Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis

BACKGROUND

 Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS).

METHODS

 A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes.

RESULTS

 Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different.

CONCLUSION

 CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Ethical Considerations Regarding Financial Incentives in Plastic Surgery-Related Health Research

To recruit enough patients to achieve adequate statistical power in clinical research, investigators often rely on financial incentives. The use of these incentives, however, remains controversial as they may cause patients to overlook risks associated with research participation. This concern is amplified in the context of plastic surgery where aesthetic procedures are often more desirable and are not typically covered by public or private insurance plans. Despite this, the ethical debate regarding the use of incentives has largely been absent from plastic surgery journals; therefore, efforts to summarize the existing literature in the context of plastic surgery are necessary. While incentives have the potential to improve sample sizes and promote the recruitment of under-represented patient populations, undue inducement and biased recruitment are possible. At present, there exists a paucity of empirical evidence to substantiate this. Despite this, efforts should be taken by investigators and research ethics boards (REBs) to limit the potential negative impacts of monetary compensation. Investigators should place reasonable limits on the value of incentives as well as select models associated with lower risks of undue influence and enrollment bias. When financial remuneration is offered, additional care should be taken by investigators to ensure participants are adequately informed of the risks associated with research participation. Current best practice recommendations suggest that proposals submitted to REBs justify the incentives used. Information regarding incentives should also be included within study consent forms and communicated to participants as part of the informed consent process.

Multidisciplinary Practice Variations of Anti-Thrombotic Strategies for Free Tissue Transfers

Background: Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. Methods: National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. Results: There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. Conclusions: There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.

What Does It Take to Become an Academic Plastic Surgeon in Canada: Hiring Trends Over the Last 50 Years

Objective: Academic plastic surgery positions have become highly competitive secondary to delayed retirement, stagnant hospital funding, and an increasing number of plastic surgery graduates. Little information is available to help residents navigate this challenging landscape. Our objectives were to evaluate the training backgrounds of all Canadian academic plastic surgeons and to develop recommendations for residents interested in an academic career. Methods: All Canadian academic plastic surgeons were included. Training histories were obtained from institutions’ websites. Surgeons were subsequently emailed to confirm this information and complete missing details. Multivariate regressions were designed to analyze the effect of gender and FRCSC year on graduate and fellowship training and time to first academic position. Results: Training information was available for 196 surgeons (22% female), with a 56% email response rate; 91% of surgeons completed residency in Canada; 94% completed fellowship training, while 43% held graduate degrees; 74% were employed where they previously trained. Female gender significantly lengthened the time from graduation to first academic job, despite equal qualification. Younger surgeons were more likely to hold graduate degrees (P < .01). Conclusions: We identified objective data that correlate with being hired at an academic centre, including training at the same institution, obtaining a graduate degree during residency, and pursuing fellowship training. In addition, we demonstrated that women take significantly longer to acquire academic positions (P < .01), despite equal qualification. Trainees should consider these patterns when planning their careers. Future research should explore gender-based discrepancies in hiring practices.

Job Satisfaction Among Plastic Surgery Residents in Canada

Objective:

Resident wellness is a focus of medical training and is prioritized in both Canadian and American accreditation processes. Job satisfaction is an important component of wellness that is not examined in the literature. The purpose of this study was to analyze job satisfaction in a national sample of plastic surgery residents, and identify factors that influence satisfaction.

Methods:

We designed a cross-sectional survey adapted from existing instruments, with attention to thorough item generation and reduction as well as pilot and clinical sensibility testing. All plastic surgery residents at Canadian institutions were surveyed regarding overall job satisfaction as well as personal- and program-specific factors that may affect satisfaction. Predictors of satisfaction were identified using multivariable regression models.

Results:

The response rate was 40%. Median overall job satisfaction was 4.0 on a 5-point Likert scale. Operative experience was considered both the most important element of a training program, and the area in most need of improvement. Senior training year (P < .01), shorter commute time (P = .04), fewer duty hours (P = .02), fewer residents (P < .01), and more fellows (P < .01) were associated with significantly greater job satisfaction.

Conclusions:

This is the first study to gather cross-sectional data on job satisfaction from a national sample of plastic surgery residents. The results from this study can inform programs in making tangible changes tailored to their trainees’ needs. Moreover, our findings may be used to inform a prospectively studied targeted intervention to increase job satisfaction and resident wellness to address North American accreditation standards.

Transitioning a randomized controlled trial to a digital registry – experience from the TAILOR-PCI digital follow-up study on onboarding, engagement and geofencing consent rate

Background/Introduction

TAILOR-PCI is the largest cardiovascular genotype-based randomized trial (NCT#01742117) investigating whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes after percutaneous coronary intervention (PCI). The TAILOR-PCI Digital Sub-Study tests the feasibility of extending original follow-up of 1 year to 2 years using state-of-the-art digital solutions. Deep phenotyping acquired during a clinical trial can be leveraged by extending follow-up in an efficient and cost-effective manner using digital technology.

