Abstracts / Résumés
Assessing Orbital Compartment Syndrome Management in the Burns ICU: A Retrospective Chart Review
Wei Lin, Abdullahi Mohamed, Justin Lee, Matthew Benson, Joshua N Wong
Edmonton, AB
Purpose: Orbital compartment syndrome (OCS) is a vision-threatening emergency. It remains without standardized screening guidelines in burn patients. This study assesses OCS incidence, risk factors, outcomes, and evaluates proposed guidelines in a burns ICU setting.
Method: A retrospective observational cohort study was conducted on patients with ≥20% total body surface area (TBSA) burns admitted to a burn ICU from January 2022 to January 2024 (n=64). Data collected included demographics, TBSA, burn distribution, escharotomy frequency, 24-h fluid resuscitation volumes, OCS incidence, and lateral canthotomy and cantholysis (LCC). Pre- and post-LCC intraocular pressure (IOP) and timing of OCS diagnosis were also reviewed. Proposed screening criteria were retrospectively applied to assess diagnostic performance. Comparative analyses between OCS and non-OCS patients were performed using independent t-tests.
Results: Seven (10.9%) developed OCS, all with facial burns and multiple anatomical regions involved, requiring bilateral LCC. Mean time to LCC was 4.7 h. Compared with non-OCS patients, those with OCS had larger burns (mean TBSA 49%), higher 24-h fluid volumes (14.6 L), and more escharotomies (5.1) (p 40%, facial burns, or resuscitation >80 mL/kg) identified all OCS cases, yielding sensitivity of 100% and specificity of 49%.
Conclusions: Large TBSA, facial burns, high resuscitation volumes, and multiple escharotomies emerged as key risk factors for developing OCS. Proposed screening criteria demonstrated excellent sensitivity, supporting their potential role in earlier detection and timely LCC. These findings underscore the need for prospective validation and standardized protocols to reduce preventable vision loss.
Rescuing the zone of stasis: topical sulfaphenazole as a novel treatment for minimizing burn depth progression in a rodent thermal injury model
Matthew Carr, Michael Lane, Claudia Dietrich, Chris Turner, Anthony Papp, David Granville
Vancouver, BC
Purpose: The transitional zone of stasis is a critical area that heavily influences burn wound progression. Ischemia due to vascular damage and reactive oxygen species exacerbate the zone of stasis, leading to worsening tissue necrosis and burn depth progression. Although previous studies have demonstrated that improved tissue perfusion within 24 h of injury can stabilize the zone of stasis, pharmacological interventions to prevent burn progression remain an unmet clinical need. We therefore investigated a potential role for sulfaphenazole – a clinically approved, off-patent cytochrome P450 inhibitor antibiotic, which our group has previously shown to reduce ischemia and reperfusion injury by attenuating post-ischemic endothelial dysfunction in animal models of myocardial infarction and cardiac allograft vasculopathy, in addition to improving tissue perfusion and wound healing in a mouse model of pressure injury.
Methods: Systemic efficacy was first examined by creating deep-dermal contact burns on adult mice, followed by daily intraperitoneal sulfaphenazole injections and wound analysis until 9 days post-injury. A novel topical formulation of sulfaphenazole was then compared head-to-head versus daily application of gold-standard flamazine in a rat burn model, and analyzed up to 7 days post-injury. Standard wound healing parameters were compared between groups using both micro- and macroscopic analyses.
Results: No adverse events were observed with systemic or topical sulfaphenazole administration. Systemic administration resulted in significantly smaller wound size and improved perfusion versus sham treatment. Topical sulfaphenazole significantly improved reduction in wound diameter relative to sham and flamazine treatments.
Conclusions: Preliminary rodent data support a potential role for the application of sulfaphenazole during the early phase of burn wound maturation, where it may minimize burn depth progression through improved perfusion in the zone of stasis.
Real-World Outcomes After Catalytic Treatment Matrix Initiation in Chronic Wounds
Carson McComb, Eric Fung, Jordan French, Joshua N Wong
Edmonton, AB
Purpose: Chronic wounds place a significant burden on the Canadian healthcare system and reduce quality of life. We evaluated Catalytic Treatment Matrix (CTM) as an adjunct to best-in-class dressings for chronic wounds in a single-surgeon practice.
Method: We retrospectively reviewed wounds treated with best-in-class dressings before and after adjunctive CTM initiation in a single-surgeon practice. Using inpatient controls, baseline was defined as wound area at presentation; treatment baseline was wound area at CTM initiation. Percent closure was calculated as (1 - area/baseline) ×100. The primary endpoint was percent closure at 12 weeks (post-presentation vs post-CTM). Longitudinal changes were modeled separately for pre- and post-CTM periods using linear mixed-effects models with a random intercept for wound and fixed effect of time (weeks) on log-relative area.
Results: 33 chronic lower limb and pressure injury wounds were included; (median duration prior to CTM: 5.0 months [IQR 1.6–25.5]). Paired 12-week data were available for 10 wounds: median closure improved from −13.3% (net enlargement) to 26.1% (net reduction), a median paired improvement of +40.7%. Mixed-effects models included 66 observations/27 wounds pre and 101 observations/26 wounds post. The pre-CTM slope was −0.0228 log-ratio/week (95% CI −0.087 to 0.042; p=0.49; ∼2.3% area reduction/week) versus −0.138 post-CTM (95% CI −0.191 to −0.086).
Conclusions: Adjunctive CTM initiation was associated with a markedly steeper healing trajectory compared to best-in-class dressings alone. Prospective comparative studies are warranted to confirm effectiveness and define optimal indications.
Comparing midface hypoplasia following palatoplasty with and without extensive nasal mucosal flap dissection
Karen Wong Riff, Eileen Tang, Kyle Stevens, Shakil Popatia, Alexandra D'Souza, Kariym Joachim, Dale Podolsky, David Fisher
Toronto, ON
Purpose: Primary closure of the nasal mucosa following dissection of nasal mucoperiosteal flaps off of the medial pterygoid plates and the hard palate shelf allows for a watertight, two-layer repair in palatoplasty. We have reported a 0.86% fistula rate in a series of 1041 cleft palate repairs using this technique. This study aimed to evaluate the effect of extensive nasal mucosal dissection on midface hypoplasia by comparing the rate of recommendation for orthognathic surgery in patients that underwent palatoplasty with no dissection (Veau I) to those that had the dissection (Veau II).
Methods: Non-syndromic patients with a Veau I or II cleft palate, ≥15 years old at last follow-up, who underwent primary palatoplasty from 2000 onwards by the senior author were included. Rates of recommendation for orthognathic surgery were collected, along with cleft characteristics, cephalometrics, and surgical details.
Results: There was no significant difference in the rate of recommendation for orthognathic surgery in those with Veau I (7/35, 20%) versus Veau II (22/97, 23%) clefts. Cephalometric measurement of SNA, SNB, and ANB angles showed no significant differences between Veau I and II clefts when orthognathic surgery was recommended. SNA and SNB were lower in Veau II compared to Veau I clefts when orthognathic surgery was not recommended, but no significant difference was noted in ANB between Veau I and II clefts.
Conclusions: Extensive dissection of nasal mucoperiosteal flaps did not lead to higher rates of recommendation for orthognathic surgery. The benefits of using these flaps to minimize tension on a primary nasal mucosal closure outweigh the risk of midface hypoplasia with this dissection.
External Validation of a Perioperative Cleft Palate Clinical Care Pathway
Rebecca Hartley, Carmen Huang, Rebecca Courtemanche, Thomas Cawthorn, Erika Henkelman
Calgary, AB
Purpose: Validation of the Alberta Children's Hospital's (ACH) perioperative clinical care pathway for cleft palate repair
Method: A comparative cohort design looking at consecutive non-syndromic infants who underwent primary cleft palate repair (2011–2023) at the BC Children's Hospital. Key aspects of the ACH perioperative pathway were implemented: pre-operative acetaminophen (30 mg/kg), intra-operative bilateral suprazygomatic maxillary nerve blocks (SMNB), and post-operative scheduled acetaminophen (15 mg/kg PO Q6H) and ibuprofen (10 mg/kg PO Q6H). Three groups were compared: (1) a historical cohort with no standardized criteria, (2) a partially adapted pathway cohort consisting of standardized analgesia but without intra-operative bilateral SMNBs, and (3) an adapted pathway cohort with intra-operative bilateral SMNBs. The primary outcomes were: (1) length of stay (LOS) (hours) and (2) cumulative post-operative opioid consumption (MME/kg). Secondary outcomes were time to oral intake, anesthesia/surgical times, and complications.
Results: The adapted pathway cohort had shorter LOS than the historical cohort (27.2 vs 37.3 h, p adj 0.0022), and comparable LOS with the partially adapted cohort (28.9 h, p adj 1.000). The adapted cohort consumed less postoperative opioids (0.014 MME/kg) compared to the historical cohort (0.697 MME/kg, p adj < 0 .001) and the partially adapted cohort (0.014 MME/kg, 0.109 p adj - 0.0314). Secondary outcomes were similar across groups except for longer surgical times in the partially adapted cohort and the adapted cohort compared to the historical cohort, and longer anesthesia time in the adapted cohort compared to the partially adapted cohort.
Conclusions: Implementation of an adapted ACH perioperative pathway was associated with significantly reduced LOS and cumulative post-operative opioid consumption. This study validates the efficacy of the pathway and supports its generalizability to other institutions.
Developing a Three- Dimensional Data Driven Model of the Unilateral Cleft Lip Nasal Deformity in Early Mixed Dentition
Ruth Tevlin, Riley Lehmann, Clay Collison, Ezgi Mercan, Raymond Tse
St. Louis, MO
Purpose: Optimal treatment of the patients with a unilateral cleft lip nasal deformity (uCLND) continues to be a challenge, and an incomplete understanding of the complex three-dimensional nasal deformity hampers clinical progress. Our group recently examined the uCLND present in infants prior to cleft lip and palate repair by developing a three-dimensional data driven model of the primary unrepaired osseocartilaginous skeleton of the nasomaxillary complex. We hypothesize that the uCLND continues to evolve secondary to growth and in response to surgical intervention. The purpose of the current study is to develop a data-driven model of the osseocartilaginous skeleton in patients with uCLND in early mixed dentition, focusing on the septum and bony nasal vault.
Methods: Computed tomographic (CT) scans of 49 patients with a history of repaired unilateral cleft lip +/- palate in early mixed dentition were identified from the institutional database. For comparison, CT scans of 49 patients with no craniofacial anomalies were identified. CT scans were analyzed using 3D Slicer with manual annotation of bone and soft tissue landmarks. Osseous landmark deviation in subjects with clefts was compared to controls. Segmentation of the osseocartilaginous septum was manually performed, and deformational differences were calculated.
Results: The average age at time of CT scan was 7 years. All patients had undergone primary cleft repair in infancy. A three-dimensional data driven model of the osseocartilaginous skeleton was generated. Notably, there was divergence of the piriform margins away from the midline. Segmentation of the septum revealed anterior deviation towards the non-cleft side.
Conclusion: Herein, we developed an objective three-dimensional data driven model of the uCLND in early mixed dentition. These analyses will allow us to better define goals of treatment and to optimize our surgical approach in patients with uCLND to optimize functional respiration and aesthetic outcomes.
Risk Factors for Nerve Injury in Pediatric Supracondylar Humeral Fractures: A Retrospective Cohort Study
Darby Little, Shirley Deng, Emily Ho, Mark Camp, Kristen Davidge
Toronto, ON
Purpose: Nerve injury is a known complication of pediatric supracondylar humeral fractures, but its risk factors remain unclear. This study aimed to identify risk factors for nerve injury in pediatric supracondylar fractures.
Methods: We conducted a retrospective cohort study at a pediatric tertiary care center (2007–2017), including children.
Results: Among 1737 patients (median age: 6 years [IQR: 3], 52% male), 248 (14%) had nerve injuries. The median nerve was the most commonly affected (71%, n=178), followed by radial (21%, n=53) and ulnar (14%, n=34); 14 patients had multiple nerve injuries. Flexion-type injuries accounted for 3% (n=57), while the majority were extension-type fractures (97%, n=1680). Univariable analyses demonstrated significant associations between nerve injury and age, vascular injury, Gartland classification, flexion mechanism, number of pins, and open reduction (p).
Conclusions: This is the largest single-center study to date examining risk factors for nerve injuries in pediatric supracondylar humeral fractures. Early identification of patients high-risk for nerve injury may support timely diagnosis and referral to peripheral nerve specialists.
Shoulder outcomes following primary nerve reconstruction of neonatal brachial plexus palsy: Analysis of predictors and surgical strategies
Raymond Tse, Sarah Lewis, Ezgi Mercan, Heidi Allen, Janine Hottovy, Jason Wright, Suzie Inchauste, Janelle Sousa, Marisa Osorio
Seattle, WA
Purpose: Shoulder motor recovery following nerve reconstruction for neonatal brachial plexus palsy (NBPP) remains limited and data to guide management is scarce. This study aimed to identify factors that correlate with outcome to provide prognosis and inform treatment.
Method: Pre- and 2-year post-operative motor scores of consecutive infants undergoing primary nerve reconstruction (n=75) were reviewed. Surgical indications followed the Toronto protocol. Treatment involved brachial plexus exploration and grafting. Adjunctive nerve transfers included spinal accessory to suprascapular nerve (SAN-SSN) and intercostal to musculocutaneous nerve (ICN-MSC) transfers. Alternative distal transfers, without brachial plexus exploration, were only considered with a failed Cookie test when there were adequate donors to satisfy all deficits (confirmed by EMG). Outcome was defined by Active Movement Scale, active range of motion, and Mallet scores and was compared using Wilcoxon rank sum and t-test. Significance was set at p failed Cookie test, when there are adequate donors for all deficits, distal transfer may be considered an alternative to exploration and grafting.
Cost and Time Savings of Point-of-Care Ultrasound in a Hand Clinic: An 18-Month Retrospective Analysis
Kevin Ghajar, Adham Elsherbini, Meerab Majeed, Jonathan Persitz, Alexandre McDougall, Kevin Zuo
Toronto, ON
Purpose: Point-of-care ultrasound (POCUS) is increasingly used in hand surgery clinics to support real-time diagnosis and management. Its economic impact within a publicly funded healthcare system remains unexplored. This study aimed to evaluate the cost savings, break-even point, and return on investment (ROI) of a handheld POCUS device in an academic hand surgery clinic compared to advanced imaging and nerve conduction studies (NCS).
Methods: A retrospective cohort of 126 patients who underwent in-clinic POCUS for three common clinical indications was analyzed, specifically: carpal tunnel syndrome, soft tissue masses, and soft tissue injuries. System-level costs were estimated using Canadian public healthcare data and published cost analyses while societal costs were quantified based on avoided hospital visits and lost productivity. Total savings, per-patient savings, ROI, and the break-even point were calculated. A subgroup analysis was performed for 70 patients who did not undergo any investigations other than in-clinic POCUS.
Results: Over 18 months, POCUS generated net savings of $40,805.07 CAD after factoring device and consumable costs of $7154.93 CAD. This corresponded to approximately $324 net savings per POCUS exam. The device reached its break-even point after approximately 18 exams, corresponding to a sevenfold ROI. Among the 70 patients who had only POCUS, net savings were about $600 per patient, highlighting the value of POCUS when it obviates the need for further investigations.
Conclusion: POCUS implementation in hand clinics is associated with substantial cost savings, rapid ROI, and reduced utilization of advanced imaging and NCS. While POCUS does not replace formal imaging in all cases, its targeted use offers a high-value diagnostic strategy in a publicly funded healthcare system.
Ultrasound Characterization of Pediatric Trigger Thumb: Early Findings from a Prospective Cohort Study
Adham Elsherbini, Jonah Perlmutter, Emily Shin, Emily Ho, Adam Mosa
Toronto, ON
Purpose: Trigger thumb (TT) is a common pediatric condition, yet predictors of spontaneous resolution remain poorly defined. This prospective study evaluates whether point-of-care ultrasound (POCUS) can identify anatomical parameters associated with TT and inform prognostication and clinical decision-making.
Methods: A prospective study was conducted on children referred for isolated TT to a tertiary pediatric hand surgery center. At the initial visit, participants underwent a POCUS exam using a high-frequency linear transducer (13–18 MHz). Longitudinal and transverse imaging of the flexor pollicis longus (FPL) tendon and A1 pulley was performed. The contralateral unaffected thumb was imaged as the matched control comparison for the affected thumb. Paired t-tests or Wilcoxon signed-rank tests were used based on data distribution. Effect sizes were reported as Cohen's d or Wilcoxon r, and false discovery rate (FDR) correction was applied for multiple comparisons.
