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.

A Streamlined Algorithmic Process for Creating Three-dimensional Printed Forearm Casts.

Three-dimensional (3D) printing is a rapidly evolving field that has found its way into the medical field, providing unsurpassed contributions to the provision of patient-centered care. Its utilization lies in optimizing preoperative planning, the creation and customization of surgical guides and implants, and the designing of models that can be used to augment patient counseling and education. We integrate a simple yet effective method of scanning the forearm using an iPad device with Xkelet software to obtain a 3D printable stereolithography file, which is then incorporated to our suggested algorithmic model for designing a 3D cast, utilizing Rhinocerus design software and Grasshopper plugin. The algorithm implements a stepwise process of retopologizing the mesh, division of the cast model, creating the base surface, applying proper clearance and thickness to the mold, and creating a lightweight structure through the addition of ventilation holes to the surface with a joint connector between the two plates. In our experience, scanning and design of the patient-specific forearm cast using Xkelet and Rhinocerus, alongside implementing an algorithmic model through Grasshopper plugin has dramatically reduced the designing process from 2 to 3 hours to 4-10 minutes, further increasing the number of patient scans that can be sequenced in a short duration. In this article, we introduce a streamlined algorithmic process for the use of 3D scanning and processing software to create forearm casts that are tailored to the patients' dimensions. We emphasize the implementation of computer-aided design software for a quicker and more accurate design process.

Access to Breast Reconstruction in Kuwait: Assessing Surgeon-related Factors as a Barrier to Referral.

It is not uncommon for breast cancer patients to undergo a mastectomy without receiving or being presented with the option of having a breast reconstruction. With a low rate of breast reconstruction in Kuwait, we aim to assess physician-related factors as a barrier to referral. Methods: This is an online questionnaire-based study to investigate the variation in the referring general surgeons' knowledge and perception towards breast reconstructive surgery. Results: A total of 141 general surgeons responded to the questionnaire, and only 63 (44.7%) always discuss the available options for reconstruction with their breast cancer patients. When asked about referral to a plastic surgeon, only 49 (34.8%) responded with always, and the majority (N = 61; 43.3%) responded with sometimes. More than half (N = 73; 51.8%) believe that the general surgeon should determine patient suitability for referral to a plastic surgeon, while only 53 (37.6%) agree that breast cancer patients should always be referred to a plastic surgeon for consideration of reconstruction. The mean knowledge score was 6.6 of 8, while the mean perception score was 8.9 of 12. Responders with a higher total knowledge score were more likely to discuss with patients the availability of reconstruction. Conclusions: Despite the acceptable knowledge scores in our general surgeons, there is a low rate of referral for breast reconstruction in Kuwait. There is a pressing need to generate legislations and a streamlined protocol for referral that facilitate access to breast reconstructive services.

The Utilization of Three-Dimensional Printing in Creating a Surgical Instrument: An Areola Cookie Cutter.

Three-dimensional (3D) printing is a rapidly evolving technology with many applications in the medical field. It involves printing solid objects from a digital file. In this paper, we describe our experience with the use of 3D printing in creating an areola cookie cutter that is compatible with sterilization. The objective of this study is to explore accurate and cost-effective methods of producing patient-specific areola cookie cutters. Auto computer-aided design (CAD) 3D software was used to design a digital model that was subsequently converted to a standard tessellation language (STL) file. The models were printed with the Formlabs Form 3+ SLA printer (Somerville, MA) using a resin material. Washing and curing were then performed followed by autoclave sterilization of the models. A total of 3 areola cookie cutters were created, each with different sizes (33, 38, and 42 mm) using resin material (Formlabs BioMed Clear Resin; Somerville, MA). All 3 models were able to withstand autoclave sterilization. The use of 3D printing has proven to be a valuable tool in Plastic surgery. We describe our experience of designing and producing an areola cookie cutter using a 3D printer; our model is compatible with the process of sterilization. We emphasize the advantages of a quick production time and accuracy in design.

A Low-cost, Sterile System for Fat Collection Using a Syringe Tube as a Reservoir.

Fat grafting is a widely performed procedure in the field of plastic surgery. It involves fat extraction, processing, and injection into a recipient site. It is imperative that the fat is collected and processed in a sterile system. A wide variety of equipment is required to perform the procedure (eg, a liposuction device, a vacuum pump, and syringes). Limitations often arise in the operating room, especially in low-resource areas, where task-specific equipment might be unavailable. This can present an opportunity for the surgeon to improvise and create a temporary solution. In this report, we describe our solution in dealing with the unavailability of a sterile vacuum pump canister during a large volume fat grafting procedure. We constructed a sterile reservoir using two syringes, through which negative pressure was delivered without breaking sterility. The items used were a 60-cm3 syringe barrel, a 10-cm3 syringe barrel, a 60-cm3 syringe plunger seal, a tube connected to the nonsterile vacuum pump, and the liposuction cannula. This technique allowed us to extract the fat in a sterile environment under the assistance of a suction device. Our novel technique was used for harvesting fat in a sterile reservoir, while still utilizing the assisted suction from the nonsterile vacuum pump, without breaking sterility.