Purpose

Our objective is to describe onboarding and engagement of participants initially recruited in a large, pragmatic, international, multi-center clinical trial to a digital registry.

Methods

TAILOR-PCI participants, within 23 months of their index PCI, were invited by letters containing a URL to the Digital Sub-Study website (http://tailorpci.eurekaplatform.org). These invitations were followed by phone calls, if no response to the letter, to determine reason for non-participation. A NIH-funded direct-to-participant digital research platform (the Eureka Research Platform) was used to onboard, consent and enroll participants for the digital follow-up. Participants were asked to answer health-related surveys at fixed intervals using the Eureka mobile app and desktop platform. To capture hospitalizations, participants could enable geofencing to allow background location tracking, which triggered surveys if a hospitalization was detected.

Result(s)

Letters were mailed to 893 of 929 eligible participants across 22 sites in the United States and Canada leading to 226 homepage visits and 118 registrations. There were 107 consents (12.0% of invited; mean age: 66.4±9.0; 19 females [18%]): 47 (44%) participants consented after the letter, 36 (34%) consented after the 1st call and 24 (22%) consented after a 2nd call. Among those who consented, 100 were eligible (7 did not have a smartphone) 81 downloaded the study mobile app and 73 agreed for geofencing (Figure 1). Among the 722 invited participants who were surveyed, 354 declined participation: due to lack of time (146; 20.2%), lack of smartphone (125; 17.3%), difficulty understanding (41; 5.7%), concern about using smartphone (34; 4.7%), concern of data privacy (14; 1.9%), concerns of location tracking (6; 0.8%) and other reasons (57; 7.9%).

Conclusion

Extended follow-up of a clinical trial using a digital platform is feasible but uptake in this study population was limited largely due to lack of time or a smartphone among participants. Based on data from other digital studies, uptake may also have been limited since digital follow-up consent was not incorporated at the time of consent for the main trial.

Figure 1. Onboarding of the digital substudy

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI)

Pregnancy and parental leave among plastic surgery residents in Canada: a nationwide survey of attitudes and experiences

SUMMARY

Small surgical residency programs like plastic surgery can be challenging environments to accommodate parental leave. This study aimed to report the experiences, attitudes and perceived support of Canadian plastic surgery residents, recent graduates and staff surgeons with respect to pregnancy and parenting during training. Residents and staff surgeons were invited via email to participate in an online survey. The results presented here explore experiences of pregnancy and parental leave of current plastic surgery residents and staff surgeons. Residents' and staff surgeons' perceptions of program director support, policies, negative comments and the impact of parental leave on the workload of others were also explored. Although the findings suggest that there may be improvements in the support of program directors, there continues to be a negative attitude in surgical culture toward pregnancy during residency. The perceived confusion of respondents with respect to programspecific policies emphasizes the need for open conversations and standardization of parental leave.

The Reporting Quality of Randomized Controlled Trial Abstracts in Plastic Surgery

BACKGROUND

When evaluating randomized controlled trials (RCTs), clinicians will often refer to the abstract for an initial assessment of the results and to determine whether a full-text review is warranted.

OBJECTIVES

This project aims to assess the reporting quality of RCT abstracts published within the top 5 plastic surgery journals utilizing the Consolidated Standards of Reporting Trials (CONSORT) for abstracts checklist.

METHODS

A computerized database search of OVID MEDLINE was performed. All primary RCTs published within the top 5 plastic surgery journals (by 2016 International Scientific Indexing impact factor) from 2011 to 2018 were included. Two reviewers, blinded to journal and author, independently and in duplicate, scored abstracts employing the 16-item CONSORT for abstracts checklist.

RESULTS

This review identified 126 RCTs that satisfied the inclusion criteria. Included studies were distributed across 5 journals: Plastic and Reconstructive Surgery (n = 83), JAMA Facial Plastic Surgery (n = 8), Aesthetic Surgery Journal (n = 33), Journal of Reconstructive Microsurgery (n = 2), and the Journal of Hand Surgery-European Volume (n = 0). Mean overall item adherence across all abstracts was 7 (SD ± 2). The most poorly reported items were "trial registration," "method of randomization," and "source of trial funding" and appeared in 4%, 2.4%, and 0% of abstracts, respectively.

CONCLUSIONS

There is limited adherence to the CONSORT for abstracts checklist among RCT abstracts published within the top 5 plastic surgery journals. Given the reliance of clinicians on abstract reporting, omitting essential trial details can lead to an inaccurate interpretation of trial results and improper application in clinical practice. Active endorsement of the CONSORT for abstracts checklist is required to improve the quality of RCT abstract reporting.

