Alexander Morzycki

Adverse Reactions to Contrast Material: A Canadian Update

Imaging techniques frequently employ contrast agents to improve image resolution and enhance pathology detection. These gadolinium- and iodine-based media, although generally considered safe, are associated with a number of adverse effects ranging from mild to severe. Reactions are classified as either anaphylactoid (“anaphylaxis-like”) or nonanaphylactoid, depending on a number of elements that will be reviewed. Herein, we have summarized predisposing risk factors for adverse events resulting from the use of contrast, their associated pathophysiological mechanisms as well as known prophylaxis for the antitreatment of high-risk patients. In the unlikely event that a serious adverse reaction does occur, we have provided a comprehensive summary of treatment protocols. Our goal was to thoroughly evaluate the current literature regarding adverse reactions to radiocontrast agents and provide an up to date review for the health care provider.

Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study

Objective: Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities. Design: Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared. Participants: Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community. Main Outcome: The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face). Results: Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not (P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips (P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity (P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time (P < .001). Conclusions: This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.

Abstract: Discrepancies between Registered and Published Primary and Secondary Outcomes in Randomized Controlled Trials within the Plastic Surgery Literature

PURPOSE: Myelomeningocele is the most common congenital malformation of the central nervous system, with a prevalence of 4.4 to 4.6 per 10,000 live births in the United States. They are most commonly observed in the lumbosacral region, as this is the last region of the neural tube to fuse. Robust, reliable and reproducible closure of lumbosacral myelomeningocele defects remains a challenge. Closure of spinal defects following neurosurgical procedures with well-vascularized flaps in high-risk patients has been shown to reduce complications in the adult population. In infants with lumbosacral myelomeningocele, in addition to the relatively standard neurosurgical repair that consists of placode tubularization and dural repair, multiple methods of soft tissue coverage have been described. These include various cutaneous, fascial and muscle flaps and grafts. We present here our unique closure technique with well-vascularized flaps following lumbosacral myelomeningocele repair. METHODS: After the neurosurgical repair of lumbosacral myelomeningocele is completed, bilateral composite latissimus dorsi musculocutanous and gluteus maximus fasciocutanous flaps are elevated. The gluteus maximus fasciocutaneous flaps are completely elevated from their insertion on the ileum and sacrum. The paraspinous muscle flaps are then elevated and medialized based on the lateral row arterial perforators to provide complete muscular coverage of the dural repair. The bilateral composite latissimus dorsi muscleocutanous and gluteus maximus fasciocutanous flaps are medialized, reapproximated with the sacrum, and closed over the paraspinous muscle flap repair.

Abstract: The Impact of Delaying Breast Reconstruction on Patient Expectations and Health Related Quality of Life

METHODS: A retrospective study of patients who underwent immediate breast reconstruction by means of pre-pectoral (Group 1) and sub-pectoral (Group 2) tissue expander placement was performed. Patients in each group were matched for age, BMI, history of neoadjuvant radiotherapy, and type of ADM. Of note, patients in Group 1 received perioperative antibiotic prophylaxis for less than 24 hours while patients in Group 2 received antibiotic prophylaxis for at least 1 week.

Are We Over Treating Hand Fractures? Current Practice of Single Metacarpal Fractures

Purpose: We conducted a national survey of Canadian plastic surgeons to assess if inconsistencies in management strategies exist for single metacarpal fractures. Methods: A cross-sectional study of Canadian plastic surgeons who perform hand surgeries was conducted. A 15-question survey was distributed to all members of the Canadian Society of Plastic Surgeons. Participants’ demographics, practice settings, and current treatment strategies for patients presenting with single metacarpal fractures were evaluated. Results: A total of 113 Canadian plastic surgeons met inclusion criteria. The majority of respondents were male (76%), with 50% in practice for more than 15 years. Canadian surgeons used a wide variety of surgical techniques for the management of single metacarpal fractures, with close reduction (94%), Kirshner wires (94%), and splinting and immobilization (89%) being the most common. The majority of plastic surgeons stated that rotational deformity (81%) was the most important indication for surgery. Surgeons demonstrated a trend toward immobilization after splinting (48%), instead of early mobilization after splinting (21%). When results were stratified by years in practice, no differences in surgical and non-surgical management were found, although surgeons in practice for less than 15 years were more likely to suggest hand therapy. Conclusion: These findings demonstrate inconsistencies in management of single metacarpal fractures among Canadian plastic surgeons. Surprisingly, surgeons in the survey tended to favor immobilization, as oppose to the literature that favors mobilization. The study highlights the lack of clear guidelines dictating treatment, possibly leading to these inconsistencies.

