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BACKGROUND: Venous leg ulcers (VLUs) are the most common type of chronic wound in the lower extremity and are often associated with redness, swelling, and pain at the site of the wound. The primary focus of VLU treatment is the promotion of wound healing through compression therapy, wound debridement, and elevation of the affected limb. Acellular matrices have gained traction as a potential adjunct to wound healing in diabetic foot ulcers. However, the clinical effect of acellular products in the setting of VLUs has not been well reported. OBJECTIVE: To review the published evidence on the use of acellular products in the management of VLUs. METHODS: PubMed, Embase, Cochrane, and Google Scholar databases were initially searched on March 2, 2023, for literature on VLU and acellular dermal matrix. Later, the search was broadened to include any and all acellular matrices, and a secondary search of the same databases was conducted on February 20, 2024. Articles obtained through collateral methods were also included. RESULTS: A total of 27 articles were identified for review. All studies were human studies. Four articles had level I evidence and 7 articles had level II evidence, while the remaining articles had level III or IV evidence. Studies included both large and small wound sizes ranging from 0.5 cm² to 100 cm2. Product application occurred once to twice weekly for 4 weeks to up to 36 months. Overall, regardless of ulcer size, the majority of studies reported favorable wound healing outcomes with the use of a variety of acellular skin coverage products with few complications. Some studies also reported pain reduction with the use of acellular skin substitutes in a small cohort of patients. CONCLUSION: Acellular products appear to have the potential to support healing in VLUs. However, more large-scale randomized controlled trials that provide level I evidence are needed.
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Dermis Acelular , Úlcera Varicosa , Cicatrización de Heridas , Humanos , Cicatrización de Heridas/fisiología , Úlcera Varicosa/terapia , Desbridamiento/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate regarding the effect of race and socioeconomic status (SES) on the timing of cleft lip and/or palate (CL ± P), craniosynostosis, and plagiocephaly presentation to clinic and possible repair. DESIGN/METHODS: A retrospective review of patients with CL ± P and head shape conditions from Jan 2001 to Feb 2022 were included. Age at first plastic surgery clinic appointment, age at repair if applicable, gender, race, and zip code were collected. The Validated Child Opportunity Index (COI) scale was calculated based on zip code as a measure of SES. Kruskal-Wallis tests and Dunn's procedures were used for continuous variables and post hoc pairwise comparisons. RESULTS: 2733 patients with CL ± P, 9974 with plagiocephaly/brachycephaly, and 59 patients with craniosynostosis were included. Among patients with CL ± P, Black and Hispanic patients presented significantly later to both first plastic surgery clinic appointment and age at repair than White patients (P < .001). White patients and higher SES were associated with a significantly earlier date of initial presentation to plastic surgery clinic for head shape conditions (P < .001). CONCLUSIONS: Race and SES may play an important role in the delay of first presentation to plastic surgery clinic and subsequent repair for these patient populations. Further educational efforts must be provided to ensure equitable care. This single institutional study may serve to encourage other academic centers to analyze the timing of care for our pediatric patients.
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Background: Evaluation of practice patterns by American Board of Plastic Surgery (ABPS) diplomates allows for a greater understanding as to how the field is progressing. Understanding evolving procedural trends can give insight into plastic surgeons' subspecialty focus and influence resident training to prepare them for future practice. Methods: American Society of Plastic Surgeons member only projections for aesthetic and reconstructive procedures were reviewed from 1999 to 2018 in 5-year increments to identify shifts in frequency between the beginning (1999-2003) and end (2014-2018) of the timeframe. Tracer utilization for all four ABPS modules were also examined between 2014 and 2018. Descriptive statistics were performed to identify significant changes (P < 0.05) in subspecialty focus and procedure trends. Results: Annual procedure incidence between 2014 and 2018 was compared with that between 1999 and 2003. The annual number of procedures more than doubled from 3,244,084 to 6,628,082. Among reconstructive procedures, there was a statistically significant increase in the number of breast reconstruction, breast implant removal, and maxillofacial surgery procedures, and a statistically significant decrease in the number of procedures focused on reconstruction of birth defects, burn injuries, and hand anomalies. In aesthetic surgery, significant increases were seen in the number of augmentation mammoplasty, abdominoplasty, and mastopexy procedures, with significant decreases in the number of blepharoplasty and rhinoplasty procedures. Conclusions: Understanding the changing practice patterns of ABPS diplomates is essential to define the direction that our specialty is taking over time, and to guide program directors in plastic surgery on areas of focus for appropriate training of plastic surgeons.
