Efficacy of Exclusive Fat Grafting for Breast Reconstruction: An Updated Systematic Review and Meta-analysis.

BACKGROUND: Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique. METHODS: We queried the PubMed electronic database from its inception until August 2023 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate. RESULTS: 41 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in Breast Conservation Therapy (BCT) patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p = 0.014) and in 41/517 BCT patients (p = 0.301) CONCLUSION: Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients. 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 Evaluation of the Quality of Health Information on Cleft Lip and Palate in the Arabic Language.

Background: The internet serves as a vital health information resource, yet the quality of data on specific health conditions, especially in Arabic, is often overlooked. This research assesses the quality of Arabic online information about cleft lip and palate (CLP) and proposes avenues for enhancement. Methods: From July to August 2022, a systematic evaluation of Arabic articles on CLP was performed using the DISCERN tool for quality assessment. Searches on Google and Bing resulted in 119 articles that met the study's criteria. Results: The quality of available Arabic information on CLP displayed substantial gaps. Commercial sources dominated (49.6%), followed by private (32.8%) and nonprofit entities (17.6%). The average DISCERN score was 2.26 of 5 (SD = 1.06), indicating the need for enhanced content, particularly concerning treatment risks. Conclusions: The study underscores the subpar quality of Arabic CLP information online, which might mislead patients and impede access to accurate advice. Nonprofit organizations should bolster their online footprint, offering refined health content. A deep dive into DISCERN scores reveals pinpointed improvement areas. Clinicians should direct patients and their families to reliable information sources. Addressing these gaps promises improved CLP knowledge in Arabic, fostering superior patient education and outcomes for those with this condition.

Chin Reduction Made Simpler.

Deformities of the chin, including both macrogenia or microgenia, can alter facial aesthetics and harmony. Various reliable approaches to correct chin abnormalities are present. Nonetheless, in this article, we propose our surgical approach to reduce the chin with a 5-mm cutting burr, without the need for osteotomy. The ultimate goal of this new procedure is to provide optimum outcomes, ensure maximum safety, reduce the complication risk, and present a simple and fast option for chin reduction.

Venous Thromboembolism Risk Assessment Models in Plastic Surgery: A Systematic Review and Meta-Analysis.

Postoperative venous thromboembolism (VTE) is the most common complication of plastic surgery procedures. Diverse risk assessment models (RAMs) exist to stratify patients by VTE risk, but due to a lack of high-quality evidence and heterogeneity in RAM data, there is no recommendation regarding RAM that can be used for plastic surgery patients. This study compares the reliability and outcomes of Caprini and American Society of Anesthesiologists (ASA) physical status classification RAMs used in plastic surgery to help surgeons stratify the risk of VTE. Methods: MEDLINE and Embase databases were searched between February 2010 and December 2021. All published English articles that report the incidence of VTE stratified by a RAM among patients who underwent plastic surgery were included. The results of the presented meta-analysis were pooled using a random-effects model. Results: The database search revealed 809 articles, out of which eight studies (n = 1,348,606) were eligible. Out of the eight studies, six utilized the Caprini score, and three utilized ASA score. Super-high-risk patients were significantly more likely to present with VTE than their high-risk [odds ratio (OR), 2.92; 95% confidence interval (CI), 1.26-6.78], medium-risk (OR, 5.29; 95% CI, 2.38-11.79), or low-risk counterparts (OR, 10.00; 95% CI, 2.32-43.10) at Caprini score. High-risk patients in ASA score showed significant increase in VTE incidents (OR, 2.72; 95% CI, 1.10-6.72). Conclusions: Both Caprini and ASA RAMs showed compelling evidence of efficacy in our study. However, the Caprini RAM is more predictive of postoperative VTE incidents in high-risk plastic surgery patients than the ASA grading system.

Risk Models to Predict Mortality in Burn Patients: A Systematic Review and Meta-analysis.

