The latest medical research on Plastic Surgery

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about plastic surgery gathered by our medical AI research bot.

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Consolidation Time and Relapse: A Systematic Review of Outcomes in Internal Versus External Midface Distraction for Syndromic Craniosynostosis.

Plastic and Reconstructive Surgery

The choice between internal versus external distraction osteogenesis for midface advancement in patients with syndromic craniosynostosis is primarily based on surgeon preference and expertise. However, differences in outcomes between the two techniques have been sparingly compared. In this work, we performed a systematic review to compare outcomes between internal versus external midface distraction.

A systematic review was performed of studies published between 1998 and 2018 (61 studies included, n=689 patients). Operative characteristics, early reoperations, complications, and relapse rates were extracted. Bias evaluation was performed using the Newcastle-Ottawa instrument. Statistical analyses were performed with independent samples t tests and linear regression analyses (p<0.05 considered significant).

We found that external distraction was associated with more Le Fort III osteotomies and hardware adjustments (p=0.023), whereas internal distraction was associated with more monobloc osteotomies and longer consolidation times (p=0.008). No significant differences in the distance of midface advancement, reoperations, complications, or relapse rates were noted between internal versus external distraction, although external distraction trended towards a slightly higher relapse rate. Regardless of distraction protocol, consolidation time was found to be a strong negative predictor for relapse (beta=-0.792, p=0.02).

Internal and external distraction for midface advancement do not demonstrate significant differences in advancement distance, reoperative rates, complication rates, or relapse rates. Regardless of distraction type, consolidation time was strongly inversely associated with relapse rates. The trend towards higher relapse in external distraction is potentially explained by the significantly lower consolidation times.

Exosomes are Comparable to Source Adipose Stem Cells in Fat Graft Retention with Up-regulating Early Inflammation and Angiogenesis.

Plastic and Reconstructive Surgery

Exosomes derived from mesenchymal stem cells possess similar functional properties to those of their parent cells, suggesting they could play a pivotal and versatile role in tissue repair and regeneration.

Using lipotransfer as a surrogate, exosomes were isolated from mouse ADSC-conditioned medium and characterized by transmission electron microscopy, NanoSight, and western blot. Minced fat tissue mixed with ADSC-derived exosomes (Exo), source ADSCs (CAL), or phosphate buffered saline (PBS) was implanted subcutaneously in the lower back of C57/BL mice bilaterally (n=16 each). Transferred fat tissues were harvested and analyzed at three and ten weeks.

At three and ten weeks after the transfer, fat grafts in groups of Exo and CAL showed better fat integrity, fewer oil cysts, and reduced fibrosis. At week ten, graft retention rates in CAL (50.9% ± 2.4%, P= 0.03) and Exo groups (56.4% ± 1.6%, P< 0.001) were significantly higher than the PBS group (40.7% ± 4.7%). Further investigations of macrophage infiltration, inflammatory factors (MIP-1α, MCP-1, IL-1β, and IL-10), angiogenic factors (HGF, bFGF), adipogenic factors (PPARγ, LDL), and extracellular matrix (Col-3α1, Col-6α3) revealed that ADSC-derived exosomes promoted angiogenesis and up-regulated early inflammation, while during mid to late stages of fat grafting, exerted a pro-adipogenic effect and also increased collagen synthesis level similar to their source ADSCs.

The ADSCs-derived exosomes demonstrated comparable effects to their source cells in achieving improved graft retention by up-regulating early inflammation and augmenting angiogenesis. These features may enable exosomes to be an attractive cell-free alternative in therapeutic regenerative medicine.

"Imiquimod acts synergistically with BMP9 via the Notch pathway as an osteoinductive agent in vitro".

Plastic and Reconstructive Surgery

Autologous bone grafts used for surgical reconstruction are limited by infection or insufficient supply of host material. Experimental agents that promote differentiation of stem cells into mature bone are currently being studied for future use in the repair of bone defects. We hypothesized that Imiquimod, a synthetic immune response modifier, increases Notch pathway gene expression and acts synergistically with BMP9 to induce differentiation of mesenchymal stem cells (MSCs) toward an osteogenic phenotype.

