Plastic surgery最新文献

Introduction: Firearm-related extremity trauma with nerve injury can lead to life-altering impairment and disability. This study evaluated the frequency of nerve injury in firearm-related extremity injuries at a Level 1 trauma centre, and the rate of nerve transection in firearm-related peripheral nerve injuries (PNIs) and brachial plexus injuries (BPIs). Methods: Following Ethics Board approval, institutional trauma and emergency databases (from 2000 to 2020) were used to identify adults with firearm-related PNI or BPI treated at a Level 1 trauma center. Each case of nerve injury was verified by chart review and excluded isolated digital nerve and other cutaneous nerve injuries. Medical charts were reviewed to retrieve patient and injury data. Results: In total, 1957 patients were identified with firearm injuries; the nerve injury study sample included 86 patients (95% males) and 98 nerves injured. The most common upper extremity nerve injured was the radial and/or posterior interosseous nerve (n = 30, 25%) and in the lower extremity, the sciatic nerve (n = 15, 13%). Nerve transection was confirmed in 21% of cases by surgical exploration (n = 19) or ultrasound imaging (n = 2). Axonotmetic injuries were confirmed in 20% of cases and in total only 41% of patients had full spontaneous functional recovery. Compared to neurapraxia, neurotmesis injuries had a significantly increased likelihood of concomitant vascular injury (P = .007) but not skeletal injuries (P = .65). Injury severity score was not associated with nerve injury severity (P = .27). Conclusion: Nerve transections due to firearm-related trauma occur more frequently than previously believed. Early identification and surgical management of nerve transection injuries is imperative.

Introduction: The necessity of postoperative drains in gender-affirming mastectomy remains unclear, with no consensus on their role in reducing complications such as seroma formation. Given this paucity of evidence, the use of drains is often at the discretion and judgment of the surgeon. Understanding patient preferences and quantifying patient risk tolerance for seroma formation and secondary procedures that may be associated with drainless mastectomy may aid in surgical decision-making and facilitate patient-centered discussions. Methods: Adolescent patients considering or having undergone gender-affirming mastectomy were surveyed. A modified standard gamble approach assessed risk tolerance for seroma formation requiring aspiration and the need for a secondary procedure. Results: Thirty participants were recruited (mean age 17.6 ± 1.3 years). Eighty percent identified as transmale, 17% as nonbinary, and 3% as gender nonconforming; 47% had a prior mastectomy. The median risk tolerance for seroma formation was 15% (interquartile range [IQR]: 5.5%-25%), and for secondary procedures, 10% (IQR: 1%-15%). Risk tolerance did not significantly differ by history of prior surgery or age. Supplementary survey findings provided insight into factors influencing concerns related to both the use of drain and drainless procedures. Conclusions: Risk tolerance for seroma and secondary procedures varies among patients, emphasizing the need for shared decision-making in gender-affirming mastectomy. Balancing patient preferences with surgical risks is essential to optimizing outcomes.

Background: Poor ergonomics may lead to musculoskeletal (MSK) injuries in surgeons, prompting practice modification, early retirement, and errors. We hypothesized that each plastic surgery subspecialty faces unique ergonomic challenges. We sought to identify the prevalence, risk factors, and impact of MSK injuries among plastic surgeons by subspecialty. Methods: In this systematic review and meta-analysis (CRD420251026702), MEDLINE, Embase, CINAHL, Web of Science, and Scopus were searched from inception to November 9, 2024, for studies reporting on injury prevalence among plastic surgeons. Methodological quality was assessed using the Joanna Briggs Institute Checklist for Prevalence Studies. The primary outcome was the literature-pooled MSK injury prevalence. Secondarily, we reviewed ergonomic risk factors and impacts. Pairwise and nonpairwise meta-analyses and random effects meta-analyses were conducted for dichotomous and continuous outcomes, respectively. Results: Fifteen studies were included, encompassing 3313 plastic surgeons. Very low-certainty evidence suggested that 72.0% reported MSK injury (95% CI [63.4, 79.3]), with the greatest prevalence in aesthetic surgeons (84.3%; 95% CI [76.0, 90.1]) and lowest among craniofacial surgeons (69.4%; 95% CI [52.8, 82.1]). Symptoms mostly occurred in the neck (47.0%), lower back (37.0%), and upper back (32.0%). Consequently, 38.6% worried about disability, 10.1% took time off, and 5.9% decreased their caseload. Practice duration, caseload, and age were risk factors. Conclusion: Ergonomic-related injuries varied among subspecialties, affecting the neck (craniofacial, oculoplastic, and microsurgeons), forearm/wrist/hands (hand surgeons), and lower back (aesthetic surgeons). Tailored ergonomic education programs are needed to protect the health and well-being of plastic surgeons.

