The provision of general surgery in rural Australia: a narrative review.

Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia. The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes. Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes. To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural-facing generalist curriculum. Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres. Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

Response to "Letter to the Editor-Exploring the Unknown: Evaluating ChatGPT's Performance in Uncovering Novel Aspects of Plastic Surgery and Identifying Areas for Future Innovation".

We appreciate Dr. Qi and Dr. Niu for their insightful comments on our study, "Exploring the Unknown: Evaluating ChatGPT's Performance in Uncovering Novel Aspects of Plastic Surgery and Identifying Areas for Future Innovation." Their observations underscore significant considerations in the application of artificial intelligence (AI) in plastic surgery. We agree with their concern about potential biases in ChatGPT's responses. The AI's frequent attribution of the title "parent of plastic surgery" to Sir Harold Delf Gillies, despite gender-neutral terminology, highlights underlying biases from training data. These biases often reflect historical texts and contemporary writings. Addressing them requires refining training datasets for balanced representation and developing algorithms that adjust dynamically to diverse inputs. The authors also question the criteria ChatGPT uses to identify key contributions to plastic surgery. The AI's focus on microsurgery, minimally invasive techniques, and tissue engineering, while significant, may prioritize keyword prevalence over a holistic evaluation. Enhancing ChatGPT's capabilities through targeted training and input from subject matter experts could improve the AI's ability to generate more balanced outputs. The identified bias favoring reconstructive over cosmetic procedures is another critical point. While reconstructive advancements are transformative, cosmetic surgery also has significant innovations. Ensuring ChatGPT presents a balanced view of both reconstructive and cosmetic advancements is essential. This can be achieved by diversifying training data and calibrating the AI to give equitable weight to different subspecialties within plastic surgery. AI models like ChatGPT are proficient in processing and generating information but lack the human elements of creativity, intuition, and emotional depth critical for groundbreaking innovations. AI should complement, not replace, the expert judgment and innovative thinking of skilled plastic surgeons. Ensuring the accuracy of AI-generated responses is crucial. Clinicians must verify AIgenerated information against established medical literature and clinical guidelines to maintain accuracy in medical practice. Continuous feedback and improvement mechanisms are vital to enhance AI's clinical utility. The improvement of AI in plastic surgery will be driven by active involvement from surgeons, providing comprehensive and balanced data for training to ensure AI systems evolve to support and enhance clinical practice effectively.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 .

Exploring the Unknown: Evaluating ChatGPT's Performance in Uncovering Novel Aspects of Plastic Surgery and Identifying Areas for Future Innovation.

BACKGROUND: Artificial intelligence (AI) has emerged as a powerful tool in various medical fields, including plastic surgery. This study aims to evaluate the performance of ChatGPT, an AI language model, in elucidating historical aspects of plastic surgery and identifying potential avenues for innovation. METHODS: A comprehensive analysis of ChatGPT's responses to a diverse range of plastic surgery-related inquiries was performed. The quality of the AI-generated responses was assessed based on their relevance, accuracy, and novelty. Additionally, the study examined the AI's ability to recognize gaps in existing knowledge and propose innovative solutions. ChatGPT's responses were analysed by specialist plastic surgeons with extensive research experience, and quantitatively analysed with a Likert scale. RESULTS: ChatGPT demonstrated a high degree of proficiency in addressing a wide array of plastic surgery-related topics. The AI-generated responses were found to be relevant and accurate in most cases. However, it demonstrated convergent thinking and failed to generate genuinely novel ideas to revolutionize plastic surgery. Instead, it suggested currently popular trends that demonstrate great potential for further advancements. Some of the references presented were also erroneous as they cannot be validated against the existing literature. CONCLUSION: Although ChatGPT requires major improvements, this study highlights its potential as an effective tool for uncovering novel aspects of plastic surgery and identifying areas for future innovation. By leveraging the capabilities of AI language models, plastic surgeons may drive advancements in the field. Further studies are needed to cautiously explore the integration of AI-driven insights into clinical practice and to evaluate their impact on patient outcomes. 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.

Thermal Challenges in Dynamic Infrared Thermography Used for Perforator Mapping.