Results: 35 patients were included, of which 12 patients were excluded due to either bilateral trigger thumbs (n=7) or missing ≥30% of ultrasound parameters (n=5), and ultimately 23 patients were included for quantitative analysis. Affected thumbs demonstrated significantly increased FPL thickness under the A1 pulley in the short-axis view compared with unaffected thumbs (mean difference 0.26 mm; r = 0.618; q = 0.026). A1 pulley cross-sectional area was also significantly greater in affected thumbs (mean difference 1.14 mm2; d = 0.95; q = 0.026). FPL thickness in long-axis, proximal thickness, distal thickness, and FPL cross-sectional area, showed trends toward increased values in affected thumbs but did not remain significant after FDR adjustment. A1 pulley thickness and FPL radial-ulnar size were not significantly different.
Conclusions: Early results from a prospective cohort suggests that POCUS identifies focal morphologic differences at the FPL-A1 pulley interface in pediatric trigger thumb.
Clinic Versus Operating Room Excision of Type B Ulnar Polydactyly: Analysis of Cost, Waste, and Safety at a Canadian Paediatric Center
Ibrahim Durowoju, Adham Elsherbini, Molly Jakeman, Kristen Davidge, Emily Ho, Adam Mosa
Toronto, ON
Purpose: To assess the cost, environmental impact, and complication rates of moving excision of type B ulnar polydactyly from the operating room (OR) to the clinic at a Canadian pediatric centre.
Method: All cases of non-syndromic postaxial polydactyly type B excision at the hospital from fiscal year 2018 to 2024 were included. Financial and emission models were built using data collected from medical records (surgical venue, anesthesia, duration of surgery, billing codes, and staffing) with literature- and institution-derived inputs (cost of procedure, mass of waste generated, and emission factors). Postoperative complication rates were collected and compared across surgical venues.
Results: Among 104 patients, 62 underwent clinic-local, 24 OR-local, and 18 OR–general anaesthesia, with mean operative times of 18, 22, and 33 min and mean costs of $297.53, $678.23, and $1195.14, respectively. Moving all eligible OR-local cases to clinic was estimated to free 6.53 OR hours per year while reducing cost per case by 56%. Mass of waste generated was 103 g per clinic-local case, 317 g per OR-local case, and 677 g per OR–GA. Greenhouse gas emissions, denoted in equivalent amount of CO₂ (kg CO₂e), were 0.875 kg CO₂e per clinic-local case versus 5.873 kg and 7.018 kg CO₂e per OR-local and OR–general case, yielding an estimated annual reduction of 61.23 kg CO₂e by moving all eligible cases to the clinic. There was no statistically significant difference in complication rates between the clinic and OR cohorts (2/62 vs 0/42, p=0.51), and no neuromas or re-operations occurred.
Conclusions: Clinic-based excision of type B ulnar polydactyly under local anaesthesia appears substantially less costly and carbon-intensive than OR-based management, with similarly low complication rates.
Comparing Morphometric Changes in Four Types of Z-Plasties in a First Webspace Model of the Hand.
Amr AlMasri, Jouseph Barkho, Sebastian Kolde
Hamilton, ON
Purpose: The first webspace contracture is the most common contracture in the hand, and webspace deepening with Z-plasty is the gold standard treatment. Four Z-Plasties are commonly used: the 2-Flap, 4-Flap, Jumping Man (5-Flap), and Serial Z-Plasty. The primary objective is to determine which of these variants provides the greatest vertical webspace deepening, and the secondary objective is to determine which provides the greatest curvilinear and planimetric lengthening.
Method: Nylon spandex was stretched over a semi-circular pegboard to simulate the first webspace of the hand. The 2-Flap, 4-Flap, Jumping Man, and Serial Z-plasty were designed per classic descriptions over a 4 cm central limb. Nine trials per flap were conducted. Outcomes were expressed as percentage change from pre- to post-flap. Linear mixed models with Z-plasty type as fixed effect and rater as a random intercept, were conducted. In addition, post-hoc Least Significant Difference (LSD) estimated marginal means with pairwise comparisons were used to analyze outcomes.
Results: The 2-Flap (mean = 209% [range 181% - 237%]) and 4-Flap (mean=176% [248% - 204%]) Z-plasties produced the greatest vertical deepening (p=0.10). The 4-Flap produced the greatest curvilinear (mean=102% [97.9% - 106%]) and planimetric lengthening (mean=68.9% [60.2%-77.6%]), followed by the 2-Flap (mean=58.1% [54.1% - 62.1%], mean=34.1% [25.4% - 42.8%] respectively.
Conclusions: The 2-Flap and 4-Flap Z-plasty provided the greatest vertical deepening, however the 4-flap provided greater curvilinear and planimetric elongation compared to the other Z-plasty variants.
Surgical site infection rates following cubital tunnel release across surgical settings and anesthesia methods
Jacob Power, Alison Wong
St. John's, NL
Purpose: To describe surgical site infection (SSI) rates following cubital tunnel release (CuTR) performed using different sterility environments and anesthesia methods, including wide-awake local anesthesia no tourniquet (WALANT), general anesthesia (GA), and regional anesthesia (RA).
Method: We performed a retrospective cohort study of adult patients undergoing CuTR. Procedures were performed in either a minor procedure room using field sterility, local operating room with full draping and gowning, or main operating room. Anesthesia methods included WALANT, GA, or RA with sedation. Primary outcome was postoperative surgical site infection. Descriptive statistics were used to summarize outcomes.
Results: A total of 132 CuTR procedures were included. Procedures were performed in a minor procedure room (n=26), local operating room (n=59), and main operating room (n=48). Overall, 8 postoperative infections were recorded. All resolved with oral antibiotics alone. No infections were observed among procedures performed in the minor procedure room. Infections occurred following procedures performed in the local operating room (n=5) and main operating room (n=3). One infection was associated with wound dehiscence following a postoperative trauma. On average, postoperative follow-up occurred on day 17, and patients were followed for an average of 71 days. No cases required revision cubital tunnel surgery.
Conclusions: SSIs following CuTR were observed following operating room procedures. No infections were observed following procedures performed in a minor procedure room. Further analysis to evaluate the effects of surgical setting and anesthesia type on postoperative infection risk is ongoing.
Successful 24-Hour Ex-Vivo Perfusion in the Swine Total Hindlimb Model
Cagdas Duru, Kate Rokoss, Alina Stoian, Felor Biniazan, Florian Le Billan, Golnaz Karoubi, Siba Haykal
Toronto, ON
Purpose: Static cold storage (SCS) at 4 °C remains the standard for preserving vascularized composite allotransplants (VCA) but limits viability to 6 h. Ex-vivo perfusion offers a promising alternative to improve VCA preservation. This study presents a 24-h sub-normothermic perfusion protocol in a swine hindlimb model.
Methods: Limbs perfused for 24 h were compared with cold-stored limbs (SCS). The perfusate contained LPD, 2.5 g/dL BSA, heparin, methylprednisolone, dextrose, insulin, L-alanyl L-glutamine, sodium bicarbonate and washed autologous RBCs (hematocrit 10-15%). In-line pressure was maintained between 60–65 mm Hg and 28–32 °C. Organ pressure was 40–45 mm Hg. Perfusate was monitored hourly. Biopsies (thigh and distal foot) were collected every 6 h for histology and ATP. Limbs were weighed at baseline and endpoint.
Results: Perfusion preserved stable ATP in proximal muscle (0.416-0.367nmol/μL) and distal muscle (0.315-0.267nmol/μL). In contrast, SCS showed significant ATP depletion in proximal muscle (0.502-0.15 nmol/μL, p=0.0086) and distal muscle (0.335-0.078nmol/μL, p=0.0216). Injury scores corroborated these findings. In proximal muscle, scores remained stable with perfusion (3.03 increasing to 3.26) but increased with SCS (2.4 increasing to 3.73, p=0.0079). In the distal muscle, scores rose in both groups (perfusion: 2.90 increasing to 4.63; SCS: 2.56 increasing to 4.0), with significance only in the control group (p = 0.0291). CD31 staining for capillary integrity in the muscle samples showed unchanged properties compared to baseline. Limb weight was unchanged (–0.53% perfusion vs −0.62% SCS).
Conclusion: 24-h swine hindlimb perfusion preserved ATP, morphology, capillary integrity, and function. Perfusion prevented ATP depletion and mitigated muscle damage compared with SCS, supporting its potential to extend VCA preservation. Transplant studies are warranted.
Transforming Clinical Facial Nerve Examination: the IRIS Augmented Reality Assessment Platform in the synkinetic post-paretic population
Fatima Saqib, Jessica Winter, Spencer Ferbers, Hongdao (Davis) Dong
Winnipeg, MB
Purpose: Facial synkinesis following facial paralysis results in functional impairment and psychosocial consequences. Current tools used to assess synkinesis are subjective, time-consuming, and dependent on clinician experience. The Interactive Rendering and Integration System (IRIS) is an augmented reality facial movement detection platform that tracks 477 facial landmarks using MediaPipe Face Landmarker technology. This pilot study aimed to determine whether IRIS can detect synkinesis in the post-paretic population.
Methods: Patients with ocular–oral or oral–ocular synkinesis following facial paralysis and healthy controls were recruited. Synkinesis severity was graded from mild to severe. Sunnybrook Facial Grading Scale (SFGS) and Synkinesis Assessment Questionnaire (SAQ) scores were collected. Participants underwent a standardized facial nerve examination using IRIS, including eyebrow elevation, gentle eye closure, closed-mouth smile, and open-mouth smile. Twenty-eight facial landmarks were selected and grouped by facial nerve branch innervation. Three-dimensional landmark movement using time-velocity curves was analyzed and compared between affected and unaffected sides and healthy controls.
Results: Eight patients with synkinesis (five ocular–oral, one oral–ocular, and 2 mixed type) and two healthy controls were included. The mean age was 52 years. Three participants were male and five were female. The average SFGS score was 50/100 and the average SAQ score was 27/45. Abnormal oral commissure movement during gentle eye closure was detected on the affected side of patients with ocular–oral and mixed synkinesis and was absent on the unaffected side, in controls, and in the patient with only oral-ocular synkinesis. These findings correlated with clinical severity.
Conclusions: The IRIS platform shows potential as an objective tool for detecting ocular–oral synkinesis in post-paretic patients. Further validation is needed to assess accuracy across different synkinesis patterns.
Intraoperative Assessment of Tissue Perfusion Using SPY Angiography in Free and Pedicled Flap Surgery: A Retrospective Study
Rayan Affes, Dominique Tremblay, Elie Boghossian
Montreal, QC
Purpose: Intraoperative assessment of flap perfusion is critical to prevent postoperative necrosis. The recently introduced SPY-PHI angiography system (Stryker, MI, USA) provides real-time intraoperative quantitative perfusion data (SPY-QP value). However, no validated perfusion value cutoff exists for reconstructive surgery. While limited breast reconstruction studies using SPY-PHI suggest perfusion cutoffs between 30%–36% as predictors of necrosis, their applicability to non-breast reconstruction remains unclear. This retrospective study explores the association between minimal SPY-QP values and postoperative flap necrosis in extra-mammary flaps.
Method: A retrospective observational study was conducted at Maisonneuve-Rosemont Hospital. Patients undergoing free or pedicled flap reconstruction (2023-2025) of the trunk and extremities with available SPY-QP intraoperative imaging were included. Demographic, clinical, and operative variables were collected. The primary perfusion metric was the minimal SPY-QP value of the final skin paddle. The primary outcome was postoperative skin flap necrosis. Results are reported as medians with interquartile ranges.
Results: Thirteen patients were included of which three developed postoperative flap necrosis. Median minimal SPY-QP on the final skin paddle were lower in the necrosis group compared to the non-necrosis group (16% [15-21] vs 30.5% [24-33]). Necrosis was observed in all flaps with minimal QP Conclusions.
Conclusion: This retrospective analysis supports previously reported perfusion cutoffs, as no flap necrosis occurred above 30%. However, in extra-mammary reconstructive setting using the newer SPY-PHI technology, the real perfusion cutoff below which flap necrosis becomes highly likely remains unknown. These results highlight the need for a prospective study, which is currently ongoing.
Competence by Design Strains Surgical Residency Training Programs
Madison Turk, Brett Ponich, Alexander Platt, Merry Faye Graff, Aaron Knox, Claire Temple-Oberle
Calgary, AB
Purpose: Since its introduction into Canadian Post-Graduate Medical Education, Competence by Design (CBD) has shifted training from time-based to the achievement of defined competencies through Entrustable Professional Activities (EPAs). Studies have raised concerns about CBD since its launch, including increased workloads, completing EPAs, and effects on stress and wellness. However, its impact on surgical residents and attending surgeons remains poorly characterized. This study examined how CBD affects surgical trainees and staff, with a focus on burnout and wellness.
Methods: A cross-sectional survey was distributed electronically to surgical residents and attending surgeons across multiple specialties at the University of Calgary between July and September 2024. Burnout was assessed using the Maslach Burnout Inventory (MBI) supplemented by a single self-reported question assessing perceived burnout. Emotional/physical, occupational, and intellectual/educational wellness were evaluated using Likert-scale items.
Results: 62 surgeons and 49 residents completed the survey. Self-reported burnout was higher among residents than surgeons (67% vs 38%), a finding confirmed by the MBI (29.6% vs 9.3%). Most residents (75%) attributed their burnout to CBD. Residents experienced greater negative effects on emotional wellness, reporting higher stress, sleep disruption, and interference with physical health related to EPA tasks. Surgeons were more likely than residents to perceive CBD as motivating (68% vs 26%) and relationship-building (33% vs 6%). Few participants believed CBD improved surgical skills, autonomy, or readiness for practice. Overall, residents reported a greater negative impact of CBD compared to surgeons.
Conclusions: Though CBD aims to prepare residents for independent practice, its implementation has introduced challenges affecting residents’ well-being and satisfaction at the University of Calgary. Our findings demonstrate the need for targeted programmatic adjustments to better support trainee wellness and meaningful competency development.
A Cost Analysis of Uncomplicated Minor Hand Injury Management in an Operating Room-Based versus Minor Procedure Room-Based Healthcare System
Tal Levit, Lucas Gallo, Helene Retrouvey, Achilles Thoma
Hamilton, ON
Purpose: Minor hand injuries, including metacarpal fractures and flexor tendon lacerations, are common presentations in the emergency department (ED). While complex cases require operating room (OR) management, many uncomplicated injuries may be treated in a minor procedure room (MPR). Institutional policy limits MPR access in Hamilton and cases are performed in the OR, whereas, for example in Calgary, they are performed in the MPR. This study compares the costs of managing uncomplicated minor hand injuries in two systems: an OR-based system where plastic surgeons assess patients in the ED and treat in the OR, and an MPR-based system where patients are referred from the ED to be assessed and treated in the MPR.
Method: Using simulated patient scenarios for an uncomplicated metacarpal fracture pinning and flexor tendon laceration repair, we performed a cost analysis comparing an OR-based system to an MPR-based system. Variable medical costs – including nursing staff, equipment reprocessing, and anesthesia costs – were calculated for each system assuming one-hour procedures. Fixed costs, such as surgeon consultation fees and basic consumables, were excluded.
Results: In the OR-based system, the per-procedure cost includes nursing ($161.44 CAD), tray reprocessing ($197.42), gowns and drapes ($22.15), anesthesiology ($264.60), and overhead ($129.12), totaling $774.73. In contrast, the cost in the MPR-based system includes nursing ($48.81), smaller tray reprocessing ($71.48), and overhead ($24.06), totaling $144.35 CAD.
Conclusion: Compared to an OR-based system, an MPR-based system, when supported by institution policy, has five times lower procedural costs for minor hand injuries without compromising access to timely and safe surgical care.
Concurrent Validity of Augmented Reality-Based Finger Joint Range of Motion Measurement Versus Manual Goniometry in Pathologic Hands
Yushi Wang, Darshan Patel, Carmine Spedaliere, Jacob Davidson, Caitlin Symonette
London, ON
Purpose: Finger range of motion (ROM) measurement is essential for tracking performance in the setting of hand injury or pathology. Augmented reality (AR) tracking is developing as an alternative to manual goniometry. This study aimed to evaluate the concurrent validity of AR measurements compared against goniometry in a pathologic hand population.
Method: AR land-mark tracking using Google MediaPipe Hands framework calculates finger joint ROM angles in real-time. Participants perform a series of hand poses captured from three camera orientations: palmar, radial oblique, and ulnar oblique. Flexion and extension ROM was measured at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of pathologic index through small fingers. AR measurements were compared to goniometry with concurrent validity categorized by median difference 20° (poor).
Results: Thirty-two hands with pathology were included in the analysis. Median age was 59.0 years (interquartile range: 16.0–72.3) and 62.5% of participants were male. The most common hand pathologies were degenerative (46.9%) and trauma (43.8%). For flexion measurements, 50.0% of median differences in joint ROM were within 10° and 41.7% were between 10°-20° of the goniometer. For extension, 66.7% of median differences in joint ROM were within 10° and 33.3% were between 10°-20° of the goniometer. Overall, 95.8% of all ROM measurements fell within 20° of median difference. Radial oblique camera views provided the most accurate measurements for 45.8% of joints, followed by ulnar oblique (37.5%), and palmar (16.7%).
