The latest medical research on Plastic Surgery

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Meta-Analyses in Plastic Surgery: Can We Trust Their Results?

Plastic and Reconstructive Surgery

Meta-analyses are common in the plastic surgery literature, but studies concerning their quality are lacking. The authors assessed the overall quality of meta-analyses in plastic surgery, and attempted to identify variables associated with scientific quality.

A systematic review of meta-analyses published in seven plastic surgery journals between 2007 and 2017 was undertaken using a computerized search. Publication descriptors and methodological and statistical details were extracted. Articles were assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews) and AMSTAR 2 instruments.

Seventy-four studies were included. The number of meta-analyses per year increased. Most meta-analyses assessed a single intervention (59.5 percent), and pooled a mean of 20.9 studies (range: 2-134), including a mean of 2,463 patients (range: 44-14,884). Most meta-analyses were published in Plastic & Reconstructive Surgery (44.6 percent), and included mid-level evidence (II to IV) primary studies. Only 16.2 percent of meta-analyses included randomized controlled trials. Meta-analyses generally reported positive (81.1 percent) and significant results (77.0 percent). Median AMSTAR score was 7/11 (interquartile range=5-8). AMSTAR scores correlated with year of publication (p=0.04, R=0.24). Higher AMSTAR scores correlated with more recent meta-analyses that provided a rationale for statistical pooling, and appropriately managed methodological heterogeneity (r=0.66, p<0.01).

Despite an increase in the number and quality of meta-analyses, these studies are at high risk of bias due to the low level of evidence of included primary studies and heterogeneity within and between primary studies. Plastic surgeons should be aware of the pitfalls of conducting and interpreting meta-analyses.

Comparison of Outcomes between Side-to-End and End-to-End Lymphovenous Anastomoses for Early-Grade Extremity Lymphedema.

Plastic and Reconstructive Surgery

Lymphovenous anastomosis (LVA) is technically challenging and could be successfully performed with advanced operating microscope, super-microsurgical instruments, and indocyanine green (ICG) lymphography. This study was to compare the outcomes between side-to-end and end-to-end LVA configurations for unilateral extremity lymphedema.

Between April 2013 and June 2017, 58 patients who preoperatively had patent lymphatic ducts by ICG lymphography were indicated for LVA, including 20 upper limb lymphedema and 38 lower limb lymphedema. Either an end-to-end or a side-to-end LVA was used to anastomose the subdermal venule to lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements.

Twenty-three patients underwent an end-to-end LVA, and 35 patients had a side-to-end LVA. All cases had an immediate patency evaluated by ICG lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At an average follow-up of 16.5 (13.4-19.6) months, the improvement of circumferential difference 3.2 (1.8-4.6)% in side-to-end group was statistically greater than 2.2 (1-3.4)% in end-to-end group (p= 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 (1.3-2.1) to 0.7 (0.3-1.1) times per year (p< 0.001), but no difference was observed between the two groups.

Both side-to-end and end-to-end LVA configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end LVA has the advantages of having a greater efficacy for lymph drainage while requiring only one anastomosis and eliminating the need to use compression garments.

A Growing Epidemic: Plastic Surgeons and Burnout - A Literature Review.

Plastic and Reconstructive Surgery

The prevalence of burnout is increasing among all physicians, including plastic surgeons. Burnout is not simply synonymous with being overworked. It is a complex physical, intellectual and psychological entity that arises when the expectation and reality of the job do not match. In this article, our goal is to define burnout, summarize its causes and consequences, and offer the plastic surgeons methods to prevent and address it METHODS:: A literature search of articles on burnout in medicine was performed. Articles that were relevant were selected, and were qualitatively analyzed to answer our questions on the definition, prevalence, causes, consequences and treatments of burnout.

Sixty five relevant articles were included. The prevalence of burnout among physicians ranges between 29% and 55%. Risk factors for physician burnout include increased workload and call, junior academic rank, and fair physician health. There is significant overlap between burnout, depression and substance abuse, and suicide is much more common among physicians than the general population. Preventing burnout involves a multi-pronged approach that addresses the physical, intellectual and psychological dimensions of the physician.

In this article, concrete steps to prevent and address burnout are presented to plastic surgeons. For physicians, the most important elements for burnout avoidance are the prevention of emotional exhaustion, and the development of professional autonomy and control.

Conflict of Interest at Plastic Surgery Conferences- Is it Significant?

