The Level of Evidence Pyramid: Indicating Levels of Evidence in Plastic and Reconstructive Surgery Articles

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients

BACKGROUND

Facial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort.

METHODS

A systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations.

RESULTS

Initial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm.

CONCLUSIONS

The core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Patient outcomes and complications following various maxillomandibular fixation techniques: A systematic review and meta-analysis

PURPOSE

Currently, there are several methods of achieving maxillomandibular fixation (MMF), each with its unique operative considerations and subsequent patient outcomes and complications. In this study, we reviewed the literature to evaluate and compare all MMF methods.

METHODS

A systematic review of all MMF types was conducted and post-operative outcome data were analyzed and compared among the different types. Conventional Erich arch bars were compared to hybrid arch bars, MMF screws, and eyelet interdental wiring. A random-effects meta-analysis was used to determine the mean differences, and 95% confidence intervals (CIs) with a statistical significance of P < 0.05.

RESULTS

Among the 4234 articles identified, 24 were included, and 17 were meta-analyzed. Time to achieve MMF (-43.38 min; 95% CI, -58.20 to -28.56; P < 0.001), total operative time (-30.33 min; 95% CI, -61.05 to 0.39; P = 0.05), incidence of wire puncture injuries and glove perforations (0.11; 95% CI, 0.04 to 0.30; P < 0.001), and incidence of poor oral hygiene (0.08; 95% CI, 0.02 to 0.28; P < 0.001) were lower for alternative MMF interventions compared to those of the conventional Erich arch bars.

CONCLUSIONS

Alternative MMF methods required shorter operative time to achieve MMF and demonstrated other increased efficiencies of practice such as shorter total operative time and decreased glove perforations, when compared to conventional Erich arch bars. If a patient is a candidate for MMF, the presented alternative MMF techniques should be considered depending on the clinical context and availability of institutional resources.

A Review of Meta-Analyses in Plastic Surgery: Need for Adequate Assessment of Publication Bias

INTRODUCTION

Publication bias describes a phenomenon in which significant positive results have a higher likelihood of being published compared to negative or nonsignificant results. Publication bias can confound the estimated therapeutic effect in meta-analyses and needs to be adequately assessed in the surgical literature.

METHODS

A review of meta-analyses published in five plastic surgery journals from 2002 to 2022 was conducted. The inclusion criteria for meta-analyses were factors that demonstrated an obligation to assess publication bias, such as interventions with comparable treatment groups and enough power for statistical analysis. Acknowledgment of publication bias risk, quality of bias assessment, methods used in assessment, and individual article factors were analyzed.

RESULTS

318 unique meta-analyses were identified in literature search, and after full-text reviews, 143 met the inclusion criteria for obligation to assess publication bias. 64% of eligible meta-analyses acknowledged the confounding potential of publication bias, and only 46% conducted a formal assessment. Of those who conducted an assessment, 49% used subjective inspection of funnel plots alone, while 47% used any statistical testing in analysis. Overall, only 9/143 (6.3%) assessed publication bias and attempted to correct for its effect. Journals with a higher average impact factor were associated with mention and assessment of publication bias, but more recent publication year and higher number of primary articles analyzed were not.

CONCLUSIONS

This review identified low rates of proper publication bias assessment in meta-analyses published in five major plastic surgery journals. Assessment of publication bias using objective statistical testing is necessary to ensure quality literature within surgical disciplines.

Long-Term Improvement of Crow's Feet Wrinkles in Combination With Cervicofacial and Temporal Lifting: Review of the Literature

BACKGROUND

The lateral orbital crow's feet area is one for which rejuvenation is most frequently requested by patients. Moreover, lateral canthal wrinkles are a common source of dissatisfaction after rhytidoplasty. Botulinum toxin injection has emerged as a most popular, easy, and effective solution; nevertheless, repeated injections are required periodically for long-term effect. Other nonsurgical options have also been described to have some demonstrable advantages. Orbicularis oculi surgical manipulations have been described as well.

MATERIAL AND METHODS

A systematic PubMed literature search was conducted to identify clinical cohort studies including more than 10 patients describing surgical approaches for improvement of crows' feet wrinkles in combination with face and/or temporal lifts. The search was complemented by Embase, Medline, and Cochrane searches in addition to screening of reference lists of selected studies and simple term searches about surgical treatment of crow's feet.