Conclusions: AR tracking demonstrates high concurrent validity for extension ROM measurements, with joint-dependent variability. Flexion measurements were less consistent due to obstructed camera views of the fingers. Further optimization and training using pathologic hands data is required prior to widespread adoption of ROM measurements using AR.
Augmented Reality–Assisted Hand Therapy Improves Pain Tolerance and Engagement: A Pilot Randomized Study
Regina Leung, Yushi Wang
London, ON
Purpose: Hand therapy is critical to recovery following hand surgery, yet up to 60% of patients fail to complete home programs due to pain and poor motivation. To address this, we developed HoloRehab, an augmented reality rhythm-based platform that delivers hand therapy through immersive, music-synchronized exercises. Based on known benefits of gaming, music, and AR/VR, we hypothesized that HoloRehab would improve pain tolerance and motivation during therapy, leading to improved compliance.
Methods: A randomized controlled pilot study was conducted with 20 healthy participants assigned to either the HoloRehab intervention (n=10) or a traditional self-guided control group (n=10). Both groups performed identical hand therapy exercise sequences. Two experiments were conducted. Experiment 1 assessed pain tolerance using hand in ice water bath submersion with time to withdrawal as the primary outcome. Experiment 2 assessed fatigue and motivation during resisted hand exercises using resistance bands, with time to fatigue as the primary outcome. Qualitative feedback on user engagement was collected.
Results: In Experiment 1, HoloRehab participants demonstrated significantly greater pain tolerance compared with controls (time to withdrawal mean: 6.94 vs 3.11 min, p=0.05; median: 6.44 vs 1.06 min, p=0.004). In Experiment 2, HoloRehab participants showed increased exercise endurance (mean: 8.29 vs 5.99 min, p=0.19; median: 8.4 vs 5.40 min, p=0.07). Qualitative analysis demonstrated higher engagement, with HoloRehab users more likely to forget they were exercising (3.6 vs 2.5, p=0.045).
Conclusion: HoloRehab is a novel AR-based hand therapy modality that significantly improves pain tolerance, engagement, and exercise endurance. These findings support further development and clinical validation for integration into hand therapy programs.
Timely Access to Care for Peripheral Nerve Injuries
Tiffany Tse, Amna Majeed, Jana Dengler, Heather Baltzer
Toronto, ON
Purpose: Peripheral nerve injuries (PNI) can result in significant functional impairment. Presentation beyond 3–6 months is associated with inferior quality-of-life outcomes. This study aimed to identify delays in identification, referral, and treatment of PNI.
Method: Peripheral nerve specialists who attended or were included on the Canadian Peripheral Nerve Symposium email list (ie, primarily plastic surgeons, orthopedic surgeons, and physiatrists) were invited to complete a survey assessing perceived barriers to timely care. Data were analyzed descriptively.
Results: The survey was distributed to 355 participants. 25 responded, most of whom were plastic surgeons (n=16, 62%). Most respondents defined delayed presentation of PNI as within 6–12 months following injury (n=16, 62%). Although clinic wait times following referral were typically within 1–3 months (n=17, 68%), most patients were evaluated within 6 months (n=20, 80%), with fewer than half of surgeons reported patients being seen within 3 months. Clinic evaluation within this timeframe did not necessarily reflect timely intervention, as additional delays were commonly reported. Electrophysiologic studies were frequently incomplete at initial assessment. The most frequently identified contributors to delayed care were lack of clarity regarding the referral process (n=9, 36%) and delayed referral from non-nerve surgical specialists (n=6, 24%). Streamlined referral pathways (n=9, 36%) and referral provider education (n=8, 32%) were ranked as the most effective strategies to reduce delays.
Conclusion: Delays in care for PNI occur primarily upstream of specialist consultation and may persist despite timely assessment, highlighting knowledge gaps as drivers of delayed care. Improving referral clarity and streamlining referral pathways may improve patient outcomes.
Topographic Anatomy of the Recurrent Motor Branch of the Median Nerve: A Cadaveric Study
Thomas Milazzo, Kevin Zuo
Toronto, ON
Purpose: The recurrent motor branch (RMB) of the median nerve innervates the thenar musculature. Injury to the RMB can cause significant functional loss. While the course of the RMB relative to the transverse carpal ligament (TCL) is widely reported, the fascicular topography of the RMB within the median nerve proper remains poorly understood.
Method: Eight cadaveric upper limbs (4 left, 4 right) were dissected. The location of the RMB origin relative to key landmarks and cross-sectional diameter was recorded. The fascicular position at origin and defined proximal intervals was characterized. Data were analyzed descriptively.
Results: All examples exhibited extraligamentous path. The median RMB cross-sectional diameter at origin off the median nerve was 1.1 mm (IQR 1 – 1.3). At the level of the volar wrist between the scaphoid and pisiform, the RMB was topographically positioned in the radial quadrant of the median nerve, specifically volar-radial (5/8) and dorsal-radial (2/8). In 5 specimens, the radially positioned RMB fascicle twisted between volar and dorsal positions when moving anterograde from the volar wrist. In one specimen, the RMB was topographically organized in the dorsal-ulnar quadrant of median nerve proper.
Conclusions: This is the first study to examine the topographic location of the RMB at the wrist. We conclude that the RMB commonly originates as an extraligamentous, radially positioned branch of the median nerve. However, we identify inconsistent and occasionally alternating position along the volar/dorsal plane and rare ulnar origin. This information about RMB topographic position within the median nerve proper may be relevant for distal nerve transfers or median nerve repairs at the level of the wrist when orienting fascicles. Additional specimens are required to validate the frequency of variations.
Conditioning After the Cut: Inducing Regeneration in a Transected Nerve
Christine Webber, Ming Chan, Karyne Rabey, Jenna-Lynn Senger
Vancouver, BC
PURPOSE: Conditioning, in which brief electrical stimulation primes neurons for accelerated regeneration, is among the most effective strategies for enhancing peripheral nerve recovery. However, all prior conditioning paradigms required stimulation before injury, preventing clinical application in patients who present with a transected nerve. The ability to induce a conditioning response after injury, in an already cut nerve, would represent a major step toward translation. This study tested whether post-injury, pre-repair conditioning electrical stimulation (CES) could evoke a conditioning-like effect in a transected nerve, enabling regeneration and reinnervation comparable to traditional pre-injury conditioning.
METHODS: Adult male Sprague–Dawley rats were randomized to four cohorts: (1) CES-cut-IR (CES 1 week prior to transection + immediate repair), (2) cut-IR (transection and immediate repair, no CES), (3) cut-DR (transection with delayed repair, no CES), and (4) cut-CES-DR (transection, CES on post-injury day 3, delayed repair on day 10). Outcomes included axonal extension (14 days post-repair), sensory recovery (von Frey thresholds, intraepidermal nerve fiber density [IENFD]), and motor recovery (toe-spread, ladder-rung performance, CMAP amplitudes, gastrocnemius mass, and reinnervated NMJs).
RESULTS: Post-injury CES significantly enhanced axonal regeneration and reinnervation versus unstimulated controls. Axonal extension in cut-CES-DR (12.1 ± 0.7 mm) matched the pre-injury CES gold standard (12.5 ± 0.9 mm, p = 0.85) and exceeded both immediate and delayed repairs without CES (6.9 ± 0.6 mm, 7.2 ± 0.5 mm; p < 0.001). Sensory and motor recovery in cut-CES-DR paralleled CES-cut-IR and were significantly greater than controls (toe-spread ∼73% vs ∼43% contralateral; ladder score 5.0 ± 0.1 vs 3.3–3.6; p < 0.001).
CONCLUSIONS: This study demonstrates, for the first time, that conditioning can be induced in a transected nerve. A single, brief post-injury CES session restores regenerative and functional outcomes to levels equivalent to pre-injury conditioning, establishing CES as a clinically feasible, biologically effective bridge-to-surgery for peripheral nerve repair.
Investigating the Effects of Age on Nerve Transfer Outcomes: A Retrospective Cohort Study
Jane Zhu, Armaan Dhanoa, Joseph Catapano, Jana Dengler
Toronto, ON
Purpose: Age-related differences in axon regeneration and reinnervation have been observed in animal models and suggested in retrospective human studies. The purpose of our study is to better characterize functional and electromyographical outcomes following nerve transfer in patients aged ≥60 years.
Methods: A single-centre, retrospective chart analysis was performed for patients undergoing motor nerve transfer in the upper extremity between 2000–2023. Data collected included demographics, comorbidities, injury characteristics, surgical procedures, complications, electromyography, and functional outcomes (MRC grading). Descriptive statistics were used to summarize data, Fisher's exact and Mann-Whitney U tests were used to calculate associations between categorical variables and groups.
Results: Thirty-two patients aged 60–78 years (mean 67; 81.3% male) underwent 40 motor nerve transfers. The ulnar nerve was most commonly involved (47.5%) followed by brachial plexus (30.0%); AIN to ulnar (47.5%) and triceps to axillary (15.0%) were the most common procedures. 45.0% of patients achieved a final MRC ≥3. Electrodiagnostic evidence of reinnervation was seen in 82.5% of patients, with an average latency to detection of nascent motor units of 7.3 ± 2.6 months. Those who achieve MRC ≥3 are significantly more likely to be younger (p = 0.003). There was also a significant association between procedure type and outcome of MRC ≥3 (p = 0.008), with AIN to ulnar nerve transfers having significantly greater proportion of MRC ≥3 outcomes.
Conclusions: Nerve transfers in an older population yield good functional outcomes, particularly AIN to ulnar nerve transfers. Future research should include multi-center cohort studies which directly compare similar nerve transfers across populations of different ages to determine positive and negative predictors of outcome.
Regional Anesthesia Brachial Plexus Block for Distal Nerve Transfers
John Gobran, Kwesi Kwofie, Emily Krauss
Halifax, ON
Purpose: Nerve surgery in the extremity has traditionally been performed under general anesthetic (GA), in part due to concerns about the effects of peripherally acting agents on nerve monitoring and healing. GA carries well-documented complications, and newer technique changes in regional anesthesia (ultrasound guidance, lower volume injection) have improved safety. We investigate the safety and effectiveness of brachial plexus block when performing distal nerve transfers.
Method: A retrospective chart review from January 2022 to December 2025 included twenty-eight patients undergoing distal nerve transfers with regional brachial plexus block. Data included procedure type, responsiveness to intraoperative nerve stimulation, conversions to GA, perioperative complications, pain control, length of post-operative care unit stay and function at the longest follow-up. Patient satisfaction with regional anesthesia was assessed one day post-operatively on a Likert scale (1–5).
Results: Of the twenty-eight patients included, twenty were ulnar nerve, five median and three radial nerve transfers. Two patients required conversion to general anesthesia due to pain and three patients required intra-operative narcotics. Successful intraoperative nerve stimulation was observed in all cases attempted (N=23). The average post-operative care unit stay was 80 (+/-15.4 95% CI) minutes, with no reported post-operative complications or admissions. Patient satisfaction with intra-operative pain control averaged 4.1 out of 5. At an average of 26.4 weeks of follow-up, all patients except for one had improved function compared to injury.
Conclusions: Brachial plexus blocks are safe and effective for distal nerve transfer surgeries. This allows for untampered nerve stimulation and demonstrates favourable outcomes in terms of function and pain control, while avoiding the complications of GA.
The Longevity of Partial and Total Wrist Denervation in Chronic Wrist Pain: A Systematic Review
Danielle Tsirulnikov, Gilad Rotem, Jonathan Persitz, Kevin Zuo
Toronto, ON
Purpose: The mainstay of surgical interventions for chronic wrist pain that failed conservative management include motion sparing and fusion techniques. Wrist denervation is an alternative soft tissue procedure that can effectively relieve pain while maintaining function, and may delay the need for salvage procedures. Our aim was to explore the longevity of symptom relief with partial wrist denervation (PWD) and total wrist denervation (TWD).
Methods: This review was registered on PROSPERO (CRD42025613565). We searched MEDLINE, Embase, and CINAHL databases. A total of 19 articles were selected, with patients split into two subgroups: TWD (n=680 cases) and PWD (n=424 cases). Demographic and surgical outcomes data were collected. Our primary outcome was longevity (time until revision surgery), and secondary outcomes included post-operative complications, functional outcomes, and patient satisfaction.
Results: Following TWD, 90% of patients did not require secondary revision surgery by 7.0 years. For PWD, 77% of patients did not require revision surgery by 5.3 years. Of the 71 revisions (10.4%) after TWD, 23 reported a weighted mean time to revision surgery of 2.9 years. Of the 99 revisions (23.3%) after PWD, 78 reported a weighted mean time to revision surgery of 2.1 years. 15/15 studies reported clinically significant reduction in pain scores, and 8/8 studies found that majority of patients (>50%) reported subjective satisfaction with the procedure. Complication rates were very low for both TWD (3%) and PWD (2%), most commonly being sensory changes, CRPS, and neuroma.
Conclusion: These results suggest that both PWD and TWD are effective at substantially reducing chronic wrist pain and can be used to delay more invasive procedures for at least 2–3 years.
Cost-analysis of Routine Histological Assessments in Hand Surgery
Jason Covone, Aslan Baradaran, Bruno Mastropasqua
Montréal, QC
Purpose: Routine histopathologic evaluation of benign hand surgery specimens remains common despite mounting evidence of low clinical yield. This study aimed to evaluate the diagnostic concordance of routine pathology for Dupuytren's disease, synovial/ganglion cysts, and osteoarthritic hand specimens over a 15-year period at a Canadian community hospital, and to estimate the cost per discrepant and discordant diagnosis from a public payer perspective.
Method: We conducted a retrospective observational study at a single community hospital in Montréal, Québec. All specimens submitted for routine histopathologic examination by two plastic surgeons between 2009 and 2023 were reviewed. Surgeon postoperative diagnoses were compared with final pathology reports and classified as concordant, discrepant (benign alternative diagnosis without management change), or discordant (management-changing). Costs were calculated using institutional technical cost units and Québec physician billing codes, yielding a total cost of $24 CAD per specimen. Cost per discrepant and discordant diagnosis was calculated.
Results: A total of 695 specimens were analyzed, including 252 Dupuytren's specimens, 397 synovial cysts, and 46 trapeziectomy specimens. Overall, 673 cases (96.8%) were concordant, 22 (3.2%) were discrepant, and no discordant diagnoses were identified. The total cost of routine pathology was $16,680 CAD. The overall cost per discrepant diagnosis was $758 CAD. By specimen type, the cost per discrepant diagnosis was $3024 CAD for Dupuytren's disease and $476 CAD for synovial cysts. No discrepant or discordant diagnoses were identified among trapeziectomy specimens.
Conclusions: Routine histopathologic evaluation of benign hand surgery specimens demonstrated no management-changing diagnoses over 15 years and incurred substantial cumulative cost. These findings suggest that routine pathology for these specimen types represents low-value care in a publicly funded healthcare system and support reconsideration of current institutional and clinical guidelines.
Quality of Life with Immediate Alloplastic Reconstruction After Prophylactic Versus Therapeutic Mastectomy: A Systematic Review and Meta-Analysis of Patient Reported Outcomes measured by the BREAST-Q
Aghaghia Mokhber, Veronica Deyoung, Glykeria Martou
Kingston, ON
Purpose: Prophylactic mastectomy with immediate alloplastic reconstruction is increasingly performed to reduce future disease risk, yet the benefits to quality-of-life (QoL) relative to therapeutic mastectomy remain uncertain. This study aimed to evaluate differences in postoperative QoL outcomes between prophylactic and therapeutic mastectomy using the BREAST-Q, to better inform patient counseling and shared decision-making.
Methods: A systematic literature search was conducted across MEDLINE, Embase, Cochrane Library, CINAHL, and PsycINFO. Eligible studies compared postoperative QoL outcomes between prophylactic and therapeutic mastectomy with immediate implant-based reconstruction using the BREAST-Q questionnaire. Data were pooled using random-effects meta-analysis, with results reported as mean differences (MD) and 95% confidence intervals (CI).
Results: Twenty-eight studies (n=27,716 patients) met inclusion criteria, of which nine were included in the meta-analysis. In total, 3426 women (12.4%) underwent prophylactic and 24,290 (87.6%) therapeutic mastectomy with reconstruction. Reported mean ages ranged from 39–60 years, with follow-up durations ranging from 1 week to 13 years. Prophylactic mastectomy was associated with significantly higher scores in Satisfaction with Breasts (MD 4.83, 95% CI 2.13-7.53, I2=11%), Physical Wellbeing (MD 4.67, 95% CI 1.63-7.71, I2=51%), Sexual Wellbeing (MD 5.35, 95% CI 0.64-10.07, I2=37%), and Psychosocial Wellbeing (MD 6.26, 95% CI 2.24-10.29, I2=0%).
