The Role of Intravenous Heparin Following Digital Replantation: A Retrospective Cohort Study on 1,155 Digits.

PURPOSE: The purpose of this study was to determine if the use of postoperative therapeutic dose intravenous heparin (POTDIVH) was indicated in digital replantation and revascularization by assessing digit survival and complications associated with heparin. METHODS: All patients with amputation distal to the carpal tunnel treated at our center from 2004 to 2020 were included for chart review. Digit survival and complication rates were compared between patients who received POTDIVH (group A) and those who did not (group B). Logistic regression analysis and subgroup analysis were conducted. RESULTS: A total of 795 patients (1,155 digits) were included in this study (248 patients/374 digits in group A and 547 patients/781 digits in group B). The overall revascularization and replantation success rate was 79.9% in the POTDIVH group and 92.8% in the non-POTDIVH group. In our retrospective regression and subgroup analyses, group A demonstrated increased odds of failure compared with group B and was associated with increased bleeding-related complications. Subgroup analyses stratified by the mechanism of injury and vein grafting also showed a significantly decreased survival in the POTDIVH group. CONCLUSIONS: Our retrospective data seem to indicate that heparin in digit replantation and revascularization appears to have no benefit on digit survival across all subgroups, including crush and avulsion injuries, and is associated with a significantly increased rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The clinical effectiveness and safety of intravenous unfractionated heparin following digital replantation and revascularization: A narrative systematic review.

BACKGROUND: Digital replants and revascularization (DRV) have been performed since the 1960s but there are no recognized standard peri-operative anticoagulation practices. A narrative systematic review of the clinical effectiveness and safety of therapeutic peri-operative unfractionated heparin following DRV was undertaken. METHODS: A review of the literature from 1985 to March 2022 was conducted using Medline, Embase, CINAHL and EBM reviews. Unfractionated heparin (UFH) use following DRV was compared to low-molecular weight heparin, other anticoagulants or no anticoagulation. Randomized trials, observational studies as well as guidelines were selected and independently screened. The Revised Cochrane risk-of-bias (RoB 2) tool and ROBINS-I were used to appraise risk of bias. RESULTS: While the search strategy identified 1490 references, only six studies met the inclusion criteria. Significant heterogeneity and the low methodological quality of the evidence precluded a meta-analysis. Among the four studies that documented the surgical success rate associated with the use of a therapeutic dose of UFH post DRV, only two reported improved clinical outcomes. Evidence of a higher complication rate related to UFH use was found in four studies. Low quality evidence suggests that a therapeutic dose of unfractionated heparin leads to a higher risk of complications when compared with heparin given as an intermittent bolus of unfractionated heparin or subcutaneous heparin, or prostaglandin E1 or no heparin. CONCLUSIONS: Current evidence suggests that IV UFH use following DRV has no significant impact on the success of the intervention. Heparin use may not be innocuous as some studies showed increased bleeding complications.

Versatility of the Medial Femoral Condyle Flap for Extremity Reconstruction and Identification of Risk Factors for Nonunion, Delayed Time to Union, and Complications.

BACKGROUND: The medial femoral condyle (MFC) flap has become a popular choice for treatment of small bony defects. We aim to describe outcomes after MFC flap treatment of upper and lower extremity osseous defects and test the null hypothesis that no factors influence risks for nonunion, increased time to union, and complications. METHODS: A retrospective chart review was performed on all patients undergoing MFC free vascularized bone flaps by the senior author between May 2010 and March 2016. Preoperative, intraoperative, and postoperative data were collected. RESULTS: We identified 29 patients for inclusion (22 upper and 7 lower extremity reconstructions) treated with the MFC flap for diagnoses including long bone nonunion, avascular necrosis (AVN), or AVN with nonunion. Mean postoperative follow-up was 56 weeks. The average patient was 38 years old (range = 17-61 years) and had undergone 1.5 previous failed surgeries. Union was achieved in 86% of patients at a mean of 15.8 weeks (83% at 17.9 weeks for the scaphoid). No patient with lunate AVN progressed. There were no intraoperative flap complications or bone flap loss, but 28% underwent additional unplanned surgical procedures. We identified previous surgery as a risk factor for delayed union but did not observe significant risk factors predictive of nonunion or complications requiring unplanned reoperation. CONCLUSIONS: Extremity reconstruction using the MFC corticocancellous flap results in a high rate of union yet minimal donor morbidity for a challenging patient cohort. Previous surgery was a risk factor for increased time to union.

Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review.

BACKGROUND: Free flaps derived from the medial genicular artery (MGA) system, including the medial femoral condyle (MFC) and medial femoral trochlear (MFT) flaps, are potential reconstructive options to address upper and lower extremity bony pathology. Our primary aim was to comprehensively search the literature to describe the spectrum of pathology treated with these flaps, and to assess patient outcomes to improve our understanding of expected union and complication rates. METHODS: Following PRISMA guidelines, a systematic review using Pubmed and Embase databases with citation cross-referencing was performed to identify all original clinical articles characterizing MGA flap treatment of upper and lower extremity pathology. RESULTS: The initial search identified 173 articles which was narrowed down to 40 meeting inclusion criteria, representing a total of 248 cases: 174 and 74 in the upper and lower extremities, respectively. Sixteen distinct recipient sites were identified with union rates ranging from 66 to 100% (98.7% overall). The majority (83.9%) of patients had undergone prior failed surgery. Major complications (those with limb/flap loss or requiring unplanned reoperation) were more frequent for lower versus upper extremity applications (17.1% vs. 6.2%, respectively). Donor site femoral fracture or persistent knee dysfunction occurred in 0.8% and 0.4% of patients, respectively. CONCLUSIONS: MGA free flaps are a versatile option for upper and lower extremity osseous reconstruction, offering high rates of union with minimal complications for a complex patient population. This study furthers our understanding of patient outcomes following MGA flap reconstruction, which previously was limited to case reports and small case series.

Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients.

PURPOSE: To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS: Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS: Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS: The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Elbow vascularized composite allotransplantation-surgical anatomy and technique.

BACKGROUND: Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA. METHODS: We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique. RESULTS: The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs. CONCLUSIONS: Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.

A Scapholunate Ligament-Sparing Technique Utilizing the Medial Femoral Condyle Corticocancellous Free Flap to Reconstruct Scaphoid Nonunions With Proximal Pole Avascular Necrosis.

This article demonstrates a technique for the treatment of scaphoid fracture waist and proximal pole nonunions with avascular necrosis using a free vascularized medial femoral condyle flap. We present our surgical technique and representative case examples in which the scapholunate ligament, a key structure required to preserve carpal kinematics, is spared.

Management of soft tissue defects of the hand.

Soft tissue coverage of the hand remains a challenging problem to the hand surgeon, but advances in the field of microsurgery have provided improved thin, pliable, durable flaps that offer cosmetic reconstructive options. The reconstructive elevator is poised to replace the reconstructive ladder, thereby allowing early reconstruction by the best available option. This reviews focus on the variety of pedicled, free fasciocutaneous, and venous flaps available for successful soft tissue coverage of the hand.

The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

BACKGROUND: Debilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual's life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. METHODS: A utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. RESULTS: A total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). CONCLUSIONS: We found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

The Reconstruction of Plastic Surgery: A Historical Perspective on the Etymology of Plastic and Reconstructive Surgery.

Although the origins of procedures now falling under the scope of modern plastic surgery date back thousands of years, it was only fairly recently that these were grouped under the umbrella term "plastic" surgery. However, mainly due to the industrialization period, the popular understanding of the term "plastic" would soon change-making way for the addition of the term "reconstructive" to the specialty's name. Through a careful look at historical trends, the authors illustrate how this unintentionally led to an ideological divide between the aesthetic and reconstructive portions of our work, prompting a recent push to unify the field under the one, original, lexical choice: "plastic" surgery.