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Across scar studies, there is a lack of dark-skinned individuals, who have a predisposition for keloid formation, altered pigmentation and poorer quality of life (QOL). There is a need for patients of colour to be included in scar scale development and validation. In this study, we evaluate the racial diversity of patients included in the validation of scar assessment scales. A systematic review was conducted for articles reporting on the validation of a scar assessment tool. Racial, ethnic and Fitzpatrick skin type (FST) data were extracted. Fifteen scar scale validation studies were included. Nine of the studies did not mention FST, race or ethnicity of the patients. Two of the studies that reported FST or race information only included White patients or included no FST V/VI patients: mapping assessment of scars (MAPS) and University of North Carolina '4P'. Only four studies included non-White patients or dark-skinned patients in the validation of their scar scale: the modified Vancouver Scar Scale (VSS), modified Patient and Observer Scar Assessment Scale (POSAS), acne QOL and SCAR-Q scales. The patients included in the modified VSS validation were 7% and 13% FST V/VI, 14% African in the modified POSAS and 4.5% FST V/VI in the SCAR-Q. We highlight the severe lack of diversity in scar scale validation, with only 4 out of 15 studies including dark-skinned patients. Given the susceptibility of darker-skinned individuals to have poorer scarring outcomes, it is critical to include patients of colour in the very assessment tools that determine their scar prognosis. Inclusion of patients of colour in scar scale development will improve scar assessment and clinical decision-making.
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Cicatriz , Calidad de Vida , Humanos , Cicatriz/patología , Pigmentación de la Piel , Cicatrización de Heridas , Piel/patologíaRESUMEN
Currently, patient reported outcome scales used to assess scar impact focus solely on psychosocial well-being, symptoms, and appearance. There remains a need to develop a broadened measure of scar impact on patients, focusing on sexual and career aspects. This study investigates the content validity of the novel Career and Sexual Well-being (CS) Scar Impact Scale. Method: The CS scale contains five questions and was developed from previous patient thematic analysis interviews describing scar impact, and covers self-conscious behavior, new partners, hiding of the scar, being hindered in the workplace, and concerns regarding unprofessional appearance. Cognitive interviews and established guidelines were used to ensure that the scale was comprehensive, reproducible, and easily understandable. Results: In total, 86 patients completed cognitive interviews. Patients had a clear understanding of the questions and elicited their intent in the interviews. An estimated 86% of patients rated the CS scale coverage of scar impact on career and sexual health at a three or above out of four; 95% said the specific instructions were clear, and 92% stated it took them less than 4 minutes to complete the scale. After the first round of interviews, a question about "perception/self-consciousness in a professional environment" was added based on patient suggestions. Conclusions: The CS scar scale demonstrated face validity, acceptability, and field-readiness through cognitive interviewing of patients at our institution. Sexual well-being and career performance are important yet often neglected themes with which scars should be assessed. Usage of these tools would serve to improve current scar scales.
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Background: The rise in Botox, fillers, and chemical peel procedures demands transparent online information that discloses all relevant risks and complications. This study assesses the quality of complication disclosure on the most popular cosmetic sites. Methods: The top 50 Google search results for "Botox," "fillers," and "chemical peel" were analyzed for their reporting on relevant complications. Websites were categorized based on their origin. An overall complication, prevention, management, prevalence, and disclaimer score were assigned to each site. Results: A total of 136 websites were analyzed. Of these websites, 31 (22.7%) did not mention any complications or risks associated with the treatment. The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels. The least-reported serious complications were toxin spread effects (31.0%) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%). Reports of serious and rare side effects were significantly lower than those of common side effects (Botox, P = .001; fillers, P = .004; chemical peels, P < .001). The overall mean (standard deviation) complication score across all websites was 2.81/5 (1.31). Online health reference and academic/hospital sites disclosed complications better than sources in most other categories (P < .001). Conclusions: The reporting of online complications for the top 3 cosmetic procedures performed in the US is highly variable, biased, and at times, completely absent. Patients pursuing cosmetic surgery are heavily influenced by the internet and vulnerable to misinformation. Cosmetic procedure websites are in need of drastic improvement to ensure the health and safety of all patients.