Alkaline phosphatase (ALP) activity was used to assess osteogenic potential of cultured mouse multipotent adipose-derived cells (iMADs) treated with 0, 4, 6, and 8 ∞g/mL of Imiquimod with and without BMP9. Adenoviral vectors expressing human-BMP9 and a dominant-negative mutant of mouse Notch1 were used to assess BMP9 and Notch blockade, on osteogenic activity, respectively. Expression of Notch signaling mediators and osteogenic markers were assayed by qPCR. Alizarin Red staining was used to assess the synergism between BMP9 and Imiquimod.

Imiquimod exposure enhanced osteogenic differentiation of iMADs by 2.8 fold (p < .001) and potentiated BMP-9 induced osteogenic differentiation of iMADs by 1.6 fold (p<.001), shown by increased ALP activity and augmented matrix mineralization. Quantitative-real time PCR analysis demonstrated that Imiquimod induced the expression of downstream genes (p<.01) of the Notch signaling pathway Hey1, Hey2, and Hes1, by a fold increase of 9.7, 22, and 2.7, respectively.

These findings identify a novel role for Imiquimod to shift MSCs toward an osteogenic phenotype. Imiquimod may be useful clinically when scaffolds are applied to treat bone defects.

Angiotensin II Type I Receptor Blockade is Associated with Decreased Cutaneous Scar Formation in a Rat Model.

Plastic and Reconstructive Surgery

Angiotensin II engagement of angiotensin II type 1 receptor (AT1R) is implicated in fibrogenesis, with AT1R blockers (ARB) used clinically to attenuate cardiac and renal fibrosis. The authors tested the hypothesis that the ARB losartan could reduce post-surgical cutaneous scarring in rats.

Human dermal fibroblasts (HDFs) were treated with losartan and assessed for viability, contractile activity, migration, and pro-fibrotic gene transcription via calcein, collagen gel, scratch, and quantitative reverse transcription polymerase chain reaction assays, respectively. Monocyte migration and adhesion to losartan-treated and control fibroblasts were examined. Losartan effects in vivo were assessed using a mechanical distraction hypertrophic scar model. Three days after incisions were made and closed on their backs, rats were randomly assigned to receive drinking water with or without losartan (1 mg/kg/d; n=6 per group). Distraction devices were applied and activated up to day 14. On day 28, scars underwent cross-sectional area and elevation index analyses, and α-SMA+ (alpha-smooth muscle actin) and CD68+ (monocyte/macrophage marker) immunostaining.

Losartan-treated HDFs displayed decreased contractile activity, migration, and gene expression of transforming growth factor-β1, collagen I and monocyte chemoattractant protein-1 relative to controls (p<0.05). Monocyte migration and adhesion to losartan-treated HDFs were reduced (p<0.01). Compared to controls, scars from losartan-treated rats demonstrated decreased cross-sectional area (19.4±3.1 versus 45.0±5.2 mm; p=0.002), elevation index (1.5±0.1 versus 2.6±0.3; p=0.003), and α-SMA+ and CD68+ immunostaining (p<0.001).

Losartan decreases myofibroblast activity and reduces monocyte trafficking to cutaneous scar. These findings support losartan as a potential novel therapy for the prevention of hypertrophic scars.

Critical Assessment of Surveys in Plastic and Reconstructive Surgery: A Systematic Review.

Plastic and Reconstructive Surgery

Surveys are a fundamental research tool used in the field of plastic surgery. Although inherent biases within surveys have been recognized, the extent to which this problem exists in the plastic surgery literature remains unknown.

We aim to (1) determine the extent to which common survey biases occur in plastic surgery surveys and (2) identify areas of improvement for survey researchers.

We conducted a systematic review of surveys in the plastic surgery literature from 1997 to 2017. After applying our inclusion and exclusion criteria, two reviewers examined a total of 199 studies containing a survey. A modified checklist based on the published literature was used to determine the presence, type, and severity of biases in plastic surgery surveys.