BACKGROUND: The aim of this study is to investigate the different approaches to thermal challenges, both cold and warm, used in dynamic infrared thermography for reconstructive surgery, and explore whether it affects the success of preoperative perforator mapping. METHODS: Literature was collected from Ovid Medline, Embase, PubMed, and Cochrane. The references of the full-text articles located from the original search were also appraised. Thirteen articles were extracted for the final qualitative analysis. A systematic review was then conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Thirteen articles looked at a cold challenge, which included airflow cooling, direct contact cooling, and evaporation-based cooling. Two articles investigated warm challenges. One paper used no challenge, suggesting it unnecessary with a highly sensitive camera. All cold challenges were positively supported by a high level of flap perfusion success and/or a high level of correlation with other forms of investigation. CONCLUSION: Cold challenges were overall superior to no challenge and warm challenges; however, this conclusion is limited by the small participant size, the possibility of detection bias, and poor methodology detailing. Airflow cooling-specifically, using a desktop fan to blow air for 2 minutes-was noted to likely cause the least discomfort due to a low cooling capacity yet simultaneously maintain effectiveness and allow for a uniform cooling application. Warm challenges showed less conclusive results and were restricted by lack of studies. This topic would benefit from larger scale studies that compare multiple approaches while using standardized equipment to eliminate confounding factors.

Anomalous anatomic variation of an absent deep inferior epigastric artery: implications for autologous breast reconstruction.

Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps.

Exploring the Role of a Large Language Model on Carpal Tunnel Syndrome Management: An Observation Study of ChatGPT.

PURPOSE: Recently, large language models, such as ChatGPT, have emerged as promising tools to facilitate scientific research and health care management. The present study aimed to explore the extent of knowledge possessed by ChatGPT concerning carpal tunnel syndrome (CTS), a compressive neuropathy that may lead to impaired hand function and that is frequently encountered in the field of hand surgery. METHODS: Six questions pertaining to diagnosis and management of CTS were posed to ChatGPT. The responses were subsequently analyzed and evaluated based on their accuracy, coherence, and comprehensiveness. In addition, ChatGPT was requested to provide five high-level evidence references in support of its answers. A simulated doctor-patient consultation was also conducted to assess whether ChatGPT could offer safe medical advice. RESULTS: ChatGPT supplied clinically relevant information regarding CTS, although at a relatively superficial level. In the context of doctor-patient interaction, ChatGPT suggested a diagnostic pathway that deviated from the widely accepted clinical consensus on CTS diagnosis. Nevertheless, it incorporated differential diagnoses and valuable management options for CTS. Although ChatGPT demonstrated the ability to retain and recall information from previous patient conversations, it infrequently produced pertinent references, many of which were either nonexistent or incorrect. CONCLUSIONS: ChatGPT displayed the capability to deliver validated medical information on CTS to nonmedical individuals. However, the generation of nonexistent and inaccurate references by ChatGPT presents a challenge to academic integrity. CLINICAL RELEVANCE: To increase their utility in medicine and academia, large language models must go through specialized reputable data set training and validation from experts. It is essential to note that at present, large language models cannot replace the expertise of health care professionals and may act as a supportive tool.

Evaluation of the Artificial Intelligence Chatbot on Breast Reconstruction and Its Efficacy in Surgical Research: A Case Study.

BACKGROUND: ChatGPT is an open-source artificial intelligence (AI) chatbot that uses deep learning to produce human-like text dialog. Its potential applications in the scientific community are vast; however, its efficacy on performing comprehensive literature searches, data analysis and report writing in aesthetic plastic surgery topics remains unknown. This study aims to evaluate both the accuracy and comprehensiveness of ChatGPT's responses to assess its suitability for use in aesthetic plastic surgery research. METHODS: Six questions were prompted to ChatGPT on post-mastectomy breast reconstruction. First two questions focused on the current evidence and options for breast reconstruction post-mastectomy, and remaining four questions focused specifically on autologous breast reconstruction. Using the Likert framework, the responses provided by ChatGPT were qualitatively assessed for accuracy and information content by two specialist plastic surgeons with extensive experience in the field. RESULTS: ChatGPT provided relevant, accurate information; however, it lacked depth. It could provide no more than a superficial overview in response to more esoteric questions and generated incorrect references. It created non-existent references, cited wrong journal and date, which poses a significant challenge in maintaining academic integrity and caution of its use in academia. CONCLUSION: While ChatGPT demonstrated proficiency in summarizing existing knowledge, it created fictitious references which poses a significant concern of its use in academia and healthcare. Caution should be exercised in interpreting its responses in the aesthetic plastic surgical field and should only be used for such with sufficient oversight. LEVEL OF EVIDENCE IV: 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 .