Plastic and Reconstructive Surgery

The Physician Payment Sunshine Act requires biomedical companies to disclose financial relationship between themselves and physicians. We compared the amount of money received by speakers at the American Society of Plastic Surgeons (ASPS), and the American Society of Aesthetic Plastic Surgeons (ASAPS) annual conferences with the average plastic surgeon.

General payments data was gathered from the Open Physician Payments Database for physicians listed as a presenter, moderator, panelist, lecturer, or instructors at the 2017 annual ASPS and ASAPS conferences. Means and medians of payments to speakers were calculated for each conference. One tailed t-tests were used to evaluate differences.

The mean and median for general payments made to conference speakers at ASAPS (n=75) and ASPS (n=249) were $75,577 and $861 and $27,562 and $1,021 respectively. In comparison to the average general payment received by plastic surgeons ($4,788 mean, $3,209 Median) these differences were significant (ASAPS p= 0.015; ASPS p = 0.0004). 12.8% of ASPS speakers and 13.2% of ASAPS speakers received over $37,000 or 10% of the average reported annual salary of plastic surgeons of $371,000.

The significant difference in payments to speakers at conferences compared to the average plastic surgeon suggests that biomedical companies may have influence over some of the conference content. It is likely that the monetary value reported underestimates the true impact of these companies. Speakers must make clear the full extent of industry relationships which could potentially may bias their presentations.

"Minced Skin Grafting for Promoting Wound Healing and Improving Donor Site Appearance after Split-thickness Skin Grafting: A Prospective Half-side Comparative Trial".

Plastic and Reconstructive Surgery

Minced skin grafting (MG) is a procedure that involves mincing of the harvested skin and grafting it back onto the wounds. We aimed to investigate whether MG reduces the healing time and improves the sequential postoperative appearance of donor sites.

A single-center, two-treatment, half-side comparative study was performed. The split-thickness skin remaining after grafting was minced until pasty. The small pasty graft mass was uniformly spread on half of the entire donor site. MG was not performed on the other side. The data from 30 patients were used for analysis.

The average time to complete healing of the donor sites in the MG and control groups was 9.4±2.5 and 12.4±3.6 days, respectively. The difference in the healing time between the 2 groups was statistically significant (p<0.001). Three blinded surgeons used a scale to grade photographs according to the degree of conspicuous donor sites in comparison with the normal skin around the donor sites. All observers reported that the differences in donor site appearance between the MG and control groups were statistically significant at postoperative months 1 and 2, and two observers reported that the differences in donor site appearance were significant at months 4, 6, and 12. The differences in the number of patients with donor site dyspigmentation between the MG and control groups at 12 months were statistically significant (p<0.05).

This prospective half-side comparative trial demonstrates that MG promotes wound healing and improves donor site appearance after split-thickness skin grafting.

Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access.

JAMA Surgery

Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009.

To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use.

This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed.

Placement of an AVF or AVG for initial permanent hemodialysis access.

A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use.

A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution.

In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.

Comparison of Targeted vs Systematic Prostate Biopsy in Men Who Are Biopsy Naive: The Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) Study.

JAMA Surgery

Magnetic resonance imaging (MRI) guidance improves the accuracy of prostate biopsy for the detection of clinically significant prostate cancer, but the optimal use of such guidance is not yet clear.

To determine the cancer detection rate (CDR) of targeting MRI-visible lesions vs systematic prostate sampling in the diagnosis of clinically significant prostate cancer in men who were biopsy naive.

This paired cohort trial, known as the Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) study, was conducted in an academic medical center from January 2015 to April 2018. Men undergoing first-time prostate biopsy were enrolled. Paired-cohort participants were a consecutive series of men with MRI-visible lesions (defined by a Prostate Imaging Reporting & Data System version 2 score  ≥ 3), who each underwent 3 biopsy methods at the same sitting: first, a systematic biopsy; second, an MRI-lesion biopsy targeted by cognitive fusion; and third, an MRI-lesion targeted by software fusion. Another consecutive series of men without MRI-visible lesions underwent systematic biopsies to help determine the false-negative rate of MRI during the trial period.

The primary end point was the detection rate of clinically significant prostate cancer (Gleason grade group ≥2) overall and by each biopsy method separately. The secondary end points were the effects of the Prostate Imaging Reporting & Data System version 2 grade, prostate-specific antigen density, and prostate volume on the primary end point. Tertiary end points were the false-negative rate of MRI and concordance of biopsy-method results by location of detected cancers within the prostate.

