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.

Larval T Cells Are Functionally Distinct from Adult T Cells in Xenopus laevis.

The amphibian Xenopus laevis tadpole provides a unique comparative experimental organism for investigating the roles of innate-like T (iT) cells in tolerogenic immunity during early development. Unlike mammals and adult frogs, where conventional T cells are dominant, tadpoles rely mostly on several prominent distinct subsets of iT cells interacting with cognate nonpolymorphic MHC class I-like molecules. In the present study, to investigate whole T cell responsiveness ontogenesis in X. laevis, we determined in tadpoles and adult frogs the capacity of splenic T cells to proliferate in vivo upon infection with two different pathogens, ranavirus FV3 and Mycobacterium marinum, as well as in vitro upon PHA stimulation using the thymidine analogous 5-ethynyl-2'-deoxyuridine and flow cytometry. We also analyzed by RT-quantitative PCR T cell responsiveness upon PHA stimulation. In vivo tadpole splenic T cells showed limited capacity to proliferate, whereas the in vitro proliferation rate was higher than adult T cells. Gene markers for T cell activation and immediate-early genes induced upon TCR activation were upregulated with similar kinetics in tadpole and adult splenocytes. However, the tadpole T cell signature included a lower amplitude in the TCR signaling, which is a hallmark of mammalian memory-like T cells and iT or "preset" T cells. This study suggests that reminiscent of mammalian neonatal T cells, tadpole T cells are functionally different from their adult counterpart.

Methodological Quality of Open Access Compared to Traditional Journal Publications in the Plastic Surgery Literature.

BACKGROUND: The methodological quality of open access studies has long been questioned due to increasing popularity and accessibility. The objective of this study is to compare the methodological quality of open access versus traditional journal publications in the plastic surgery literature. METHODS: Four traditional plastic surgery journals with their sister open access journals were chosen. For each of the eight journals, 10 articles were randomly selected for inclusion. Methodological quality was examined using validated instruments. Publication descriptors were compared to methodological quality values using ANOVA. Logistic regression was used to compare quality scores between open access and traditional journals. RESULTS: There was a wide distribution of levels of evidence, with a quarter being level one. Regression of non-randomized studies indicated a significantly higher proportion of traditional journal articles were of high methodological quality (89.6%) when compared to open access journals (55.6%; p < 0.05). This difference persisted in three quarter of the sister journal groups. No publication descriptions were associated with methodological quality. CONCLUSIONS: Methodological quality scores were higher among traditional access journals. Higher degrees of peer review may be necessary to ensure appropriate methodological quality in open access plastic surgery publications. 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 .

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review.

BACKGROUND: Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery. METHODS: A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type. RESULTS: Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery. CONCLUSIONS: Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Environmental endocrine disruptors and amphibian immunity: A bridge between the thyroid hormone axis and T cell development.

Immunity is susceptible to reprogramming by environmental chemical and endocrine signals. Notably, numerous thyroid disrupting chemicals (TDCs) have the potential to perturb immune endpoints, but data are lacking on the mechanisms by which TDCs can influence the development of the immune system. T cell immunity is particularly vulnerable to modulation by TDCs during thymic education, differentiation, and selection. The following review discusses the ways in which thyroid hormones may influence T cell development, as well as emerging TDCs with potential to impact both thyroid hormone physiology and immune outcomes. To overcome the challenges of studying TDC impacts on immune toxicological endpoints, a comparative approach using the amphibian Xenopus laevis is recommended. X. laevis are ideally suited to studying TDC impacts on immunity due to the importance of thyroid hormones for metamorphosis, and the wealth of immunological models to measure immune endpoints in both tadpoles and adult frogs.

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis.

BACKGROUND: Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate. METHODS: A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates. RESULTS: Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality. CONCLUSION: The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Developmental exposure to thyroid disrupting chemical mixtures alters metamorphosis and post-metamorphic thymocyte differentiation.

While there is some evidence to suggest that disruption of the thyroid hormone (TH)-axis during perinatal development may weaken T cell immunity later in life, data are currently lacking on whether environmentally relevant thyroid disrupting chemicals (TDCs) can induce similar outcomes. To fill this gap in knowledge, X. laevis tadpoles were exposed to an environmentally relevant mixture of TDCs, either during early tadpole development, or immediately before and during metamorphosis, to assess T cell differentiation and anti-viral immune response against FV3 infection after metamorphosis. Extending our previous study showing a delay in metamorphosis completion, here we report that TDC exposure prior to metamorphosis reduced the frequency of surface MHC-II + splenic lymphocytes and weakened some aspects of the anti-viral immune response. TDC exposure during metamorphosis slowed post-metamorphic migration of the thymus reduced the renewal of cortical thymocytes and splenic CD8 + T cells. The results indicate that TDC exposure during perinatal development may perturb the formation of T cell immunity later in life.