Aesthetic Surgery Advice and Counseling from Artificial Intelligence: A Rhinoplasty Consultation with ChatGPT.

BACKGROUND: ChatGPT is an open-source artificial large language model that uses deep learning to produce human-like text dialogue. This observational study evaluated the ability of ChatGPT to provide informative and accurate responses to a set of hypothetical questions designed to simulate an initial consultation about rhinoplasty. METHODS: Nine questions were prompted to ChatGPT on rhinoplasty. The questions were sourced from a checklist published by the American Society of Plastic Surgeons, and the responses were assessed for accessibility, informativeness, and accuracy by Specialist Plastic Surgeons with extensive experience in rhinoplasty. RESULTS: ChatGPT was able to provide coherent and easily comprehensible answers to the questions posed, demonstrating its understanding of natural language in a health-specific context. The responses emphasized the importance of an individualized approach, particularly in aesthetic plastic surgery. However, the study also highlighted ChatGPT's limitations in providing more detailed or personalized advice. CONCLUSION: Overall, the results suggest that ChatGPT has the potential to provide valuable information to patients in a medical context, particularly in situations where patients may be hesitant to seek advice from medical professionals or where access to medical advice is limited. However, further research is needed to determine the scope and limitations of AI language models in this domain and to assess the potential benefits and risks associated with their use. LEVEL OF EVIDENCE V: Observational study under respected authorities. 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 .

Evaluating Chatbot Efficacy for Answering Frequently Asked Questions in Plastic Surgery: A ChatGPT Case Study Focused on Breast Augmentation.

BACKGROUND: The integration of artificial intelligence (AI) and machine learning (ML) technologies into healthcare is transforming patient-practitioner interaction and could offer an additional platform for patient education and support. OBJECTIVES: This study investigated whether ChatGPT-4 could provide safe and up-to-date medical information about breast augmentation that is comparable to other patient information sources. METHODS: ChatGPT-4 was asked to generate 6 commonly asked questions regarding breast augmentation and respond to them. Its responses were qualitatively evaluated by a panel of specialist plastic and reconstructive surgeons and reconciled with a literature search of 2 large medical databases for accuracy, informativeness, and accessibility. RESULTS: ChatGPT-4 provided well-structured, grammatically accurate, and comprehensive responses to the questions posed; however, it was limited in providing personalized advice and sometimes generated inappropriate or outdated references. ChatGPT consistently encouraged engagement with a specialist for specific information. CONCLUSIONS: Although ChatGPT-4 showed promise as an adjunct tool in patient education regarding breast augmentation, there are areas requiring improvement. Additional advancements and software engineering are needed to enhance the reliability and applicability of AI-driven chatbots in patient education and support systems.

The arterialised saphenous venous flow-through flap for managing the radial forearm free flap donor site.

BACKGROUND: The radial forearm fasciocutaneous flap (RFFF) is a workhorse flap, however concerns with donor site morbidity include tendon exposure, delayed wound healing, impaired sensitivity, and poor cosmesis, have seen it fall out of favor. We present a method of using an arterialised saphenous flow through flap to reconstruct the RFFF donor site. METHOD: A cohort study of six patients (five male, one female; mean age 59 [range 19-90]) who had their RFFF donor site reconstructed with an arterialised saphenous flow through flap is presented. The use of multiple peripheral efferent venous anastomoses, flap rotation 180 degrees prior to inset, and the ligation of intra-flap connecting veins were three modifications employed. Primary outcomes include complication rates. Secondary outcomes were patient reported outcome measures via the Michigan Hand Outcomes Questionnaire, and patency and flow through the flap. RESULTS: In all six cases, there was flap survival. RFFF dimensions ranging from lengths of 6-15 cm (mean 11.5 cm) and widths of 4-6 cm (mean 5.3 cm), with an average flap area of 58 cm2 (range 24-90). There were no total flap losses, one partial superficial flap loss and one minor donor site delayed healing, over a mean follow-up of 6 months (4-24 months). The average overall patient satisfaction was 91 on Michigan Hand Outcomes Questionnaire. Pain was well tolerated with a low average pain score of 15. CONCLUSION: The modified arterialised saphenous flow through flap is a useful option for reconstructing the soft tissue defect and reconstituting the radial artery after RFFF harvest.

Anatomical differences in the abdominal wall between animal species with implications for the transversus abdominis plane block: a systematic review.