A total of 300 men participated; 248 had MRI-visible lesions (mean [SD] age, 65.5 [7.7] years; 197 were white [79.4%]), and 52 were control participants (mean [SD] age, 63.6 [5.9] years; 39 were white [75%]). The overall CDR was 70% in the paired cohort group, achieved by combining systematic and targeted biopsy results. The CDR by systematic sampling was 15% in the group without MRI-visible lesions. In the paired-cohort group, CDRs varied from 47% (116 of 248 men) when using cognitive fusion biopsy alone, to approximately 60% when using systematic biopsy (149 of 248 men) or either fusion method alone (154 of 248 men), to 70% (174 of 248 men) when combining systematic and targeted biopsy. Discordance of tumor locations suggests that the different biopsy methods detect different tumors. Thus, combining targeting and systematic sampling provide greatest sensitivity for detection of clinically significant prostate cancer. For all biopsy methods, the Prostate Imaging Reporting & Data System version 2 grade and prostate-specific antigen density were directly associated with CDRs, and prostate volume was inversely associated.

An MRI-visible lesion in men undergoing first-time prostate biopsy identifies those with a heightened risk of clinically significant prostate cancer. Combining targeted and systematic biopsy offers the best chances of detecting the cancer.

Role of Hepatic Artery Infusion Chemotherapy in Treatment of Initially Unresectable Colorectal Liver Metastases: A Review.

JAMA Surgery

Although liver metastasis develops in more than half of patients with colorectal cancer, only 15% to 20% of these patients have resectable liver metastasis at presentation. Moreover, patients with initially unresectable colorectal liver metastasis (IU-CRLM) who progress on first-line systemic chemotherapy have limited treatment options. Hepatic arterial infusion chemotherapy (HAIC), in combination with systemic chemotherapy, leverages a multimodality approach to achieving control of hepatic disease and/or expanding resectability in patients with liver-only disease or liver-dominant disease.

Intra-arterial delivery of agents with high first-pass hepatic extraction (eg, floxuridine) limits systemic toxic effects and allows for administration of systemic chemotherapy at near-full doses. Hepatic arterial infusion chemotherapy in conjunction with systemic chemotherapy augments response rates up to 92% in patients who are chemotherapy naive, and up to 85% in pretreated patients with IU-CRLM. In turn, these responses translate into encouraging rates of conversion to resectability (CTR). Prospective trials have reported CTR rates as high as 52% in heavily pretreated patients with IU-CRLM who have an extensive hepatic disease burden. As such, CTR remains a compelling indication for liver-directed chemotherapy in this subset of patients. This review discusses the biological rationale for HAIC, evolution of rational combinations with systemic chemotherapy, contemporary evidence for CTR using HAIC and systemic chemotherapy, juxtaposition with rates of CTR using systemic chemotherapy alone, and morbidity and toxic effect profiles of HAIC.

The argument is made for consideration of earlier initiation of HAIC in patients with IU-CRLM who are chemotherapy naive and for adoption of HAIC strategies to augment rates of resectability in patients who have failed first-line systemic chemotherapy before proceeding to second-line or third-line regimens.

Age at craniosynostosis surgery and its impact on ophthalmologic diagnoses-a single-center retrospective review.

Plastic and Reconstructive Surgery

Ocular pathology in craniosynostosis is a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, we hypothesize that operating early will have no bearing on post-operative ophthalmologic outcomes.

Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multi-suture craniosynostosis, syndromic diagnoses, no pre-operative ophthalmology evaluation, and less than two years of follow-up were excluded. Logistic regression was used to determine odds of pre- and post-operative ophthalmologic abnormalities by age, while controlling for patient-level covariates.

172 patients met inclusion criteria. The median age at surgery was 10 months (IQR 7-12.9 months). Increasing age at the time of surgery was associated with increased odds of pre-operative ophthalmologic diagnoses (OR: 1.06; p=0.037) but not post-operative diagnoses (OR: 1.00; p=0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR 1.04, p=0.08). Patients with coronal synostosis (OR 3.94, p=0.036) had significantly higher odds of pre-operative ophthalmologic diagnoses. Patients with metopic (OR: 5.60; p<0.001) and coronal (OR: 7.13; p<0.001) synostosis had significantly higher odds of post-operative ophthalmologic diagnoses.

After reviewing an expansive cohort, associations between both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. Our findings thus run counter to the theory that early surgical intervention lessens the likelihood of post-operative ophthalmologic diagnoses and improves ophthalmologic outcomes.

Adipose-Derived Stem Cells (ASCs) and Ceiling Culture-Derived Preadipocytes (ccdPAs) Cultured from Subcutaneous Fat Tissue Differ in their Epigenetic Characteristics and Osteogenic Potential.

