Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review.

BACKGROUND: It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS: A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS: Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION: The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.

Role of Electrical Stimulation in Peripheral Nerve Regeneration: A Systematic Review.

Functional recovery after peripheral nerve injury is often suboptimal despite the intrinsic permissive growth environment of the peripheral nervous system. The objective of this systematic review is to explore the use of electrical stimulation (ES) for peripheral nerve regeneration. Methods: A systematic literature search was conducted from inception to March 2, 2021 to retrieve articles on ES for peripheral nerve regeneration using the PubMed, Ovid MEDLINE, and Embase databases. Primary outcome measures included objective measures of motor and sensory nerve function. Results: Four randomized control trials, two case reports, and three case series that addressed the aims were identified. The stimulation parameters varied greatly between studies, without an apparent commonality for a given electrical conduit. Outcomes measured included motor (n = 8) and sensory (n = 7) modalities (cold detection, static two-point discrimination, tactile discrimination, and pressure detection), nerve-specific muscle function and bulk, and electromyography (EMG) motor and sensory terminal latency. Different parameters for measurement were utilized and improvement was observed across the studies compared with controls (n = 4) or pre-intervention measurements (n = 5). One randomized control trial reported no benefit of ES and attributed their findings to their stimulation protocol. Complications were documented in three patients only and included wire remnant removal, skin pigmentation, and bone formation. Conclusions: ES in peripheral nerve regeneration is beneficial in improving and accelerating recovery. A meta-analysis was not performed due to the heterogeneity, but all studies showed positive findings and minor to no complications. These results provide a primer for further development of delivery methods.

"Locoregional perforator flaps in breast reconstruction: An anatomic review & quadrant algorithm".

BACKGROUND: Plastic surgeons' firm grasp of perforator anatomy allows them to be increasingly mindful of esthetic outcomes, patient satisfaction, and donor-site function when approaching breast reconstruction. Mindfulness of these outcomes has contributed to the widespread use of locoregional perforator flaps in post-mastectomy and post-BCS reconstruction. METHODS: A literature search of the PubMed database was performed to identify relevant studies reporting the use of locoregional perforator flaps in post-mastectomy breast reconstruction. Selected manuscripts were analyzed and grouped by pedicled flap category. Articles were additionally assessed for the advantages and disadvantages of each flap and reported complications. RESULTS: Following three rounds of review, 30 of 101 (29.7%) articles were retained as specifically pertinent to the use of locoregional flaps in breast reconstruction surgery. They were categorized by locoregional perforator flap used (TDAP, LICAP, AICAP, LTAP, or IMAP). In total, the included studies reported on the use of perforator flaps in 829 patients, with complications occurring in 73 of 418 patients (17.5%). Commonly reported complications across all included studies were hematomas (n = 10), infection (n = 7), fat necrosis/steatofibrosis (n = 31), extruded expanders (n = 1), dehiscence (n = 2), seroma (n = 2), required cosmetic correction of the donor area (n = 5), flap congestion (n = 11), flap failure (n = 2), poor esthetic outcome (n = 4), grade II capsular contracture (n = 3, all of whom received postoperative radiation), and keloid scars(n = 1). CONCLUSIONS: Though the available literature remains anecdotal, locoregional flap-based reconstruction may provide some benefit in post-BCS reconstruction by sparing donor-site musculature and nerve supply and by minimizing adverse events.

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 Potential Role of Corticosteroid Prophylaxis for the Prevention of Microscopic Fat Embolism Syndrome in Gluteal Augmentations.

BACKGROUND: Microscopic fat embolism syndrome (micro-FES) has been recently identified as a potentially fatal complication following gluteal augmentation utilizing autologous fat grafts; safety recommendations advocating for subcutaneous lipo-injections may be insufficient for its prevention. OBJECTIVES: The authors of this systematic review evaluated the potential role of corticosteroid prophylaxis for the prevention of micro-FES in gluteal augmentation procedures. METHODS: The authors performed a systematic search employing the National Library of Medicine (PubMed), Medline, and Embase databases. Search terms were those pertaining to studies reporting the efficacy of prophylactic corticosteroid administration on micro-FES incidence in a high-risk surrogate population. RESULTS: Thirteen articles met the inclusion criteria for review, comprising 2 studies reporting on the efficacy of a single intravenous (IV) corticosteroid dose for the prophylaxis of micro-FES, 9 studies reporting on multiple prophylactic IV doses, and 2 additional studies reporting on the efficacy of inhaled corticosteroids in this context. All studies were identified from the orthopedic literature given that none were available directly from within plastic surgery. The prophylactic efficacy of multiple IV doses of methylprednisolone, or a single larger dose, was established, whereas the efficacy of inhaled corticosteroids remains elusive. CONCLUSIONS: A single perioperative IV dose of methylprednisolone may be most appropriate for utilization by plastic surgeons; the safety and implication of this therapy on wound healing and fat graft survival are discussed. Further studies directly evaluating the efficacy of corticosteroid prophylaxis in the gluteal augmentation population are indicated. Finally, recommendations pertaining to the prevention, timely recognition, and effective management of micro-FES are discussed.

Treatment of breast animation deformity: A systematic review.

