A Practical Approach to Artificial Intelligence in Plastic Surgery.

Understanding the intersection of technology and plastic surgery has been and will be essential to positioning plastic surgeons at the forefront of surgical innovation. This account of the current and future applications of artificial intelligence (AI) in reconstructive and aesthetic surgery introduces us to the subset of issues amenable to support from this technology. It equips plastic surgeons with the knowledge to navigate technical conversations with peers, trainees, patients, and technical partners for collaboration and to usher in a new era of technology in plastic surgery. From the mathematical basis of AI to its commercially viable applications, topics introduced herein constitute a framework for design and execution of quantitative studies that will better outcomes and benefit patients. Finally, adherence to the principles of quality data collection will leverage and amplify plastic surgeons' creativity and undoubtedly drive the field forward.

Efficacy of Local Anesthesia in the Face and Scalp: A Prospective Trial.

BACKGROUND: The use of local anesthesia has allowed for the excision and repair of lesions of the head and neck to be done in an office-based setting. There is a gap of knowledge on how surgeons can improve operative flow related to the onset of action. A prospective trial was undertaken to determine the length of time for full anesthesia effect in the head and neck regions. METHODS: Consecutive patients undergoing head and neck cutaneous cancer resection over a 3-month period were enrolled in the study. Local anesthesia injection and lesion excision were all done by a single surgeon. All patients received the standard of care of local anesthesia injection. RESULTS: Overall, 102 patients were included in the prospective trial. The upper face took significantly longer (153.54 seconds) compared with the lower face and ears (69.37 and 60.2 seconds, respectively) (P < 0.001) to become fully anesthetized. In addition, there was no significant difference found when adjusting for the amount of local anesthesia used, type, and size of lesion (P > 0.05). Using the time to full anesthesia effect for each local injection, a heat map was generated to show the relative times of the face and scalp to achieve full effect. CONCLUSIONS: This prospective trial demonstrated that for the same local anesthetic and concentration, upper forehead and scalp lesions take significantly longer to anesthetize than other lesions in the lower face and ear. This can help surgeons tailor all aspects of their practice, which utilizes local anesthesia to help with patient satisfaction and operative flow.

Making Augmented and Virtual Reality Work for the Plastic Surgeon.

Augmented and virtual reality is an evolving technology at the forefront of medicine. It can provide physicians with hands-free, real-time access to the vast resources of the Internet and electronic medical records, allowing simultaneously recording of clinical encounters or procedures. Mixed reality platforms can be applied as a clinical tool, educational resource, or as an aid in enhancing communication in health care. This article will explore how various augmented and virtual reality platforms have enabled real-time visualization of patient information, recording of surgical cases, point-of-view photography, and intraoperative consults-all while remaining sterile in the operating room. Although this technology is of potential value to a number of different surgical and medical specialties, plastic surgery is ideally suited to lead this charge.

Role of artificial intelligence in the care of patients with nonsmall cell lung cancer.

BACKGROUND: Lung cancer is the leading cause of cancer death worldwide. In up to 57% of patients, it is diagnosed at an advanced stage and the 5-year survival rate ranges between 10%-16%. There has been a significant amount of research using machine learning to generate tools using patient data to improve outcomes. METHODS: This narrative review is based on research material obtained from PubMed up to Nov 2017. The search terms include "artificial intelligence," "machine learning," "lung cancer," "Nonsmall Cell Lung Cancer (NSCLC)," "diagnosis" and "treatment." RESULTS: Recent studies support the use of computer-aided systems and the use of radiomic features to help diagnose lung cancer earlier. Other studies have looked at machine learning (ML) methods that offer prognostic tools to doctors and help them in choosing personalized treatment options for their patients based on molecular, genetics and histological features. Combining artificial intelligence approaches into health care may serve as a beneficial tool for patients with NSCLC, and this review outlines these benefits and current shortcomings throughout the continuum of care. CONCLUSION: We present a review of the various applications of ML methods in NSCLC as it relates to improving diagnosis, treatment and outcomes.

The role of ultrasound technology in plastic surgery.