The predictive capability of various risk assessment models (RAMs) in evaluating the risk of mortality in burn patients is not well established. It is also unclear which RAM provides the highest discriminative ability and presents the highest clinical utility. We pooled all available studies to establish this validity and compare the predictive capability of the various RAMs. Methods: We reviewed PubMed, MEDLINE, and Embase from their inception up until December 2021 for studies evaluating risk of mortality in burn patients as stratified by RAMs. Data were pooled using random-effect models and presented as area under the receiver operating characteristic (AUROC) curve. Results: Thirty-four studies, comprising of a total of 98,610 patients, were included in our analysis. Most studies were found to have a low risk of bias and a good measure of applicability. Nine RAMs were evaluated. We discovered that the classic Baux; the revised Baux; and the Fatality by Longevity, APACHE II score, Measured Extent of burn, and Sex (FLAMES) scores presented with the highest discriminative power with there being no significant difference between the results presented by them [AUROCs (95% CI), 0.92 (0.90-0.95), 0.92 (0.90-0.93), 0.94 (0.91-0.97), respectively, with P < 0.00001 for all]. Conclusions: Many RAMs exist with no consensus on the optimal model to utilize and assess risk of mortality for burn patients. This study is the first systematic review and meta-analysis to compare the current RAMs' discriminative ability to predict mortality in patients with burn injuries. This meta-analysis demonstrated that RAMs designed for assessing mortality in individuals with burns have acceptable to great discriminative capacity, with the classic Baux, revised Baux, and FLAMES demonstrating superior discriminative performance in predicting death. FLAMES exhibited the highest discriminative ability among the RAMs studied.

Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis.

Breast reconstruction (BR) is a unique surgical procedure that provides patients undergoing mastectomy with significant psychosocial and aesthetic benefits and has also become a crucial part of the treatment pathway for women with breast cancer. Due to methodological inadequacies and the absence of substantial risk factor analysis, no conclusion can be drawn about the correlation between risk variables and post-surgical complications in BR surgery. We aim to identify the potential risk factors associated with postoperative complications. Methods: We queried MEDLINE and Cochrane CENTRAL from their inception to March 2022, for published randomized controlled trials and observational studies that assessed complications post-reconstruction procedure in breast cancer patients following mastectomy or evaluated at least one of the following outcomes of major or reoperative complications. The results from the studies were presented as odds ratios with 95% confidence intervals and were pooled using a random-effects model. Results: Our pooled analysis demonstrated a significant correlation with BR postoperative complications and risk factors such as diabetes, hypertension, and obesity. Diabetes and the development of seroma were found to have a significant relationship. Risk variables such as age, radiotherapy, COPD, and smoking had no significant connection with 0-to-30-day readmission and 30-to-90-day readmission. Conclusion: This meta-analysis shows that risk factors like age, smoking history, high blood pressure, and body mass index (BMI) have a big effect on complications after BR, and patients with risk factors have a high rate of developing infection.

Plastic Surgery in the Gulf Cooperation Council Countries: Role of Telemedicine.

Internationally, telemedicine is finding its way into common day plastic surgery practice as a result of the COVID-19 pandemic. Nonetheless, no data about its practice in the Gulf region are available to date. Methodology: This is a cross-sectional survey-based study that was sent online to the plastic surgeons practicing in the Gulf region. The study aimed to look into the integration of telemedicine into the practice and the surgeons' attitude and future vision about it. Participation was voluntary, and confidentiality was preserved. Results: A total of 229 plastic surgeons enrolled in this study in mid-2020. There were 192 male participants (83.8%) and 37 female participants (16.2%). Of these, 99 (43.2%) practiced in Saudi Arabia, 85 (37.1%) in the United Arab Emirates, 24 (10.5%) in Oman, 18 (7.9%) in Kuwait, and three (1.3%) in Bahrain. In total, 85 (37.1%) used telemedicine during lockdown, and 144 (62.9%) thought that its usage will remain beneficial in the future. There was no significant difference in practicing telemedicine in different plastic surgery subspecialties, varying level of experience, and country of practice. Among those who used virtual consultations, 62 (72.9%) did not charge for consultation fees. Conclusion: The tendency toward telemedicine integration in plastic surgery practice is growing worldwide, especially after COVID-19. Its limitations are outweighed by its advantages and, with time, many of these will be bypassed. New innovations driven by advancement in technology will further embed telemedicine into the practice.

When a Traditional Medicine Customer Becomes a Plastic Surgery Patient.

Traditional medicine therapy is practiced locally in the Middle Eastern communities. The balance between benefit and harm might tip toward the latter if its practice continues unregulated. Herein is a case of a young man who presented to our clinic complaining of keloid scars that developed following a cupping therapy session. He underwent multiple cupping sessions, without prior consent or information regarding potential complications. Finally, we present an algorithm for cupping practitioners to follow to minimize abnormal scarring.