Même si les origines des interventions qui font désormais partie du champ de la chirurgie plastique moderne remontent à des millénaires, ces interventions n'ont été regroupées que récemment sous le vocable de chirurgie "plastique". Cependant, en grande partie à cause de l'industrialisation, la compréhension populaire du terme "plastique" allait bientôt changer, laissant place à l'ajout du terme "reconstructive" au nom de la spécialité. Par un examen attentif des tendances historiques, les auteurs démontrent que cet ajout a involontairement entraîné un fossé idéologique entre la partie esthétique et reconstructive du travail, ce qui a suscité une récente impulsion en vue d'unifier le domaine sous un choix lexical unique et original : chirurgie "plastique".

The Utility of Online Information Sessions for Medical Student Recruitment in Plastic Surgery: A New Paradigm Amidst the COVID-19 Pandemic.

Background: The COVID-19 pandemic has led to increased barriers for medical students seeking to engage with plastic surgery. Traditional approaches such as pursuing clinical electives broadly are no longer feasible and medical students are seeking innovative approaches for engagement. The current study evaluated the efficacy of online information sessions on medical student perception and proposed a timeline for longitudinal medical student recruitment. Methods: The McGill Plastic and Reconstructive Surgery residency program held an online information session for medical students focusing on a wide array of topics related to plastic surgery and residency. Following the session, an anonymous survey was sent to participants gauging their satisfaction with the event and potential effects it had on career planning. Results: Thirty-four participants completed the survey, comprising more than 60% of annual applicants to Canadian plastic surgery programs. 94% of participants stated that their view of McGill's training program improved and reported a desire for additional sessions from other training programs. 68% of respondents reported being more likely to consider training at McGill and 100% agreed that such sessions could influence their decision to pursue a given training program. Social media was the most common resource used by participants to gain information on training programs. Conclusion: Online information sessions are valuable tools for medical student recruitment and can directly influence their views of a specific training program and affect career planning. Investing in generating high quality content through online forms of communication is paramount as most medical students are turning to these platforms amidst the pandemic.

Historique: La pandémie de COVID-19 a accru les obstacles pour les étudiants en médecine qui souhaitent aller en chirurgie plastique. Il n'est plus possible de recourir aux approches classiques, comme la recherche très vaste de stages cliniques, et les étudiants en médecine cherchent des moyens novateurs de procéder. L'étude actuelle a permis d'évaluer l'efficacité des séances d'information en ligne sur la perception des étudiants en médecine et de proposer un calendrier de recrutement longitudinal de ces étudiants en médecine. Méthodologie: Le programme de résidence en chirurgie reconstructive et plastique de l'Université McGill a tenu une séance d'information en ligne pour les étudiants en médecine sur un vaste éventail de sujets liés à la chirurgie plastique et à la résidence. Après la séance, les participants ont reçu un sondage anonyme pour évaluer leur satisfaction par rapport à l'événement et les effets potentiels sur leur planification de carrière. Résultats: Au total, 34 participants ont rempli le sondage, représentant plus de 60% des candidats annuels aux programmes canadiens en chirurgie plastique. Dans l'ensemble, 94% des participants ont déclaré que leur perception du programme de formation de McGill s'était améliorée et qu'ils souhaitaient participer aux séances d'autres programmes de formation. Par ailleurs, 68% des répondants ont signalé être plus susceptibles d'envisager une formation à McGill et 100% ont convenu que ces séances pouvaient influer sur leur décision d'opter pour un programme de formation donné. Les réseaux sociaux étaient la principale ressource qu'utilisaient les participants pour obtenir de l'information sur les programmes de formation. Conclusion: Les séances d'information en ligne sont des outils précieux pour recruter des étudiants en médecine, peuvent avoir une influence directe sur leurs points de vue au sujet d'un programme de formation donné et peuvent se répercuter sur leur planification de carrière. Il est essentiel d'investir dans la production de contenu de qualité transmis par diverses formes de communications en ligne, car la plupart des étudiants en médecine se tournent vers ces plateformes en cette période de pandémie.

