Jonathan Kanevsky

Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis.

Background: Infantile hemangiomas are benign vascular neoplasms that can cause numerous functional or cosmetic problems. The authors reviewed the pathogenesis of hemangioma and compared the efficacy and complications related to therapy with propranolol versus corticosteroids. Methods: A comprehensive review of the literature was conducted from 1965 to March of 2012 using MEDLINE, PubMed, Ovid, Cochrane Review database, and Google Scholar. All articles were reviewed for reports of clinical cases, reported side effects, doses, duration of treatment, number of patients, and response rate to treatment. Results: A total of 1162 studies were identified. Of those, only 56 articles met inclusion criteria after review by two independent reviewers (A.I. and J.K.). For the meta-analysis, 16 studies comprising 2629 patients and 25 studies comprising 795 patients were included. Less than 90 percent of patients treated with corticosteroids responded to therapy, compared with 99 percent of patients treated with propranolol after 12 months of follow-up. Meta-analysis demonstrated the corticosteroid studies to have a pooled response rate of 69 percent versus the propranolol response rate of 97 percent (p < 0.001). Conclusions: Propranolol is a relatively recent therapy of hemangiomas with fewer side effects, a different mechanism of action, and greater efficacy than current first-line corticosteroid therapy. Many of these studies do not have the same patient population or duration/regimen of treatment for hemangiomas; however, based on available data in the literature, it appears that propranolol could be an emerging and effective treatment for infantile hemangiomas. Further randomized controlled trials are recommended. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lipofibromatous hamartoma of the median nerve: a comprehensive review and systematic approach to evaluation, diagnosis, and treatment.

Many modalities exist for diagnosing and treating lipofibromatous hamartoma (LFH), with no clear consensus. This is the first comprehensive study to review the existing literature on LFH of the median nerve and to suggest a systematic approach to its diagnosis and treatment. An electronic and manual search was conducted on Medline, Embase, Google Scholar, Current Contents, and Science Citation Index for original and review articles in English or French, from 1946 to November 2012. After 2 levels of screening, 106 references containing case reports were retained. Data extraction included patient demographics, clinical information, diagnostic modalities, treatment, and follow-up. A total of 180 cases were reported in the literature. One third of patients had associated macrodactyly (32%). Gender distribution is equal in LFH with or without macrodactyly, with most patients (71%) presenting before age 30 years. The main presenting symptom is an enlargement (88%) over the volar forearm, wrist, or hand, with or without digital hypertrophy, followed by paresthesia (39%). A soft, mobile, nontender, nonfluctuant mass with variable degree of compressive median neuropathy is found on physical examination. Biopsy, which reveals abundant mature fat cells and fibrous connective tissue infiltrating between nerve fascicles and the space between the epineurium and the perineurium, is not necessary because the pathognomonic features of the mass on magnetic resonance imaging offer an accurate diagnosis. Treatment of nerve compression symptoms and macrodactyly should be addressed separately. Carpal tunnel release is the mainstay of treatment for neuropathy, and ray or digital amputation, wedge osteotomy, middle phalangectomy with arthroplasty, and epiphysiodesis are suggested options in the management of macrodactyly. Based on our review of the literature, we propose an algorithm for the diagnosis and treatment of LFH of the median nerve with or without macrodactyly.

Big Data and Machine Learning in Plastic Surgery: A New Frontier in Surgical Innovation

Summary: Medical decision-making is increasingly based on quantifiable data. From the moment patients come into contact with the health care system, their entire medical history is recorded electronically. Whether a patient is in the operating room or on the hospital ward, technological advancement has facilitated the expedient and reliable measurement of clinically relevant health metrics, all in an effort to guide care and ensure the best possible clinical outcomes. However, as the volume and complexity of biomedical data grow, it becomes challenging to effectively process “big data” using conventional techniques. Physicians and scientists must be prepared to look beyond classic methods of data processing to extract clinically relevant information. The purpose of this article is to introduce the modern plastic surgeon to machine learning and computational interpretation of large data sets. What is machine learning? Machine learning, a subfield of artificial intelligence, can address clinically relevant problems in several domains of plastic surgery, including burn surgery; microsurgery; and craniofacial, peripheral nerve, and aesthetic surgery. This article provides a brief introduction to current research and suggests future projects that will allow plastic surgeons to explore this new frontier of surgical science.

Optimizing Radiotherapy for Keloids: A Meta-Analysis Systematic Review Comparing Recurrence Rates Between Different Radiation Modalities.