INTRODUCTION: The modern medical era is in part characterized by the increased availability of portable imaging devices. Ultrasound devices are used for either high-resolution non-invasive imaging or as a focused acoustic energy source capable of sculpting and shaping tissue. Given the broad scope of the field, plastic and reconstructive surgeons have the unique ability to implement and tailor the use of ultrasound in a variety of clinical situations. This article will review novel uses for ultrasound in the field of plastic surgery. METHODS: A systematic electronic search was performed using the PubMed database. Search terms used were "ultrasonography" or "ultrasound" and "plastic surgery". Two independent reviewers subsequently reviewed the resultant articles based on strict inclusion and exclusion criteria. Selected manuscripts were analyzed and grouped by procedure categories. RESULTS: 303 articles were included in the study, spanning six procedure categories. The categories included breast, head and neck, microsurgery and reconstruction, skin, aesthetic, and other innovative applications. Ultrasound imaging was shown useful in vascular mapping, dermal and adipose volumetric evaluation, and postoperative flap monitoring. As an energy source, ultrasound has been described for skin tightening, adipose tissue removal, facial rejuvenation, increased neocollagenesis, and bone healing. Reported benefits of incorporating ultrasound into routine clinical practice included promising procedural outcomes, minimal complications, comprehensive patient follow-up and quantitative anatomic evaluation of results. CONCLUSION: Ultrasound offers a portable and non-invasive bedside means to obtain real-time visualization of patients' anatomy, while also providing an effective, focused and safe energy source for procedures. This review highlights novel applications of ultrasonography in the hands of a modern plastic surgeon, across the entire breadth of the specialty.

A Novel Mohs Precision Tool.

BACKGROUND: Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. OBJECTIVE: To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. MATERIALS AND METHODS: A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012-2015). RESULTS: Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: -0.01 to -0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12-1.3, p < .01). CONCLUSION: Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

Optimizing Radiotherapy for Keloids: A Meta-Analysis Systematic Review Comparing Recurrence Rates Between Different Radiation Modalities.

BACKGROUND: The high recurrence rate of keloids has lead to the use of multiple treatment adjuncts to improve cosmetic outcomes after surgery. To date, there has been no single, standardized modality agreed upon to produce the best results. The purpose of this study was to review the radiation-based treatments (brachytherapy, electron beam and X-ray) used for keloid management and compare their outcomes. METHODS: A literature review was performed from 1942 to October 2014 using the databases: PubMed database of the National Center of Biotechnology Information, MEDLINE, Biosis, Embase, Google scholar, and Cochrane database. Articles were reviewed for case numbers, patient demographics, keloid location, follow up, radiation modality, dose, keloid recurrence, and complications. RESULTS: A total of 72 studies met the inclusion criteria representing 9048 keloids. These studies were categorized by treatment: brachytherapy, electron, or X-ray. Meta-analysis demonstrated that radiotherapy after surgery had less recurrence when compared to radiotherapy alone (22% and 37%, respectively, P = 0.005). Comparison between modalities revealed that postoperative brachytherapy yielded the lowest recurrence rate (15%) compared with X-ray and electron beam (23% and 23%, respectively; P =0.04, P = 0.1). Subgroup analysis by location demonstrated chest keloids have the highest recurrence rate. The most commonly reported side effect of radiotherapy was changes in skin pigmentation. CONCLUSIONS: The results of this study reinforce postoperative radiotherapy as effective management for keloids. Specifically, brachytherapy was the most effective of the currently used radiation modalities.

Big Data and Machine Learning in Plastic Surgery: A New Frontier in Surgical Innovation.

Medical decision-making is increasingly based on quantifiable data. From the moment patients come into contact with the health care system, their entire medical history is recorded electronically. Whether a patient is in the operating room or on the hospital ward, technological advancement has facilitated the expedient and reliable measurement of clinically relevant health metrics, all in an effort to guide care and ensure the best possible clinical outcomes. However, as the volume and complexity of biomedical data grow, it becomes challenging to effectively process "big data" using conventional techniques. Physicians and scientists must be prepared to look beyond classic methods of data processing to extract clinically relevant information. The purpose of this article is to introduce the modern plastic surgeon to machine learning and computational interpretation of large data sets. What is machine learning? Machine learning, a subfield of artificial intelligence, can address clinically relevant problems in several domains of plastic surgery, including burn surgery; microsurgery; and craniofacial, peripheral nerve, and aesthetic surgery. This article provides a brief introduction to current research and suggests future projects that will allow plastic surgeons to explore this new frontier of surgical science.