Conclusions: Women undergoing prophylactic mastectomy with immediate implant-based reconstruction report better QoL outcomes compared to those undergoing therapeutic mastectomy. These findings suggest that prophylactic surgery confers meaningful QoL-related benefits beyond cancer risk reduction, underscoring its role as a patient-centered option for women considering risk-reducing strategies.
Immediate Breast Reconstruction in Patients with Inflammatory Breast Cancer: A Systematic Review
Carla Herman, Aurélia Bouffard, Johnny Efanov
Montreal, QC
Purpose: Inflammatory breast cancer (IBC) is a rare, aggressive subtype with poor survival and high locoregional and systemic recurrence. Immediate breast reconstruction (IBR) was historically discouraged due to oncologic safety concerns. With recent improvements in oncologic outcomes through multimodal therapy, IBR warrants reconsideration. This study aims to evaluate the oncologic and surgical safety of IBR in patients with IBC.
Method: A systematic review was conducted per PRISMA guidelines. MEDLINE, EMBASE, and Cochrane databases were searched. All studies evaluating IBR among patients with IBC were included. Assessed outcomes comprised survival, recurrence, surgical complications, adjuvant therapy timing, and patient-reported outcomes. Risk of bias was evaluated using the JBI Critical Appraisal Tools. Descriptive statistics were conducted.
Results: Eleven retrospective studies involving 1192 patients were included. Most patients received trimodal therapy with neoadjuvant chemotherapy, mastectomy with immediate reconstruction, and adjuvant radiotherapy. IBR included autologous reconstruction (29.7%), implant-based reconstruction (16.0%), combined techniques (5.4%), and unspecified approaches (48.9%). Survival was similar between IBR patients and those without reconstruction. Locoregional recurrence was uncommon (7.1%), whereas distant metastases occurred in 44.2% of patients, mostly within the first postoperative year. Low rates of surgical complications were observed, including autologous tissue loss (2.1%), partial flap necrosis (4.9%), infection (6.9%), implant-related complications (7.0%), and tissue expander removal (12.5%). 56.5% of patients required revision surgery, predominantly for elective aesthetic optimization. IBR did not delay adjuvant therapy, with radiotherapy initiated within 49–52 days. Patient-reported outcomes demonstrated high satisfaction and improved quality-of-life.
Conclusions: In carefully selected patients with IBC, IBR can be safely integrated into multimodal therapy, offering improvements in quality of life without affecting oncologic outcomes.
Autoimmunity and Cancer-Related Lymphedema Development after Axillary Surgery: A Decade of Outcomes from A Tertiary Cancer Center
Sarah Fargey, Stav Brown, Noor Sibat, Siba Haykal
Toronto, ON
Background: Despite emerging evidence implicating immune dysregulation in the pathogenesis of breast-cancer–related lymphedema (BCRL), the contribution of autoimmune comorbidities to lymphedema development remains poorly defined. The purpose of this study was to investigate the association between a broad range of autoimmune and inflammatory conditions and lymphedema development following axillary surgery.
Methods: All patients who underwent axillary surgery at a tertiary cancer center between 2013 and 2025 were included. Demographic and clinical variables, including age, sex, race, body mass index (BMI), chemotherapy and radiation therapy exposure, and comorbid conditions (diabetes, asthma, and autoimmune diseases), were extracted. The primary outcome was postoperative lymphedema. Univariate and multivariable logistic regression analyses were performed to identify factors independently associated with lymphedema development.
Results: A total of 16,754 patients were included, of whom 2665 (15.9%) developed lymphedema. On multivariable analysis, established risk factors including obesity (BMI >30; OR 1.35, 95% CI 1.23-1.49), radiation therapy (OR 2.10, 95% CI 1.91-2.31), and chemotherapy (OR 2.35, 95% CI 2.12-2.62) were strongly associated with lymphedema (all).
Conclusion: In this large institutional cohort, select autoimmune and inflammatory conditions were independently associated with an increased risk of lymphedema following axillary surgery. These findings support a potential role for immune-mediated mechanisms in lymphedema development and highlight the importance of incorporating immune comorbidity profiles into postoperative risk stratification.
The Long-Term Fate of Textured Breast Implants After Recall: Patient Decision-Making in a Canadian Breast Cancer Reconstruction Cohort
Victoria Tucci, Darby Little, Adrian McArdle, Laura Snell, Joan Lipa
Toronto, ON
Purpose: The 2019 global recall of Biocell macrotextured devices prompted widespread patient concern and clinical re-evaluation in the context of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) risk. The longitudinal impact of this recall on textured breast implant (TBI) disposition and patient decision-making within breast cancer survivorship care remains poorly understood. We examined time-dependent probability of TBI retention and the clinical and patient-driven factors influencing intervention decisions in a long-term Canadian breast reconstruction cohort.
Methods: An REB-approved 25-year retrospective cohort study (2000–2025) was conducted among post-mastectomy breast cancer patients with TBI reconstruction identified from senior authors’ operative logbooks. Indications for TBI exposure termination were classified based on clinical symptoms, oncologic events, and patient-driven factors. Descriptive statistics described cohort characteristics and outcomes, while Kaplan-Meier analysis estimated time-dependent probability of TBI retention.
Results: Among 225 breast cancer reconstruction patients, 397 TBIs were placed (66% Biocell) and 186 of total TBIs (47%) were removed over a median exposure of 9.5-years. Common indications included capsular contracture (33%), ALCL-related anxiety (26%), cosmesis (12%), and rupture (10%). BIA-ALCL was diagnosed in two patients (one bilateral case), yielding a patient-level incidence of 0.9% overall and 1.3% among Biocell-exposed patients. Kaplan–Meier analysis estimated the probability of a TBI remaining in-situ to be approximately 75% at 10-years and 10% at 20-years.
Conclusions: In a large Canadian breast cancer reconstruction population, TBI removal reflects both objective reconstructive morbidity and patient-driven risk perception, with leading indications of capsular contracture, recall-associated BIA-ALCL anxiety, and cosmetic concerns. These findings highlight the importance of counseling that considers quantitative risk, quality-of-life, and the prolonged time horizon of TBI removal.
Integration of an Epic-integrated Patient-reported Outcome Measure (PROM) into Gender-affirming Surgical Practice: A Single-institution Implementation Study Using the GENDER-Q
Dave Gwun, Potter Emery, Soumia Meiyappan, Anne Klassen, Kathleen Armstrong
Toronto, ON
Purpose: The GENDER-Q is a validated patient-reported outcome (PRO) instrument for gender-affirming care. With advances in digital health, PROs can be collected electronically and integrated into electronic medical records (EMRs), supporting both clinical care and quality improvement. We report findings from an initial pilot implementing the GENDER-Q in Epic at Women's College Hospital.
Method: Using co-design, mixed-methods evaluation, and iterative Plan–Do–Study–Act (PDSA) cycles, we developed and tested an Epic-integrated workflow to administer GENDER-Q questionnaires before and after initial surgical counselling visits. Before the visit, transmasculine and nonbinary patients undergoing masculinizing top surgery (ie, gender-affirming mastectomy or breast reduction) were invited to complete an online pre-visit package including the GENDER-Q Gender Dysphoria (GD), Body Image (BI), and Chest domains. After the visit, patients were invited to complete a post-visit questionnaire. Feasibility and acceptability were assessed through workflow performance, completion rates, and discussions of barriers and facilitators to uptake.
Results: The GENDER-Q was successfully integrated and operationalized within Epic. Since its launch in November 2025, 28 patients received pre- and post-visit questionnaires. Pre-visit completion rates for BI, GD, and Chest domains were 92.9%, 89.3%, and 96.4%, respectively. Post-visit completion was 50%. Four respondents reported dissatisfaction with counselling on management of postoperative symptoms (pain, itching), prompting proactive follow-up. Key barriers to uptake included language barriers and delays between visit completion and post-visit survey delivery. Planned refinements for the next PDSA iteration include deploying multilingual versions of the GENDER-Q and delivering the post-visit survey at visit completion to improve uptake.
Conclusions: Early findings suggest Epic-integrated GENDER-Q collection is feasible and can surface actionable concerns to support personalized care. This approach enables scalable PRO-driven quality improvement and the generation of real-world evidence for gender-affirming surgery services.
Aesthetic, Sensory and Functional Experiences Following Transfeminine Gender-Affirming Bottom Surgery – An International Qualitative Study
Alisha Sharma, Sylvie Cornacchi, Anne Klassen, Manraj Kaur, Kathleen Armstrong
Toronto, ON
Purpose: Feminizing genital surgery aims to improve gender congruence, sexual wellbeing and body image. Patient-reported outcome measures (PROMs) are essential for evaluating these outcomes; however, validated instruments for transgender and gender-diverse (TGD) populations remain limited, with most tools relying on metrics developed for cisgender individuals. The GENDER-Q framework is a comprehensive, international PROM evaluating outcomes of gender-affirming interventions in TGD adults. This study analyzes GENDER-Q data generated during instrument development to characterize aesthetic, sensory, and functional experiences following feminizing genital surgery.
Method: Concept elicitation interviews were conducted with 84 TGD individuals from Canada, USA, Denmark and the Netherlands. Twenty-two had undergone feminizing genital surgery. The codes for genital surgery were reanalyzed via descriptive analysis to derive top-level domains and themes, providing a comprehensive understanding of patient experiences.
Results: Four core themes were identified: genital appearance, urinary function, sexual function, and sexual satisfaction. Most participants reported satisfaction with vaginal appearance, citing a feminine aesthetic with acceptable depth and width. Common concerns included visible scarring, labial asymmetry, and limited clitoral hood definition. Early postoperative urinary stream irregularities were frequently reported, with some noting improved stream consistency over time. Sexual function outcomes commonly included increased arousal, heightened clitoral sensitivity, and improved orgasm experience, although some reported a longer time to orgasm. Overall sexual satisfaction was high, with many participants describing reduced gender dysphoria and greater sexual fulfillment.
Conclusions: This study identified key aesthetic, functional, and sensory outcomes following feminizing genital surgery. The results highlight the need for TGD-specific PROMs, such as the GENDER-Q, that capture these domains and support shared decision-making to optimize surgical care and postoperative satisfaction.
Advancing Sustainability in Pediatric Hand Surgery: An Environmental Analysis of the WALANT Method for Trigger Thumb Release
Aidan Shulkin, Ophelie Doucet, Daniel Borsuk, Emilie Bougie
Montréal, QC
Purpose: The healthcare system accounts for 5% of national greenhouse gas (GHG) emissions. As institutions commit to more sustainable practices, healthcare professionals must develop methods to reduce the sector's carbon footprint without compromising patient care. For hand surgeons, Wide Awake Local Anesthesia No Tourniquet (WALANT) has emerged as a potential solution. This study aims to quantify the environmental impact of WALANT compared with general anesthesia (GA) in pediatric hand surgery.
Method: A life-cycle assessment was conducted to compare the GHG emissions of two standardized approaches for pediatric trigger thumb release at the CHU Sainte-Justine: WALANT in an outpatient minor procedure room (MPR), and GA in a traditional operating room (OR). Emission sources included surgical supply manufacturing, waste elimination, facility energy consumption, and anesthetic gases. Validated environmental metrics were applied to quantify the GHG emissions associated with each technique.
Results: WALANT was associated with considerably lower GHG emissions from surgical supply manufacturing (3.13 kg CO2e vs 7.27 kg CO2e), waste elimination (0.21 kg CO2e vs 0.55 kg CO2e), and facility energy consumption (2.99 kg CO2e vs 28.79 kg CO2e). The sterilization of surgical instruments yielded 0.96 kg CO2e per case for both techniques. Anesthetic gases contributed an additional 1.71 kg CO2e per case performed under GA. Overall, WALANT resulted in an 81.4% reduction in total GHG emissions per case (7.29 kg CO2e vs 39.28 kg CO2e).
Conclusions: WALANT in an outpatient MPR represents an environmentally responsible alternative for pediatric hand surgery, while maintaining favourable clinical outcomes, comfort and safety. Thus, efforts are required to expand its application in children. Complementary sustainability strategies must also be implemented to further reduce the carbon footprint of operative care.
Characterization of Chronic Wrist Pain in Pediatric Patients: A Retrospective Review
Alice Kim, Kevin Cheung
Ottawa, ON
Purpose: Chronic wrist pain in children arises from various etiologies; however, there is limited understanding of its clinical patterns and management in pediatric populations. Although existing literature addresses approaches to triangular fibrocartilage complex (TFCC) injuries and scaphoid fractures, most evidence for other conditions come from adult studies. Therefore, this study aims to characterize pediatric patients with chronic wrist pain, including their clinical presentations, diagnoses, and treatments.
Method: We conducted a retrospective study with patients under 18 years of age, who were referred with chronic wrist pain (lasting more than 3 months) to a tertiary pediatric center between 2015 and 2024. Patients with acute injuries, chronic pain not involving the wrist, congenital wrist conditions, and isolated ganglion cysts were excluded. Demographics, clinical data, and outcomes were collected.
Results: A total of 142 patients were included. The mean age at initial assessment was 14.5 years (SD=2.4), with symptom onset at 12.9 years (SD=2.5). Seventy percent (n=100) were female. A specific wrist injury was reported in 95 patients (67.0%), with 21 patients presenting an initial fracture. TFCC and SL injuries were the most common diagnoses, representing 31 and 19 patients, respectively. Thirty-five patients underwent surgery, while 107 patients were managed conservatively, receiving treatments such as corticosteroid injections, splinting, and hand therapy. Of 35 patients lost to follow-up, 17 were successfully contacted for the purposes of this study. In total, 73 patients reported symptom resolution, 51 reported persistent pain, and 18 remained lost to follow-up.
Conclusions: This study provides an overview of clinical presentations, diagnoses, and treatments for pediatric chronic wrist pain. These findings highlight common injury patterns and management strategies, while emphasizing the need for further research to evaluate outcomes and guide clinical decision-making.
An Objective Three-Dimensional Model of the Bilateral Cleft Lip Nasal Deformity Before Primary Repair
Riley Lehmann, Raymond Tse, Ezgi Mercan, Clay Collison, Ruth Tevlin, Ryan Badiee
Seattle, WA
Purpose: The complexity and lack of objective characterization of the three-dimensional bilateral cleft lip nasal deformity (bCLND) pose significant obstacles to appropriate primary correction. While prior work from our group has focused on unilateral deformity, less is known about the skeletal and surface morphology of bCLND. The purpose of this study is to develop an objective, three-dimensional characterization of the bCLND using both skeletal and surface anatomy and assess bCLND morphological differences relative to controls.
Methods: Previously acquired computed tomographic (CT) scans of 9 children with unrepaired bilateral cleft lip +/- palate were assessed and compared to CT scans of age-matched control subjects without craniofacial anomalies. Bone and soft tissue landmarks were identified, and the osseocartilaginous septum was manually segmented. Deviations in the landmark position of bCLND compared to controls were assessed using t-tests (p Results).
Three-dimensional models of the bCLND were generated for both skeletal and surface anatomy. Relative to control, the rhinion was deprojected and piriform apices displaced postero-lateral. At the surface, subalare landmarks were displaced lateral and the alar curvature landmarks were displaced lateral and posterior. The antero-posterior distances between ANS and piriform apices and between subnasale and subalare landmarks were 2-fold greater with bCLND relative to control (8.6 vs 4.3 and 6.2 vs 2.9 respectively;).
Conclusion: This study presents an objective, three-dimensional characterization of the bilateral cleft lip nasal deformity using skeletal and surface analysis. These data-driven models provide a framework for improved understanding of bCLND morphology. These findings will help to more specifically define treatment goals and improve aesthetic outcomes for bCLND patients.
Survey on comfort with burn injury management among providers in a remote and rural setting
Darby Little, George Ho, Margharita Elloso, Shahriar Shahrokhi
Toronto, ON
Introduction: Rural and remote communities often rely on primary care providers to complete the initial management and referral of burn injuries. This study aimed to assess frontline providers’ comfort with the initial assessment and management of burn injuries in a rural and remote setting.
Methods: A cross-sectional survey was distributed to primary and wound care providers across 10 healthcare facilities in a large rural and remote region between August and December 2024. Self-reported comfort levels with 15 aspects of burn care were assessed using a five-point Likert scale. Wilcoxon rank-sum tests were used to compare survey responses across practice characteristics.
Results: Fifty-nine providers participated, including family physicians (44%), nurse practitioners (20%), emergency physicians (10%), and others. While 90% saw at least one burn injury per year, only 42% saw more than five. Most respondents reported comfort with tetanus prophylaxis (72%) and burn first aid (66%). However, fewer felt comfortable assessing burn size (31%) or depth (27%), initiating fluid resuscitation (27%), or applying the American Burn Association guidelines for burn center transfer (24%). Providers managing five or more burns annually reported significantly greater comfort across multiple domains (p).