RESULTS

Fourteen studies satisfied the inclusion criteria and were included in this review describing various muscle excision techniques including vertical strip excision, lateral partial resection, wedge resection, muscle resection in "C" pattern, and enlarged myectomy of about one-third of the whole orbital extension in addition to muscle manipulation modalities, including muscle splaying, muscle division, muscle division and splaying, muscle undermining with partial denervation, and muscle suspension. Interposition of fascia between orbicularis muscle and overlying skin was also reported.

CONCLUSION

View the few studies retrieved and the wide spectrum of reported techniques, it is not possible to determine from this review the most effective modality. Nevertheless, it seems that subcutaneous undermining of the lateral canthal area combined with splaying and traction of the orbicularis oculi muscle and fixation to the temporalis fascia with or without muscle division would yield the best long-term results. This review indicates also that surgical correction of crow's feet during rhytidectomy or temporal lift could be a positive complement to improve aesthetic outcome. Unfortunately, if not underreported, it is definitely neglected. We believe that this review may be an eye-opener for surgeons.

Effectiveness and Role of Using Hyaluronic Acid Injections for Gluteal Augmentation: A Comprehensive Systematic Review of Techniques and Outcomes

INTRODUCTION

There has been a rapid increase in the number of patients undergoing non-surgical gluteal augmentation in recent years, leading to an increase in the number of articles in the literature regarding the use of hyaluronic acid (HA) for gluteal augmentation. No systematic review has been published on the effectiveness of HA for gluteal augmentation. This study aimed to provide a comprehensive review regarding the effectiveness and role of using HA for gluteal augmentation.

METHODS

This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. We conducted a search across MEDLINE, EMBASE, Cochrane, and Google Scholar, using the following search keywords: gluteus, buttocks, gluteoplasty, gluteal augmentation, hyaluronic acid, and filler.

RESULTS

Ten articles published between 2013 and 2022 that included 168 patients. The estimated duration of product effectiveness is 16.16 months. Most studies showed statistically significant improvements in patients' satisfaction. Mean volume of HA injected for optimal gluteal fat augmentation was 206.71 ml. Of included studies, two reported major complications, five patients experienced bruising and erythema as minor complications, five patients experienced effusion and inflammation at the injection site, three patients experienced gel dislocation, and one patient experienced irregular contours.

CONCLUSIONS

Based on our findings, HA is a predictable method for gluteal augmentation. Patients were satisfied with their outcomes. Despite gluteal augmentation with HA having a modest complication rate, it can still involve serious complications such as diffuse alveolar hemorrhage and death. There is a need for further research in a randomized control trial.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tissue adjuncts in primary cleft palate reconstruction: A systematic review

BACKGROUND

Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty.

METHODS

A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables.

RESULTS

A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03).

CONCLUSIONS

Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Gender-Affirming Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations

BACKGROUND

The number of transgender adolescents seeking gender-affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender-affirming surgery for individuals under the age of legal majority and propose directions for future research.

METHODS

A scoping review of recent literature was performed to assess evidence on gender-affirming surgery in individuals under the age of legal majority. Articles were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion.

RESULTS

Twelve articles were identified that met inclusion criteria. Ten of these articles discussed ethical challenges in adolescent GAS, seven discussed legal challenges, and five discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the effects of puberty blockade on natal tissue.

CONCLUSIONS

Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema

BACKGROUND

 Evidence-based medicine uses the current best evidence for decisions about patient care. Lymphedema is a chronic debilitating medical condition caused by a dysfunctional lymphatic system. This study analyzes the most cited articles, including the levels of evidence, for the surgical treatment of lymphedema.

METHODS

 The Web of Science Sci-Expanded Index was utilized to search for surgical treatment of lymphedema. Articles were examined by three independent reviewers and the top 100 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed.

RESULTS

 Since 1970, the top 100 articles have been cited 7,300 times. The average citation count was 68 and standard deviation was 55. The majority was case series (71), followed by retrospective cohort (8), prospective cohort (7), retrospective case-control (5), and randomized controlled trials (2). Based on the "Level of Evidence Pyramid," 71 articles were level IV, 13 articles were level III, and 9 articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation Scale, there were 71 articles with "very low," 20 articles with "low," and 2 articles with "moderate" quality of evidence.

CONCLUSION

 The top 100 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of lymphedema will continue to improve.

Expanding Indications of the Medial Femoral Condyle Free Flap: Systematic Review in Head and Neck Reconstruction

The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck.

Methods

A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm². The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture.