A Comparative Cost Analysis of Local Anesthesia versus Brachial Plexus Block for Complex Hand Surgery.

BACKGROUND: Local anesthesia has shown to be safe and cost-effective for elective hand surgery procedures performed outside of the operating room. The economic benefits of local anesthesia compared to regional anesthesia for hand surgeries performed in the operating room involving repair of tendons, nerves, arteries, or bones are unclear. This study aimed to compare costs pertinent to hand surgeries performed in the main operating room under local anesthesia (LA) or brachial plexus (BP) block. METHODS: We performed a cross-sectional study on the first 70 randomized patients from a prospective controlled trial of anesthesia modalities for hand surgery. The primary objective was to determine the mean anesthesia-related cost, and the secondary objectives were to analyze block performance time, block onset time, duration of anesthesia, duration of surgery, and time in the recovery room. RESULTS: The mean anesthesia-related cost of performing hand surgery under LA as a wrist and/or digital block was $236 ± 30, compared to $435 ± 43 for BP, a difference of $199 per case. The mean block performance time was shorter for LA (1.3 minutes) versus BP (7.0 minutes). The mean anesthesia-related time was longer in BP (30.7 ± 16 minutes) compared to LA (17.7 ± 6.7 minutes), and consequently the total anesthesia time was longer in BP. CONCLUSIONS: We demonstrated that local anesthesia compared to brachial plexus block achieved substantial cost savings in complex hand surgeries by decreasing major expenses. In an era of cost-consciousness, the use of LA represents an important modality for health systems to optimize patient flow and increase cost-effectiveness.

Patient-Reported Quality of Recovery after Local Anesthesia versus Brachial Plexus Block in Hand Surgery: A Randomized Controlled Study.

BACKGROUND: Both local anesthesia (LA) and brachial plexus (BP) anesthesia are commonly used in hand surgery. LA has increased efficiency and reduced costs, but BP is often favored for more complex hand surgery, despite requiring greater time and resources. The primary objective of this study was to assess the quality of recovery of patients who received LA or BP block for hand surgery. Secondary objectives were to compare postoperative pain and opioid use. METHODS: This randomized, controlled, noninferiority study enrolled patients undergoing surgery distal to the carpal bones. Patients were randomized to either LA (wrist or digital block) or BP block (infraclavicular block) before surgery. Patients completed the Quality of Recovery-15 questionnaire on postoperative day (POD) 1. Pain level was assessed with a numeric pain rating scale, and narcotic consumption was recorded on POD1 and POD3. RESULTS: A total of 76 patients completed the study (LA, n = 46, BP, n = 30). No statistically significant difference was found for median Quality of Recovery-15 score between LA [127.5 (interquartile range, 28)] and BP block [123.5 (interquartile range, 31)]. The inferiority margin of LA to BP block at the 95% confidence interval was less than the minimal clinically important difference of 8, demonstrating noninferiority of LA compared with BP block. There was no statistically significant difference between LA and BP block for numeric pain rating scale scores or narcotic consumption on POD1 and POD3 ( P > 0.05). CONCLUSION: LA is noninferior to BP block for hand surgery with regard to patient-reported quality of recovery, postoperative pain, and narcotic use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Gender Equality in Plastic Surgery Training: A Canadian Nationwide Cross-sectional Analysis.

Introduction: One of the important factors in achieving gender equity is ensuring equitable surgical training for all. Previous studies have shown that females get significantly lower surgical exposure than males in certain surgical specialties. Gender gap in surgical exposure has never been assessed in plastic surgery. To that end, the goal of this study was to assess if there are any differences in plastic surgery training between male and female residents. Methods: A survey was sent to all plastic surgery residency programs in Canada to assess the No. of surgeries residents operated on as a co-surgeon or primary assistant during their training. The survey also assessed career goals, level of interest in the specialty, and subjective perception of gender bias. Results: A total of 89 plastic surgery residents (59.3% participation rate) completed the survey and were included in the study. The average No. of reconstructive cases residents operated on as a co-surgeon or primary assistant was 245 ± 312 cases. There was no difference in either reconstructive or aesthetic surgery case logs between male and female residents (p > .05). However, a significantly larger proportion of females (39%) compared to males (4%) felt that their gender limited their exposure to surgical cases and led to a worsening of their overall surgical training (p < .001). Finally, a larger proportion of male residents were interested in academic careers while a larger proportion of female residents were interested in a community practice (p = .024). Conclusion: While there is no evidence of differences in the volume of logged cases between genders, female surgical residents still feel that their respective gender limits their overall surgical training. Gender inequalities in training should be addressed by residency programs.