Patient Safety Initiatives in Cosmetic Breast Surgery: A Systematic Review.

BACKGROUND: Improved patient safety (PS) in cosmetic breast surgery relies upon high-quality evidence. The objective of this study was to systematically review the existing evidence for PS and quality improvement (QI) in cosmetic breast surgery. METHODS: A systematic review of published plastic surgery literature from 1965 to 2021 was undertaken through a computerized search following PRISMA guidelines. Publication descriptors, methodological details, and overall results were extracted. Articles were assessed for methodological quality using either the MINORS, Cochrane ROB2, or AMSTAR 2 instrument depending on the type of study. RESULTS: Sixty studies were included. Most studies were retrospective, and 43.3 percent were from the 3rd level of evidence. Overall, the scientific quality was moderate, with randomized controlled trials and non-comparative non-randomized studies generally being rated of higher quality. Studies investigating approaches to antisepsis (38.3 percent) in cosmetic breast surgery indicated conflicting opinions on prophylactic antibiotics. Studies focusing on risk factor assessment tools (8.3 percent) held possible utility in identifying high-risk patients for cosmetic surgery. Studies assessing anesthesia in cosmetic breast surgery (5 percent) demonstrated a significant benefit to tumescent local anesthesia. Drains for decreasing hematoma and seroma (8.3 percent) largely showed no benefit. CONCLUSIONS: Overall, PS and QI studies were of moderate quality and investigated numerous interventions. Our review identified a need for additional studies to decrease infection and other breast implant morbidities, specifically breast implant-associated anaplastic large cell lymphoma and capsular contracture.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction.

BACKGROUND: Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. METHODS: A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. RESULTS: Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. CONCLUSIONS: Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

Hand Rejuvenation: A Systematic Review of Techniques, Outcomes, and Complications.

BACKGROUND: Hand rejuvenation is an increasingly popular cosmetic procedure for hand atrophy and aging. The objective of this study is to systematically evaluate the techniques, outcomes, and complications of surgical hand rejuvenation. METHODS: A systematic review was undertaken using a computerized search. Publication descriptors, methodological details, techniques, outcomes, and complications were extracted. Articles were assessed using the MINORS and Cochrane instruments. RESULTS: Thirty-one studies were included. Most studies were published in the last five years (51.6 percent) and were prospective case series (35.5 percent). The mean age of patients was 56 (range 21-82), while the mean sample size was 47 (range 10-220). The most commonly examined interventions were Radiesse (32.2 percent) and fat grafting (32.2 percent). Major complications were not observed in any study, while minor complications such as edema and pain were temporary. Injection techniques varied, however, the proximal to distal fanning technique and using a cannula was associated with a lower risk of complications. Both Radiesse and fat grafting had robust long-term esthetic outcomes. CONCLUSIONS: Hand rejuvenation is a safe and efficacious surgical intervention to reduce dorsal hand atrophy. Further studies are needed to compare the long-term outcomes of common interventions. 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 Systematic Review of Feeding Interventions for Infants with Cleft Palate.

OBJECTIVE: Various devices and techniques have been proposed to reduce feeding difficulties experienced by infants with cleft palate. The aim of this review is to identify and assess the scope and quality of evidence for these interventions. METHODS: A systematic review of published literature evaluating feeding interventions for infants with cleft palate (with or without cleft lip) from database inception to 2021 was conducted using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using a methodological index for nonrandomized studies, Cochrane, or a measurement tool to assess systematic reviews 2 instruments, according to study type. RESULTS: Fourteen studies met inclusion criteria, with the majority (71%) of studies consisting of second-level evidence. Included interventions were specialty bottles (21%), alternative feeding delivery systems (14%), obturators (14%), and educational programs (14%). Specialty bottles and palatal obturators did not appear to offer any substantial growth advantages compared to traditional bottles or no intervention, respectively. Designated education programs for the mothers of infants with clefts had a positive impact on infant growth. CONCLUSIONS: Overall evidence evaluating feeding interventions for infants with cleft palate was moderate to low. While it does not appear that specialized feeding delivery systems or palatal obturators significantly improve growth in infants with clefts compared to children without cleft conditions, education programs do appear to be beneficial.