Plastic and Reconstructive Surgery

Adipose-derived stem cells (ASCs) and ceiling culture-derived preadipocytes (ccdPAs) can be harvested from subcutaneous adipose tissue. Little is known about the epigenetic differences, which may contribute to differences in osteogenic potential, between these cell types.

The purpose of this study was to address the osteogenic potential and underlying epigenetic status of ASCs and ccdPAs.

ASCs and ccdPAs were cultured from abdominal subcutaneous fat tissues of four metabolically healthy, lean females. After seven weeks of culture, cellular responses to osteogenic differentiation media were examined. To evaluate the osteogenic potentials of undifferentiated ASCs and ccdPAs, two types of epigenetic assessment were performed using next generation sequencing: DNA methylation assays with a 450K BeadChip; and chromatin immunoprecipitation assays (ChIP-Seq) for trimethylation of histone H3 at lysine 4 (H3K4me3).

Human ccdPAs showed greater osteogenic differentiation ability than did ASCs. In an epigenetic survey of the promoters of four osteogenic regulator genes (RUNX2, SP7, ATF4, and BGLAP), we found a general trend toward decreased CpG methylation and increased H3K4me3 levels in ccdPAs as compared to ASCs, indicating that these genes were more likely to be highly expressed in ccdPAs.

The surveyed epigenetic differences between ASCs and ccdPAs were consistent with the observed differences in osteogenic potential. These results enhance our understanding of these cells and will facilitate their further application in regenerative medicine.

"A Prospective Evaluation of Complications after Use of Exposed Pins in the Hand and Wrist".

Plastic and Reconstructive Surgery

Kirschner wires (K-wires) are commonly used during hand surgical procedures. These pins are often left exposed (protruding from the skin) for ease of removal. Complications such as loosening, migration, or infection are not uncommon (ranging from 7-18% in current retrospective studies) and can compromise surgical outcome. This study evaluated the frequency of K-wire related complications.

All patients who had K-wires placed as part of their surgical procedure in the hand or wrist by one of 12 attending hand surgeons over a 6-month period were enrolled prospectively. Complications were recorded by the attending surgeon at follow-up visits. Demographics and patient comorbidities including diabetes mellitus and smoking history were recorded.

There were 141 patients enrolled and 230 pins used, including 65 women and 76 men. The mean age was 40.7 years. Thirteen patients were smokers, and 8 had a history of diabetes. There were 35 soft tissue procedures and 106 fractures. There were 35 complications (25%). There was a 12% rate of infection (n=17) including 2 cases of osteomyelitis. There were 18 other complications 9 of which were major complications (6.4%). Smoking, age, and location (hand/fingers vs. wrist) were significantly associated with infection.

In this study, one in four patients treated with K-wires developed a minor or major complication, a rate which is substantially higher than reported in existing retrospective studies. While K-wires are often needed during hand surgery, surgeons should be aware that adverse events are frequent. Patients and surgeons should be vigilant in the peri-operative period.

Airway Analysis in Apert Syndrome.

Plastic and Reconstructive Surgery

Apert syndrome is frequently combined with respiratory insufficiency, due to the mid-facial deformity, which, in turn, is influenced by the malformation of the skull base. Respiratory impairment resulting from Apert syndrome is caused by multilevel limitations in airway space. Therefore, this study evaluated the segmented nasopharyngeal and laryngopharyngeal anatomy to clarify subcranial anatomy in children with Apert syndrome and its relevance to clinical management.

Twenty-seven patients (Apert, n=10; control, n=17) were included. All of the CT scans were obtained from the patients preoperatively, and no patient had confounding disease comorbidity. CT scans were analyzed using Surgicase CMF. Craniometric data relating to the midface, airway, and sub-cranial structures were collected. Statistical significance was determined using t-test analysis.

Although all the nasal measurements were consistent with those of the controls, the distance between nasion-PNS, sphenethmoid-PNS, sella-PNS, and basion-PNS were decreased 20% (p<0.001), 23% (p=0.001), 29% (p<0.001), and 22% (p<0.001), respectively. The distance between bilateral gonions and condylions was decreased 17% (p=0.017) and 18% (p=0.004) respectively. The pharyngeal airway volume was reduced by 40% (p=0.01).

The airway compromise seen in patients with Apert syndrome is more attributable to the pharyngeal region than the nasal cavity, with a gradually worsening trend from the anterior to the posterior airway, resulting in a significantly reduced volume in the hypopharynx.