus, and Ralstonia spp., without any statistically significant differences between groups. The use of antiseptic and antimicrobial agents during implant insertion did not demonstrate any impact on reducing or altering the risk of developing BIA-ALCL. Our systematic review reveals that the current evidence is inadequate to link bacterial etiology as a central factor in the development of BIA-ALCL. The limitations in the existing data prevent a complete dismissal of the role of biofilms in its pathogenesis. The observed gap in knowledge underscores the need for more focused and comprehensive research, which should be structured in a multi-faceted approach. Initially, this involves the utilization of sophisticated genomic and proteomic methods. Following this, it is crucial to delve into the study of immunological reactions specifically induced by biofilms. Finally, this research should incorporate extended observational studies, meticulously tracking the evolution of biofilm development and its correlation with the emergence of BIA-ALCL. In light of the inconclusive nature of current findings, further investigation is not only justified but urgently needed to clarify these unresolved issues.

Dorsal Preservation versus Component Dorsal Hump Reduction Rhinoplasty: An Assessment of Patient-reported Outcomes.

Background: The literature on patient-reported outcomes (PROs) discussing dorsal preservation rhinoplasty (DPR) and component dorsal hump reduction (CDHR) is scarce. This study aims to fill the gap in PROs between these techniques. Methods: A systematic review was conducted to investigate PROs of DPR and CDHR. A proportion meta-analysis was conducted using Stata statistical software. Results: A total of 25 studies met our inclusion criteria, pooling 1706 participants, with 13 studies on CDHP and 12 studies on DPR. Overall satisfaction rates were high, varying from 84% to 100% across studies. A subgroup analysis revealed that both techniques exhibited equally high satisfaction with no statistical differences (P = 0.18). A random-effects model revealed that about two of 100 treated patients underwent revisions across our cohort (95% interquartile range: 0-4). Notably, the CDHR technique was associated with a significant 53.7-point reduction in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS)-cosmetic domain [95% confidence interval (CI): -62.7 to -44.8, P < 0.001], along with a meaningful improvement in SCHNOS-obstructive scores by -27.3 points (95% CI: -50.5 to -4.04, P = 0.02). Conversely, the DPR was linked to a 55.3-point reduction in the SCHNOS-cosmetic domain (95% CI: -60.7 to -49.9, P < 0.001), and a -19.5 point change in the SCHNOS-obstructive domain (95% CI: -27.9 to -11.1, P < 0.001). Conclusion: Although PROs are comparable, the literature suggests that CDHR outcomes may be better than DPR in alleviating obstructive symptoms, potentially offering an evidence-based choice for addressing functional concerns in rhinoplasty.

Utilization of patient-reported outcome measures in plastic surgery clinical trials: A systematic review.

BACKGROUND: Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs). METHODS: A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis. RESULTS: Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade. CONCLUSIONS: The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.

Comparing Collagenase and Tissue Subcision for Cellulite Treatment of the Buttock and Thigh Regions: A Systematic Review and Meta-analysis.

Background: In this systematic review, we assessed the therapeutic efficacy and safety of Clostridium histolyticum collagenase (CCH) and tissue subcision (TS) for treating cellulite, which ranges from subtle to pronounced lesions. Methods: A systematic review was performed following PRISMA guidelines for CCH and TS treatment to the thigh and gluteal regions. A proportion meta-analysis was then conducted using Stata statistical software. Results: A total of 14 studies were incorporated into the final analysis. Nine focused on TS and five on CCH injection, collectively reporting outcomes for 1254 patients. Of these, 465 received CCH injection and 789 underwent subcision. For bruising, rates were 89% [95% confidence interval (CI), 71%-96%] with CCH injection and 99% (95% CI, 85%-99%) for subcision; pain requiring analgesic was reported at 74% (95% CI, 55%-87%) for CCH and 60% (95% CI, 43%-76%) for subcision; both showed induration at 7% (95% CI, 5%-11% for CCH, 95% CI, 2%-25% for subcision), whereas skin discoloration was higher post-CCH injection at 16% (95% CI, 10%-26%) compared with 7% (95% CI, 5%-10%) postsubcision. Conclusions: Both CCH and TS seem effective treatments for cellulite. However, upon evaluating the adverse outcomes between the two modalities, subcision demonstrated a higher incidence of bruising, albeit similar rates of induration compared with CCH injection. Conversely, the CCH injection group manifested a higher propensity for pain requiring analgesia and notably exhibited increased instances of skin discoloration compared with their subcision patient group. Further standardized research is crucial for more informed cellulite treatment decisions and for comparing efficacy, safety, and cost-effectiveness between TS and CCH.