PURPOSE: With the increased use of simulation-based training using animal models for the education of surgical and anaesthetic techniques, an increased understanding of the anatomy of such models and how they compare to humans is required. The transversus abdominis plane block is a regional anaesthetic technique that requires an understanding of the abdominal wall anatomy along with proficient ultrasound use. The current review aims to compare the anatomy of the abdominal wall across species, particularly focussing on the pertinent differences within the class of mammals, and secondarily, it aims to address the implications of these differences for the use of simulation-based training of the transversus abdominis plane block. METHODS: To achieve this, the PubMed, Web of Science and Google Scholar databases were searched for relevant literature. Studies pertaining to the musculature, vasculature or innervation of the anterolateral abdominal wall across species were included. RESULTS: The mammalian abdominal wall differs in its musculature, vasculature or innervation from that of amphibians, birds or reptiles; however, among species of mammals, the structure of the abdominal wall follows a similar framework. Particular differences among mammals include the additional muscular layer of the panniculus carnosus found in most mammals other than humans, the variable arterial origins and dominant vascular supply of the abdominal wall and the number of thoracolumbar nerves innervating the abdominal wall. CONCLUSION: When using animal models for simulation-based training, the pig is recommended for the transversus abdominis plane block given its closely homologous abdominal wall structure, availability and larger comparative size.

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review.

BACKGROUND: Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. METHODS: A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. RESULTS: A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). CONCLUSION: Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

How should we manage women with fat necrosis following autologous breast reconstruction: An algorithmic approach.

Fat necrosis is a common complication of autologous breast reconstruction; however, diagnostic criteria are yet to be standardized, making comparison of autologous breast reconstructive techniques challenging. A systematic review found six of 556 articles met inclusion criteria. These results were used to generate an algorithm for managing fat necrosis after autologous breast reconstruction.

Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases.

Genital lymphedema is a rare condition in males that can lead to difficulty in voiding, sexual function, hygiene, and mobility. Only several methods of treatment have been developed and studied, primarily focusing on restoring patency of diseased lymph channels or resection of affected tissue. We are the first to describe the surgical technique and our experience of using free submental and submandibular arterio-venous vascularized lymph node transfer specifically for the treatment of scrotal edema. We report on two patients who have undergone selective neck dissection of submental and submandibular lymph nodes based off the facial artery and vein. These vascularized lymph nodes were then transferred to the groin, with anastomosis to the deep inferior epigastric perforator artery and vein. The first patient, a 63 year old had initial pretreatment measurement of the anal verge to base of penis was 18 cm in length, and maximum circumference of scrotum 27 cm for the first patient, and 31-42 cm, respectively, for the second patient, a 66 year old. At 9-month review for the first patient and 6-month review for the second patient, both donor and recipient site wounds had healed. The anal verge to base of penis length had decreased to 16 cm, while maximum circumference of scrotum had decreased to 23 cm, and 25-38 cm, respectively, for the second patient. We have had good success with reducing the burden on patients using this novel technique, and hence it should be considered as a viable treatment methodology in appropriately selected patients.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

BACKGROUND: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS: A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS: One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. CONCLUSION: Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes.

INTRODUCTION: Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons. METHODS: A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria. RESULTS: Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis. CONCLUSION: The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential. 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 .

Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review.

PURPOSE: The purpose of the current review was to estimate failure rates of trapeziometacarpal (TMC) implants and compare against failure rates of nonimplant techniques for surgical treatment of TMC joint (basal thumb joint) arthritis. METHODS: A systematic review was conducted to identify articles reporting on thumb implant arthroplasty and on nonimplant arthroplasty techniques for treatment of base of thumb arthritis in the English literature. The collected data were combined to calculate failure rates per 100 procedure-years. Failure was defined by the requirement for a secondary salvage procedure. The failure rates between different implant and nonimplant arthroplasty groups were compared directly and implants with higher than anticipated failure rates were identified. RESULTS: One hundred twenty-five articles on implant arthroplasty and 33 articles on the outcome of nonimplant surgical arthroplasty of the TMC joint were included. The implant arthroplasty failure rates per 100 procedure-years were total joint replacement (2.4), hemiarthroplasty (2.5), interposition with partial trapezial resection (4.5), interposition with complete trapezial resection (1.7), and interposition with no trapezial resection (4.5). The nonimplant arthroplasty failure rates per 100 procedure-years were: trapeziectomy (0.49), joint fusion (0.52), and trapeziectomy with ligament reconstruction ± tendon interposition (0.23). CONCLUSIONS: Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of nonimplant techniques were lower than those of implant arthroplasty. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.