The success of salvage procedures for failing digital replants: A retrospective cohort study

BACKGROUND

The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants.

METHODS

Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded.

RESULTS

Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged.

CONCLUSION

Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

An evaluation of accessibility and content of microsurgery fellowship websites

BACKGROUND

Websites for residency and fellowship programs serve as effective educational and recruitment tools.

OBJECTIVE

To evaluate the accessibility and content of fellowship websites that are commonly used by microsurgery applicants for career development.

METHODS

A list of one-year microsurgery fellowship websites (MFWs) was compiled by visiting the centralized American Society for Reconstructive Microsurgery (ASRM) website, followed by performing an extensive 'Google' search in October 2015. Accessibility of MFWs was assessed. Website content regarding key recruitment and education variables was also comprehensively reviewed. Website content was correlated with program characteristics using t tests and ANOVA (two-tailed; P<0.05 was considered to be statistically significant).

RESULTS

A list of 53 eligible programs was compiled. Only 15 of 51 (29%) ASRM program links were functional. On average, the combined content from ASRM website and individual MFWs had 2.91 of 6 recruitment variables and 1.32 of 6 education variables, respectively. The majority of programs listed 'eligibility criteria' (87%) and 'general information' (87%). 'Evaluation criteria' were most poorly reported (4%). Recruitment score was higher for United States programs compared with international counterparts (51% versus 33%, respectively; P=0.02). It was also higher in programs that focus on 'extremity' versus 'breast' (58% versus 37%; P=0.0028). Education scores did not differ according to location, program size, subspecialty of focus or participation in the Microsurgery Match process.

CONCLUSION

Information regarding recruitment and education on most MFWs is scarce. Academic institutions should keep website content up to date and comprehensive to better assist candidates in the application process.

An evaluation of accessibility and content of microsurgery fellowship websites

Background

Websites for residency and fellowship programs serve as effective educational and recruitment tools.

Objective

To evaluate the accessibility and content of fellowship websites that are commonly used by microsurgery applicants for career development.

Methods

A list of one-year microsurgery fellowship websites (MFWs) was compiled by visiting the centralized American Society for Reconstructive Microsurgery (ASRM) website, followed by performing an extensive ‘Google’ search in October 2015. Accessibility of MFWs was assessed. Website content regarding key recruitment and education variables was also comprehensively reviewed. Website content was correlated with program characteristics using t tests and ANOVA (two-tailed; P<0.05 was considered to be statistically significant).

Results

A list of 53 eligible programs was compiled. Only 15 of 51 (29%) ASRM program links were functional. On average, the combined content from ASRM website and individual MFWs had 2.91 of 6 recruitment variables and 1.32 of 6 education variables, respectively. The majority of programs listed ‘eligibility criteria’ (87%) and ‘general information’ (87%). ‘Evaluation criteria’ were most poorly reported (4%). Recruitment score was higher for United States programs compared with international counterparts (51% versus 33%, respectively; P=0.02). It was also higher in programs that focus on ‘extremity’ versus ‘breast’ (58% versus 37%; P=0.0028). Education scores did not differ according to location, program size, subspecialty of focus or participation in the Microsurgery Match process.

Conclusion

Information regarding recruitment and education on most MFWs is scarce. Academic institutions should keep website content up to date and comprehensive to better assist candidates in the application process.

Consensus Document on Intermittent Claudication from the Central European Vascular Forum (C.E.V.F.)-3rd revision (2013) with the sharing of the Mediterranean League of Angiology and Vascular Surgery, and the North Africa and Middle East Chapter of International Union of Angiology

This paper is the review of the Consensus Document on Intermittent Claudication of the Central European Vascular Forum (CEVF), published in 2008, and and shared with the North Africa and Middle East Chapter of International Union of Angiology and the Mediterranean League of Angiology and Vascular Surgery. The Document presents suggestions for general practitioners and vascular specialists for more precise and appropriate management of PAD, particularly of intermittent claudication, and underlines the investigations that should be required by GPs and what the GP should expect from the vascular specialist (angiologist, vascular surgeon). The idea of the Faculty is to produce a short document, which is an easy reference in daily clinical practice, both for the GPs and vascular specialists.

Posterior interosseous nerve compression secondary to a parosteal lipoma: Case report and literature review

An unusual case of limited radial nerve palsy secondary to a parosteal lipoma is presented, along with a thorough review of the literature. Palsy of the posterior interosseous nerve secondary to compression by a lipoma is a rare occurrence. Most cases tend to occur in the fifth to eighth decades of life. The pattern of physical symptoms may be quite variable. A high degree of suspicion must be maintained in the setting of unexplained symptoms. The literature review revealed the presence of a diagnostic proximal forearm radiolucent mass in 13 of 15 patients. Although they are used as diagnostic aids, computed tomography and magnetic resonance imaging have not been shown to alter management. Though benign tumours constitute a minority of such cases, a plain radiograph is recommended in addition to electromyographic and nerve conduction studies.

Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: a meta-analysis

BACKGROUND

The main priorities in the surgical treatment of patients with breast cancer are to achieve cure, local control and prevent recurrence. It is increasingly important to address quality of life and self-image with women undergoing surgical intervention for breast cancer. There is a lack of consensus as to the oncologic safety of immediate breast reconstruction (IBR). The purpose of this paper is to systematically review the literature and compare the frequency of recurrence in patients with and without IBR following mastectomy for breast cancer.

METHODS

Two independent investigators searched PubMed, Embase, and the Cochrane database using predefined search terms. After application of inclusion and exclusion criteria, 10 articles remained. Each article was assessed for quality. Relevant data was collected including recurrence rates, cancer stage, type of mastectomy and reconstruction, adjuvant treatments, and duration of follow-up.

RESULTS

Inter-rater reliability was good at 74% (95% CI: 0, 93%). There was no evidence of study heterogeneity (p for Q-statistic=0.34 and I(2)=12%). The OR ratio for recurrence of breast cancer for mastectomy with IBR as compared to mastectomy alone was 0.98 (95% CI: 0.62, 1.54).

CONCLUSION

This meta-analysis demonstrated no evidence for increased frequency of local breast cancer recurrence with IBR compared with mastectomy alone.

Comparison of the biochemical responses to human parathyroid hormone-(1-31)NH2 and hPTH-(1-34) in healthy humans

The 1-31 fragment of human PTH [hPTH-(1-31)NH2] has been shown, like hPTH-(1-34), to have anabolic effects on the skeletons of ovariectomized rats when given intermittently, but, unlike hPTH-(1-34), it does so without affecting serum calcium concentrations and does not activate the protein kinase C second messenger pathway in some target cells. To investigate the biochemical responses to hPTH-(1-31) in humans, we have directly compared it to hPTH-(1-34) during the course of slow infusions of each. Ten healthy adults, five men and five women, aged 26+/-5 yr (range, 22-37), each received 8-h continuous infusions of 8 pmol/kg.h hPTH-(1-34) and hPTH-(1-31) given in random order at least 2 weeks apart. During the infusions there were significant increases in both plasma and urinary cAMP (P < 0.05), but there were no differences in the responses between the two peptides (P = 0.362 for plasma; P = 0.987 for urine). There were also significant phosphaturic and natriuretic responses to the two peptides, which again were not different between peptides. During the infusion of hPTH-(1-34) serum ionized calcium (Ca2+) increased from 1.21+/-0.033 to 1.29+/-0.046 mmol/L (P < 0.01), and endogenous hPTH-(1-84) decreased from 29.6+/-9 to 15.0+/-5.7 pg/mL (P < 0.01), such that there was a negative correlation between them (r2 = 0.45). However, when hPTH-(1-31) was infused, neither serum Ca2+ (1.24+/-0.03 vs. 1.25+/-0.03) nor hPTH-(1-84) (26.8+/-5 vs. 30.7+/-12 pg/mL) was affected. Circulating concentrations of 1,25-dihydroxyvitamin D3 increased from 92+/-42 to 131+/-63 pmol/L (P < 0.05) during infusion of hPTH-(1-34) and from 92+/-27 to 110+/-42 pmol/L (P = NS) during hPTH-(1-31) infusion. There was also a significant increase in the urinary measure of type I collagen degradation of aminoterminal telopeptides from 78+/-45 to 101+/-51 nmol/mmol creatinine (P < 0.05) when hPTH-(1-34) was infused, but it was not affected (68+/-30 vs. 66+/-24 nmol/mmol creatinine) by hPTH-(1-31). Therefore, hPTH-(1-31) appears to be equivalent and equipotent to hPTH-(1-34) in the release of cAMP from target tissues and the renal handling of phosphate and sodium. However, at the doses employed, it does not increase serum calcium, is a weaker stimulator of the 25-hydroxyvitamin D-1alpha-hydroxylase, and does not induce rapid bone resorption.

Immunologic investigation in cardiomyopathies

A group of 6 patients with congestive cardiomyopathy were investigated from the immunologic pint of view. Changes of serum immunoglobulins with increase of IgA and IgM were observed in all the patients. The immunofluorescence test in myocardial fragments, taken by transparietal biopsy from the six patients, confirmed the presence of IgA and IgG in two cases. A pathogenic immunologic mechanism is discussed in cardiomyopathies and especially in the alcoholic one.