Background: Accurate diagnosis of scaphoid fractures in children is challenging. Many children are treated with empiric immobilization to avoid missing an occult fracture, but this results in unnecessary immobilization, investigation, and patient and healthcare-related costs. It is unknown if clinical predictors exist to guide clinicians on which patients are at high risk for fracture or require advanced imaging. This study aimed to systematically review the use of clinical predictors in the diagnosis of suspected pediatric scaphoid fractures. Methods: A systematic review of all studies evaluating clinical predictors for suspected pediatric scaphoid fractures was performed by searching MEDLINE, Embase, CENTRAL, and CINAHL databases. Studies were included if there was clinical assessment of the wrist prior to confirmatory imaging with plain radiography, magnetic resonance imaging, computed tomography, and/or bone scintigraphy. Studies were excluded if they lacked primary data, if pediatric data could not be extracted, or if they were written in a language other than English. Results: Five studies examining 7 clinical examination techniques met the criteria for inclusion in the systematic review. Study and test characteristics were extracted, but studies were too heterogeneous to permit meta-analysis. Quality assessment of the included studies demonstrated risk of bias in index testing and inconsistent definition of the reference standard. Conclusions: Evidence supporting clinical predictors in children with suspected scaphoid fracture is lacking. Further understanding of clinical predictors and the role of imaging in children with suspected scaphoid injuries is required to reduce the burden of overtreated patients.

Facial nerve palsy affecting the lower face may compromise essential functions such as speech and eating. The associated facial asymmetry can contribute to social isolation. Facial nerve reconstruction using a combination of interposition nerve grafts and/or nerve transfers offers significant improvement. However, these options are limited by insufficient donor nerves and unwanted synkinesis if a single donor nerve is used for the entire hemi-face. To ameliorate both limitations, we perform an ansa cervicalis to marginal mandibular nerve transfer to restore tone and symmetry to the lower third of the face. We have found this a safe and feasible technique with minimal donor site morbidity. The anatomy is favorable both in terms of donor nerve length and size match between nerves. We report 9 cases with at least 6 months follow up which demonstrate improved lower lip tone and symmetry and improved oral competence. Early donor site morbidity and postoperative complications are minimal. This method is a reliable adjunct in facial nerve reconstruction to address the marginal mandibular nerve paralysis.

Introduction: Gender-affirming surgery (GAS) is a critical step for many transgender individuals seeking alignment between their physical appearance and gender identity. However, disparities in access to GAS across racial and ethnic groups remain inadequately addressed. This study aims to examine racial and ethnic disparities in access to top and bottom gender-affirming surgeries. Methods: A retrospective cohort analysis was conducted using the TriNetX database (2014-2024). Patients aged 18+ with a diagnosis of gender dysphoria who completed at least 6 months of hormone therapy were included. Patients were identified using ICD-10 and CPT codes and stratified by race and ethnicity: African American, Asian, Native Hawaiian, American Indian, Hispanic, and White. Propensity score matching adjusted for demographic and clinical variables. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to compare the likelihood of undergoing top or bottom surgery at 6 months and 1-year posteligibility. A P value <.05 was considered significant. Results: At 6 months posteligibility, African American patients had significantly lower odds of undergoing top (OR = 0.876, P = .0480) and bottom surgeries (OR = 0.399, P = .0111) compared to White patients. Hispanic patients also had lower odds for top (OR = 0.873, P = 0.0014) and bottom surgeries (OR = 0.872, P = 0.0314). In contrast, Asian patients had higher odds of receiving top (OR = 1.267, P = .0079) and bottom surgeries (OR = 1.333, P = 0.0007). These disparities remained evident at the 1-year mark, with African American and Hispanic patients continuing to experience reduced surgical access relative to White patients. Conclusion: Significant racial and ethnic disparities persist in GAS access. Targeted interventions are needed to promote equitable surgical care for transgender individuals.

