The Implementation of International Electives for Plastic Surgery Residents: Current State and Future Directions.

INTRODUCTION: Interest in international surgical missions has been rising exponentially, with the plastic surgery community being a leader in this endeavor. The role of residents in such missions remains a topic of debate. This systematic review aims to consolidate the literature relevant to the inclusion of plastic surgery residents on international surgical missions to devise an algorithm to facilitate resident participation. MATERIALS AND METHODS: A comprehensive search of PubMed, Medline, and EMBASE was performed to identify studies relevant to plastic surgery resident involvement in the context of surgical missions. Relevant conclusions were retrieved from each study and compiled according to category. RESULTS: Of 418 initial studies, 26 were retained for the qualitative synthesis. These were grouped into 3 categories: surveys (n=12), reflections (n=7), and reviews (n=7). The survey studies addressed the perceived value, educational impact, and long-term effect on participating residents. Three reflection studies were from the perspective of residents and 4 from staff, while all recounted the many benefits gained for participating residents. Review studies addressed the issue of accreditation and the ethics surrounding resident involvement. CONCLUSION: This systematic review highlights the overwhelming support from residents and staff, the highly regarded educational value, and the positive global health effects associated with plastic surgery resident participation in international surgical missions. The authors hope this will encourage and facilitate the implementation of formal opportunities for residents within residency training programs.

Local Versus General Anesthesia in Pediatric Otoplasty: A Cost and Efficiency Analysis.

OBJECTIVE: Quantify the cost benefits of otoplasty under local as opposed to general anaesthesia. DESIGN: A cost analysis of all components of otoplasty surgery under local anaesthesia (LA) in a minor operating room (OR) and general anaesthesia in a main OR was performed. SETTING: Our institution, compared to provincial/federal data, with costs converted into 2022 Canadian dollars. PATIENTS, PARTICIPANTS: Patients undergoing otoplasty under LA in the last year. INTERVENTIONS: An efficiency analysis was performed by means of an opportunity cost, and the cost of failure was added to the overall LA costs. MAIN OUTCOME MEASURE: Expenses for infrastructure, surgical and anaesthetic material, salaries, and personnel costs were derived from the literature, our hospital OR catalog and federal/provincial salary data, respectively. The cost of failure to tolerate local anaesthesia for such cases was also tabulated. RESULTS: The true cost of LA otoplasty was computed as the absolute cost ($611.73) added to the cost of failure ($10.80), resulting in a total of $622.53/procedure. The true cost of GA otoplasty was calculated as the absolute cost ($2033.05) added to the opportunity cost ($1108.94), representing 3141.99$/procedure. The total savings when performing LA otoplasty to GA otoplasty are thus 2519.44$/case, with 1 GA otoplasty costing 5.05 LA otoplasties. CONCLUSION: Otoplasty under local anaesthesia offers significant cost savings when compared with the same procedure under general anaesthesia. Economic considerations must be given particular attention given the elective nature of this procedure, which is often publicly funded.

Determination of Novel, Cranium-Based Relationships for Construct Placement in Microtia Reconstruction for Hemifacial Microsomia Patients.

OBJECTIVE: Determine if the ideal location of the construct in microtia reconstruction for hemifacial microsomia (HFM) can be more accurately derived from measurements on the cranium. DESIGN: High-resolution computerized tomography (CT) images were analyzed through craniometric linear relationships. SETTING: Our tertiary care institution from 2000 to 2021. PATIENTS/PARTICIPANTS: Patients diagnosed with HFM and microtia, who had high-resolution craniofacial CT scans, yielding 36 patients accounting for 44 CT scans. MAIN OUTCOME MEASURE(S): First, the integrity of the posterior cranial vault among HFM patients was determined. If proven to be unaffected, it could be used as a reference in the placement of the construct. Second, the position of the ear in relation to the cranium was assessed in healthy age-matched controls. Third, if proven to be useful, the concordance of these cranium-based relationships could be validated among our HFM cohort. RESULTS: The posterior cranial vault is unaffected in HFM (P > .001). Further, craniometric relationships between the tragus and the Foramen Magnum, as well as between the tragus and the posterior cranium, have been shown to be highly similar and equally precise in predicting tragus position in healthy controls (P > .001). These relationships held true across all age groups (P > .001), and importantly among HFM patients, where the mean absolute difference in predicted tragus position never surpassed 1.5 mm. CONCLUSIONS: Relationships between the tragus and the cranium may be used as an alternative to distorted facial anatomy or surgeon's experience to assist in pre-operative planning of construct placement in microtia reconstruction for HFM patients.

Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis.

BACKGROUND: Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. METHODS: We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. RESULTS: A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. CONCLUSION: These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis.