Conclusions: This study demonstrates that providers working in a rural and remote region reported limited comfort with burn size and depth assessment, initiating fluid resuscitation, and applying burn center referral guidelines – important skills for initial injury management and referral. These findings highlight a need for system-level supports and educational resources for providers in regions remote from specialized burn centers.
Impact of Substance Use and Withdrawal Management on Clinical Outcomes Following Burn Injury
Wei Lin, Sebastian Kilcommons, Justin Lee, Sharada Manchikanti, Joshua N Wong, Alexis Armour
Edmonton, AB
Purpose: Substance use and its impact on burn care are a growing concern, with a 50% increase in emergency calls for overdoses in recent years. Despite this, literature evaluating the effect of withdrawal management on burn outcomes remains limited. This study examined the association between substance use and clinical outcomes following burn injury and evaluated whether withdrawal treatment modified these outcomes.
Method: A chart review was conducted on adult burn patients admitted to our center from 2022–2024. Primary variables included substance use history, burn mechanism, and burn severity. Secondary outcomes included length of stay, hospital disposition, complications, and withdrawal treatment. Statistical analyses included Student's t-tests and/or Welch's t-test and Chi-Square tests.
Results: Among 576 patients, 315 had a history of substance use and were younger than those without. Substance use was associated with higher rates of frostbite (29.2% vs 8.8%) and full-thickness burns (57.5% vs 42.9%) but not TBSA. Patients with substance use had longer stays (23.8 vs 16.4 days), more complications (17.2% vs 10.1%), and a 15-fold higher risk of unscheduled discharge. Of 250 patients using on admission, 171 (68.4%) received inpatient withdrawal management. Stimulant use (60.7%) was less frequently managed than opioid (72.4%) or alcohol use (80.3%). Withdrawal management did not significantly affect outcomes, with unscheduled discharge rates remaining 26% in both groups.
Conclusions: Substance use is associated with worse clinical outcomes following burn injury; however, withdrawal treatment did not influence these outcomes. These findings highlight the complexity of substance use in burn populations and support the need for integrated addiction treatment strategies.
Early Primary Care Follow-Up and Long-Term Mortality in Burn Survivors: A Population-Based Cohort Study
Darby Little, Elliott Yee, Barbara Haas, Laura Rosella, Gemma Postill, Brandon Zagorski, Liisa Jaakkimainen, Stephanie Mason
Toronto, ON
Purpose: Major burn injury survivors have complex long-term sequelae and are at high risk of long-term mortality. In other hospitalized populations, early follow-up with a primary care provider (PCP) has been associated with improved long-term survival. We hypothesized that early PCP follow-up post-discharge is associated with improved post-discharge survival in burn survivors.
Methods: We performed a retrospective, population-based cohort study of adults attached to a PCP who survived hospitalization for a major burn injury between 2010 and 2022. The exposure of interest was a visit with a patient's own PCP within 30 days of discharge. The primary outcome was one-year all-cause mortality. Cox proportional hazards models were used to estimate the association between early PCP follow-up and one-year mortality, adjusting for age, sex, comorbidities, rurality, and socioeconomic characteristics.
Results: Among 1690 burn survivors (71% male, median [IQR] age 48 [27] years) attached to a PCP prior to injury, 40% of patients had an early PCP follow-up visit. Those with early PCP follow-up were older, more often female, living in rural areas, and had greater comorbidity burden. One-year mortality was 4% overall; 3% for those with early PCP follow-up, and 5% for those without (p = 0.02). After covariate adjustment, early PCP follow-up was associated with a 65% reduction in one-year mortality (HR = 0.35, 95% CI 0.20-0.62).
Conclusions: Early primary care follow-up was associated with greater one-year survival in burn survivors. To our knowledge, this is the first study to demonstrate an association between a post-discharge intervention and improved long-term survival in this population. Burn centres should prioritize the coordination of primary care follow-up at discharge as a strategy to support long-term health.
Axolotl extracellular matrix–derived biomaterial to enhance skin regeneration: A quest to non-scarring healing
Jacob Bouchard, Stephane Roy
Montréal, QC
Purpose: Despite optimal use of skin grafting and commercially available dermal substitutes, deep wounds such as burns frequently result in significant functional and aesthetic sequelae due to incomplete dermal regeneration and fibrotic healing. In contrast, certain vertebrates, notably the axolotl (Ambystoma mexicanum), exhibit scarless skin regeneration, a phenomenon partly attributed to the unique properties of their extracellular matrix (ECM). This study aims to evaluate the therapeutic potential of an axolotl-derived ECM biomaterial to stimulate regenerative wound healing responses in non-regenerating mammalian models.
Methods: Decellularized ECM (dECM) scaffolds were produced from adult axolotl skin and evaluated in vivo using a 10-mm full-thickness excisional wound model in mice. To minimize wound contraction, a titanium mesh splinting technique was applied, as described in the literature. Wounds treated with axolotl dECM were compared with a commercially available dermal substitute (Symbios PerioDerm) and a control group consisting of titanium mesh alone. Macroscopic and histological semi-quantitative analyses were performed to assess wound healing, tissue organization, and structural integrity at postoperative days 7 and 30.
Results: Axolotl dECM was well tolerated in the murine model, with no evidence of immune rejection. Compared to PerioDerm and control groups, wounds treated with axolotl dECM demonstrated enhanced re-epithelialization, increased cellular density, improved collagen deposition with an architecture resembling native skin, and increased angiogenesis. Notably, hair follicle and sebaceous gland–like structures were observed exclusively in the axolotl dECM group.
Conclusions: These findings suggest that axolotl-derived dECM promotes a denser, less fibrotic wound healing response with features of cutaneous appendage regeneration. This biomaterial demonstrates strong therapeutic potential and supports further investigation toward translational and clinically relevant axolotl-derived dermal substitute development.
Move It or Lose It: Evaluation of an early active range of motion protocol for simple pediatric hand fractures
Alexander Platt, Sebastian Kilcommons, Robertson Harrop, Frankie Fraulin, Yoga Dhanapala, Thomas Cawthorn, Rebecca Hartley
Calgary, AB
Purpose: Pediatric hand fractures are common and typically managed with immobilization. However, prolonged immobilization can cause stiffness and delayed return to activity. This study assessed the efficacy and safety of the Alberta Children's Hospital (ACH) Simple Fracture Protocol for the management of simple pediatric hand fractures.
Methods: A prospective cohort study was conducted. Patients with simple hand fractures (defined by the Calgary Kids’ Hand Rule) were treated according to the ACH Simple Fracture Protocol. The protocol combines thermoplastic splint immobilization with immediate initiation of active ROM exercises (4 times per day) for 4 weeks, followed by splint weaning and return to full activity over 2 weeks (total of 6 weeks). Patients were evaluated at three points: within 1 week of injury; 4 weeks post-injury, and 6 weeks post-injury. Primary outcomes: (1) time to clinical healing; (2) ROM; (3) time to return to full activities. Secondary outcomes: pain, complications, need for surgery, and radiographic union. Data were analyzed using descriptive statistics.
Results: Forty patients completed the study protocol. Mean age: 12.7 years (range: 6–17) with 71% male patients. All patients demonstrated clinical healing and return to full activities by 6 weeks post-injury. At 4 weeks post-injury, 90% of patients achieved a full fist closure; by 6 weeks all patients achieved full fist closure. All patients had pain resolution and radiographic evidence of healing at 6 weeks. No patients required operative intervention. No complications were identified.
Conclusions: An early active ROM protocol for simple fractures appears safe and effective: all patients demonstrated clinical healing, full ROM, and return to activity by 6 weeks post-injury. This work supports shifting practice away from prolonged immobilization for simple hand fractures.
Does restoring elbow flexion downgrade wrist flexion? Outcomes of elbow flexion and wrist flexion in patients with Narakas 2 brachial plexus birth injury
Kimberley Yuen, Preksha Rathod, Avalon O'Connor, Hannah Bauer, Deborah Gjertsen, James Bain, Brian Chin
Hamilton, ON
Introduction: Narakas type 2 brachial plexus birth injuries (BPBI) involves damage to the C5, C6, and C7 nerve roots which results in weakness of the shoulder, elbow flexion, supination, and wrist extension. Flexor carpi radialis (FCR) is also compromised as it has contributions from the C6 and C7 roots. Therefore, using flexor carpi ulnaris (FCU) as a donor nerve transfer to the musculocutaneous nerve to restore elbow flexion could further downgrade wrist flexion. We aimed to determine whether the use of a wrist flexor fascicle as a donor diminishes wrist flexion in patients with Narakas type 2 BPBI measured by the Active Movement Scale (AMS).
Methods: This was a retrospective cohort study of patients with Narakas type 2 BPBI who had a nerve transfer using a wrist flexor fascicle to restore elbow flexion by a single surgeon (JRB). Demographic, surgical data, and AMS scores were collected at the following time points: pre-operative, 12-months, and 24-months post-operative. Friedman test was used to analyze change in AMS scores. Post-hoc pairwise comparisons with Wilcoxon signed-rank test with Bonferroni correction were used.
Results: Sixteen patients (10 female: 6 male) with complete data were included. Most patients had an Oberlin transfer (n=11), followed by FCR (n=3), and double fascicular transfer (n=2). Average age at time to presentation and surgery were 1.8 and 5.3 months respectively. At 24-months post-op the mean AMS score for elbow flexion improved to 5.1 from a pre-operative score of 1.9 without downgrading of wrist flexion which had a mean AMS score of 7.
Conclusions: In patients with Narakas type II BPBI, a nerve transfer using a wrist flexor donor can be safely used to restore elbow flexion without compromising wrist flexion function.
Calgary Conquers Swelling: Expanding the Role of Immediate Lymphatic Reconstruction for “Orphaned” Patients in the Prevention of Cancer-Related Lymphedema
Spencer Yakaback, Holly Loreman, Claire Temple-Oberle
Calgary, AB
Purpose: Immediate lymphatic reconstruction (ILR) reduces cancer-related lymphedema (CRL) following lymphadenectomy in selected breast cancer and melanoma patients studied in randomized controlled trials (RCTs). However, many patients encountered in clinical practice do not meet inclusion criteria for these trials and represent a real-world “orphaned” population for whom preventive strategies remain understudied. This study evaluates ILR outcomes in a trial-ineligible population.
Method: This prospective phase II pilot study included adults undergoing axillary or inguinal lymph node dissections whose clinical or oncologic characteristics would preclude inclusion in existing ILR RCTs. All patients underwent ILR using lymphaticovenous anastomosis at the time of oncologic resection. The primary outcome was operative-limb lymphedema, defined as a >10% interlimb volume difference based on standardized measurements. Adjuvant therapies and postoperative complications were recorded.
Results: Twenty-nine patients were included (14 male, 15 female). Diagnoses included melanoma (n=14), squamous cell carcinoma (n=6), colon adenocarcinoma (n=3), Merkel cell carcinoma (n=3), male breast cancer (n=1), hidradenocarcinoma (n=1), and ovarian adenocarcinoma (n=1). Patient characteristics that would have excluded them from previous RCT eligibility included disease recurrence or in-transit metastasis in melanoma (n=9), non-standard cancer types not represented in existing trials (n=15), bilateral lymphadenectomy (n=3), and pre-existing lymphedema (n=2). Surgical sites included unilateral groin (n=18), bilateral groin (n=3), and unilateral axilla (n=8). Overall, four patients developed CRL, including one melanoma patient and three non-melanoma patients (p=0.299). Radiation was administered to eight melanoma patients compared to fourteen non-melanoma patients (p=0.044). CRL rates did not differ by lymphadenectomy location (p=0.31). Overall, twenty-two patients experienced no postoperative complications.
Conclusions: In an all-comers population, ILR was associated with low lymphedema rates and a favourable safety profile. These findings provide real-world evidence supporting broader application of ILR beyond highly selected trial cohorts.
Better Care Sooner: Assessing Efficiency and Resident Educational Value of Dedicated Plastic Surgery Trauma Clinics
Camille Zeitouni, Therese McCurdy, Jason Williams, Margaret Wheelock, Emily Krauss
Halifax, NS
Purpose: In 2025, the Dalhousie plastic surgery department implemented dedicated twice weekly trauma clinics to optimize trauma referral management. This quality improvement project evaluated whether centralizing trauma referrals improved efficiency and timeliness of patient care, while also assessing the perceived impact of this model on resident education, workflow, and provider satisfaction.
Method: Part 1 consisted of a retrospective chart review of plastic surgery trauma referrals three months before and after implementation of the trauma clinic model. Outcomes included time from referral to consultation, consultation to surgery, and referral to surgery. Type of procedure and location (main OR vs procedure room) were collected. Part 2 involved an anonymous survey distributed to all plastic surgery residents and staff. Likert-scale and free-text questions were used to assess satisfaction and educational value of the model. Quantitative data was analyzed with descriptive statistics. Pre- and post-implementation data was compared using a two-sample independent t-test.
Results: A total of 1185 trauma referrals were analyzed over six months, of which 22.2% required procedural intervention. Significant reductions observed in time from referral to consultation (11.8→5.4 days), consultation to surgery (3.9→1.4 days), and referral to surgery (11.4→5.7 days) (all p).
Conclusions: The implementation of dedicated trauma clinics significantly improved care efficiency while simultaneously enhancing provider satisfaction, communication, and resident education. These findings support our trauma clinic model as an effective and sustainable approach to trauma care delivery, informed by both objective outcome measures and provider perspectives.
Cost of hospitalization after autologous breast reconstruction and factors associated with increased cost: A population-based cohort study
Oluwatobi R. Olaiya, Beraki Abraha, Xi Ming Zhu, Lucas Gallo, Sophocles H Voineskos, Christopher J Coroneos, Lawrence Mbuagbaw, Mark McRae
Hamilton, ON
Purpose: This study aimed to explore factors associated with increased hospitalization costs following autologous breast reconstruction.
Methods: This is a retrospective cohort study including patients undergoing free tissue postmastectomy breast reconstruction from 2005 to 2020 in the province of Ontario, Canada (population 14 million). We performed a retrospective cohort study of women who underwent autologous breast reconstruction surgery with either a pedicled transverse rectus myocutaneous (TRAM) flap or free tissue transfer. Cost analysis was performed from the individual hospital perspective. The time horizon was from hospital admission to discharge after autologous breast reconstruction surgery.
Results: This cohort included 2634 patients. Of the cohort, 380 patients (14%) underwent pedicled TRAM reconstruction and 2256 (86%) underwent free flap reconstruction. The median hospitalization cost was CAD 8816 (interquartile range [IQR] $793, minimum $3,383, maximum $90,974). Common drivers of cost identified in the univariate analysis included length of admission, free flap reconstruction, age, income quintile, laterality (unilateral vs bilateral), and emergency reoperation within seven days. Our adjusted multivariate analysis revealed type of reconstruction (free flap reconstruction: 13% cost increase, p < 0. 001), age above 70 (31% increase, p=0.01), income quintile (quintile 5 v. quintile 2: 10% increase, p=0.001), and bilateral reconstruction (11% increase, p = 0.02) were all independently associated with increased costs. Factors such as type of hospital (teaching vs non-teaching hospital), geographic region, timing of reconstruction (immediate), preoperative radiation, patient comorbidities, and rurality did not impact hospitalization costs.
Conclusion: The study highlights the financial implications of different reconstructive approaches and patient demographics in a publicly funded healthcare system. Targeted strategies to understand and address risk factors to manage costs should be conducted to reduce healthcare expenditure.
Early Sensory and Patient Reported Outcomes Following Mastectomy and Breast Reconstruction: A Prospective Self-Controlled Cohort Study
Rawan ElAbd, Marion Sylvain, Maitha AlShamsi, Tyler Safran, Blair Peters, Joshua Vorstenbosch.
Montreal, QC
Purpose: Sensory loss following mastectomy and implant-based breast reconstruction remains a major patient concern, yet prospective data linking objective sensory recovery with patient-reported outcomes are limited. This study evaluates early postoperative sensory changes and psychosocial outcomes following unilateral prepectoral implant-based breast reconstruction.
Methods: This prospective, single-center, single-surgeon, self-controlled cohort study enrolled patients undergoing primary unilateral mastectomy with immediate prepectoral reconstruction since July 2024. Exclusion criteria included prior breast surgery, radiation therapy, BRCA mutation, or refusal to participate. Objective sensory testing using Semmes-Weinstein monofilaments, two-point discrimination, and pain assessment was performed preoperatively and at 3 and 6 months postoperatively across standardized breast zones. Patient-reported outcomes were measured using the BREAST-Q. Paired and unpaired t-tests and correlation analyses were conducted with significance set at p<0.05.