Conclusion

The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

The Impact of Diabetes Mellitus on Breast Reconstruction Outcomes and Complications: A Systematic Literature Review and Meta-analysis

INTRODUCTION

As the incidence of breast cancer and diabetes rises, so does the number of patients with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at a higher risk for post-operative complications. The current study examined the effects of diabetes on BR wound outcomes and overall complications post-operatively.

METHODS

This study followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We conducted a systematic search and meta-analysis for published articles on the effects of DM on BR in January 2022 using the PubMed, MEDLINE, and Cochrane databases. Diabetes, breast reconstruction, and complications were used as keywords.

RESULTS

Forty-three studies were included in the qualitative synthesis, and five provided data to be included in the meta-analysis published between 2006 and 2020. A total of 19,731 patients (9.07%) had diabetes, whereas 197,812 patients had no diabetes. The results of the pooled outcomes revealed no differences in the risk of total flap loss (p = 0.892) and wound infection (p = 0.579,). Nevertheless, the risk of wound dehiscence was significantly higher among patients with diabetes than their non-diabetic counterparts (p < 0.0001).

CONCLUSION

Diabetic patients undergoing BR have a significantly higher risk of wound dehiscence. As a result of the adverse effects of diabetes status on BR outcomes, patients need to be counseled about optimizing their diabetes management before surgery. Because of the heterogeneity in our results, prospective randomized studies are needed to shed light on the consequences of diabetes mellitus in BR surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Erosive Pustular Dermatosis: Delving into Etiopathogenesis and Management

Erosive pustular dermatosis (EPD) is a chronic inflammatory skin disorder that usually affects mature individuals. It predominantly affects the scalp and can lead to scarring alopecia. Risk factors include actinic damage and androgenetic alopecia. A traumatic insult to the skin is considered a vital trigger of the condition. EPD is a diagnosis of exclusion; thus, several neoplastic, infectious, vesiculobullous, and inflammatory conditions should be ruled out. Biopsy and clinicopathologic correlation are required to differentiate between EPD and these entities. A dysregulated, chronic immune response is considered central to the etiopathogenesis of EPD. We performed an evidence-based systematic review of the management options. There were predominantly studies with level IV and V evidence and only two with level III. Despite the responsiveness of EPD to potent topical steroids, such as clobetasol propionate, recurrence occurs after treatment withdrawal. With the available data, tacrolimus 0.1%, curettage-assisted aminolevulinic acid-photodynamic therapy, and systemic retinoids can be considered second-line options for EPD with a role in maintenance regimens. However, controlled data and more powerful studies are needed to make solid recommendations.

"Anesthesia for Endoscopic Carpal Tunnel Syndrome Release: A Comprehensive Systematic Review and Meta-Analysis of Local Versus Regional Versus General Anesthesia"

Background

Worldwide, carpal tunnel syndrome (CTS) is the most common peripheral neuropathy due to compression. A minimally invasive endoscopic carpal tunnel release (ECTR) procedure is available to treat this condition. This study aims to identify and compare the different types of anesthesia in ECTR, particularly in terms of functional outcomes, patient satisfaction, and operative time.

Methods

PRISMA guideline was used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were searched systematically from inception to May 2022. For the search, MeSH terms such as ECTR, general anesthesia, local anesthesia (LA), and regional anesthesia were used.

Results

As a result of reviewing the literature, 198 publications were reviewed. After implanting our criteria, 12 studies were included. We included 14589 patients who underwent ECTR. LA has a higher satisfaction rate and a shorter operative time than general anesthesia. LA had a mean operative time of 20.1 min, compared to 45 min and 51 min for regional anesthesia and general anesthesia. The number of patients with postoperative ECTR surgical complications was 2.7% (95%CI). After ECTR with LA, 95% of patients are back to their daily routine within six months.

Conclusion

All the reported methods were effective, with LA being the most commonly used. Furthermore, it showed a shorter operative time and a higher satisfaction rate than other types of anesthesia. Due to the heterogeneity of the data, we recommend future randomized controlled trials to highlight the differences in anesthesia types used in ETCR.

Level of evidence

III, risk/prognostic study.

The Impact of Senior Author Profile on Publication Level of Evidence in Plastic and Reconstructive Surgery

Plastic and Reconstructive Surgery (PRS) incorporated the level of evidence (LOE) pyramid in 2011 to highlight evidence-based medicine in plastic surgery. This study aimed to assess the relationship between the profile of senior authors publishing in PRS and the LOE of publications.