Introduction: L'un des facteurs importants pour atteindre l'égalité des genres est d'assurer une formation chirurgicale équitable pour tous. Des études antérieures ont montré que les femmes ont une exposition significativement moindre à la chirurgie que les hommes dans certaines spécialités chirurgicales. L'écart entre genres pour l'exposition à la chirurgie n'a jamais été évalué en chirurgie plastique. À cette fin, la présente étude a eu pour objectif d'évaluer s'il y avait des différences dans la formation à la chirurgie plastique entre les résidents masculins et féminins. Méthodes: Une enquête a été envoyée à tous les programmes canadiens de résidence en chirurgie plastique pour évaluer le nombre d'interventions auxquelles les résidents ont participé en tant que co-chirurgien ou assistant principal au cours de leur formation. L'enquête a également évalué les objectifs de carrière, le niveau d'intérêt dans la spécialité et la perception subjective d'un biais lié au genre. Résultats: En tout, 89 résidents en chirurgie plastique (taux de participation de 59,3 %) ont répondu à l'enquête et ont été inclus dans l'étude. Le nombre moyen de cas de chirurgie reconstructrice au cours desquelles les résidents sont intervenus en tant que co-chirurgien ou principal assistant était de 245 ± 312 cas. Il n'y a pas eu de différence entre les journaux de cas, qu'il s'agisse de chirurgie reconstructrice ou de chirurgie esthétique entre résidents masculins et féminins (P > 0,05). Cependant, un nettement plus grand pourcentage de femmes (39 %) que d'hommes (4 %) estimait que leur genre limitait leur exposition à des cas chirurgicaux et résultait dans une aggravation de leur formation globale à la chirurgie (P < 0,001). Enfin, un plus grand pourcentage de résidents masculins était intéressé par une carrière universitaire alors qu'un plus grand pourcentage de résidentes était intéressé par une pratique dans la communauté (P = 0,024). Conclusion: Bien qu'il n'y ait pas de données probantes étayant des différences de volume des cas consignés entre les genres, les résidentes féminines en chirurgie pensent encore que leur genre limite leur formation chirurgicale. Les inégalités entre genres devraient être abordées par les programmes de résidence.

Utility outcome scores for unilateral facial paralysis.

BACKGROUND: Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. METHODS: Utility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. RESULTS: A total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56±0.18, 0.78±0.21, and 0.79±0.21 respectively] were significantly different (P<0.0001) from the corresponding outcome scores for monocular blindness [0.61±0.21, 0.83±0.21, and 0.85±0.18, respectively] and binocular blindness [0.33±0.18, 0.65±0.28, and 0.65±0.29, respectively]. Linear regression analysis using age, race, income, and education as predictors of each of the utility scores for facial paralysis showed no statistical significance. CONCLUSIONS: In samples of the general population and medical students, all utility score outcome measures for facial paralysis were lower than those for monocular blindness. Our sample population, if faced with unilateral facial paralysis, would theoretically undergo facial reanimation procedures with a willingness to sacrifice 8 years of life and be willing to undergo a procedure with a 21% chance of mortality to attain perfect health, respectively.

The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: a utility outcomes score assessment.