Piezosurgery versus Conventional Cutting Techniques in Craniofacial Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Despite its increasing use in craniofacial surgery, the evidence for piezosurgery over conventional bone-cutting techniques has not been critically appraised. The purpose of this systematic review and meta-analysis was to identify and assess the evidence that exists for the use of piezosurgery in craniofacial surgery. METHODS: A systematic review was undertaken using a computerized search. Publication descriptors, methodologic details, and outcomes were extracted. Articles were assessed using the methodologic index for nonrandomized studies and Cochrane instruments. Random effects meta-analysis was completed. RESULTS: Thirty-nine studies were included. Most studies were published within the past 5 years (51.3 percent) and were randomized controlled trials (56.4 percent). The mean age of patients was 27 years (range, 0.2 to 57 years), and the mean sample size was 44 (range, 12 to 180). Meta-analysis revealed that compared to conventional instruments, piezosurgery had a lower postoperative incidence of sensory disturbance, principally in mandibular procedures (OR, 0.29; 95 percent CI, 0.11 to 0.77; p = 0.01) and pain at postoperative day 3 (mean difference, -0.86; 95 percent CI, -1.20 to -0.53; p < 0.01). There was no statistically significant difference in operating room time (mean difference, 8.60; 95 percent CI, -1.27 to 18.47; p = 0.80) or osteotomy time (mean difference, 0.35; 95 percent CI, -2.99 to 3.68; p = 0.84). Most studies were clinically homogenous (92 percent) and of high quality based on the methodologic index for nonrandomized studies instrument (84 percent). Few studies had domains at high risk of bias based on the Cochrane instrument (28.6 percent). CONCLUSIONS: Piezosurgery has considerable benefits when compared to conventional instruments. Future studies should investigate its cost-effectiveness and benefits in terms of blood loss, edema/ecchymosis, and patient satisfaction.

The Role of Senior Resident Clinics in Plastic Surgery Education in Canada.

BACKGROUND: Senior resident clinics are a means to encourage independent practice and problem solving and enhance surgical skills. The objective of this study is to investigate senior resident clinics across Canada and their utility in providing comprehensive plastic surgery training. METHODS: A web-based survey was sent to all plastic surgery program directors (PDs) and senior residents (SRs; postgraduate years 3, 4, and 5) across Canada. The surveys focused on demographics, clinic structure, procedures commonly performed, perceived autonomy, educational benefit, competency-based design considerations, and areas for improvement. Chi-square tests were used to compare responses between PDs and SRs. RESULTS: A total of 10 PDs (100% response rate) and 26 SRs (41% response rate) responded. Half of the training programs across Canada currently have senior clinics, and the format varies between institutions. Clinics generally focus on hand trauma and aesthetics. Both PDs and SRs felt that there is considerable autonomy for resident care in both the pre/post-operative and operative setting. Common barriers to implementing a senior clinic include not enough staff, not enough time, and the medicolegal risk. Most core competencies are felt to be addressed through the use of senior clinics. Methods to improve senior clinics could include more regular and higher volume clinics, enhanced equipment, and separation of hand and aesthetics clinics. CONCLUSIONS: Senior clinics are a useful method to improve plastic surgery education and address many core aspects of plastic surgery training. Implementation of supported clinics focused on hand and aesthetics surgery separately may be useful for training programs that currently lack a senior clinic.

Thyroid Disrupting Chemicals in Mixture Perturb Thymocyte Differentiation in Xenopus laevis Tadpoles.

Endocrine disrupting chemicals (EDCs) can perturb the hypothalamic-pituitary-thyroid axis affecting human and wildlife health. Thyroid hormones (TH) are crucial regulators of metabolism, growth, and differentiation. The perinatal stage is most reliant on TH, thus vulnerable to TH disrupting chemicals. Dysregulation of TH signaling during perinatal development can weaken T cell function in maturity, raising the question of whether TH disrupting chemicals can perturb thymocyte development. Using Xenopus laevis tadpoles as model, we determined TH disrupting effects and thymocyte alterations following exposure to a mixture of common waterborne TH disrupting chemicals at concentrations similar to those found in contaminated water. This mixture included naphthalene, ethylene glycol, ethoxylated nonylphenol, and octylphenol, which have documented TH disrupting activity. Besides hypertrophy-like pathology in the thyroid gland and delayed metamorphosis, exposure to the mixture antagonized TH receptor-induced transcription of the Krüppel-like factor 9 transcription factor and significantly raised thyroid-stimulating hormone gene expression in the brain, two genes that modulate thymocyte differentiation. Importantly, exposure to this mixture reduced the number of Xenopus immature cortical thymocyte-specific-antigen (CTX+) and mature CD8+ thymocytes, whereas co-exposure with exogenous TH (T3) abolished the effect. When each chemical of the mixture was individually tested, only ethylene glycol induced significant antagonist effects on brain, thymic gene expression, and CD8+ thymocytes. These results suggest that EDCs in mixture are more potent than each chemical alone to perturb thymocyte development through TH-dependent pathway, and provide a starting point to research TH influence on thymocyte development.