The mean percentage of biased questions in each survey was 24%. The most common biases were moderate (12%) and low impact biases (10%). Specifically, the most common biases were forced choice questions (6%), horizontal responses (6%), and double-barreled questions (1%). Only 13% of the articles that fit our inclusion criteria contained a full-length survey.

Although surveys in plastic surgery do not contain high impact biases, we have identified areas of improvement for surveys used in this specialty. We found that the surveys contain biases in question structure and the survey design, which can be improved through minor revisions to the question stem or responses. Moreover, journals should require researchers to submit a full-text survey for research transparency.

Osseous Transformation with Facial Feminization Surgery: Improved Anatomic Accuracy with Virtual Planning.

Plastic and Reconstructive Surgery

Facial Feminization Surgery (FFS) entails a series of surgical procedures that help the trans-woman pass as their affirmed gender. While virtual surgical planning (VSP) with intra-operative cutting guides and custom plates have been shown helpful for craniomaxillofacial reconstruction, they have not yet been studied for FFS. We used cadaveric analysis for morphologic typing and to demonstrate the utility of VSP in FFS procedures.

Male cadaveric heads underwent morphological typing analysis of the frontal brow, lateral brow, mandibular angle, and chin regions (n=50). Subsequently, the cadavers were split into two groups; 1) VSP intra-operative cutting guides and 2) No preoperative planning. Both groups underwent a)anterior frontal sinus wall set-back, b)lateral supraorbital recontouring, c)mandibular angle reduction, and d)osseous genioplasty narrowing. Efficiency (measured as operative time), safety (determined by dural or nerve injury), and accuracy (scored with 3D CT preop plan vs postop result) were compared between groups with significance being p<0.05 (*).

For Frontal Brow/Lateral Lower Face Morphologic Type 3 (severe) predominated; For Lateral Brow/Chin Type 2 (moderate) predominated. For Frontal Sinus wall setback, VSP improved efficiency (19 vs 44min*), safety (100% vs 88%*; less intracranial entry), and accuracy (97% vs 79%*) compared to 'No preoperative planning'. For mandibular angle reduction, VSP improved safety (100% vs 88%*; less inferior alveolar nerve injury) and accuracy (95% vs 58%*).

Preoperative planning for FFS is helpful to determine morphologic typing; VSP with the use of cutting guides/custom plates improved efficiency, safety, and accuracy when performing 4 key craniofacial techniques for FFS.

Algorithm for free perforator flap selection in lower extremity reconstruction based on 563 cases.

Plastic and Reconstructive Surgery

Microsurgical lower extremity reconstruction remains a challenge. The use of perforator flaps in lower extremity reconstruction is expanding. The objective of this article is to review our experience and present an algorithm to guide in the selection of the ideal free perforator flap that can be tailored to each lower extremity defect.

We conducted a retrospective review of lower extremity reconstruction using free perforator flaps over a 7-year period. Demographics, comorbidities, defect characteristics, operative details, complications and secondary procedures were documented. To facilitate algorithm creation, pairwise comparisons of flap types were performed to differentiate flaps on the basis of flap size, thickness and pedicle length.

A total of 563 free perforator flaps were performed. The most common etiologies were trauma (36.5%) and diabetes (24.4%). Nine flap types were used with the most common being SCIP (51.2%) and ALT (33.2%). Flap size differed significantly between flap types (p<0.05), with the exception of TDAP vs. GAP flaps (p=0.26). The thinnest flaps were PIAP (3.7±0.5mm) and SCIP (5.4±0.8mm). The thickest flaps were DIEP (11.1±3.9mm) and ALT (9.0±1.5mm). The shortest pedicles were in PIAP (3.3±0.3cm) and SCIP flaps (5.2±0.8cm). The longest pedicles were in DIEP (11.7±1.4cm), TDAP (9.3±1.4cm) and ALT flaps (9.2±0.8cm).

Free perforator flaps are reliable in lower extremity reconstruction. We present an algorithm for flap selection based on patient position, flap size, thickness, composition and pedicle length. We believe this approach helps to optimize form and function, decrease operative time, while minimizing donor site morbidity and secondary procedures.