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

Historique : La popularité de la chirurgie esthétique est en hausse, tout comme les attentes des patients envers l'excellence des résultats chirurgicaux. Pour répondre à ces attentes, il est nécessaire de nommer et de résoudre les facteurs de risque qui entravent les résultats souhaités, tels que le tabagisme. À cet effet, la présente étude résume une analyse systématique à jour des effets du tabagisme sur les interventions et les résultats en chirurgie esthétique. Méthodologie: Dans une analyse systématique des études, les chercheurs ont comparé les résultats de la chirurgie esthétique chez des fumeurs et des non-fumeurs en fonction de l'intervention, après une fouille dans les bases de données de PubMed, d'Embase et de Cochrane. Ils ont extrait les données relatives aux résultats des opérations et ont procédé à la méta-analyse à l'aide d'un modèle à effets aléatoires, conjointement avec la méthode statistique de Mantel-Haenszel. Résultats : Au total, les chercheurs ont inclus 82 études dans la synthèse définitive. Les interventions les plus fréquentes étaient les abdominoplasties et les panniculectomies (n = 19 cohortes), de même que les réductions mammaires (n = 27 cohortes). À part dans les cas de mastopexie et de rhinoplastie, le tabagisme provoquait une augmentation statistiquement significative du risque de complications globales dans tous les cas d'interventions esthétiques à l'étude. Conclusions : Les données ont démontré que le tabagisme est un facteur de risque évident dans la majorité des chirurgies esthétiques à l'étude. Même si la méta-analyse a indiqué que le tabagisme n'est pas un facteur de risque de complications dans les cas de mastopexie et de rhinoplastie, ces deux analyses peuvent avoir été biaisées et devraient donc être réévaluées d'après de futures données complémentaires. Les résultats de cette analyse systématique confirment l'importance de l'arrêt du tabagisme et de l'éducation sur les résultats des interventions chirurgicales esthétiques courantes.

The Reconstruction of Plastic Surgery: A Historical Perspective on the Etymology of Plastic and Reconstructive Surgery.

Although the origins of procedures now falling under the scope of modern plastic surgery date back thousands of years, it was only fairly recently that these were grouped under the umbrella term "plastic" surgery. However, mainly due to the industrialization period, the popular understanding of the term "plastic" would soon change-making way for the addition of the term "reconstructive" to the specialty's name. Through a careful look at historical trends, the authors illustrate how this unintentionally led to an ideological divide between the aesthetic and reconstructive portions of our work, prompting a recent push to unify the field under the one, original, lexical choice: "plastic" surgery.

Même si les origines des interventions qui font désormais partie du champ de la chirurgie plastique moderne remontent à des millénaires, ces interventions n'ont été regroupées que récemment sous le vocable de chirurgie "plastique". Cependant, en grande partie à cause de l'industrialisation, la compréhension populaire du terme "plastique" allait bientôt changer, laissant place à l'ajout du terme "reconstructive" au nom de la spécialité. Par un examen attentif des tendances historiques, les auteurs démontrent que cet ajout a involontairement entraîné un fossé idéologique entre la partie esthétique et reconstructive du travail, ce qui a suscité une récente impulsion en vue d'unifier le domaine sous un choix lexical unique et original : chirurgie "plastique".

How Big Is Too Big? Exploring the Relationship between Breast Implant Volume and Postoperative Complication Rates in Primary Breast Augmentations.

There is no consensus regarding implant size as an independent risk factor for complications in primary breast augmentation. Choosing appropriate implant volume is an integral part of the preoperative planning process. The current study aims to assess the relationship between implant size and the development of complications following augmentation mammaplasty. Methods: A retrospective chart review of patients undergoing primary breast augmentation at the Westmount Institute of Plastic Surgery between January 2000 and December 2021 was conducted. Demographics, implant characteristics, surgical technique, postoperative complications, and follow-up times were recorded. Univariate logistic regression was used to identify independent predictors, which were then included in multivariate logistic regressions of implant volume and implant volume/body mass index (BMI) ratio regarding complications. Results: A total of 1017 patients (2034 breasts) were included in this study. The average implant volume used was 321.4 ± 57.5 cm3 (range: 110-605). Increased volume and volume/BMI ratio were associated with a significant increase in risk of implant rupture (odds ratio = 1.012, P < 0.001 and 1.282, P < 0.001 respectively). Rates of asymmetry were significantly associated with increases in implant volume and volume/BMI ratio (odds ratio = 1.005, P = 0.004 and 1.151, P < 0.001, respectively). No single implant volume or volume/BMI ratio above which risks of complications significantly increase was identified. Conclusions: Implant rupture and postoperative asymmetries are positively correlated with bigger implant volumes. Implant size could likely be a useful independent predictor of certain complications, especially in patients with high implant to BMI ratios.

Usage trends, perceptions and ethical views regarding social media: A survey of Canadian plastic surgeons.