Application rates to surgical residency programs in Canada.

PURPOSE: The purpose of this study is to identify if the previously reported declining interest in surgery amongst medical students persists, and also to provide more descriptive analysis of trends by surgical specialty and medical school. Our hypothesis is that the previously reported decreasing interest in surgery remains constant for some surgical disciplines. METHODS: The Canadian Resident Matching Service and the Association of Faculties of Medicine of Canada provided data for this study. Several metrics of interest in surgery, including overall application trends, applications by discipline, and rankings by school of graduation were evaluated. Descriptive statistics and linear regression modeling were used. RESULTS: Between 2007 and 2017 the number of non-surgical residency positions and Canadian medical graduates increased significantly. However, the number of surgical residency positions and applications to surgical programs did not change significantly. The number of rankings to orthopedic and vascular surgery decreased significantly. Likewise, applicants to general, orthopedic, plastic, otolaryngology, and vascular surgery decreased significantly. Vascular surgery saw a significant decrease in first choice rankings. Total rankings to surgical programs increased significantly at McGill, with no significant change at other Canadian institutions. CONCLUSIONS: The findings of this study suggest that while the number of applicants to surgical residency positions has been consistent, it is not keeping pace with the growing number of both CMGs and non-surgical residency positions. Furthermore, by using other measures of medical student interest in surgical specialties, such as the total number of rankings to a specialty through the residency matching process, the total number of applicants applying to a surgical discipline and the total number of first choice ranks that each surgical discipline received, we have demonstrated that there is a possible declining interest in some surgical discipline.

OBJECTIF: Cette étude vise à établir s'il persiste un déclin de l'intérêt pour la chirurgie parmi les étudiants en médecine, etfournir une analyse plus descriptive des tendances par spécialité chirurgicale et par faculté de médecine. Notre hypothèse est que le déclin précédemment rapporté de l'intérêt pour la chirurgie reste constant pour certaines disciplines chirurgicales. MÉTHODES: Le Service canadien de jumelage des résidents et l'Association des facultés de médecine du Canada ont fourni les données pour la présente étude. Plusieurs paramètres d'intérêt en chirurgie ont été évalués, dont les tendances globales des demandes d'admission, les demandes par discipline et les classements par faculté de diplomation. Nous avons eu recours à des statistiques descriptives et à une modélisation par régression linéaire. RÉSULTATS: Entre 2007 et 2017, le nombre de postes de résidence dans des spécialités non chirurgicales et de diplômés canadiens en médecine a augmenté de manière importante. Toutefois, le nombre de postes de résidence en chirurgie et de demandes d'admission pour ces programmes n'a pas varié de façon significative. Le nombre de classements pour la chirurgie orthopédique et vasculaire a diminué significativement. Le nombre de demandes d'admission en chirurgie générale, orthopédique, plastique, otorhinolaryngologique et vasculaire a également diminué significativement. On a aussi observé une baisse significative des classements comme premier choix pour la chirurgie vasculaire. Les classements totaux pour les programmes de chirurgie ont augmenté de manière importante à McGill, sans changement significatif dans les autres institutions canadiennes. CONCLUSIONS: Bien que le nombre de demandes d'admission à des postes de résidence en chirurgie ait été constant, les résultats de cette étude suggèrent qu'elles ne suivent pas le rythme du nombre croissant de DMC et de postes de résidence non chirurgicale. En outre, à l'aide d'autres mesures d'intérêt des étudiants pour les spécialités chirurgicales, comme le nombre total de classements pour une spécialité via le processus de jumelage des résidents, le nombre total de demandes d'admission àune discipline chirurgicale et le nombre total de classements comme premier choix pour chaque discipline chirurgicale, nous avons démontré qu'il existe un déclin possible de l'intérêt pour certaines disciplines chirurgicales.