Skin Preservation in the Debridement of Necrotizing Fasciitis: A Demonstrative Case Report.

Necrotizing fasciitis (NF) is a rare yet potentially fatal soft-tissue, polymicrobial infection. Aggressive debridement of the fascia and overlying skin as well as antimicrobial coverage constitute the mainstay of management, often leaving large skin defects. However, we demonstrate in this paper a case of a young woman who developed NF after liposuction and was treated by fascial debridement with minimal skin excision. Skin preservation will reduce the morbidity and improve the final aesthetic outcome.

Do Our Colleagues Accurately Know What We Do?

INTRODUCTION: Plastic surgery is a unique field' and its scope is beyond a specific demographic group or anatomic part. The poor understanding and misconception about plastic surgeons' scope of practice has been well-established among the public, especially in Saudi Arabia; but the question is, do healthcare physicians share the same misconception? This study aims to answer this question. METHODS: This study was conducted between September 11, 2021 and November 1, 2021. This is a cross-sectional, survey-based study utilizing a self-structured questionnaire targeting physicians in Saudi Arabia. RESULTS: A total of 261 medical and surgical physicians participated in this study. Nearly 45% of them demonstrated a poor understanding of plastic surgery and its scope of practice, whereas only 16.1% were sufficiently knowledgeable. Male physicians were more likely to understand the field of plastic surgery when compared with female physicians. More than 80% of the physicians knew that cosmetic operations are done by plastic surgeons, whereas 50% or less knew that reconstructive operations are conducted by plastic surgeons. CONCLUSION: This study shows that 44.1% of the participating physicians demonstrate poor knowledge regarding plastic surgery as a field, in addition to a lack of understanding about the scope of practice of plastic surgeons. We recommend enhancing promotional efforts that raise awareness about the nature of plastic surgery as a specialty among healthcare physicians.

Challenging the Subcostal Incision Scar with the Two-staged Abdominoplasty: An Innovative Approach.

Abdominoplasty is a commonly sought-after procedure due to its life-transforming results, but is limited, as in any other operation, by a number of contraindications. One of these contraindications is a subcostal scar, which may jeopardize blood supply to the upper flap of the abdominoplasty, resulting in skin necrosis. Herein, we challenge this dogma by introducing the two-staged abdominoplasty with the utilization of a delayed flap in a 48-year-old multiparous woman presenting with a Kocher incision of open cholecystectomy, with good results and a complication-free course of 3 postoperative months. We recommend this approach in patients with subcostal scars. However, more research into the utilization of delayed flaps in abdominoplasty should be done to have a more well-founded conclusion.

The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report.

INTRODUCTION AND IMPORTANCE: Locoregional flaps, particularly the pedicled lateral forehead flap, are not usually used in reconstructing oral floor defects following oncologic resection. Rather, microscopic free flaps have evolved to be the standard of care in head and neck reconstruction. However, the pedicled lateral forehead flap could be valuable in floor of the mouth reconstruction in the absence of resources or other options. CASE PRESENTATION: A-56 years old lady with multiple comorbidities who underwent near total glossectomy, bilateral supraomohyoid neck dissection, and right lateral mandibulotomy due to a locally advanced lingual squamous carcinoma. The last resort was the pedicled lateral forehead flap after many unsuccessful reconstructive attempts utilizing the free anterolateral flap, free radial forearm flap, and pedicled pectoralis major flap. CLINICAL DISCUSSION: Decreased donor site morbidity and reliable anatomy are among many of the advantages that made free flaps favorable over locoregional pedicled flaps, especially in oral cavity defects coverage. Of the latter, the pedicled forehead flap, rich in vascularity and neighboring the oropharyngeal defects, could be used with different techniques and modifications. Close monitoring and patient condition optimization is required. CONCLUSION: Choosing a particular reconstructive option should be done considering the available resources and expertise and the patient's condition. The pedicled forehead flap remains valuable when other options are inappropriate or have failed.