Cellular phone collateral damage: A review of burns associated with lithium battery powered mobile devices.

AIM: The spontaneous destruction of lithium battery powered cellphones has raised concern about the safety of these devices. We present a case report and review of the literature of burn injuries sustained in association with cellular phone usage. METHODS: A Medline search was performed to identify articles describing cellular phone associated thermal injuries using key search words including "burn," "burn injury," "cellular phone," "cellphone," "thermal injury," and "telephone." Articles were reviewed for etiology, location, severity and treatment. We also present a case of a burn to the upper thigh resulting from cellular phone battery malfunction. RESULTS: Six case reports were identified detailing burn injuries obtained from cellphone use. Half of these cases occurred from battery malfunction with second degree being the most common severity. All cases were managed conservatively except one case, which required excision and primary closure. CONCLUSION: Lithium powered cellular phones are susceptible to overheating and destruction from inadequate heat dissipation during thermal runaway. This process can be initiated by local short-circuiting from direct contact with a low resistance conductor such as keys or coins. We reinforce the importance of safe cell phone battery practices including avoiding overcharging and direct skin exposure to minimize thermal injury risk.

Lipofibromatous hamartoma of the median nerve: a comprehensive review and systematic approach to evaluation, diagnosis, and treatment.

Many modalities exist for diagnosing and treating lipofibromatous hamartoma (LFH), with no clear consensus. This is the first comprehensive study to review the existing literature on LFH of the median nerve and to suggest a systematic approach to its diagnosis and treatment. An electronic and manual search was conducted on Medline, Embase, Google Scholar, Current Contents, and Science Citation Index for original and review articles in English or French, from 1946 to November 2012. After 2 levels of screening, 106 references containing case reports were retained. Data extraction included patient demographics, clinical information, diagnostic modalities, treatment, and follow-up. A total of 180 cases were reported in the literature. One third of patients had associated macrodactyly (32%). Gender distribution is equal in LFH with or without macrodactyly, with most patients (71%) presenting before age 30 years. The main presenting symptom is an enlargement (88%) over the volar forearm, wrist, or hand, with or without digital hypertrophy, followed by paresthesia (39%). A soft, mobile, nontender, nonfluctuant mass with variable degree of compressive median neuropathy is found on physical examination. Biopsy, which reveals abundant mature fat cells and fibrous connective tissue infiltrating between nerve fascicles and the space between the epineurium and the perineurium, is not necessary because the pathognomonic features of the mass on magnetic resonance imaging offer an accurate diagnosis. Treatment of nerve compression symptoms and macrodactyly should be addressed separately. Carpal tunnel release is the mainstay of treatment for neuropathy, and ray or digital amputation, wedge osteotomy, middle phalangectomy with arthroplasty, and epiphysiodesis are suggested options in the management of macrodactyly. Based on our review of the literature, we propose an algorithm for the diagnosis and treatment of LFH of the median nerve with or without macrodactyly.

Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis.

BACKGROUND: Infantile hemangiomas are benign vascular neoplasms that can cause numerous functional or cosmetic problems. The authors reviewed the pathogenesis of hemangioma and compared the efficacy and complications related to therapy with propranolol versus corticosteroids. METHODS: A comprehensive review of the literature was conducted from 1965 to March of 2012 using MEDLINE, PubMed, Ovid, Cochrane Review database, and Google Scholar. All articles were reviewed for reports of clinical cases, reported side effects, doses, duration of treatment, number of patients, and response rate to treatment. RESULTS: A total of 1162 studies were identified. Of those, only 56 articles met inclusion criteria after review by two independent reviewers (A.I. and J.K.). For the meta-analysis, 16 studies comprising 2629 patients and 25 studies comprising 795 patients were included. Less than 90 percent of patients treated with corticosteroids responded to therapy, compared with 99 percent of patients treated with propranolol after 12 months of follow-up. Meta-analysis demonstrated the corticosteroid studies to have a pooled response rate of 69 percent versus the propranolol response rate of 97 percent (p < 0.001). CONCLUSIONS: Propranolol is a relatively recent therapy of hemangiomas with fewer side effects, a different mechanism of action, and greater efficacy than current first-line corticosteroid therapy. Many of these studies do not have the same patient population or duration/regimen of treatment for hemangiomas; however, based on available data in the literature, it appears that propranolol could be an emerging and effective treatment for infantile hemangiomas. Further randomized controlled trials are recommended.