Results: Of 257 patients screened, 43 met inclusion criteria and completed baseline testing; 14 completed early postoperative follow-up (3 or 6 months). Mean age was 52.7±11.2 years and mean BMI was 26.8±5.7. Baseline sensory asymmetry was observed, with lower sensation on the mastectomy side (p=0.03). Greater mastectomy weight, tumor size, BMI, and breast dimensions were associated with reduced baseline sensation (p<0.05). Soft touch, two-point discrimination, and pain sensation significantly declined at 3 months postoperatively, with partial recovery by 6 months. Sensory improvement between 3 and 6 months was most notable for two-point discrimination (p=0.01). BREAST-Q sensation scores declined early but normalized by 3 months, with no sustained changes in other domains.
Conclusions: Unilateral prepectoral implant-based breast reconstruction is associated with an early postoperative decline in breast sensation, followed by measurable sensory recovery beginning within the first 3–6 months. Objective sensory improvement parallels stabilization of patient-reported outcomes. Anatomical factors strongly influence baseline sensation and should be incorporated into preoperative counseling.
Comparing Plastic Surgery Training Models: A Cross-National Review
Maxime Berthout, Gabriel Bensimon, Nayan Bhindi, Giulia Pieracci, Claudia Boucher, Temir Kenbayev, Chanel Beaudoin-Cloutier, Émilie Mailhot, Céline Roberge
Quebec City, QC
Montreal, QC
Melbourne, Australia
Purpose: Plastic surgery training structures differ widely across countries in duration, autonomy, and educational philosophy. Understanding these differences provides valuable insight into how varying systems cultivate surgical independence, technical mastery, and professional development. This review compares national training models to identify opportunities for cross-learning and the evolution of competency-based education.
Method: A narrative comparative review was conducted using official publications and peer-reviewed literature from the Royal College of Physicians and Surgeons of Canada (RCPSC), Accreditation Council for Graduate Medical Education (ACGME), Royal College of Surgeons (UK), and Royal Australasian College of Surgeons (RACS). Domains analyzed included training structure, assessment methods, research integration, and trainee autonomy.
Results: Training duration ranged from five years in Canada to eight years in the United Kingdom. Canada employs a Competence by Design framework, while the United States uses milestone-based evaluations within the ACGME model. The UK and Australia retain apprenticeship-style systems with formal summative examinations (FRCS(Plast), FRACS). Research expectations are highest in Canada and the U.S., whereas graded autonomy and mentorship most strongly influence the development of surgical confidence and independent practice across all systems.
Conclusions: Distinct training philosophies among Canada, the United States, the UK, and Australia produce surgeons with varying balances of technical autonomy, academic focus, and procedural depth. Recognizing and integrating best practices across systems may enhance global competency standards and strengthen surgical education.
Ontario Plastic Surgeons’ Social Media Presence on Instagram: Overuse, Underuse, or Misuse?
Patrick Kim, Alice Wang, Tracy Xiong, Helene Retrouvey
Hamilton, ON
Purpose: Despite widespread use of social media in plastic surgery, the type of content shared and variations by practice setting are poorly understood. We characterized how plastic surgeons use Instagram and examined differences in content patterns and post engagement across different practice settings.
Methods: This observational cross-sectional study analyzed professional Instagram profiles of registered Ontario plastic surgeons. Profiles were categorized into academic, community, or mixed practice. Up to 30 posts per account since January 1, 2020, were coded by content type and clinical domain. Associations between surgeon characteristics and posting patterns were assessed using Chi-square and analysis of variance. Engagement rates were compared using the Kruskal-Wallis test.
Results: Eighty-six of 261 (33%) plastic surgeons had professional Instagram profiles, yielding 2032 posts. The most common content type was pre-/post-procedure results (32%) and the most represented domain was facial aesthetics (20%). Compared to community/mixed practice surgeons, academic surgeons posted more announcements and research-related content (p).
Conclusions: Plastic surgeons’ Instagram use varies substantially by practice setting, with oversaturation of cosmetic content and underrepresentation of academic content, despite higher engagement. This mismatch between what is posted and what audiences engage with can influence public perceptions of the specialty's scope and priorities. These findings highlight the need for more intentional, professionally aligned approaches to social media use in plastic surgery.
Stop DALY-ing in Global Health and Plastic Surgery: Advantages of Utilities for Cost-Effective Resource Allocation
Karen Chung, Gebremedhin Gebretekle, Mekonen Eshete, Andrew Howard, Eleanor Pullenayegum, Christopher Forrest and Beate Sander
Toronto, ON
Purpose: Disability-Adjusted Life Years (DALYs) derived from Global Burden of Disease disability weights are widely used in global health cost-effectiveness analyses. However, these weights are largely informed by data from high-income settings and underestimate the severity of plastic surgical conditions. For example, untreated cleft lip and/or palate (CL/P) is assigned a disability weight comparable to acne or alopecia. Although low-resource settings such as Ethiopia increasingly use utility-based measures to inform policy, utilities for plastic surgery are missing. This study measured societal utilities for CL/P in Ethiopia.
Methods: We conducted an REB approved seven-month cross-sectional study in Addis Ababa using standardized, in-person interviews. Direct utility elicitation methods (visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG)) were administered to societal participants assessing health states of untreated CL/P and CL/P treated with surgery with or without speech therapy. Utilities were analysed as interval-scaled measures anchored at 0 (death) and 1 (full health).
Results: A total of 135 societal participants were recruited, meeting targeted sample sizes. When comparing similar utility values across settings, untreated CL/P in Ethiopia had a substantially lower utility (TTO = 0.41) than corresponding Canadian estimates (TTO = 0.85) and was comparable in severity to the most severe depression health state measured in Ethiopia (TTO = 0.45). The incremental utility gain associated with surgical treatment was also greater than three times the incremental benefit implied by DALY disability weights for CL/P.
Conclusions: DALYs misrepresent the severity and treatment benefits of CL/P, resulting in systematic undervaluation in existing cost-effectiveness analyses. Without a concerted effort to measure local utilities, plastic surgery is likely to remain neglected in funding for resource allocation for low-resource settings.
Engineering Precision in Scaphoid Fracture Management - Scaphoid Advanced Fixation Equipment (SAFE)
Henry Zhao1, Ashvin Moro2, Matthew Hickey2, Alexander Seal1, Nicholas Carr1, Antony Hodgson2,3
Vancouver, BC
Purpose: Scaphoid fractures represent 60%–85% of carpal bone fractures in adults and are associated with substantial functional and economic burden. In surgical fixation, accurate guidewire placement along the scaphoid's central axis is technically challenging and highly operator dependent. This study evaluates the accuracy and precision of the Scaphoid Advanced Fixation Equipment (SAFE), an adjustable computer vision-based drill-guide system.
Methods: The efficacy of the SAFE device was evaluated in porcine and human cadaveric models with experienced hand surgeon operators. Device-software performance and targeting accuracy was assessed on porcine specimens (n=4) using pre-defined target points as the gold standard. Cadaveric wrist specimens (n=4) were used to assess usability and identify challenges posed by human wrist anatomy. In both scenarios, final guidewire trajectories were confirmed with fluoroscopic imaging and deviations were quantified in millimetres and angle. Usability and performance refinements were conducted iteratively. Descriptive statistics were performed.
Results: Device-software performance in porcine models demonstrated high accuracy; final guidewire placement matched the calculated trajectory in all four cases. Testing in human cadaveric models demonstrated consistent targeting of a clinically acceptable central scaphoid axis, with no cortical breach in all cases. Surgeons reported improved procedural confidence and procedural familiarity compared to the standard of care. No device-related failures were encountered during the testing period.
Conclusions: SAFE has demonstrated the ability to address the key technical challenges in scaphoid fracture fixation: accurate and reproducible guidewire placement. It has the potential to transform scaphoid fracture management by improving access to surgery and consistency within and between surgeons’ practices, thus enhancing patient outcomes.
Outcomes of the Induced Membrane (Masquelet) Technique in the Reconstruction of Bone Defects in the Hand and Upper Extremity
Thomas Milazzo, Jonathan Persitz, Barbara Jemec, Heather Baltzer, Ryan Paul, Kevin Zuo
Toronto, ON
Purpose: The reconstruction of segmental bone defects in the hand and upper extremity is challenging. Traditional methods such as autografts and vascularized bone transfers have notable limitations, including cost, prolonged recovery, and variable success rates. We evaluate the Masquelet technique, originally developed for long bone reconstruction, in the management of segmental bone defects in the hand and upper extremity
Methods: This retrospective review included all patients treated with the Masquelet technique for upper extremity bone defects between January 2015 and January 2025 at a single institution. In each case, a temporary cement spacer was used to induce a vascularized membrane prior to secondary autologous bone grafting. Data collected included demographics, operative details, and outcomes at 3-, 6-, and 12-months post-reconstruction. Primary outcome was radiographic union. Secondary outcomes included pain, patient reported function, and complication rates.
Results: Twelve patients were identified with median age 41 years (IQR, 34.5-53.7 years) and an average bone defect length of 2.1 cm (IQR, 1.1-2.5 cm). Involved bones included phalanges (n=4), metacarpals (n=3), ulna (n=3), radius (n=1), and humerus (n=1). No acute post-operative complications occurred. 1 patient was lost to follow-up. Radiographic union was achieved in 9 patients (82%) by 6-months post-operatively. At final follow up, 9 patients (82%) reported no significant pain and 8 (73%) returned to daily activities. Two patients developed persistent non-union, both involving the ulnar diaphysis: one required revision for hardware loosening.
Conclusions: The Masquelet technique is a safe, reproducible and effective option for managing segmental bone defects in the hand and upper extremity, demonstrating high union rates, low complication rates, and favorable functional recovery.
Beyond Decompression: The Role of Nerve Transfer Reconstruction in Cervical Spondylotic Amyotrophy
Mariana Gutierrez Salazar, Parker Thibert, Nicolas Dea, Michael J Berger, Sean Bristol, Christopher Doherty
Vancouver, BC
Purpose: Cervical spondylotic amyotrophy (CSA) is a rare condition characterized by severe upper limb weakness with minimal sensory disturbance. Despite multiple operative strategies, there remains no consensus on optimal surgical management of CSA. This study compares functional outcomes of patients with proximal CSA treated with cervical decompression versus nerve transfer reconstruction.
Method: A retrospective cohort study was performed of adult patients with C5–C6 CSA between 2010–2024. Patients underwent either cervical decompression (with or without fusion) or nerve transfer reconstruction. Nerve transfer procedures included Triceps to Axillary and Flexor Digitorum Superficialis to Musculocutaneous +/- Spinal Accessory to Suprascapular nerve transfers. Functional outcomes were assessed using Medical Research Council (MRC) grades for shoulder abduction and elbow flexion. MRC numerical values were modified for statistical analysis.
Results: Twelve patients were included (6 decompression; 6 nerve transfer). Mean age was similar between groups and all patients were male. Preoperative weakness was significantly more severe in the nerve transfer group, with mean preoperative MRC of 0.86 for shoulder abduction and 2.62 for elbow flexion, compared to 4.09 and 4.10 respectively in the decompression group.
Postoperatively, patients undergoing nerve transfer demonstrated significantly greater improvement in shoulder abduction strength (mean ΔMRC +1.86 vs +0.08), despite lower absolute postoperative strength. Improvements in elbow flexion were modest and comparable between groups (+0.52 vs +0.43). Additionally, pain scores using visual analog scale (VAS) at last follow-up were lower in the nerve transfer group (0.5 vs 2.0).
Conclusions: Nerve transfers provide meaningful functional improvement in patients with severe proximal CSA and may be effective in cases with severe weakness. These findings support nerve transfer as a valuable adjunct or potential alternative to cervical decompression in selected patients.
Predictive Modeling of Patient-Reported Outcomes Following Ulnar Nerve Decompression.
Salem Alshammari, Lauryn Seaward, Alison Wong
Dalhousie, NS
Purpose: To develop and internally validate a multivariate predictive model for postoperative patient-reported outcomes (PROs) after ulnar nerve decompression using pre-operative and peri-operative data.
Method: A prospective cohort of 108 patients undergoing ulnar nerve decompression was studied. Baseline variables included age, sex, comorbidities, symptom duration, pre-operative grip strength, electrophysiologic severity, and psychosocial stressors. Intra-operative factors such as operative time and adjunctive procedures were recorded. The primary outcome was the change in the PROMIS-UE total score. Logistic regression model estimated the probability of achieving a clinically meaningful improvement. Model performance was assessed with the area under the receiver-operating-characteristic curve (AUC).
Results: The final model retained multiple predictors: age, symptom duration > 12 months, baseline PROMIS-UE score, presence of severe electrophysiologic abnormality, and active smoking. The model demonstrated good discrimination (AUC = 0.82). A nomogram was generated for bedside risk and benefit estimation.
Conclusions: A concise, evidence-based predictive model accurately forecasts patient-reported functional recovery after ulnar nerve decompression. Incorporating this tool into pre-operative counseling may aid shared decision making and identify patients who could benefit from tailored peri-operative interventions.
Development and Validation of a Prediction Model for Thirty-day Emergency Department Visits Following Adult Hand and Wrist Fractures: A Population-based Cohort Study
Chloe Wong, Bettina Hansen, David Urbach, Karen Tu, Christopher Witiw, Heather Baltzer
Toronto, ON
Purpose: This study aimed to develop, internally validate, and derive a clinically interpretable scoring system to predict 30-day ED visit risk following adult hand and wrist fractures.
Methods: A retrospective population-based cohort study was conducted using linked health administrative data from Ontario, Canada (2015–2019). Adults (18–65 years) with an index hand or wrist fracture were included. A multivariable Cox proportional hazards model identified predictors of 30-day ED visits. Model performance was assessed using Harrell's C-index, time-dependent area under the curve (AUC), calibration slope, and Brier score. Regression coefficients were rescaled to create a point-based risk score.
Results: Among 153,662 adults (median age 44 years; 51% male), 26% returned to the ED within 30 days. Predictors of higher visit risk included operative fractures (HR=1.48, 95% CI 1.38–1.59), opioid prescription at the index encounter (HR=1.76, 95% CI 1.70–1.83) and within 30 days before injury (HR=1.28, 95% CI 1.24–1.32), sports-related injuries (HR=1.72, 95% CI 1.42–2.09), violence-related injuries (HR=1.19, 95% CI 1.09–1.31), weekend presentation (HR=1.10, 95% CI 1.07–1.13), and older age (HR=1.003, 95% CI 1.002–1.004). Lower hazard ratios were observed for severe injury requiring hospitalization, prior trauma, prior healthcare contact, substance-use disorder, and homelessness. The internally validated model demonstrated an AUC=0.629, calibration slope=1.00, and Brier score=0.19. When applied to the validation cohort, observed 30-day visit rates increased across risk tertiles (16.8%, 25.9%, and 37.3%).
Conclusions: One in four patients returned to the ED within 30 days of a hand or wrist fracture. The internally validated prediction model and point-based score identify patients at increased risk of revisit and may help guide targeted follow-up in hand trauma care.
Save a Buck and Save the Planet: Economic and Environmental Impact of WALANT Versus Operating Room Settings in Flexor Tendon Repair
Jessie Li, Karen Farag, Laurent Tessier, Jacques Haddad
Montréal, QC
Sherbrooke, QC
Purpose: Flexor tendon lacerations are commonly managed surgically in the operating room (OR) under general or regional anesthesia, requiring significant perioperative resources. The wide-awake local anesthesia no tourniquet (WALANT) technique has emerged as a safe and efficient alternative, enabling procedures in ambulatory settings while allowing intraoperative functional assessment.
Although prior studies have demonstrated comparable clinical outcomes and potential cost savings with WALANT, data specific to flexor tendon repair remain limited. Furthermore, the environmental impact of surgical care is increasingly recognized, with OR-based procedures contributing substantially to healthcare-related carbon emissions.
This study aims to compare the economic cost and environmental footprint of flexor tendon repair, distal to the carpal bones, performed under WALANT versus conventional OR settings using a combined cost analysis and life-cycle assessment (LCA).
Method: A qualitative cost analysis and LCA were conducted comparing flexor tendon repair performed in a WALANT ambulatory setting versus a conventional OR setting at a single university-affiliated center. Two standardized procedures were randomly selected, excluding patient-specific variables and neurovascular injury.
Cost Analysis: Direct procedural costs included surgical and anesthetic supplies, staff remuneration, utilities and sterilization.
Data were obtained through institutional records, manufacturer specifications, and direct consultation with healthcare personnel.
Environmental Impact Assessment: A life-cycle assessment (LCA) was performed in accordance with CIRAIG guidelines, including surgical supply manufacturing, waste generation (hazardous and non-hazardous), energy consumption and instrument sterilization.
