COVID-19: Initial experience of an international group of hand surgeons

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

m-Health for Burn Injury Consultations in a Low-Resource Setting: An Acceptability Study Among Health Care Providers

Introduction:The rapid adoption of smartphones, especially in low- and middle-income countries, has opened up novel ways to deliver health care, including diagnosis and management of burns. This study was conducted to measure acceptability and to identify factors that influence health care provider’s attitudes toward m-health technology for emergency care of burn patients.

Methods:An extended version of the technology acceptance model (TAM) was used to assess the acceptability toward using m-health for burns. A questionnaire was distributed to health professionals at four hospitals in Dar Es Salaam, Tanzania. The questionnaire was based on several validated instruments and has previously been adopted for the sub-Saharan context. It measured constructs, including acceptability, usefulness, ease of use, social influences, and voluntariness. Univariate analysis was used to test our proposed hypotheses, and structural equation modeling was used to test the extended version of TAM.

Results:In our proposed test-model based on TAM, we found a significant relationship between compatibility—usefulness and usefulness—attitudes. The univariate analysis further revealed some differences between subgroups. Almost all health professionals in our sample already use smartphones for work purposes and were positive about using smartphones for burn consultations. Despite participants perceiving the application to be easy to use, they suggested that training and ongoing support should be available. Barriers mentioned include access to wireless internet and access to hospital-provided smartphones.

Popliteal fossa reconstruction with medial genicular artery flap in a low resource setting: A report of two cases

Background: Popliteal fossa defects are common arising from several causes. Options of reconstruction around the knee could be limited by the cause of defect or interventions. Medial genicular artery flap is known in the books but not in popular use despite its obvious advantages of superior vascularity, adequate size, suppleness, and hidden donor site.

Aim: To promote the use of this flap due to its advantages and ease of use especially in resource poor settings.

Patients and methods: We report two patients from a low resource setting aged 23 and 20 years respectively. The first case was managed for avulsion wound of the popliteal fossa while the second had post burn knee contracture release. The resultant large popliteal fossa defects on both patients were seen on clinical examination. Both patients were offered popliteal fossa reconstruction for the popliteal fossa defects using medial genicular artery flap with good outcome.

Conclusion: The medial genicular artery flap is a veritable option of popliteal fossa reconstruction especially for defects that are located contiguous to the flap and when other regional flap options are not available. Flap survival is excellent and donor site is hidden

The Preferred Management of a Single-Digit Distal Phalanx Amputation

Background: Replantation of a single digit at the distal phalanx level is not routinely performed since it is technically challenging with questionable cost-effectiveness. The purpose of this study was to analyze international microsurgeons’ clinical decisions when faced with this common scenario.

Methods: A survey of a right-middle finger distal phalanx transverse complete amputation case was conducted via online and paper questionnaires. Microsurgeons around the world were invited to provide their treatment recommendations. In total, 383 microsurgeons replied, and their responses were stratified and analyzed by geographical areas, specialties, microsurgery fellowship training, and clinical experiences.

Results: Among 383 microsurgeons, 170 (44.3%) chose replantation as their preferred management option, 137 (35.8%) chose revision amputation, 62 (16.2%) chose local flap coverage, 8 (2.1%) chose composite graft, and 6 (1.6%) favored other choices as their reconstruction method for the case study. Microsurgeons from the Asia-Pacific, Middle East/South Asia, and Central/South America regions tend to perform replantation (70.7, 68.8, and 67.4%, respectively) whereas surgeons from North America and Europe showed a lower preference toward replantation (20.5 and 26.8%, respectively p < 0.001). Having completed a microsurgery fellowship increased the attempt rate of replantation by 15.3% (p = 0.004). Clinical experience and the surgeons' specialties did not show statistical significance in clinical decision making. Conclusion: From the present study, the geographic preferences and microsurgery fellowship experience influence the method of reconstruction for distal phalanx amputation. Multiple factors are taken into consideration in selecting the most suitable reconstructive method for each case scenario. In addition to the technical challenges of the proposed surgery, the cost of the procedure and the type of facility needed are important variables in the decision making process.

Use of Social Media to Teach Global Reconstructive Surgery: Initiation of a Secret Facebook Group

The ReSurge Global Training Program (RGTP) is a model for building reconstructive surgery capacity in low- and middle-income countries.1 The aim of this study is to assess attitudes toward social media, to develop an initial RGTP Facebook Education Group, and to assess the early results of the group’s implementation.

A survey of the RGTP community assessed group demographic, interests, concerns, and familiarity with Facebook from July to August of 2018. A “secret” Facebook group was launched on October 30, 2018. Narrated lectures were posted weekly to the group. Educational cases were shared on the group’s discussion page. Facebook “Group Insights” and individual post review were used to obtain group statistics.

Senior faculty were less likely to have an existing Facebook account (58% vs 93%, P < 0.05). Trainees were more confident using Facebook (97% vs 54%, P < 0.05) and favored viewing the training curriculum through Facebook (93.0%, P < 0.05). At 6 months, the group enrolled 103 members from 14 countries. Twenty-two lectures were posted, obtaining an average of 59.4 views (range, 36–78). Fourteen cases were presented for group discussion with an average of 61.1 views (range, 43–87).

The RGTP Facebook group has continued to expand in its early months. This group allows our community to view RGTP’s training curriculum, while providing global access to expert opinion and collaboration. The secret Facebook group can be used as an effective and easy-to-use platform for educational outreach in global reconstructive surgery.

Managing the soft tissue defects over the dorsum of hand: Our experience with Posterior Interosseous Artery (PIA) flap

Objective: To determine the outcome of posterior interosseous artery (PIA) flap in terms of coverage of the defects and survival of the flap in patients with complex defects over the dorsum of hand and distal forearm.

Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College, Lahore, Pakistan from 15th July 2017 to 15th August 2019.All patients with complex defects of the dorsum of the hand and distal forearm were treated with posterior interosseous artery (PIA) flap. Post operatively the grafts were observed for coverage of the defects and graft survival.

Results: The total number of patients were 24 with 19(79.1%) males and 05(20.8%) females. The mean age was 37±7SD(range 21 to 56 years). Right hand was involved in 17(70.8%) patients and left in 7(29.1%) patients. Complete coverage of the defects were achieved in all cases. Successful graft survival and uptake was seen in 20(83.3%) flaps. Partial loss was seen in 03 (12.5%) flaps which required debridement and subsequent Split Thickness Skin Grafting. Complete graft loss was seen in 01 (4.1%) flap

Conclusion: Posterior interosseous artery flap (PIA) had higher survival rates and larger area of the dorsum of the hand and distal forearm were entirely covered with this graft. We recommend posterior interosseous artery flap as first line surgical technique to treat complex tissue defects of the dorsum of the hand and distal forearm

Changes in Electrical Activity of the Masseter Muscle and Masticatory Force After the Use of the Masseter Nerve as Donor in Facial Reanimation Surgery

The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim.
To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force.
Materials and Methods
An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements.
The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter-buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 ( p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 ( p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 ( p = 0.1) after the procedure
Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status.

Is Quality of Life After Mastectomy Comparable to That After Breast Conservation Surgery? A 5-year Follow Up Study From Mumbai, India

Breast cancer is the commonest cancer in women worldwide. Surgery is a central part of the treatment. Modified radical mastectomy (MRM) is often replaced by breast conserving therapy (BCT) in high-income countries. MRM is still the standard choice, in low- and middle-income countries (LMICs) as radiotherapy, a mandatory component of BCT is not widely available. It is important to understand whether quality of life (QOL) after MRM is comparable to that after BCT. This has not been studied well in LMICs. We present, 5-year follow-up of QOL scores in breast cancer patients from India.

We interviewed women undergoing breast cancer surgery preoperatively, at 6 months after surgery, and at 1 year and 5 years, postoperatively. QOL scores were evaluated using FACT B questionnaire. Average QOL scores of women undergoing BCT were compared with those undergoing MRM. Total scores, domain scores and trends of scores over time were analyzed.

We interviewed 54 women with a mean age of 53 years (SD 9 ± years). QOL scores in all the women, dipped during the treatment period, in all subscales but improved thereafter and even surpassed the baseline in physical, emotional and breast-specific domains (p < 0.05) at 5 years. At the end of 5 years, there was no statistically significant difference between the MRM and BCT groups in any of the total or domain scores.

QOL scores in Indian women did not differ significantly between MRM and BCT in the long term. Both options are acceptable in the study setting.

Reliability and versatility of the Wise pattern, medial pedicle for breast reduction in South Africa

Breast hypertrophy is a condition of abnormal enlargement of the breast which may continue until each breast weighs more than 1.5 kg (macromastia) or even more than 2 kg (gigantomastia). Supporting such heavy weights leads to cervical and upper thoracic back pain, costochondritis, and fungal infections in the mammary folds, making reduction mammoplasty essential. However, there is a lack of consensus among plastic surgeons as to the best technique. This study reports the results of reduction mammoplasties in South African women using the Wise pattern, minimally undermined with a medial pedicle.

A retrospective record review of the reduction mammoplasties was conducted over a 1-year period. Patient records were assessed for early complications related to vascular reliability.

One hundred and fourteen Wise pattern minimally undermined, medial pedicle techniques were performed on 57 consecutive patients in the 1-year period at the NetCare Rand Clinic in Berea, Johannesburg, South Africa (EN). The patients’ sternal notch to nipple distances ranged from 28 to 52 cm. The volume of breast reduction ranged from 345 g to 3300 g per breast. The overall complication rate was 9.7%, consisting of fat necrosis (3.5%), infection (1.7%), dehiscence (3.5%), and nipple epidermolysis (0.9%).

The minimally undermined Wise pattern medial pedicle breast reduction technique proved to be a reliable technique for breast reduction in the South African population. Safety in pedicle breast reduction with sternal notch to nipple distances of up to 50 cm, as well as reliability and versatility in a wide range of breast sizes, was demonstrated.

Global Burden of Craniofacial Disorders Where Should Volunteering Plastic Surgeons and Governments Focus Their Care?

Approximately 11% of the global burden of disease is surgically treatable. When located within the head, face, and neck region, plastic surgeons are particularly trained to treat these conditions. The purpose of this study was to describe the etiology, disability, and barriers to receiving care for diseases of the head, face, mouth, and neck region across 4 low-and-middle-income countries.

The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cluster randomized, cross-sectional, national survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies demographic characteristics, etiology, disease timing, proportion seeking/receiving care, barriers to care, and disability.

Across the 4 countries, 1413 diseases of head, face, mouth, and neck region were identified. Masses (22.13%) and trauma (32.8%) were the most common etiology. Nepal reported the largest proportion of masses (40.22%) and Rwanda reported the largest amount of trauma (52.65%) (P < 0.001). Rwanda had the highest proportion of individuals seeking (89.6%) and receiving care (83.63%) while Sierra Leone reported the fewest (60% versus 47.77%, P < 0.001). In our multi-variate analysis literacy and chronic conditions were predictors for receiving care while diseases causing the greatest disability predicted not receiving care (ORa .58 and .48 versus 1.31 P < 0.001).

The global volunteering plastic surgeon should be prepared to treat chronic craniofacial conditions. Furthermore, governments should address structural barriers, such as health illiteracy and lack of access to local plastic surgery care by supporting local training efforts.