Outcome of Recurrent Surgery in Dupuytren's Disease; Comparison with Initial Treatment.

Plastic and Reconstructive Surgery

There are multiple studies about the effectiveness of primary treatment in Dupuytren's disease. However, such studies concerning treatment effectiveness of recurrent disease are scarce. Therefore, the primary aim of this study is to compare treatment effectiveness of initial and repeated surgery in patients with Dupuytren's disease.

Patients who underwent both initial and repeated treatment were selected from a prospectively maintained database. Outcome measurements consisted of finger goniometry, the Michigan Hand Outcomes Questionnaire (MHQ) and complications. Treatment effectiveness was defined as improvement in extension deficit and patient-reported hand function. In addition, measurements at intake of both treatments were compared. Subgroup analysis were done to evaluate influence of type of surgery of initial treatment on outcomes of repeated treatment.

114 Patients were included in the final analyses. Improvement in extension deficit and MHQ outcomes was equal for initial and repeated treatments. Extension deficit and MHQ were worse at intake of repeated treatment compared to these outcomes at intake of initial treatment. In addition, patients who initially underwent needle fasciotomy achieved a better contracture reduction after repeated treatment.

This study demonstrates that treatment of recurrent Dupuytren's disease is as effective as initial treatment, despite larger extension deficit and worse self-assessed hand function before undergoing repeated treatment. Complication rates were similar for initial and repeated treatments. Furthermore, needle fasciotomy for initial treatment results in better outcomes of repeated treatment compared to patients who initially underwent limited fasciectomy. These findings can be used for a more evidence-based preoperative counseling with patients with recurrent Dupuytren's disease.

Perceptions of Surgery Residents About Parental Leave During Training.

JAMA Surgery

To our knowledge, there has been little research conducted on the attitudes of residents toward their pregnant peers and parental leave.

To examine the perceptions of current surgery residents regarding parental leave.

A 36-item survey was distributed to current US general surgery residents and residents in surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. Questions were associated with general information/demographics, parental leave, having children, and respondents' knowledge regarding the current parental leave policy as set by the American Board of Surgery. The study was conducted from August to September 2018 and the data were analyzed in October 2018.

Main outcomes included the attitudes of residents toward pregnancy and parental leave, parental leave policy, and the association of parental leave with residency programs.

A total of 2188 completed responses were obtained; of these, 1049 (50.2%) were women, 1572 (75.8%) were white, 164 (7.9%) were Hispanic/Latinx, 75 (3.6%) were African American, 2 (0.1%) were American Indian or Alaskan Native, 263 (12.7%) were Asian, and 5 (0.2%) were Native Hawaiian or Pacific Islander. From the number of residents who had/were expecting children (581 [28.6%]), 474 (81.6%) had or were going to have a child during the clinical years of residency. Many residents (247 [42.5%]) took fewer than 2 weeks of parental leave. Many residents did not feel supported in taking parental leave (177 [30.4%] did not feel supported by other residents and 190 [32.71%] did not feel supported by the faculty). Only 83 respondents (3.8%%) correctly identified the current American Board of Surgery parental leave policy. Residents who took parental leave identified a lack of a universal leave policy, strain on the residency program, a loss of education/training time, a lack of flexibility of programs, and a perceived or actual lack of support from faculty/peers as the top 5 biggest obstacles to taking leave during the clinical years of residency.

Most of the modifiable factors that inhibit residents from having children during residency are associated with policies (eg, a lack of universal leave policy and lack of flexibility) and personnel (eg, a strain on the residency program and lack of support from peers/faculty). These data suggest that policies at the level of the Accreditation Council for Graduate Medical Education or Resident Review Committee (RRC), as well as education and the normalization of pregnancy during training, may be effective interventions.

Association of Residents' Neural Signatures With Stress Resilience During Surgery.

JAMA Surgery

Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC).

To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline.

Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake.

Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-minute per knot time restriction).

A composite deterioration score was computed based on between-condition differences in task performance metrics (task progression score [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate.

Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral PFC in the SP condition and in the VLPFC in the TP condition. In contrast, Q4 residents demonstrated decreases in HbO2 in both conditions. The magnitude of PFC activation (change in HbO2) was significantly greater in Q1 than Q4 across the bilateral VLPFC during both SP (mean [SD] left VLPFC: Q1, 0.44 [1.30] μM; Q4, -0.21 [2.05] μM; P < .001; right VLPFC: Q1, 0.46 [1.12] μM; Q4, -0.15 [2.14] μM; P < .001) and TP (mean [SD] left VLPFC: Q1, 0.44 [1.36] μM; Q4, -0.03 [1.83] μM; P = .001; right VLPFC: Q1, 0.49 [1.70] μM; Q4, -0.32 [2.00] μM; P < .001) conditions. There were no significant between-group differences in Surgical Task Load Index or heart rate in either condition.

Performance stability within TP is associated with sustained prefrontal activation indicative of preserved attention and concentration, whereas performance decline is associated with prefrontal deactivation that may represent task disengagement.

Outcomes After Inguinal Hernia Repair With Mesh Performed by Medical Doctors and Surgeons in Ghana.

JAMA Surgery

Inguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair.

To compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana.

This prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia.

The primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year.

Two-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; P < .001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons.

This study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease.

Association Between the Use of Social Media and Photograph Editing Applications, Self-esteem, and Cosmetic Surgery Acceptance.

JAMA Facial Plastic Surgery

Social media platforms and photograph (photo) editing applications are increasingly popular sources of inspiration for individuals interested in cosmetic surgery. However, the specific associations between social media and photo editing application use and perceptions of cosmetic surgery remain unknown.

To assess whether self-esteem and the use of social media and photo editing applications are associated with cosmetic surgery attitudes.

A population-based survey study was conducted from July 1 to September 19, 2018. The web-based survey was administered through online platforms to 252 participants.

Each participant's self-esteem was measured using the Rosenberg Self-esteem Scale (scores range from 0-30; higher scores indicate higher self-esteem) and the Contingencies of Self-worth Scale (scores range from 1-7; higher scores indicate higher self-worth). Cosmetic surgery attitude was measured using the Acceptance of Cosmetic Surgery Scale (scores range from 1-7; higher scores indicate higher acceptance of cosmetic surgery). Unpaired, 2-tailed t tests were used to assess the significance of self-esteem and cosmetic surgery attitude score differences among users of various social media and photo editing applications. Structural equation modeling was used to assess the association between social media investment and cosmetic surgery attitudes.

Of the 252 participants, 184 (73.0%) were women, 134 (53.2%) reported themselves to be white, and the mean age was 24.7 (range, 18-55) years. Scores on the Rosenberg Self-esteem Scale from users and nonusers across applications were compared, with lower self-esteem scores noted in participants who reported using YouTube (difference in scores, -1.56; 95% CI, -3.01 to -0.10), WhatsApp (difference in scores, -1.47; 95% CI, -2.78 to -0.17), VSCO (difference in scores, -3.20; 95% CI, -4.98 to -1.42), and Photoshop (difference in scores, -2.92; 95% CI, -5.65 to -0.19). Comparison of self-esteem scores for participants who reported using other social media and photo editing applications yielded no significant differences. Social media investment had a positive association with consideration of cosmetic surgery (R, 0.35; 95% CI, 0.04-0.66). A higher overall score on the Acceptance of Cosmetic Surgery Scale was noted in users of Tinder (difference in means, 0.79; 95% CI, 0.34-1.23), Snapchat (difference in means, 0.39; 95% CI, 0.07 to 0.71), and/or Snapchat photo filters (difference in means, 0.44; 95% CI, 0.16-0.72). Increased consideration of cosmetic surgery but not overall acceptance of surgery was noted in users of VSCO (difference in means, 0.84; 95% CI, 0.32-1.35) and Instagram photo filters (difference in means, 0.38; 95% CI, 0.01-0.76) compared with nonusers.

This study's findings suggest that the use of certain social media and photo editing applications may be associated with increased acceptance of cosmetic surgery. These findings can help guide future patient-physician discussions regarding cosmetic surgery perceptions, which vary by social media or photo editing application use.