Emission factors were derived from established databases (ICE, Eco-invent, Healthcare LCA). The analysis was limited to intraoperative time.
Outcomes: Primary outcomes include total procedural cost (CAD) and greenhouse gas emissions (kgCO₂-equivalent) for each procedural environment. Secondary outcomes include the measure of waste of each procedure in Kg.
Results:
Cost Analysis: Total procedural cost was $911.62 CAD for WALANT and $6602.04 CAD for OR repair, representing a cost reduction of $5690.41 CAD (86.2%). When broken down into the categories mentioned above:
Staff: $703.80 (WALANT) versus $1064.81 (OR)
Utilities: negligible (WALANT) versus $5248.89 (OR)
Supplies: $127.82 (WALANT) versus $208.34 (OR)
Sterilization: equivalent ($80)
Environmental Impact: Total emissions were 14.34 kgCO₂e (WALANT) versus 23.13 kgCO₂e (OR), corresponding to a 38% reduction. Breakdown of emissions (kgCO₂e) include:
Material production: 12.58 (WALANT) versus 20.28 (OR)
Waste disposal: 0.12 versus 0.56
Energy consumption: 0.09 versus 0.74
Sterilization: equivalent (1.55)
WALANT also generated significantly less solid waste (0.637 kg vs 3.175 kg).
Conclusion: Flexor tendon repair performed under WALANT in an ambulatory setting is associated with substantially lower costs and reduced environmental impact compared to traditional OR-based surgery. These findings support WALANT as a cost-effective and environmentally sustainable alternative, with potential for significant healthcare savings and carbon footprint reduction if broadly adopted.
Macroeconomic Burden of Hand Injuries in Canada and the World: 2009–2021
Sukhmeet Sachal, Zili Zhou, Tanis Quaife, Spencer Chambers, Douglas Ross, Stahs Pripotnev
London, ON
Purpose: Hand injuries are common, yet their macroeconomic impact is rarely quantified. This study quantifies the macroeconomic burden of hand injuries in Canada and globally, identifying high-impact injury subtypes and populations most relevant to Canadian plastic surgery workforce planning and trauma care delivery.
Method: Disability estimates from the Global Burden of Disease (GBD) 2021 study were linked with World Bank Gross Domestic Product (GDP) data to calculate the Value of Lost Welfare (VLW) from 2009–2021 using income-adjusted value-of-statistical-life-year (VSLY) functions. Analyses were conducted globally and for Canada, stratified by injury subtype, age, and sex. Percent-of-GDP burden enabled international comparison. Multivariable linear regression assessed adjusted associations.
Results: Globally, VLW attributable to hand injuries increased by 56% over the study period (3.7% annually, p<0.05). Thumb amputations imposed a 9%–10% higher economic burden than finger amputations, while distal hand injuries generated substantially lower losses. Males and adults aged 20–59 years accounted for most global economic burden.
In Canada, VLW increased by 38% (2.7% annually, p<0.05). Thumb amputations imposed a 2.1-fold higher economic burden than finger amputations—double the global differential—highlighting the disproportionate national impact of thumb loss. Men experienced a 1.8-fold higher burden, with working-age Canadians driving most losses. Canada's percent-of-GDP burden (0.02-0.04%) was comparable to other high-income regions but varied markedly by injury subtype.
Conclusions: Hand injuries impose a growing and economically significant burden globally and in Canada. The disproportionate impact of thumb amputations and injuries affecting working-age Canadians supports targeted investment in hand trauma systems and microsurgical reconstruction capacity to inform Canadian surgical workforce and health system planning.
Dorsal Webspace Versus Palmar Approach for Trigger Finger Corticosteroid Injection: A Randomized Controlled Trial of Patient-Reported Pain
Natasha Barone, Muhammadhasan Nasser, Daniel Antflek, Jonathan Persitz, Kevin Zuo
Toronto, ON
Purpose: To compare pain scores following trigger finger (TF) corticosteroid injection via traditional palmar (PA) versus dorsal webspace (DWA) approaches.
Methods: REB#24–5288. This was an interventional, randomized, unblinded control trial; accrual period 02/07/2024-19/08/2025. Participants included adult patients (≥ 18 years) with a clinical diagnosis of TF who elected for management with CSI (0.5 cc triamcinolone 10 mg/mL and 0.5 cc 1% lidocaine). Participants were randomized 1:1 to receive CSI into the A1 pulley via DWA or PA. Pain was assessed at 0h, 4h and 24h post-injection using the short form McGill Pain Questionnaire (SF-MPQ), numerical rating scale (NRS) and present pain intensity (PPI). Median (IQR) was calculated for SF-MPQ at each time point. Mean pain over time was analyzed between groups using a mixed-ANOVA.
Results: 60 participants were included (30/group). Across all instruments and timepoints, DWA demonstrated numerically lower pain scores at 0h, 4h and 24h than PA, although this did not reach statistical significance at every assessment. On the SF-MPQ, scores were statistically lower in DWA at 4h (2.05 vs 3.95, p=0.009) and 24h (1 vs 1.9, p < 0 .0001). Using NRS, scores were statistically lower with DWA at 4h (0.77 vs 1.97, p=0.0169) and at 24h (0.52 vs 1.67, p=0.0226). Using PPI, pain was statistically lower at 4h (0.47 vs 1.03, p=0.0191) in the DWA group. No difference in further procedures by 6-months post-treatment (p=0.7049).
Conclusions: Compared with PA, DWA demonstrated a consistent pattern of lower post-injection pain across multiple patient-reported measures, with statistically significant reductions at several key timepoints and similar effectiveness. The DWA is a safe and simple alternative that may improve post-injection comfort and can be considered during procedural counselling and approach selection.
Comparison of Pre-Operative Use of Lidocaine-Prilocaine Cream (2.5%:2.5%), Lidocaine Cream (5%), and Placebo For Pain Management in Open Carpal Tunnel Surgery: a Randomized Control Trial – ANALYSIS
December Sampson, Xiya Ma, Jason Covone, Elie Boghossian, Dominique Tremblay, Jordan Gornitsky, Sabrina Sanzari, Bruno Mastropasqua
Montréal, QC
Purpose: To evaluate whether topical anesthetic creams reduce pain during local-regional anesthesia for CTR.
Method: This was a single-center, prospective, randomized, double-blind, placebo-controlled trial. Patients undergoing CTR between June 2024 to June 2025 were recruited. Exclusion criteria included; allergies to the anesthetic creams’ contents, regular analgesic medication use, chronic pain illness diagnosis, previous CTR on the ipsilateral hand, concurrent procedures or incomplete study form. Patients were randomized to receive one of three treatments: lidocaine-prilocaine 2.5%:2.5%, liposomal lidocaine 5%, or placebo. Primary outcome was pain during local-regional anesthesia. Secondary outcomes included postoperative pain scores, analgesic consumption and pre-operative anxiety scores. Pain outcomes were additionally stratified by surgeon to assess the impact of individual injection techniques. Regression models were used in a subgroup analysis to identify predictors of pain.
Results: A total of 117 wrists from 98 patients were analyzed. There were no significant differences in visual analogue scale (VAS1) scores (p = 0.2313), or postoperative pain scores (VAS2: p = 0.9301; VAS3: p = 0.1947) or analgesic consumption (acetaminophen p = 0.9061; celecoxib p = 0.8373; hydromorphone p = 0.5010). Univariate regression showed that male sex (p = 0.0018), lower anxiety scores (p < 0.0001) and injection technique (p < 0.0134) were associated with lower pain scores. Multivariate regression modeling identified female sex and anxiety as the best predictors of higher pain scores during injection.
Conclusions: Topical anesthetic creams did not significantly reduce pain during local-regional anesthesia or postoperative analgesic consumption. Variability in pain was associated with injector technique, sex, and anxiety. Therefore, provider training and addressing patient anxiety may be more impactful than topical agents.
The effect of forearm nerve blocks on pain-free tourniquet time compared to local anesthetic for awake hand surgery
Justine Ring, Kaitlyn Rourke, Sydnee Tuckett, Jessica Winter, Leif Sigurdson, Christian Petropolis
Winnipeg, MB
Purpose: To determine if surgeon-administered forearm nerve blocks prolong pain-free tourniquet time compared to local anesthetic infiltration during awake hand surgery.
Methods: A single center, randomized control trial. Inclusion criteria included patients over age of 18 with a hand injury requiring open surgical intervention, either metacarpal open reduction internal fixation (ORIF) or flexor tendon. Patients were randomized to either a forearm level, ultrasound-guided nerve block of the median, ulnar, and radial nerves (intervention) or localized local anesthesia (LA) injection around the operative digit (control group). The primary outcome was length of tourniquet time prior to experiencing pain. Secondary outcome was amount of LA, complications and patient experience.
Results: 28 patients were enrolled in the study, however 3 were excluded due to incomplete forms. 25 patients were included in the analysis, 11 intervention and 14 control. For procedures, there were 23 ORIF metacarpal and 2 flexor tendons. The primary outcome, pain-free tourniquet time, was significantly longer in the intervention group (37.2 min vs 28.7 min, P=0.037). There was significantly more LA was given in the intervention group (28.6 vs 19 mL, P=0.008). There were no LA related complications. In the patient-administered survey, there was no significant difference in overall pain or overall experience.
Conclusion: Pain free tourniquet time was significantly increased with forearm level, surgeon administered US-guided nerve blocks compared with local infiltration. While LA volumes used were higher in the intervention group, we did not experience complications related to LA doses.
PATIENT FACTORS THAT IMPACT FACE-Q AESTHETICS OUTCOMES: AN EXPLORATORY CROSS-SECTIONAL REGRESSION ANALYSIS
Lucas Gallo, Anne Klassen
Hamilton, ON
Introduction: FACE-Q Aesthetics is a validated patient reported outcome measure designed to evaluate outcomes from the patient's perspective, following surgical and nonsurgical facial aesthetic procedures. An understanding of patient variables that may impact FACE-Q scale scores is necessary to account for potential confounding in future research. The objective of this study was to identify factors that impact FACE-Q Aesthetic scores.
Methods: An online sample (Ie, Prolific platform) of international participants, aged ≥20 years, that underwent non-invasive facial aesthetic interventions within the last year, completed an online cross-sectional survey. Demographic and clinical data were collected. Univariable and multivariable linear regression analyses were used to determine statistically significant predictors for the FACE-Q Face Overall, Psychological and Social scales.
Results: 1259 participants were included in this analysis. Mean age of the sample was 42.6 (±11.9) years. Respondents had a mean (±SD) score of 52.4 (±18.3), 56.5 (±23.7), and 62.7 (±24.0) for the FACE-Q Face Overall, Psychological and Social scales, respectively. Improved appearance, psychological and social scores were routinely associated (p BMI, African American ethnicity, male gender, Fitzpatrick V, United States residence, financial stability, and ongoing effects from prior aesthetic interventions that have not ‘worn-off’. Improved overall appearance was associated with younger age.
Conclusion: This cross-sectional analysis identified statistically significant patient factors that were predictors for Face Overall, Psychological and Social FACE-Q scales. The findings from this analysis may provide a more nuanced understanding of patient perspectives that impact results following facial aesthetic interventions and should be adjusted for within future studies using the FACE-Q Aesthetics.
Spare Parts in Rhinoplasty: Repurposing Scar Tissue as Autologous Tip Grafts
Shaishav Datta, Matthew Morris, Alexia Lucas, Sophie Queler, Steven Hanna, David Mattos, Richard Reish
Toronto, ON
Background: Revision rhinoplasty is challenging due to altered anatomy, limited graft availability, and a thinned soft-tissue envelope. Nasal tip onlay grafts are commonly used for contour refinement, but traditional graft options may require additional donor-site harvest. Scar tissue from prior surgery is routinely encountered in revision rhinoplasty and represents a potential autologous graft source.
Methods: A retrospective review was performed of all open rhinoplasty procedures by a single surgeon between May 2015 and August 2024 in which native nasal scar tissue was used as a tip onlay graft. Primary rhinoplasty patients, Results: 2755 charts were reviewed, with 734 revision rhinoplasty cases. 450 underwent scar tissue grafting with a mean follow-up of 22.8 months. Post-operative infection occurred in 6 patients (1.3%), all successfully managed with oral antibiotics. 13 patients (2.9%) underwent revision surgery, most commonly for under-projection. No cases demonstrated appreciable graft necrosis, resorption, or skin envelope compromise. Infection and revision rates were similar between scar tissue and mastoid fascia cohorts.
Conclusions: Autologous scar tissue provides a readily available, pliable, and biocompatible material for tip grafting in revision rhinoplasty. This technique eliminates donor-site morbidity and additional operative time while maintaining low infection and revision rates. Patients with minimal or poor-quality scar tissue, may require alternative graft sources.
Challenging the Donor Age Bias: Donor Age-Related Performance of Fresh-Frozen Costal Cartilage in Rhinoplasty
Shaishav Datta, Kenneth Pessino, Alexia Lucas, Sophie Queler, Steven Hanna, David Mattos, Richard Reish
Toronto, ON
Background: Fresh-frozen costal cartilage (FFCC) has become a popular graft for rhinoplasty. Concerns persist that donor age may influence cartilage quality and surgical outcomes, wherein younger donors are preferred due to less calcification and greater elasticity. This study evaluates whether donor-age groups differ in postoperative infection or revision rates in patients undergoing rhinoplasty with FFCC.
Methods: A retrospective review was conducted of patients who underwent open rhinoplasty using FFCC by a single surgeon between May 2018–October 2024. Inclusion criteria were ≥12 months of follow-up and availability of FFCC serial number. Donor ages were grouped as ≤30 years (Under-30) and >30 years (Over-30). Demographics, infection, and revision rates were compared using chi-square and t-tests. Post-hoc analyses using donor-age cutoffs of ≤40 and ≤50 years were performed.
Results: 343 / 2755 rhinoplasty cases met inclusion criteria. Mean follow-up was 18.7 months. There were no significant demographic differences between groups except for sex distribution, with more female patients in the Over-30 group (p=0.031). Overall infection rate was 1.3% (n=4) and revision rate 3.8% (n=13). Infection (p=0.140; p=0.359) and revision rates showed no statistically significant differences between groups. Post-hoc analyses revealed no additional associations.
Conclusions: Donor age did not significantly influence infection or revision rates following rhinoplasty using FFCC. This may relate to surgical technique, wherein only the straightest portion of graft is used after a minimum 1-h thaw to reveal intrinsic warp. FFCC from older donors perform comparably to grafts from younger donors, supporting broader use of FFCC across a wide donor age range.
Optimizing Breast Cancer Surveillance and Care After Gender-Affirming Mastectomy in Individuals with High-risk or Concurrent Oncological Needs: A Case Series and Review of the Literature
Linda Wu, Kathleen Armstrong
Toronto, ON
Purpose: Gender-affirming mastectomy (GAM) significantly reduces but does not eliminate breast cancer risk. Postoperative surveillance and clinical practice recommendations remain poorly established. Our study synthesizes institutional experience and existing literature to inform post-GAM management and surveillance practices in high-risk populations.
Method: We reviewed the senior author's GAM cases from 2022–2025 for individuals presenting for GAM with elevated breast cancer risk or a breast cancer diagnosis. We then performed a comprehensive literature review for articles discussing postoperative breast cancer surveillance and diagnosis to characterize management practices.
Results: Five non-binary AFAB individuals (ages 27-50) underwent GAM at our institution. Four patients had elevated oncologic risks, including BRCA mutations (n = 2), prior mantle radiation for Hodgkin's lymphoma (n = 1), and a strong family history with an elevated IBIS score (n = 1). Two patients were found to have malignancy on preoperative pathology.
Surgical approaches included inverted-T and double-incision mastectomies, emphasizing maximal breast tissue removal. Plastic Gender-Affirming Surgery performed all prophylactic mastectomies, reviewed intraoperatively by the oncologic breast surgeon to confirm completeness. When malignancy was present, oncologic resection and sentinel lymph node biopsy were performed by Breast Surgery. Plastic Gender-Affirming Surgery completed all final closures, liposuction, and nipple–areolar complex reconstruction.
All patients were followed annually by Breast Surgery without routine imaging. Individuals with concurrent oncologic indications frequently required postoperative adjuvant therapy. Literature review demonstrated a small but persistent risk of breast cancer following GAM, with limited consensus on surveillance, particularly for high-risk patients.
Conclusions: Post-GAM management varies by preoperative cancer status, risk profile, and residual tissue volume. Risk-stratified surveillance strategies are needed, particularly for individuals with high risk or concurrent oncological needs.