Public Awareness of Breast Implant-associated Anaplastic Large Cell Lymphoma in Saudi Arabia.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was first reported in 1997. Since then, the number of reported cases has been increasing, and patients' knowledge and perceptions about this condition are unclear. This study aimed to evaluate the public knowledge and perceptions toward BIA-ALCL and its association with cosmetic/reconstructive breast implants in Saudi Arabia. METHODS: In this cross-sectional, online survey-based study, women aged 18-60 years in Saudi Arabia were the target population on social media platforms. Questions included data on demographics, experience of implants, and knowledge and concerns regarding BIA-ALCL. RESULTS: A total of 543 women participated in this study, with a mean age of 34 years. Only 1.9% had breast implants due to cosmetic or reconstructive reasons, whereas 9.8% expressed their desire of having implants in the future. More than half (57.3%) of the respondents had never heard of BIA-ALCL in comparison with 21.7% who had an established background. After reading the highlights on BIA-ALCL, 60% of the women with breast implants still wanted to keep their implants and 42.5% of the ones who desired breast implants would still aim to have them. Almost all the sample stated that BIA-ALCL should be included in the written consent. CONCLUSIONS: Nearly half of Saudi women have not heard of BIA-ALCL, and report that it is an important part of the surgical consultation and informed consent. Our role as plastic surgeons is to raise the awareness of BIA-ALCL through social media and health care settings to maximize the safety of women with breast implants.

Role of the Pedicled Mentalis Muscle Flap in Closure of Chin Implants in Genioplasty.

With the purpose of obtaining an aesthetically pleasing chin appearance, genioplasty or chin augmentation can be performed through osteotomy or chin implantation, with the latter available in different sizes and materials such as silicone and porous polyethylene. The implants are traditionally placed in a subperiosteal or supraperiosteal plane with different advantages and disadvantages to each. This procedure has evolved through time with many techniques and modifications; and this article is an addition to this ongoing refinement by advocating for closure of the mentalis muscle (a paired chin muscle originating from the incisor fossa to the chin skin) over the implant after securing its position with screws (in the case of porous polyethylene) or creating a snug pocket (in the case of silicone). In this retrospective analysis, 15 patients underwent this procedure with an excellent outcome. A single patient developed numbness in the mandibular nerve territory, while another one developed a fistulating radicular cyst that was unrelated to this technique. In addition to the simple learning curve, the potential advantages of this technique include less chances of fistula formation, implant exposure, infection, extrusion, or malpositioning. Prospective studies with more subjects are required to cement our findings.

Factors Influencing the Choice of Plastic Surgery as a Specialty in Saudi Arabia.

Graduates of medical school must choose a specific specialty as a life-long practice from a large pool of medical specialties. This decision stands out as one of the most memorable and critical in their lifetimes. To reach such a decision with satisfaction, medical school graduates consider a variety of factors. This is the first study to explore the influential factors on pursuing plastic surgery as a career in Saudi Arabia. METHODS: This is a cross-sectional, unicentral study based on an electronic questionnaire that has been constructed with an assistance of field experts to ensure a sufficient coverage of the influential factors. Only those with an established interest in plastic surgery were included. Institutional review board approval was obtained for this study. RESULTS: Of the 695 questionnaires fully completed by third-year medical students up to intern doctors, only 32 (4.6%) expressed an interest in the pursuit of plastic surgery as a future career, with a female predominance of 62.5% (N = 20). The factors that influenced their decision of specialty choice were the geographic advantage (81.3%), predominance of nonurgent cases (71.9%), the reward associated with immediate outcome (71.9%), and prior significant events (71.9%). CONCLUSIONS: Certain factors, as explored by this study, strongly influence the choice of plastic surgery as a future specialty, among Saudi medical graduates. Cultivating more knowledge about plastic surgery as a specialty may help consider scientific research as an impactful factor in the future for further development in the field.

Rhinoplasty for Hypertrophied Transverse Nasalis Muscle: A Case Report.

Negatively impacting the aesthetics of the face, nasal deformities can be attributed to many congenital or acquired causes, of which muscular hypertrophy is uncustomary. In this article, we narrate a case of a 26-year-old woman with a prominently wide mid-vault, in addition to other abnormalities of the nose. It was thought to originate from soft tissue because it was thick and firm to palpation. Open rhinoplasty was done where hypertrophy of the paired transverse nasalis muscle was observed and resected. The patient enjoyed a safe postoperative period with excellent cosmetic results and minimal effect on the nasal function in terms of breathing and pronunciation. We recommend this approach to any patient with a similar disfigurement due to its simplicity and ability to correct other co-existing nasal disfigurements.