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BACKGROUND: Understanding the extent of practice management education within plastic surgery residency may serve to enhance elements of current curricular training. METHODS: A survey was sent to private practice plastic surgeons who completed training between 2008 and 2020. The survey elicited opinions about their practice management training during residency and experiences as attendings. RESULTS: Forty-nine private practice plastic surgeons completed the survey with a mean of 5 years in practice. 96% of respondents entered private practice immediately following their final training program. 48% of respondents cited "autonomy" as the primary reason for pursuing private practice. Surgeon's narrative responses regarding practice management skills learned outside of residency revealed the most grouped into the following themes: "Finance, Marketing, Accounting, Human Resources (HR), Operations" (n = 19), "Hiring, Firing, Employee Management" (n = 17), "Insurance Coverage, Billing, Coding" (n = 13), "General Skills" (n = 12), and "Starting & Running a Practice" (n = 11). 71.4% of respondents reported that they learned practice management skills from on-the-job training. Almost all respondents felt that there should be formal training in practice management (n = 35), with "Finance & Accounting" and "Management" cited as the most important skills to learn as a plastic surgeon. 51% of current surgeons felt allowing senior residents additional opportunities to rotate in private practices was the best way to enhance residency curricula. CONCLUSION: Incorporating practice management skills into training curricula will address the demonstrated knowledge gap and accelerate plastic surgeons' career growth. 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 .
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Internado y Residencia , Procedimientos de Cirugía Plástica , Gestión de la Práctica Profesional , Cirugía Plástica , Humanos , Cirugía Plástica/educación , Encuestas y CuestionariosRESUMEN
Scarring negatively impacts patient mental health, causing worsened self-confidence, body image, and social interactions, as well as anxiety and depression. The objective of this study is to evaluate the scarring impact after facial surgery, breast surgery, and full abdominoplasty for symptoms, appearance, psychosocial health, career, and sexual well-being using validated patient-reported outcome measures. Method: A total of 901 patients from five providers completed the SCAR-Q (covering symptoms, appearance, and psychosocial) and Career/Sexual Well-being assessments via phone or email where a higher score indicated a more positive scar perception. Results: Of the 901 patients, 38.1% had abdominoplasty surgery, 38.1% breast reduction, 15.3% facial surgery, 4.7% breast lift, and 3.9% breast augmentation. The differences in SCAR-Q, appearance, and symptom scores between the five procedures were statistically significant. Breast augmentation SCAR-Q scores (median = 256) and facial surgery (median = 242) were significantly higher than those of abdominoplasty patients (median = 219; P = 0.003 and P = 0.001, respectively). Duration after surgery was positively correlated with improved symptom scale scores for abdominoplasty (r = 0.24, P < 0.001), breast augmentation (r = 0.71, P = 0.015), and facial surgery patients (r = 0.28, P = 0.001), but not for other procedures. Conclusions: This study is the first to show that breast augmentation and facial surgery patients have a more positive perception of their scars in terms of appearance, symptoms, psychosocial, career, and sexual well-being impact than abdominoplasty patients. Furthermore, the data suggest that symptoms may improve over time for abdominoplasty, breast augmentation, and facial surgery patients. This study highlights the need for further follow-up, counseling, or other improvements to postoperative scar care.