BACKGROUND: Revision rhinoplasty for functional deformities can be both an aesthetic and reconstructive surgical challenge. We set out to quantify the health state utility assessment of living with the physical appearance of nasal asymmetry along with having nasal obstruction. The use of utility scores has helped to establish the health burden of living with various medical conditions. We sought to quantify living with a health state of nasal asymmetry with nasal obstruction after primary rhinoplasty using utility outcome scores. METHODS: We used previously validated utility outcome measures to quantify the health burden of this clinical scenario in 128 prospective subjects. These subjects were from a sample of the population and medical students recruited to complete a survey to determine the utility outcome score of revision rhinoplasty using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) tests to obtain utility scores for revision rhinoplasty. Linear regression and Student t test were used for statistical analysis. RESULTS: All measures (VAS, TTO, and SG) for functional nasal deformity (0.80±0.13, 0.90±0.12, and 0.91±0.13, respectively) of the 128 prospective subjects participating in this online study were significantly different (P<0.005) from the corresponding scores for monocular blindness (0.63±0.15, 0.85±0.16, and 0.85±0.19, respectively) and binocular blindness (0.38±0.18, 0.66±0.25, and 0.69±0.24, respectively). Being white was inversely related to the VAS utility scores for rhinoplasty (P<0.05). Additionally, female sex was positively correlated to the TTO score. Age, income, and education were not predictors of utility scores. CONCLUSIONS: In a sample of the population and medical students, VAS, TTO, and SG utility scores for revision rhinoplasty were determined and can be compared objectively with other health states and diseases with known utility scores. In a preoperative setting, women were objectively willing to potentially "trade" more years of life to treat a functional nasal deformity. If faced with a deformed nose after primary rhinoplasty, our sample population would consent to undergo a revision rhinoplasty procedure with a theoretical 9% chance of mortality and were willing to trade 3.6 years of their remaining life.

The effects of COVID-19 on Canadian surgical residents' education and wellness.

Background: The COVID-19 pandemic has challenged health care systems. We sought to comprehend the impact of the COVID-19 pandemic on surgical residents' education and mental well-being across Canada. Methods: An online 51-question survey was distributed to surgical residents across all 17 Canadian post- graduate surgical residency programs. The questionnaire contained questions concerning demographic factors, perceived effects of COVID-19 pandemic on surgical training and residents' mental health (categorically demonstrating whether it improved, stayed the same, or worsened). Health habits were measured as continuous variables and compared before and during the pandemic. Additionally, participants reported the performance of wellness offices' response to their needs during this crisis. Results: A total of 122 out of 650 (19%) residents from all surgical specialities anonymously completed the survey. The majority (68%) reported a worsening in their surgical training. 94% of participants favored online teaching as a complementary method to in-person teaching. As to health habits, 38% reported a rise in their alcohol consumption and time spent seated. Only a minority (25%) felt happier and 41% reported experiencing more anxiety in comparison to surgical training pre-COVID-19. Merely 14% reported benefitting from wellness programs. Conclusion: The COVID-19 pandemic had a negative effect on the perceived quality of surgical training, education, and resident mental health. There is an urgent need to reconsider the implemented measures in medical education and urge us to develop better agendas to face the current or future waves.

Contexte: La pandémie de la COVID-19 a mis au défi les systèmes de soins de santé. Nous avons tenté de mesurer les impacts de la pandémie sur la formation et le bien-être mental des résidents en chirurgie au Canada. Méthodes: Un sondage en ligne comportant 51 questions a été effectué auprès des résidents des 17 programmes de résidence en chirurgie au Canada. Les questions concernaient les facteurs démographiques et les effets perçus de la pandémie de la COVID-19 sur la formation en chirurgie et sur la santé mentale des résidents (indiquant si leur santé mentale s'était améliorée, si elle était restée inchangée ou si elle s'était détériorée). Les habitudes de santé ont été mesurées en tant que variables continues, et comparées avant et pendant la pandémie. De plus, les participants se sont prononcés sur la capacité des services d'aide au bien-être de répondre à leurs besoins pendant la crise. Résultats: Au total, 122 des 650 résidents (19 %), toutes spécialités chirurgicales confondues, ont répondu au sondage de manière anonyme. La plupart des participants (68 %) ont signalé une détérioration de leur formation en chirurgie et 94 % d'entre eux se sont dits favorables à l'enseignement en ligne comme méthode complémentaire à l'enseignement en personne. En ce qui concerne les habitudes de santé, 38 % des participants ont signalé une augmentation de leur consommation d'alcool et du temps passé assis. Une minorité de résidents (25 %) se sont sentis plus heureux et 41 % ont déclaré éprouver plus d'anxiété dans leur formation chirurgicale qu'avant la pandémie. Seulement 14 % des participants affirment avoir profité des programmes d'aide au bien-être. Conclusion: La pandémie de la COVID-19 a eu un effet négatif sur la perception des résidents quant à la qualité de la formation chirurgicale, de l'éducation et de leur santé mentale. Il est urgent de revoir les mesures mises en œuvre dans l'enseignement médical et d'élaborer de meilleurs plans d'action pour faire face à la vague actuelle ou toute autre vague future.