Assessment of the Academic Productivity of Plastic Surgeons in Saudi Arabia Using the h-index.

Hirsch-index (or h-index) is a bibliometric measure calculated for researchers based on number of publications and their citations. This study examined the h-index of board-certified plastic surgeons in Saudi Arabia and the different factors that may influence it. METHOD: In this cross-sectional study, an electronic questionnaire was sent to 156 board-certified plastic surgeons practicing in Saudi Arabia. Using their names, we conducted an online search on Scopus, Semantic scholar, and Google scholar to calculate their h-index. Bivariate and multiple regression analyses were conducted to determine the relationship of those factors with the index. RESULTS: A total of 84 surgeons participated in this study, of whom 83.3% were men. Our sample scored a mean index of 1.7 and published a mean of 5 articles. More publications and a higher academic rank predicted a higher h-index, (ß = 0.79, P < 0.001) and (ß = 0.14, P 0.017), respectively. On the other end of the spectrum, the country of residency training (P 0.33), the year of training completion (P 0.95), attaining fellowship training (P 0.95), the number of fellowships (P 0.20), interest in research (P 0.74), working in an academic hospital (P 0.44), or attaining a higher degree (P 0.61) were not significant independent predictors of the index. CONCLUSIONS: More publications and a higher rank predicted increased academic productivity among the plastic surgeons in Saudi Arabia. Despite its limitations, h-index is a useful measure that can be considered in promotions and applications to prestigious plastic surgery centers in adjunct to other factors.

The Ideal Applicant to the Saudi Plastic Surgery Residency Program.

Securing a plastic surgery position is a demanding task for students. Although many papers have been published internationally discussing the traits and features deemed important from the point of view of plastic surgery program directors, a gap exists in the literature where this aspect is not covered in Saudi Arabia. The aim of this study was to fill this gap. METHODS: In this cross-sectional study, a survey was developed targeting all current and former Saudi plastic surgery training program directors. SPSS was used to calculate frequencies and present percentages; independent t-test was done to look for mean differences. Ethical approval was obtained from a local institution. RESULTS: All current and former Saudi plastic surgery program directors participated (n = 17), including the 8 (47.1%) current directors. When asked to rank 7 items on a scale of importance, they scored a mean of 6.2, 5.8, 5.4, 4.88, 4.82, 4.6, and 3.7 for good impression on interviews, prior experience, research experience, the grade point average (GPA), oral or poster presentations on events, the Saudi Medical Licensing Examination (SMLE), and attaining a post-graduate degree, respectively. The majority [n = 7 (41%)] considers the mode of communication, such as phone calls, as the most important aspect in recommendations. They prefer candidates who took electives/rotations at their department [n = 12 (71%)] and give more value to high-quality publications [n = 9 (47%)]. Applicant's gender was not important. CONCLUSION: With early planning, this article could serve as a guide for medical students interested in plastic surgery to build their assets toward a successful interview.

Academic and Clinical Background of Plastic Surgery Residents of the Saudi Training Program.

Plastic surgery residents are required to contribute to the scientific milieu, apart from honing their surgical skills. Data regarding their academic and clinical background are limited locally in comparison with their counterparts. This is the first study of its kind on the Saudi training program, with suggested potential solutions to shortcomings. METHODS: This is a cross-sectional study based on an electronic, 27-element, self-administered questionnaire sent to a WhatsApp group gathering all 40 plastic surgery residents of the Saudi program, with the exclusion of a single participant. RESULTS: The mean of overall residents' publications was 2.29 articles. No significant difference (P = 0.438) was found in the number of publications among residents of different levels. However, seniors have published significantly (P = 0.002) more articles (mean = 1.6; SD = 1.24) during residency compared with juniors (mean = 0.42; SD = 1). The group that had taken rotations in plastic surgery abroad published more articles (P = 0.02) than the group that did not. Using η correlation, a positive correlation (η = 0.36) was found between taking courses in research and publication. CONCLUSIONS: The Saudi plastic surgery residents are ahead of their colleagues in other local specialties but fall behind their counterparts internationally. The relatively poor contribution in terms of research, posters, and oral presentations could be remedied with measures such as providing protected research time and mentorship. They should be emboldened to pursue postgraduate studies, as only 3 residents had a Master of Science degree.