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INTRODUCTION: Clinical options are lacking for the management of chronic wounds or ulcers following failed debridement, skin grafting, or negative pressure wound therapy dressings. OBJECTIVE: This retrospective case series evaluated the efficacy of injectable AAM in the management and closure of chronic wounds. MATERIALS AND METHODS: Patients with nonhealing wounds of any etiology, anatomic location, and length of chronicity were included; those with multiple chronic wounds or prior skin grafting for wound repair were excluded. Data on location, etiology, chronicity, and number of AAM applications were collected for each wound. Patients were evaluated for possible complications related to wound healing and infection. Eleven patients (7 males, 4 females), each with 1 chronic wound, were recruited (average age, 65 years). Wound etiologies were postoperative (n = 7), traumatic (n = 2), and foot ulcer (n = 2). Average wound dimensions were 8.45 mm × 7.36 mm, and the average chronicity was 3.77 months. Ten patients received only 1 application of AAM, and 1 patient received 2 treatments 5 days apart. Average follow-up time was 6.6 weeks. RESULTS: Seven patients (63%) achieved wound closure, 4 of which (57%) healed within 1 week of application. CONCLUSION: Most patients with chronic wounds treated with AAM experienced complete wound closure. AAM shows promising results for enhancing wound healing by providing scaffolding for cell growth.
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Pie Diabético , Úlcera del Pie , Terapia de Presión Negativa para Heridas , Anciano , Aloinjertos , Pie Diabético/terapia , Femenino , Úlcera del Pie/terapia , Humanos , Masculino , Estudios Retrospectivos , Cicatrización de HeridasRESUMEN
BACKGROUND: Because of the high volume of Asian eyelid operations performed and the complexity of the Asian eye, there is a need to define exactly what anthropometric measurements determine attractiveness. METHODS: Eye photographs of young East Asian women were collected from publicly available sources online. Photographs were evaluated on a Likert scale ranging from 1 to 5 for attractiveness. Thirty-seven anthropometric measurements were collected using ImageJ from the most attractive and least attractive eyes to discover which features play the most important role in attractiveness. RESULTS: A total of 322 right eye photographs were evaluated for attractiveness. Sixty-six eyes received a median score of greater than or equal to 4.0 and were included in the attractive cohort. Forty-three eyes received a score of less than or equal to 2.0 and were included in the unattractive cohort. The superior brow peak was more lateralized compared to the upper lid crease and upper lash line peaks in attractive eyes. A greater palpebral aperture height-to-upper lid show ratio was found to be more associated with attractive eyes than with unattractive eyes. At the midpupillary line, the ratio was on average 1.58 ± 0.32 in attractive eyes and 1.22 ± 0.43 in unattractive eyes ( p < 0.001). Eyes with convergence of the upper lid crease with the upper lash line were more likely to be deemed unattractive ( p < 0.001). CONCLUSIONS: East Asian eyes have specific anthropometric measurements that are more associated with attractiveness. These ideal measurements are different from those in Caucasians, suggesting ethnic variability in features defining attractiveness and a need to tailor surgical care appropriately.
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Belleza , Párpados , Humanos , Femenino , Párpados/cirugía , Pueblo Asiatico , Población Blanca , Estudios de CohortesRESUMEN
OBJECTIVE: Obturator nerve injury can occur as a complication of gynecologic surgeries, occurring most frequently in patients with endometriosis and genitourinary malignancies. The resulting injury causes paresthesia and major weakness in adduction and atrophy of the adductor group of lower extremity muscles. The objective of this study was to conduct a systematic review and meta-analysis of the effectiveness of end-to-end repair, nerve grafting, and nerve transfer in improving motor function in patients with obturator nerve injury. METHODS: PubMed, Cochrane, Medline, and Embase libraries were searched from May 1994 to August 2020 according to the PRISMA guidelines for articles that present functional outcomes after obturator nerve injury in patients treated with nerve grafting, end-to-end repair, or nerve transfer. RESULTS: A total of 25 patients from 22 studies were included in the study, 15 of whom were treated with end-to-end repair (60%), nine with nerve grafting (36%), and one with nerve transfer (4%). Of the 15 patients with transection data, two had incomplete (13%) and 13 had complete (87%) nerve transections. The patients underwent pelvic lymphadenectomy (n=24) and radical cystectomy (n=1) operations. The mean Medical Research Council (MRC) score was 2.95±1.7 immediately after treatment and 4.77±0.6 at the final follow-up. All patients achieved good outcomes (MRC ≥3) at the final follow-up. The mean MRC score for end-to-end repair (n=15), nerve grafting (n=9), and nerve transfer (n=1) was 4.8±0.6, 4.7±0.8, and 5, respectively. Patients with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting (p=0.03) and tended to achieve full functional recovery after shorter periods of time (rho=-0.65, p=0.049). Other parameters did not correlate with MRC. CONCLUSION: End-to-end repair, nerve grafting, and nerve transfer are equally effective in restoring function in patients with obturator nerve injury. However, patients treated with end-to-end repair had higher immediate post-operative strength than those treated with nerve grafting.