INTRODUCTION: Animation deformity (AD) is a known complication of subpectoral implant placement and results from the contraction of the pectoralis major muscle with resultant movement of the underlying implant. This can lead to a poor cosmetic result, with the implant becoming distinctly visible postbreast reconstruction and augmentation. The prevalence and clinical significance of AD remain unclear. To date, there exists no published review outlining the treatment modalities for AD and their effectiveness. The objective of this study is to appraise the effectiveness of various treatment options through a systematic review of the literature. METHODS: The MEDLINE search tool was used to carry out a search of the PubMed. Two separate reviewers independently assessed the initial resultant papers based on strict inclusion and exclusion criteria. Factors evaluated included patient demographics, publication information, study design, number of patients, preventative/treatment technique, and type and size of implant. RESULTS: The search strategy yielded 504 articles, of which eight articles met all the inclusion criteria. This represents 214 individual breasts that underwent surgical correction for AD. Of the 214 included breasts, 151 were postmastectomy and reconstruction, while 63 were primary augmentation. Of the reconstructed breasts, 5.6% (n = 12) received radiation. Overall, interventions for treating AD were successful in all (n = 214) of the documented cases, with an overall complication rate of 11.6% (n = 25) reported in the studies after treatment. The techniques used to treat AD included subfascial plane change (n = 8), prepectoral (subglandular/subcutaneous) plane change (n = 187), and muscle-splitting techniques (n = 19). CONCLUSION: In conclusion, AD is likely an underestimated complication that is increasing in incidence with the growing number of breast implants being placed in the subpectoral plane. This review successfully identified the highly effective treatment modalities to combat AD. Patient characteristics and surgical technique must be tailored on a case-by-case basis to allow for optimum esthetic outcome given the substantial complication rate of these treatment modalities.

The Canadian Plastic Surgery Workforce Analysis: Forecasting Future Need.

BACKGROUND: Projecting the demand for plastic surgeons has become increasingly important in a climate of scarce public resource within a single payer health-care system. The goal of this study is to provide a comprehensive workforce update and describe the perceptions of the workforce among Canadian Plastic Surgery residents and surgeons. METHODS: Two questionnaires were developed by a national task force under the Canadian Plastic Surgery Research Collaborative. The surveys were distributed to residents and practicing surgeons, respectively. RESULTS: Two-hundred fifteen (49%) surgeons responded, with a mean age of 51.4 years (standard deviation [SD] = 11.5); 78% were male. Thirty-three percent had been in practice for 25 years or longer. More than half of respondents were practicing in a large urban center. Fifty-nine percent believed their group was going to hire in the next 2 to 3 years; however, only 36% believed their health authority/provincial government had the necessary resources. The mean desired age of retirement was 67 years (SD = 6.4). We predict the surgeons-to-population ratio to be 1.55:100 000 and the graduate-to-retiree ratio to be 2.16:1 within the next 5 to 10 years. Seventy-seven (49%) residents responded. Most were "very satisfied" with their training (61%) and operative experience (90%). Eighty-nine percent of respondents planned to pursue addqitional training after residency, with 70% stating that the current job market was contributing to their decision. Most residents responded that they were concerned with the current job market. CONCLUSIONS: The results of this study predict an adequate number of plastic surgeons will be trained within the next 10 years to suit the population's requirements; however, there is concern that newly trained surgeons will not have access to the necessary resources to meet growing demands. Furthermore, there is an evident shortage of those practicing in rural areas. Many trainees worry about the availability of jobs, despite evidence of active recruitment. The workforce may benefit from structured career mentorship in residency and improved transparency in hiring practices, particularly to attract young surgeons to smaller communities. It may also benefit from a coordinated national approach to recruitment and succession planning.

HISTORIQUE: Il est de plus en plus important de projeter la demande de plasticiens compte tenu des ressources publiques rares dans un système de santé à un seul payeur. La présente étude vise à présenter une mise à jour complète des effectifs et à décrire les perceptions de la main-d'œuvre chez les résidents et les chirurgiens canadiens en chirurgie plastique. MÉTHODOLOGIE: Un groupe de travail national relevant du Canadian Plastic Surgery Research Collaborative a créé deux questionnaires, qui ont été distribués respectivement aux résidents et aux chirurgiens en exercice. RÉSULTATS: Deux cent quinze chirurgiens (49 %), d'un âge moyen de 51,4 ans (ÉT = 11,5) ont répondu; 78 % étaient de sexe masculin. Trente-trois pour cent exerçaient depuis au moins 25 ans. Plus de la moitié exerçait dans un grand centre urbain. Cinquante-neuf pour cent pensaient que leur groupe embaucherait dans les deux à trois années suivantes, mais seulement 36 % étaient d'avis que leur autorité sanitaire ou leur gouvernement provincial possédait les ressources nécessaires. En moyenne, les répondants souhaitaient prendre leur retraite à 67 ans (ÉT = 6,4). Les chercheurs prédisent que le ratio entre les chirurgiens et la population serait de 1,55:100 000, et que le ratio entre les diplômés et les retraités serait de 2,16:1 d'ici cinq à dix ans. Soixante-dix-sept résidents (49 %) ont répondu. La plupart étaient « très satisfaits ¼ de leur formation (61 %) et de leur expérience opératoire (90 %). Quatre-vingt-neuf pour cent planifiaient poursuivre leur formation après la résidence, et 70 % affirmaient que le marché du travail actuel contribuait à leur décision. La plupart des résidents ont répondu qu'ils étaient inquiets du marché du travail actuel. CONCLUSIONS: Selon les résultats de cette étude, un nombre suffisant de plasticiens seront formés d'ici dix ans pour répondre aux besoins de la population, mais on craint que les chirurgiens nouvellement formés n'aient pas accès aux ressources nécessaires pour répondre à la demande croissante. De plus, on constate une pénurie évidente en région rurale. De nombreux résidents s'inquiètent de la disponibilité des emplois malgré des preuves de recrutement actif. La main-d'œuvre pourrait profiter d'un mentorat professionnel structuré en résidence et d'une plus grande transparence des pratiques d'embauche, particulièrement pour attirer de jeunes chirurgiens dans de plus petites localités. Elle pourrait également profiter d'une approche nationale coordonnée du recrutement et de la planification de la succession.