Parallel to the rise in usage of Social Media (SoMe) worldwide, plastic surgeons are becoming increasingly present online. Although more are being published, there is a paucity of studies regarding academic and international plastic surgeons. The authors sought to determine current usage trends among Canadian plastic surgeons. A 16-item survey concerning usage, post content, perceptions and ethics towards SoMe was sent to academic and esthetic plastic surgeons across Canada. The survey yielded a 14.2% response rate, from which 37% had a single SoMe account for both personal and professional use, with Instagram (36%) being the most preferred platform and only 10% of post content being academically inclined. Surgeons without a professional account seemed to be more likely to believe it is unethical to discuss procedures with patients over SoMe (75% vs. 29%) and were more likely to believe it is unethical to post procedural/intra-operative videos on SoMe (75% vs. 21%). This survey highlights the diverging views regarding the ethics surrounding SoMe usage, which can be influenced by the type of accounts managed by surgeons. The authors hope this can help elucidate more ethical, safe and effective practices of SoMe.

Validating a Novel Device to Improve Skin Color Matching for Face Transplants.

Facial vascularized composite allotransplantation (VCA) offers an added layer of complexity when compared to solid organ transplantation. VCAs must account for aesthetic variables such as skin tone and color. The goal of this study is to validate the Nix Color Sensor as a novel tool to be added to the plastic surgeon's armamentarium for evaluating skin color match of the donor and recipient. Methods: A prospective study of 100 individuals was conducted. All participants were photographed and scanned with the Nix Color Sensor. Sixty pairwise comparisons were randomly generated. Skin color analysis was performed using photographs and the Nix Color Sensor. Delta E2000 values were compared to mean evaluator ratings using a Spearman correlation analysis. Results: One hundred patients were included. A Spearman's correlation demonstrated a strong inverse correlation between Delta E2000 values and the mean evaluator ratings. The higher the mean evaluator rating for likeness, the lower the delta. A correlation coefficient of -0.850 demonstrates a statistically significant relationship (P < 0.01). Conclusions: When the Delta E2000 rises above 5 there is a significant drop in the mean evaluator ratings. As mean evaluator ratings of 5 and above would be considered adequate for face transplant amongst most plastic surgeons, an E2000 value of 5 or lower should be targeted when matching donors with recipients for face transplant. The Nix Color Sensor positively correlates to the plastic surgeon's perception of skin color and can serve as an adjunct in donor selection for facial VCAs.

Surgical Microtia Reconstruction in Hemifacial Microsomia Patients: Current State and Future Directions.

Background: Hemifacial microsomia (HFM) is one of the most common congenital craniofacial disorders. Among many other features, microtia is present in the large majority of these patients. However, mainly due to the unilateral hypoplastic anatomy, microtia reconstruction among this patient population remains a reconstructive challenge for plastic surgeons. Given that no clear standards exist, an evidence-based synthesis of the literature was devised. Methods: A systematic search of Pubmed, Medline, and Embase was carried out, in accordance with the PRISMA guidelines. Studies discussing surgical microtia reconstruction for HFM patients were retained. Qualitative data regarding study design, challenges addressed, specific recommendations, and their respective strengths/limitations were extracted from each. Retrieved recommendations were consolidated and assigned a level of evidence grade. Results: Although only 11 studies were included in this review, these provided 22 main recommendations regarding the eight HFM-specific challenges identified, which were of either grade C (n = 5) or D (n = 17). Included studies addressed construct location (n = 7), the low hairline (n = 6), soft tissue construct coverage (n = 6), earlobe reconstruction (n = 6), construct projection (n = 5), anomalies of the relevant neurovascular systems (n = 2), retroauricular construct coverage (n = 2), and sizing of the construct (n = 2). Conclusions: Given the many persisting reconstructive challenges regarding surgical microtia reconstruction for HFM patients, the authors present a comprehensive and evidence-based consolidation of recommendations specific to these challenges. The authors hope this systematic review can appropriately guide plastic surgeons and will ultimately improve care for this patient population.

Expanding the Classic Facial Canons: Quantifying Intercanthal Distance in a Diverse Patient Population.