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Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools. Method: A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception. Results: Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232 ± 79 versus 203 ± 116), appearance (66 ± 26 versus 55 ± 29), and Career/Sexual Well-Being (16 ± 2 versus 15 ± 5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores. Conclusions: African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.
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BACKGROUND: Aggregated data show that Black patients undergo disproportionately lower rates of cosmetic surgery than their Caucasian counterparts. Similarly, laboratory findings indicate that social media representation is lower among Black patients for breast reconstruction surgery, and it is expected that this could be the case in cosmetic surgery as well. OBJECTIVES: The aim of this study was to explore the social media representation of Black patients and physicians in the 5 most common cosmetic surgery procedures: rhinoplasty, blepharoplasty, abdominoplasty, breast augmentation, and liposuction. METHODS: Data were collected from RealSelf (Seattle, WA), the most popular social media site for sharing cosmetic surgery outcomes. The skin tone of 1000 images of patients in each of the top 5 cosmetic surgeries was assessed according to the Fitzpatrick scale, a commonly utilized skin tone range. Additionally, the Fitzpatrick scores of 72 providers who posted photographs within each surgical category were collected. RESULTS: Black patients and providers are underrepresented in rhinoplasty, blepharoplasty, breast augmentation, and liposuction compared with the general population (defined by the US Census Bureau), but were proportionately represented in abdominoplasty. Additionally, it was found that patients most often matched Fitzpatrick scores when both had scores of 2, whereas patients with a score of 5 and 6 rarely matched their provider's score. CONCLUSIONS: The underrepresentation of Black patients and providers in social media for cosmetic surgery may well discourage Black patients from pursuing cosmetic surgeries. Therefore, it is essential to properly represent patients to encourage patients interested in considering cosmetic surgery.
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Abdominoplastia , Lipectomía , Médicos , Medios de Comunicación Sociales , Cirugía Plástica , HumanosRESUMEN
Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.
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Transferencia de Nervios , Heridas por Arma de Fuego , Adolescente , Adulto , Humanos , Procedimientos Neuroquirúrgicos , Nervio Peroneo/lesiones , Nervio Peroneo/cirugía , Nervio Sural , Nervio Tibial/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
The fingertip is defined as the part of the digit distal to the insertion of the extensor and flexor tendons on the distal phalanx. Devastating injuries to the hand occur every year that lead fingertip amputations in thousands of people. The highest incidence rates are usually seen in children less than five years old and in adults over the age of 65. There are various presentations of injury that may end up with post-traumatic fingertip amputation, including lacerations, avulsions, and crush injuries. The fingertip is vital for sensation, as it has a high concentration of sensory receptors, and hence the restoration of sensation is the most important focus of treatment. The three main goals of treatment are the restoration of sensation and durability in the tip and assuring proper bone support to allow for nail growth. Many complications can arise after fingertip amputation, including delayed wound healing, nail deformities with poor aesthetics, hypersensitivity, residual pain, cold intolerance, scar retraction, flexion contractures, chronic ulceration, infection, and flap loss. The objective of this study is to provide an overview of the anatomy of the fingertip, the presentation of fingertip injuries and their management, and complications that might arise after surgery.