Background The high recurrence rate of keloids has lead to the use of multiple treatment adjuncts to improve cosmetic outcomes after surgery. To date, there has been no single, standardized modality agreed upon to produce the best results. The purpose of this study was to review the radiation-based treatments (brachytherapy, electron beam and X-ray) used for keloid management and compare their outcomes. Methods A literature review was performed from 1942 to October 2014 using the databases: PubMed database of the National Center of Biotechnology Information, MEDLINE, Biosis, Embase, Google scholar, and Cochrane database. Articles were reviewed for case numbers, patient demographics, keloid location, follow up, radiation modality, dose, keloid recurrence, and complications. Results A total of 72 studies met the inclusion criteria representing 9048 keloids. These studies were categorized by treatment: brachytherapy, electron, or X-ray. Meta-analysis demonstrated that radiotherapy after surgery had less recurrence when compared to radiotherapy alone (22% and 37%, respectively, P = 0.005). Comparison between modalities revealed that postoperative brachytherapy yielded the lowest recurrence rate (15%) compared with X-ray and electron beam (23% and 23%, respectively; P =0.04, P = 0.1). Subgroup analysis by location demonstrated chest keloids have the highest recurrence rate. The most commonly reported side effect of radiotherapy was changes in skin pigmentation. Conclusions The results of this study reinforce postoperative radiotherapy as effective management for keloids. Specifically, brachytherapy was the most effective of the currently used radiation modalities.

Meshed acellular dermal matrix: technique and application in implant based breast reconstruction

Alloderm was the first acellular dermal matrix used and remains a popular choice among plastic surgeons. However, while the overall surgical outcome of breast reconstruction using alloderm has been a success, the economic burden on the health care system makes it a subject of frequent re-evaluations in cost-effectiveness. Prompted by the high price of

Disclosure of funding source and conflict of interest: exposure of biases affecting evidence and clinical utility of plastic surgery publications

3,700 USD for a 6 cm × 16 cm area, our group proposes the meshing of AlloDerm to decrease the total amount needed for breast reconstruction, while achieving comparable surgical outcomes as using unmeshed alloderm.

A Novel Mohs Precision Tool

The objective of the study is to investigate associations between research topics, level of evidence, conflict of interest, and declared sources of funding in articles published in major plastic surgery journals. All articles published in four major plastic surgery journals from September 2008 to September 2010 (Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Aesthetic Surgery) were reviewed. Published articles were assessed with regards to funding sources, level of evidence (I–V), research topics, and conflicts of interest. The association between these variables was described using contingency tables and compared using chi-square tests. The 1,706 articles were reviewed from four major plastic surgery journals. Level III studies comprised the majority of studies (634, 37%). The level of evidence least frequently observed in the plastic surgery journals was level I (25, 1.4%). Studies not reporting funding sources were significantly associated with a lower level of evidence (p = 0.002). There was no significant association between source of funding and level of evidence (p = 0.219) or between the source of funding and the type of study (p = 0.075). Finally, the source of funding is significantly associated with the presence of a conflict of interest (p < 0.005). While the level of evidence was related to publication of funding, further analysis of public and private funding revealed that the level of evidence of the research conducted is independent of the source of funding. Privately funded studies are more likely to present a conflict of interest.

Development and assessment of a cutaneous tissue stretch device as a novel scar therapy

BACKGROUND Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. OBJECTIVE To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. MATERIALS AND METHODS A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012–2015). RESULTS Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: −0.01 to −0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12–1.3, p < .01). CONCLUSION Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

Rupture of the flexor carpi radialis tendon secondary to trauma: case report and literature review

1Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, QC H3G 1B3, Canada. 2Section of Plastic and Reconstructive Surgery, University of Manitoba, Winnipeg, MB R3T 2N2, Canada. 3McGill Medical School, McGill University, Montreal, QC H3G 2M1, Canada. 4Division of General Surgery, University of Sherbrooke, Sherbrooke, QC J1K 2R1, Canada. 5Division of Plastic and Reconstructive Surgery, Indiana University, Indianapolis, IN 46202, USA. 6Biomedical Engineering Department, Artificial Cells and Organs Research Centre, Montreal, QC H3A 2B4, Canada.

Development and Assessment of a Cutaneous Tissue Stretch Device as Scar Therapy

The flexor carpi radialis (FCR) is one of the long flexors, which is important in flexing and abducting the hand at the wrist. It originates at the medial epicondyle of the humerus and attaches at the base of the second metacarpal. Closed rupture of the long flexors of the finger is well-described, especially in association with rheumatoid hands. However, rupture of the FCR is rare; only 11 cases reported in the literature, most of them associated with scaphotrapezial-trapezoidal osteoarthritis. We describe 1 case of complete FCR rupture secondary to trauma, showing that long-term disability following FCR rupture is minimal.