Role of Electrical Stimulation in Peripheral Nerve Regeneration: A Systematic Review.

Functional recovery after peripheral nerve injury is often suboptimal despite the intrinsic permissive growth environment of the peripheral nervous system. The objective of this systematic review is to explore the use of electrical stimulation (ES) for peripheral nerve regeneration. Methods: A systematic literature search was conducted from inception to March 2, 2021 to retrieve articles on ES for peripheral nerve regeneration using the PubMed, Ovid MEDLINE, and Embase databases. Primary outcome measures included objective measures of motor and sensory nerve function. Results: Four randomized control trials, two case reports, and three case series that addressed the aims were identified. The stimulation parameters varied greatly between studies, without an apparent commonality for a given electrical conduit. Outcomes measured included motor (n = 8) and sensory (n = 7) modalities (cold detection, static two-point discrimination, tactile discrimination, and pressure detection), nerve-specific muscle function and bulk, and electromyography (EMG) motor and sensory terminal latency. Different parameters for measurement were utilized and improvement was observed across the studies compared with controls (n = 4) or pre-intervention measurements (n = 5). One randomized control trial reported no benefit of ES and attributed their findings to their stimulation protocol. Complications were documented in three patients only and included wire remnant removal, skin pigmentation, and bone formation. Conclusions: ES in peripheral nerve regeneration is beneficial in improving and accelerating recovery. A meta-analysis was not performed due to the heterogeneity, but all studies showed positive findings and minor to no complications. These results provide a primer for further development of delivery methods.

Utility of Ultrasonography and Significance of Surgical Anatomy in the Management of de Quervain Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: The role of ultrasound in plastic surgery practice has grown significantly over the past decade, with notable applications for conditions of the upper extremity. Its utility for the management of de Quervain disease, however, remains to be established, and the prevalence of first dorsal compartment anatomical variations needs to be adequately assessed. METHODS: A systematic review was performed to evaluate the role of ultrasound in the diagnosis, anatomical characterization, and clinical management of de Quervain disease. A meta-analysis was conducted to establish the prevalence of first dorsal compartment anatomical variations in the de Quervain disease and general population, along with the diagnostic accuracy of ultrasound for their detection. Outcomes were documented and compared to alternative treatment options. RESULTS: Extensor retinaculum thickening, tendon sheath swelling, peritendinous edema, and tendon enlargement were the most common sonographic features of de Quervain disease. The prevalence of an intercompartmental septum in the de Quervain disease surgical population was shown to be significantly greater than in the general cadaveric population (67 percent versus 35 percent, respectively). Although the efficacy of energy-based therapeutic ultrasound remains elusive, ultrasound-guided corticosteroid injections were shown to be more accurate than manual injections (90 to 100 percent versus 40 to 100 percent), and to confer significantly better treatment outcomes (73 to 100 percent versus 59 to 83 percent success rates, respectively). CONCLUSIONS: Ultrasound use is essential to achieve the best evidence-based outcomes in the management of de Quervain disease. The varied prevalence of first dorsal compartment anatomical variations and high accuracy of ultrasound for their detection carry significant prognostic implications.