Plastic Surgery最新文献

Background: Exposure to plastic surgery during medical school is limited. Most interested applicants form their perceptions of careers in this surgical specialty during elective rotations.

Objective: To investigate the perceptions of Canadian medical students considering a career in plastic surgery. The results obtained were then compared with current Canadian plastic surgery residents' perceptions.

Methods: The data were collected via two separate self-administered online surveys that were distributed to either Canadian plastic surgery residents or medical students. The questionnaires were similar and focused on three aspects: applicant details; driving force behind interest in the field; and essential character traits and competencies related to successful matching.

Results: Fifty-nine plastic surgery residents and 477 medical students participated in the online survey. The most commonly reported driving forces for interest in a plastic surgery career in both groups were variety of career choice, complexity of the field, future lifestyle and enjoyable rotations in plastic surgery. Despite these similarities, the proportion of medical students and residents who opted for future lifestyle and enjoyable rotations differed in a statistically significant manner (P=0.015 and P=0.029, respectively). In terms of the essential competencies to match into a plastic surgery training spot, the groups differed statistically in their opinions on the relevance of intellect (P<0.001), manual dexterity (P<0.001), spatial sense (P<0.001) and clerkship grades (P=0.004).

Conclusion: Interested applicants should be encouraged to obtain as much elective experience as possible to assist both students in their career choice and selection committees in identifying capable applicants.

Background: The acidity of lidocaine preparations is believed to contribute to the pain of local anesthetic injection.

Objective: To investigate the effect of buffering lidocaine on the pain of injection and duration of anesthetic effect.

Methods: A double-blind, randomized trial involving 44 healthy volunteers was conducted. The upper lip was injected with a solution of: lidocaine 1% (Xylocaine, AstraZeneca, Canada, Inc) with epinephrine; and lidocaine 1% with epinephrine and 8.4% sodium bicarbonate. Volunteers reported pain of injection and duration of anesthetic effect.

Results: Twenty-six participants found the unbuffered solution to be more painful. Fifteen participants found the buffered solution to be more painful; the difference was not statistically significant. Twenty-one volunteers reported duration of anesthetic effect. The buffered solution provided longer anesthetic effect than the unbuffered solution (P=0.004).

Conclusion: Although buffering increased the duration of lidocaine's anesthetic effect in this particular model, a decrease in the pain of the injection was not demonstrated, likely due to limitations of the study.

Abdominal-based autologous free tissue breast reconstruction has undergone significant changes over the past decade. The evolution has focused on limiting morbidity of the donor site. The transition from the transverse rectus abdominus muscle free flap to the muscle-sparing transverse rectus abdominus muscle free flap to the deep inferior epigastric artery perforator free flap has markedly improved abdominal-based autologous breast reconstruction. However, all of these flaps involve an incision through the anterior rectus fascia and potential damage of intercostal motor and sensory nerves. The superficial inferior epigastric artery flap (SIEA) reliably perfuses the ipsilateral hemiabdomen, yet does not violate the fascia or any motor nerves. As a result, the incidence of hernia, abdominal wall weakness and bulging is essentially eliminated. Nevertheless, use of the SIEA flap remains marginal. Vessel size, dissection difficulties and lack of understanding of the relevant anatomy have limited its acceptance. The present article describes a rapid, reliable and safe dissection technique with an algorithm for harvesting the SIEA flap in autologous breast reconstruction.

Background: In a socialized medicine model, prioritization of referrals for specialist consultation is highly important in the distribution of heath care. For high-burden diseases, such as carpal tunnel syndrome (CTS), the factors that influence prioritization are not well understood.

Objective: To determine the factors that influence the prioritization of referrals for CTS consultation by plastic surgeons in Canada.

Methods: All members of the Canadian Society of Plastic Surgery with e-mail addresses were invited to participate in an online survey regarding the method by which they prioritize referrals for CTS.

Results: Forty per cent of invited members completed the survey (150 surgeons). Of these, 118 (79%) stated that they performed CTS surgery. The majority of respondents who performed CTS surgery prioritized their consultation list chronologically (77%). Factors that would alter the chronological order or prioritization included subsequent contact by the referring physician (24%); personal relationship with the patient (16%); and specific information in the referral letter (15%), which usually involved symptom severity or electromyography findings. Sixty-six per cent of plastic surgeons stated that there was no conscious decision on how they came to choose the method of prioritization they used for referrals regarding CTS.

Discussion: The majority of plastic surgeons in Canada prioritize referrals for consultation on CTS chronologically. A minority of respondents reported reassigning priority based on clinical severity. The rationale for the methods by which Canadian Society of Plastic Surgery members prioritize these referrals is poorly understood. Further study on developing evidence-based prioritization methods may be useful in assisting surgeons and their patients in outcome-based decisions.

Background: The potential ramifications of radiation use can be of particular concern in the breast reconstruction population, in which both surgical and aesthetic outcomes are important. Presently, there remains a paucity of data detailing the influence of radiation on specific reconstruction aesthetic outcomes.

Objective: To conduct a quantitative evaluation of aesthetic outcomes for expander-implant breast reconstruction in radiated and nonradiated patients using a validated scoring scale.

Methods: A series of consecutive expander-implant breast reconstruction operations performed by the senior author between 2004 and 2012 were reviewed. Four blinded members of the Division of Plastic and Reconstructive Surgery at Northwestern University (Illinois, USA) independently rated postoperative photographs of patients' breasts using a validated scoring scale with respect to five distinct aesthetic domains.

Results: Of the 206 patients meeting the inclusion criteria, 69 received radiotherapy and 137 did not. The radiated cohort had lower scores in each aesthetic domain, with significant differences in contour (1.33 versus 1.51; P=0.041) and placement (1.45 versus 1.73; P<0.001). Linear regression analysis revealed a significant association between placement scores and radiation, and radiated patients had a significantly higher overall rate of complications.

Discussion: Variances in scores may represent the relative difficulty of expansions and proper implant placement in irradiated tissue, with possible skin fibrosis and decreased flexibility hindering prosthesis manipulation.

Conclusion: Radiation adversely impacts breast contour and placement, with possible negative contributions to volume, scarring and inframammary fold definition, and results in higher rates of complications. Such detailed evaluation of the impact of radiation on aesthetics will enhance the management of patient expectations.

Background: Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost.

Objectives: To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced.

Methods: A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair.

Results: On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada.

Conclusions: The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.

Objective: To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas.

Methods: A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy.

Results: Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%).

Conclusions: Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.