The differing perceptions of plastic surgery between potential applicants and current trainees: The importance of clinical exposure and electives for medical students.

BACKGROUND: Exposure to plastic surgery during medical school is limited. Most interested applicants form their perceptions of careers in this surgical specialty during elective rotations. OBJECTIVE: To investigate the perceptions of Canadian medical students considering a career in plastic surgery. The results obtained were then compared with current Canadian plastic surgery residents' perceptions. METHODS: The data were collected via two separate self-administered online surveys that were distributed to either Canadian plastic surgery residents or medical students. The questionnaires were similar and focused on three aspects: applicant details; driving force behind interest in the field; and essential character traits and competencies related to successful matching. RESULTS: Fifty-nine plastic surgery residents and 477 medical students participated in the online survey. The most commonly reported driving forces for interest in a plastic surgery career in both groups were variety of career choice, complexity of the field, future lifestyle and enjoyable rotations in plastic surgery. Despite these similarities, the proportion of medical students and residents who opted for future lifestyle and enjoyable rotations differed in a statistically significant manner (P=0.015 and P=0.029, respectively). In terms of the essential competencies to match into a plastic surgery training spot, the groups differed statistically in their opinions on the relevance of intellect (P<0.001), manual dexterity (P<0.001), spatial sense (P<0.001) and clerkship grades (P=0.004). CONCLUSION: Interested applicants should be encouraged to obtain as much elective experience as possible to assist both students in their career choice and selection committees in identifying capable applicants.

HISTORIQUE: L'exposition à la chirurgie plastique est limitée pendant les études en médecine. Les candidats les plus intéressés forment leurs perceptions de carrière dans cette spécialité de la chirurgie pendant leurs stages facultatifs. OBJECTIF: Examiner les perceptions des étudiants en médecine canadiens qui envisagent une carrière en chirurgie plastique. Les résultats obtenus ont ensuite été comparés aux perceptions des résidents canadiens étudiant déjà en chirurgie plastique. MÉTHODOLOGIE: Les chercheurs ont colligé les données au moyen de deux sondages virtuels autoadministrés distribués soit à des résidents en chirurgie plastique, soit à des étudiants en médecine du Canada. Les questionnaires étaient similaires et portaient sur trois aspects: l'information sur les candidats, les moteurs de leur intérêt dans le domaine et les principaux traits de caractère et compétences liés à un jumelage fructueux. RÉSULTATS: Cinquante-neuf résidents en chirurgie plastique et 477 étudiants en médecine ont participé au sondage virtuel. Dans les deux groupes, une variété de choix de carrière, de complexité du domaine, de futur mode de vie et de stages agréables étaient les moteurs les plus signalés d'un intérêt pour une carrière en chirurgie plastique. Malgré ces similarités, la proportion d'étudiants en médecine et de résidents qui avaient opté pour un futur mode de vie et des stages agréables différait de manière statistiquement significative (P=0,015 et P=0,029,respectivement). Pour ce qui est des compétences essentielles pour être apparié à une place de formation en chirurgie plastique, les groupes différaient statistiquement pour ce qui était de leur avis sur la pertinence de l'intellect (P<0,001), la dextérité manuelle (P<0,001), la perception spatiale (P<0,001) et les notes de stage (P=0,004). CONCLUSION: Les candidats intéressés devraient être encouragés à obtenir le plus d'expérience de stage possible, à la fois pour les aider dans leur choix de carrière et pour aider les comités de sélection à déterminer les candidats capables.