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARB) Are Protective Against ICU Admission and Mortality for Patients With COVID-19 Disease.

Introduction: Corona Virus disease 2019 (COVID-19) caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. The aim of this study was to investigate the impact of being on an Angiotensin-Converting Enzyme Inhibitors (ACEI) and/or Angiotensin Receptor Blockers (ARB) on hospital admission, on the following COVID-19 outcomes: disease severity, ICU admission, and mortality. Methods: The charts of all patients consecutively diagnosed with COVID-19 from the 24th of February to the 16th of June of the year 2020 in Jaber Al-Ahmed Al-Sabah hospital in Kuwait were checked. All related patient information and clinical data was retrieved from the hospitals electronic medical record system. The primary outcome was COVID-19 disease severity defined as the need for Intensive Care Unit (ICU) admission. Secondary outcome was mortality. Results: A total of 4,019 COVID-19 patients were included, of which 325 patients (8.1%) used ACEI/ARB, users of ACEI/ARB were found to be significantly older (54.4 vs. 40.5 years). ACEI/ARB users were found to have more co-morbidities; diabetes (45.8 vs. 14.8%) and hypertension (92.9 vs. 13.0%). ACEI/ARB use was found to be significantly associated with greater risk of ICU admission in the unadjusted analysis [OR, 1.51 (95% CI: 1.04-2.19), p = 0.028]. After adjustment for age, gender, nationality, coronary artery disease, diabetes and hypertension, ICU admission was found to be inversely associated with ACEI use [OR, 0.57 (95% CI: 0.34-0.88), p = 0.01] and inversely associated with mortality [OR, 0.56 (95% CI: 0.33-0.95), p = 0.032]. Conclusion: The current evidence in the literature supports continuation of ACEI/ARB medications for patients with co-morbidities that acquire COVID-19 infection. Although, the protective effects of such medications on COVID-19 disease severity and mortality remain unclear, the findings of the present study support the use of ACEI/ARB medication.

Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Our main objective is to evaluate the effect of body contouring surgery (BCS) on the magnitude and durability of weight loss after bariatric surgery. METHODS: Medline, EMBASE, Cochrane, and Scopus search were conducted from the time of their inception to June 2020. We included comparative studies that assessed weight progression, in terms of Body Mass Index change (∆BMI), Total Body Weight Loss (TBWL%), and Excess Weight Loss (%EWL) for the post-bariatric patient population and the effect of BCS on weight progression. RESULTS: Eleven articles were included. The pooled sample size was 2307, of which 691 were cases who underwent BCS post-bariatric surgery, and 1616 were comparative controls. The mean follow-up time for cases and controls were 61.6 ± 23.8 months and 52.2 ± 23.8 months, respectively. Nine studies reported results of BMI changes, six provided %EWL, and five used %TBWL. Significant improvement in weight loss was observed in the BCS group when measured by either ∆BMI (3 kg/m2 points decrease, p 0.023), %TBWL (6% increase, P < 0.0001), or %EWL (14% increase, P < 0.0001). Sub-group analysis showed that increased follow-up time was associated with higher TBWL% (p 0.02). CONCLUSION: The evidence provided in this review strongly supports the added long-term benefits of body contouring surgery for selected patients after massive weight loss following bariatric surgery. Having a multidisciplinary team that involves a bariatric and a plastic surgeon as well as nutritionists and psychologists for the management of patients with obesity going through the bariatric pathway is recommended. 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 biomarker based severity progression indicator for COVID-19: the Kuwait prognosis indicator score.

BACKGROUND: COVID-19 is a worldwide pandemic that is mild in most patients but can result in a pneumonia like illness with progression to acute respiratory distress syndrome and death. Predicting the disease severity at time of diagnosis can be helpful in prioritizing hospital admission and resources. METHODS: We prospectively recruited 1096 consecutive patients of whom 643 met the inclusion criterion with COVID-19 from Jaber Hospital, a COVID-19 facility in Kuwait, between 24 February and 20 April 2020. The primary endpoint of interest was disease severity defined algorithmically. Predefined risk variables were collected at the time of PCR based diagnosis of the infection. Prognostic model development used 5-fold cross-validated regularized logit regression. The model was externally validated against data from Wuhan, China. RESULTS: There were 643 patients with clinical course data of whom 94 developed severe COVID-19. In the final model, age, CRP, procalcitonin, lymphocyte percentage, monocyte percentages and serum albumin were independent predictors of a more severe illness course. The final prognostic model demonstrated good discrimination, and both discrimination and calibration were confirmed with an external dataset. CONCLUSION: We developed and validated a simple score calculated at time of diagnosis that can predict patients with severe COVID-19 disease reliably and that has been validated externally. The KPI score calculator is now available online at covidkscore.com.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review.

PURPOSE: To determine the role of night orthosis use after surgical correction of Dupuytren contracture. METHODS: We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument. RESULTS: Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups. CONCLUSIONS: The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.