Undergraduate Plastic Surgery Education: A National Survey of Clerkship Directors

Background: The delivery of medical education has received increased attention in recent years due to ongoing time and financial constraints faced by medical educators. Given the recent calls to action by the Carnegie Foundation and Health Canada, an evaluation of the specialty education sector is warranted. To our knowledge, this is the first assessment of the Canadian plastic surgery undergraduate clerkship curriculum. Method: An anonymous electronic survey was distributed to the plastic surgery clerkship directors of all Canadian medical schools (N = 17). The survey consisted of Likert scales and open-ended short answer questions. Themes included general clerkship information, exposure characteristics, teaching characteristics, resource characteristics, and challenges and barriers faced by clerkship directors. Results: Survey response rate was 88%. All responding schools offered a clerkship rotation of varying length in time (1-4 weeks). Students had the most exposure to breast surgery (100%) and general plastic surgery (100%) and the least exposure to aesthetic surgery (40%). Sixty percent of schools indicated the use of modern educational methods. Resources available for teaching students varied. Rotations received excellent feedback from medical students (67%). More than half of respondents would like to see a universal, nationally formulated plastic surgery clerkship curriculum. Conclusion: There is significant heterogeneity in the delivery of plastic surgery clerkship in Canada. A number of areas for improvement have been identified. We hope to establish a national plastic surgery clerkship task force to address the concerns raised here and improve the delivery of undergraduate medical education. Assessment of students based on a national curriculum may help in decision-making regarding plastic surgery program admissions by introducing an element of standardization to clerkship exposure.

How Competitive Is Plastic Surgery? An Analysis of the Canadian and American Residency Match:

Background: Plastic surgery (PS) is considered to be one of the most competitive specialties. As a result, some students are discouraged from applying, reducing the overall number of PS candidates. Still, much of what we know of the match is based in conjecture. Objective: To examine the Canadian PS match data from 1997 to 2016. To our knowledge, this is the first long-term analysis of the Canadian PS residency match. Method: We examined the Canadian Residency Matching Service reports from 1997 to 2016, extracting key match statistics, including available positions, number of applicants, positions filled, positions unfilled, and gender-specific match results. To examine competitiveness, the ratio of total applicants per quota per year (CR) and the ratio of applicants who chose PS as their first-choice specialty per quota per year were calculated (FC-CR). The National Residency Matching Program data were used to assess the American integrated PS match over the past decade and served as a comparison. Results: The CR of Canadian PS programs declined over the last 20 years (P < .001), indicating fewer applicants applied to the program per available position. Similarly, the FC-CR also declined over the last 20 years (P < .001). The number of females matching to their first-choice discipline of PS increased from 1997 (P < .001). There was no significant change in the number of males matching to their first-choice discipline of PS (P = .15). There was no significant change in the competitiveness (CR) of the American integrated PS match over the last decade (P = 0.087). Conclusion: Encouragingly, today PS has more training positions and more female residents; yet, the overall number of applicants has remained relatively static over the past 20 years. This analysis serves as a valuable reference for PS programs and should assist in developing strategies to encourage the best applicants to apply.

Dog bites in the emergency department: a descriptive analysis

OBJECTIVE The purpose of this study was to assess the pattern of adult dog bites presenting to a medium size Canadian city’s Emergency Departments. METHODS All adult (≥16 years) patients presenting to Emergency Departments in our region during a 30-month period (January 2013 to June 2015) were identified. Demographics, injury patterns, and dog-specific characteristics were studied. RESULTS A total of 475 dog bites were identified. The greatest proportion of dog bites occurred in the summer months (140, 30%). Pit-bull type was the most frequently implicated breed (27%). The majority of patients identified were female (295, 62%). The majority of bites occurred in the hands (264 cases, 56%). Bites occurring in the head and neck accounted for 11% of all injuries. Although 50% of injuries required only washout and dressing, 15 cases (3%) required a complex primary closure. The operating room was utilized in the reconstruction of eight defects (2%). There were four (1%) tendon repairs, one (0.2%) nerve repair, and one injury requiring a skin graft (0.2%). Three patients were admitted to hospital. We identified an overall infection rate of 10%. CONCLUSIONS Dog bites most commonly occurred in the hands and upper extremities, and carried an infection risk of approximately 10%. Large, muscular breeds were the most frequently implicated. The effectiveness of breed-specific legislation remains unclear, but educational programs for dog owners, children, and health care workers may help decrease the number and severity of attacks.

Digital Myopericytoma: A Case Report and Systematic Literature Review

A myopericytoma (MP) is an exceedingly rare perivascular tumor of unknown etiology. Given their potential for mimicry and malignancy, MP tumors pose a unique challenge for surgeons and may be overlooked on differential diagnosis. We present a case report of an otherwise healthy 33-year-old right-hand dominant male who presented to our outpatient clinic with a 2-month history of painless swelling and erythema of the pulp of his left index finger. Subsequent plain film X-ray showed near-complete bony destruction of his distal phalanx. Pathological evaluation of an incisional biopsy showed a benign variant of MP. The lesion was treated by excision with tumor shelling, and there was no evidence of recurrence 81 days postoperatively. A systematic literature review of the management and outcome of all known cases of hand and wrist MP is presented.