Introduction: Craniofacial and cleft surgeries demand high precision, often leading to significant ergonomic challenges for surgeons. This review highlights critical recommendations for mitigating musculoskeletal disorders and enhancing surgeon well-being through equipment optimization, posture adjustments, and innovative technologies. Methods: To conduct this scoping review, a search of the literature yielded 18 studies which discuss ergonomics in the realm of cleft lip and palate surgery. Results: Eighteen studies were reviewed. Investigated ergonomic strategies in cleft lip and palate surgery encompassed headlights, loupes, microscopes, robots, videoscopes, endoscopes, exoscopes, positioning techniques, breaks, exercise, workshops, intubation methods, operating room design, and training programs. Most studies were classified as low risk of bias. Robotic systems and advanced visualization tools such as videoscopes and exoscopes demonstrated significant ergonomic benefits by improving surgeon posture, reducing musculoskeletal strain, and enhancing surgical precision. Microscopes and loupes offered improved magnification and comfort but were still associated with some reported musculoskeletal symptoms. Strategies including micro-breaks, exercise, ergonomic positioning, and optimized operating room setup showed potential to reduce physical discomfort during surgery. However, formal ergonomics education remains scarce in surgical training despite its recognized importance. Conclusion: Appropriate tools and positioning decrease the incidence of musculoskeletal disorders among cleft lip and palate surgeons. Further studies should focus on the outcomes of implementing such programs.

Introduction: Bilateral breast reduction (BBR) is one of the most common Ministry of Health-funded plastic surgery procedures. Surgeon variation in BBR management has been reported. In this study, we aimed to answer the following: what are the current variations in plastic surgeons' management of BBR in Hamilton, Ontario?, and what are the cost implications of these practice variations to the healthcare system and patients? Methods: An online survey was conducted to gather demographic and practice data from all plastic surgeons practicing in Hamilton from 2019 to 2024. Reference costs for pre-, intra-, and postoperative components of BBR were obtained from a tertiary academic care center, the Ontario Schedule of Benefits for Physician Services, and local nursing care agencies, and used in the calculation of individual surgeons' healthcare and patient costs. Results: Among 17 plastic surgeons practicing in Hamilton, 9 perform BBR, and 7 participated in the survey (response rate = 77.8%). Variations in practice were identified across several areas, including drain use, nursing care, OR time, and frequency of physician appointments. The mean healthcare costs per BBR patient were $5156 and $7146 for the lowest- and highest-costing surgeons, respectively, resulting in a difference of up to $2034 per patient. Patient-borne costs varied from $92 to $179 between surgical practices. Conclusion: There is considerable variability in BBR practice among plastic surgeons in Hamilton, contributing to a difference in overall healthcare and patient costs. Given the importance of cost savings in a single-payer system, future research is warranted to standardize BBR practices.

Introduction: Reduction mammoplasty alleviates physical and psychological discomfort in patients with large breasts. The present study sought to determine preoperative markers that may herald postoperative complications. Methods: The NSQIP 2021 data file was queried using CPT and ICD-10 diagnosis codes to identify patients who underwent reduction mammoplasty at participating hospitals. To reduce confounders, patients undergoing gender affirming surgeries and males were excluded from the analysis. Preoperative comorbidities and laboratory values were analyzed using univariate and multivariate regression to determine their association with overall 30-day postoperative complications. Results: In total, 5909 reduction mammoplasty patients were identified. Patients aged ≥ 65 years had 1.47 times higher odds of developing complications after breast reduction compared to those who were younger in age (95% CI 1.02 - 2.07, P < 0.05). Tobacco use had 1.65 times higher chance of developing complications after their surgery compared to no tobacco use (95% CI 1.11-2.38, P < 0.05) and similarly, patients with ASA class III-V had 1.6 times higher odds of complications after their surgery compared to ASA class I-II (1.25-2.03, P < 0.05). Conclusion: Patients aged ≥ 65 years, those who smoke tobacco, have obesity (BMI ≥ 30), and/or are classified as ASA III-V are significantly associated with increased 30-day complication rates following reduction mammoplasty. Preoperative counseling of these patients should emphasize the importance of modifying risk factors-such as smoking cessation and weight reduction-and clearly communicate their high risk of postoperative complications to support informed decision-making and foster realistic patients expectations.