Background: The intercanthal distance (ICD) is central to our perception of facial proportions, and it varies according to gender and ethnicity. Current standardized reference values do not reflect the diversity among patients. Therefore, the authors sought to provide an evidence-based and gender/ethnicity-specific reference when evaluating patients' ICD. Methods: As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of PubMed, Medline, and Embase was carried out for studies reporting on the ICD. Demographics, study characteristics, and ICDs were extracted from included studies. ICD values were then pooled for each ethnicity and stratified by gender. The difference between men and women, and that across ethnicities and measurement types were compared by means of independent sample t-test and one-way ANOVA (SPSS v.24). Results: A total of 67 studies accounting for 22,638 patients and 118 ethnic cohorts were included in this pooled analysis. The most reported ethnicities were Middle Eastern (n = 6629) and Asian (n = 5473). ICD values (mm) in decreasing order were: African 38.5 ± 3.2, Asian 36.4 ± 1.6, Southeast Asian 32.8 ± 2.0, Hispanic 32.3 ± 2.0, White 31.4 ± 2.5, and Middle Eastern 31.2 ± 1.5. A statistically significant difference (P < 0.05) existed between all ethnic cohorts, between genders among most cohorts, and between most values stratified by measurement type. Conclusions: Our standards of craniofacial anthropometry must evolve from the neoclassical canons using White values as references. The values provided in this review can aid surgeons in appreciating the gender- and ethnic-specific differences in the ICD of their patients.

The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes.

BACKGROUND: There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects. METHODS: A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates. RESULTS: Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013). CONCLUSIONS: The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.

Spontaneous necrosis of a single digit: watershed necrosis.

Anatomical variations in the superficial and deep palmar arches are common, but rarely lead to digital necrosis. We report the case of necrosis of the third digit caused by a 'watershed' effect in the context of atherosclerotic disease and rare congenital variations of the superficial and deep palmar arches.

Use of Decision Analysis and Economic Evaluation in Breast Reconstruction: A Systematic Review.

BACKGROUND: Decision analysis allows clinicians to compare different strategies in the context of uncertainty, through explicit and quantitative measures such as quality of life outcomes and costing data. This is especially important in breast reconstruction, where multiple strategies can be offered to patients. This systematic review aims to appraise and review the different decision analytic models used in breast reconstruction. METHODS: A search of English articles in PubMed, Ovid, and Embase databases was performed. All articles regardless of date of publishing were considered. Two reviewers independently assessed each article, based on strict inclusion criteria. RESULTS: Out of 442 articles identified, 27 fit within the inclusion criteria. These were then grouped according to aspects of breast reconstruction, with implant-based reconstruction (n = 13) being the most commonly reported. Decision analysis (n = 19) and/or economic analyses (n = 27) were employed to discuss reconstructive options. The most common outcome was cost (n = 27). The decision analysis models compared and contrasted surgical strategies, management options, and novel adjuncts. CONCLUSIONS: Decision analysis in breast reconstruction is growing exponentially.The most common model used was a simple decision tree. Models published were of high quality but could be improved with a more in-depth sensitivity analysis. It is essential for surgeons to familiarize themselves with the concept of decision analysis to better tackle complicated decisions, due to its intrinsic advantage of being able to weigh risks and benefits of multiple strategies while using probabilistic models.

Perception of Implants among Breast Reconstruction Patients in Montreal.

BACKGROUND: In light of the recent surge of media coverage and social media influence regarding breast implants, it is essential to understand patients' concerns and misconceptions so that we can better serve them. METHODS: The authors designed a survey study for assessing the awareness and perception of patients toward breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII). In total, 130 patients presenting to the senior author's breast reconstruction clinic completed the survey. The survey assessed patients' knowledge on and their perception of BIA-ALCL and BII. RESULTS: "News article" and "Television" were most often selected as sources of information for BIA-ALCL (21% and 20%, respectively) and BII (20% and 25%, respectively). A total of 100 patients (77%) had previous knowledge of BIA-ALCL. Forty-seven percent (n = 47/100) responded that they were unsure of the fate of a person diagnosed with BIA-ALCL, and 25% (n = 25/100) were unaware of the association between BIA-ALCL and specific implant type. Patients who were unaware of BIA-ALCL prognosis reported being less likely to receive breast implants in the future (P = 0.012, χ2 = 19.48). Eighty-nine patients (68%) had previous knowledge of BII. A total of 60 symptoms were mentioned by patients, with "Fatigue" (12%, n = 26) being cited the most often. CONCLUSIONS: The present survey highlights the importance for plastic surgeons to frequently discuss these entities with their patients. This should be done despite the obscurity of BII, in an effort to offer the best available evidence to our patients.

Peripherally Inserted Central Catheters as Potential Risk Factors for Failure in Pedicled Latissimus Dorsi Flaps.

Pedicled latissimus dorsi musculocutaneous flaps are reliable options for reconstruction of torso and head and neck defects. After ensuring that no kink or external compression occurs on the pedicle, the survival rate exceeds 99%. However, we experienced a complete necrosis of the flap after insertion of a peripherally inserted central catheter line. Intraoperative findings demonstrated thrombosis of the subclavian vein over a large segment, which was found to be the cause of flap failure. The clinical significance of this case report is aimed at raising awareness against insertion of peripherally inserted central catheter lines on the ipsilateral arm of a pedicled latissimus dorsi flap.