Classic versus Composite Nipple Areolar Complex Grafting in Masculinizing Chest Surgery: A Comparative Study on Nipple Projection and Aesthetics
Michelle Bonapace-Potvin, Frédérique Leroux, Rui Heng Chen, Pauline Navals, Blair Peters
Montreal, QC
Purpose: Double-incision mastectomy with free nipple grafting (FNG) is the most common technique for transmasculine chest masculinization. However, FNG is often associated with postoperative nipple flattening and poor nipple-areola complex (NAC) delimitation, limiting aesthetic control and leading some patients to forgo grafting in favor of later NAC tattooing. At our institution, both classic FNG and composite nipple grafting are used. This study describes our composite technique and compares its aesthetic outcomes with classic grafts among surgeons and transmasculine individuals.
Method: A blinded survey of plastic surgeons/trainees and transmasculine individuals evaluated standardized postoperative photographs of double-incision mastectomies with composite or classic nipple grafts performed between July 2024 and July 2025 by four surgeons (two performing each technique). Respondents rated NAC aesthetics across three domains: overall appearance, nipple-areola distinction with projection, and nipple size.
Results: A total of 110 plastic surgeons and trainees completed the survey, including attendings (28.7%), fellows (3.7%), residents (38.0%), and clerks (29.6%); 50.0% practiced in the United States, 46.3% in Canada, and 42.1% performed transmasculine top surgery. Additionally, 117 transmasculine individuals responded, 90% of whom had undergone top surgery. Likert-scale responses were normalized to percentage scores for each composite and classic grafted patient. Standardized averages were determined for both surgeon and transmasculine groups. Two-way ANOVA demonstrated significantly higher mean aesthetic scores for composite nipple grafts compared with classic grafts across all domains in both surgeon and transmasculine cohorts (p
Conclusions: These findings demonstrate that composite grafting offers improved aesthetic control in NAC reconstruction following masculinizing chest surgery. Further studies incorporating patient-reported outcomes and long-term follow-up are warranted to better define its clinical value.
Comparative Analysis of the Quality and Reliability of Patient Education Video Content on Social Media Platforms in Aesthetic Surgery and the Determinants of Popularity
Nader Henry, Sara Morel, Ammar Saed Aldien, Ari Meguerditchian, Laura Snell
Toronto, ON
Purpose: Video-based social media platforms (SMPs) such as Instagram (IG), TikTok (TT), and YouTube (YT) are widely used by patients seeking aesthetic-surgery information, yet content quality remains uncertain. Breast augmentation is among the most performed aesthetic procedures worldwide. This study compared the quality, reliability, and engagement of breast augmentation–related videos across IG, TT, and YT using validated assessment tools.
Methods: A cross-sectional analysis was conducted on January 8, 2025. Searches for “breast augmentation,” “breast implants,” and “boob job” were performed on IG, TT, and YT using private browsing mode and newly created accounts. The top 100 videos per search term per platform were screened. After exclusions, 432 videos were analysed. Videos were categorized by platform and creator type. Two independent reviewers assessed quality using the Global Quality Scale (GQS) and the DISCERN instrument. Engagement metrics and associations were analyzed using non-parametric testing, correlation analysis, and linear regression.
Results: YouTube accounted for 48.6% of videos, followed by IG (36.3%) and TT (15.0%). Plastic surgeons produced nearly half of all content (49.5%) and were most prevalent on YT and IG, whereas patients were over-represented on TT (p).
Conclusions: Breast augmentation content on SMPs demonstrates wide variability in educational quality, with most videos rated poor to fair. Higher engagement does not reliably indicate higher informational value. Surgeon-generated videos, particularly longer-form videos on YouTube, provide the most reliable content.
Heath-Related, Quality-of-Life trajectories of patients who do not undergo Breast Reconstruction: findings from the ROSE Study.
Glykeria Martou, Cameo Hao, Karen Eden, Emily Smith, Olivia Ginty, Laryssa Kemp, Patrick Norman, Susan Brogly, R. Wesley Edmunds
Kingston, ON
Purpose: The Breast Cancer & Reconstruction Outcome SurvEy (ROSE Study) is the first Canadian electronic database capturing quality-of-life outcomes of Breast Cancer patients, with or without reconstruction prospectively.
Methods: The BREAST-Q measures QoL in breast surgery and was distributed pre-operatively and post-operatively at 6, 12 and 24-months. Included: female patients, ≥ 18 years-old with a new diagnosis of breast cancer and/or breast cancer gene, undergoing either a lumpectomy or mastectomy. The study compares QoL scores over a 2-year period. Pre-operative scores are compared to normative population data.1
Results: Preoperatively, the ROSE cohort (Lumpectomy (n = 173) and Mastectomy (n = 29)) scored significantly higher for Satisfaction with Breast, than a normative population (65.96 vs 58, p
Conclusions: Results point towards maintenance of QoL for Lumpectomy patients. Mastectomy patients show a decline in all BREAST-Q Domains indicating the negative impact of mastectomy without reconstruction on QofL. This is the first, prospective study demonstrating this evolution of BREAST-Q scores. This evidence-based information is a critical adjunct to assisting patients as they navigate their breast cancer journey.
Design and Implementation of a Canadian Breast Implant Registry
Henry Zhao, Zaima Chowdhury, Jenna-Lynn Senger, Alex Seal, Peter Davison, Christopher Doherty, Esta Bovill, Sheina Macadam, Peter Lennox, Nancy Van Laeken, Nick Carr, Kathryn Isaac
Vancouver, BC
Purpose: Breast implants are widely used in Canada; however, no national system currently exists to track outcomes, complications, or device performance. This study describes the development and pilot implementation of a multi-institutional Canadian breast implant registry.
Methods: A steering committee of 10 breast surgeons from academic and private practices was formed to guide registry development. Using the International Collaboration of Breast Registry Activities (ICOBRA) minimum dataset as a reference standard, a core dataset was refined through expert consensus. Stakeholder engagement with plastic surgeons, international registry leaders, health policy experts, and patient advocates informed data governance and workflow integration. Patients were enrolled using an opt-in consent model, and data were collected prospectively using structured electronic forms within REDCap. Registry entries were manually verified against clinical documentation and data completeness was assessed.
Results: The pilot demonstrated feasibility of implementing a breast implant registry across diverse practice environments. Minimizing surgeon involvement was identified as critical to reducing administrative burden and improving data completeness. Key strategies included customizable data entry templates based on surgeon preference and procedure type, and pre-populated data fields. Core ICOBRA variables were retained, with the addition of three supplementary variables: neopocket formation, occlusive nipple shields utilization, and smoking status. Barriers to data completeness were primarily technical rather than workflow related.
Conclusions: A Canadian breast implant registry is feasible using a modified ICOBRA minimum dataset. Successful implementation requires streamlined workflows that minimize administrative burden while maintaining high-quality data capture. Findings from this pilot will inform ongoing refinement of data elements, governance structures, and data-collection strategies to support future national implementation.
Patient Safety in Breast Augmentation: Learnings from Canadian Medico-Legal Cases
Meerab Majeed, Joanna Zaslow, Kate Barbosa, Richard Liu, Jugpal Arneja, Gary Garber
Toronto, ON
Purpose: Cosmetic breast augmentation is a common aesthetic procedure in Canada, but can carry medico-legal risk. Despite its frequency, augmentation-specific medico-legal data are scarce. This study analyzed national cases to identify patterns that can enhance patient safety and reduce medico-legal risk.
Method: We conducted a retrospective analysis of medico-legal cases related to breast augmentation from 2020 to 2024, using data from the Canadian Medical Protective Association (CMPA), excluding reconstructive or breast cancer surgeries. Eligible cases included civil legal, college, and hospital complaints across all surgical settings. Extracted variables included patient, provider, and procedural characteristics. Case-level data encompassed reason for complaint, type and level of harm, peer expert review, and outcome.
Results: Among 38,378 closed CMPA cases, 926 involved plastic surgeons, including 110 breast augmentation cases. Most were legal (51%) or college complaints (48%). The top reasons for complaint by patients included deficient history and evaluation (47.3%), consent issues (41.8%), and/or clinical knowledge or technique (31.8%). In cases where harm occurred, 36% were considered harmful incidents, while 35% were evaluated as events that were inherent risks of breast augmentation surgery. Peer experts criticized care in more than half of cases, with inadequate consent process (25%), inadequate documentation (24%), and office-procedure deficiencies (15%) identified as common contributors. Across cases, implant-sizing disagreements, consent documentation, and miscommunication were common.
Conclusions: As the first national review of medico-legal trends in Canadian breast augmentation, this study identifies consent, documentation, and communication failures as major risks. Greater awareness of these issues may help providers understand their medico-legal risk and provide safe medical care in aesthetic breast surgery.
Breast Cancer Patient Awareness and Reasons for Foregoing Breast Reconstruction
Souzan Yacob, Michelle Weller, Karen Eden, Patrick Norman, Susan Brogly, R. Wesley Edmunds, Glykeria Martou
Kingston, ON
Purpose: To explore patient-reported reasons for foregoing breast reconstruction after breast cancer surgery and the factors influencing decision-making.
Methods: We conducted a mixed-methods analysis of patients who chose to forego breast reconstruction following breast cancer surgery at a single academic centre. Participants completed a Reasons for No Reconstruction survey that included closed-ended items and a free-text response capturing decision-making factors. Survey responses were summarized quantitatively, and free-text responses underwent thematic analysis. Research ethics board approval was obtained.
Results: Of the 349 participants enrolled, 199 (57%) did not undergo breast reconstruction, and of these, 179 (90%) completed the Reasons for No Reconstruction survey and 109 provided free-text responses. Of the 179 patients who did not undergo reconstruction, 32% recalled discussing reconstruction with their breast surgeon, 13% were offered a plastic surgery consultation, and 3% attended one. The most commonly cited reasons for foregoing reconstruction were acceptance of appearance (48%), belief that reconstruction was not essential to health (34%), and feeling they had enough intervention (16%). Thematic analysis of free-text responses identified several recurrent themes influencing decision-making, including gaps in treatment information, perceived ineligibility after lumpectomy, and personal factors such as age and a desire to avoid further treatment.
Conclusions: Over half of patients did not undergo breast reconstruction following breast cancer surgery. Decisions were influenced by patient preference, physician referral, and information barriers. These findings may support more informed, patient-centred surgical care.
Examining revisional surgery rates in breast cancer patients in Alberta who have undergone breast conserving surgery
Taylor Onysyk, Matthew Curran, Lisa Korus, Justin Lee, Courtney Wilkes, Athena Bennett
Edmonton, AB
Purpose: Breast cancer remains a leading cause of cancer-related mortality among North American women. Advances in surgical techniques sparked breast-conserving surgery (BCS) as primary treatment for early-stage breast cancer, offering oncologic safety while maintaining aesthetic and psychosocial benefits. However, limited multi-center data exist regarding reconstructive surgery rates following BCS. We aimed to determine the province-wide rate of reconstructive procedures post-BCS and identify factors influencing the likelihood of undergoing reconstruction.
Method: This retrospective cohort study analyzed all adult female breast cancer patients who underwent BCS in Alberta from 2002–2023. Patient data sourced from Alberta Cancer Registry, Discharge Abstract Database, and National Ambulatory Care Reporting System. Reconstructive procedures identified using Canadian Classification of Health Interventions. Variables examined: patient demographics, geographic location, tumor stage, and comorbidities. Statistical analyses assessed trends in reconstructive procedures and factors associated with revision surgery.
Results: 8134 BCS cases analyzed, 72% (n=5836) underwent breast reconstruction; autograft/homograft the predominant technique (n=5397). Mastectomy, breast reduction, and augmentation accounted for 22% (n=1760), 5% (n=435), and 1% (n=76), respectively. Younger patients and rural more likely to undergo repeat procedures. Frequency of revision surgeries increased over time, peaking at 9% (2014–2019) before decreasing to 8% (2020–2023). Cancer stage significantly influenced revision rates, with stage 0 patients more likely to undergo repeat surgery than stage I (21% vs 12%, p=0.0001). Chronic obstructive pulmonary disease (COPD) was the only comorbidity significantly associated with repeat surgery (p=0.01).
Conclusions: This study highlights significant factors influencing reconstructive surgery post-BCS, emphasizing the role of patient demographics, cancer stage, and geographic variation in surgical decision-making. The 21-year study period demonstrated 29.7% secondary operation rate, with breast reconstruction using autograft the most common.
Postoperative Complications in Oncoplastic Surgery with Simultaneous Symmetry Procedures: A BREAST-Q Focused Analysis
Adolfo Lopez Rios, Jing Zhang
Ottawa, ON
Purpose: This study aims to evaluate postoperative complications and patient-reported outcomes, focusing on BREAST-Q satisfaction and well-being scores in women who underwent oncoplastic breast-conserving surgery combined with simultaneous symmetry procedures.
Method: A retrospective chart review was conducted involving women with breast cancer who underwent oncoplastic breast-conserving surgery with immediate contralateral symmetrization at a tertiary academic center between 2018 and 2023. Clinical variables, postoperative complications, and revision procedures were recorded. The BREAST-Q® instrument was administered preoperatively and at 3 and 12 months postoperatively to assess satisfaction with outcomes, breasts, information received, medical staff, surgeon, and domains of physical, sexual, and psychosocial well-being. Descriptive statistics and bivariate analyses were performed.
Results: Seventy-six women were included in the study (mean age: 63.7 years), of whom 50% had a BMI of 30 or higher. Minor complications occurred in 35.5% of patients, major complications in 11.8%, and no medical complications were reported. The BREAST-Q analysis showed significant postoperative improvement in satisfaction with overall outcomes, information received, medical staff, office staff, and the surgeon (p ≤ 0.003). Sexual well-being scores significantly improved over time (p = 0.03). Satisfaction with breasts and nipples, psychosocial well-being, and chest physical well-being also improved, although not statistically significantly. These improvements were sustained at 12 months postoperatively.
Conclusions: Oncoplastic breast-conserving surgery with simultaneous symmetry procedures is associated with high patient satisfaction and improved quality-of-life outcomes as measured by BREAST-Q, despite acceptable rates of surgical complications. These findings support the safety and patient-centred benefits of this approach.
Exploring the impact of plastic surgeon shortages on patients in Northern Ontario
Sarah Hunt, Joshua Cerasuolo, Joseph Caswell, Meagan McGaughey, Mariah Mesic, Amanda Fortin
London, ON
Purpose: Northern Ontario (NO) encompasses 800,000 km2 and is home to 800,000 Ontarians. Plastic surgeon coverage in NO is driven by three regional hospitals. Each of these suffer from chronic plastic surgeon shortages, affecting provision of care in this region. This study quantifies the impact of regional plastic surgeon shortages on patients in NO.
Methods: Administrative healthcare databases were used to analyze adult patients (18 years and older) from Ontario who underwent plastic surgery consultation or elective procedures for hand, breast, skin cancer, and general reconstruction defined by OHIP billing codes between 2004–2020. Patients from NO were compared to their Southern Ontario (SO) counterparts using descriptive statistics and Cox regression models.
Results: NO patients travelled significantly further than SO patients for consultation (83 km ± 181 km vs 22 km ± 42 km; d=0.47) and elective procedures (76 km ± 167 km vs 26 km ± 49 km; d=0.41). Regional differences existed between Northeastern and Northwestern Ontario. While over 99% of SO patients received care within their region, some Northerners travelled to SO for consultation (n=5259; 8%) and elective surgery (n=8209; 10%). NO patients were more likely to travel to SO for breast reconstruction (18%) and flap-based reconstruction (21%). Compared to their SO counterparts, the rates of autologous and alloplastic breast reconstruction among NO residents were 25% (HR 0.75; CL 0.65–0.87) and 18% lower (HR 0.82; CL 0.72–0.93), respectively, within a 1-year period following consultation.
Conclusions: Plastic surgeon shortages in NO contribute to travel burden and longer surgical wait times. These inequities in regional plastic surgery care underscore the importance of having adequate plastic surgery coverage in NO.
Assessing Burnout and the Impact of a Structured Wellness Program in Plastic Surgery Training: Experience from a Single Canadian Institution
Kimberley Yuen, Taylor Incze, Avalon O'Connor, Vanessa De Rubeis, Arianna Dal Cin, Ammara Ghumman
Hamilton, ON
Purpose: Wellness programs have emerged as an important strategy to mitigate burnout for surgical residents. We aimed to evaluate whether burnout among plastic surgery residents changed over one academic year following the introduction of a formalized wellness program, and to assess the program's feasibility and acceptability.
Methods: This was a prospective cohort study including McMaster plastic surgery residents. The wellness program included monthly events. Burnout was measured using the Maslach Burnout Inventory (MBI) over one academic year. Feasibility and acceptability were assessed through attendance and post-event surveys. Paired t-tests and Cohen's d were used to analyze burnout change scores from baseline to 12 months.
Results: Fifteen of 16 residents (94%) completed the needs assessment. Average attendance for wellness events and survey response rate were 55% and 52%. Satisfaction with events was 93%. Over half of residents scored moderate-high on at least one MBI subscale, suggesting risk of burnout. Emotional exhaustion and depersonalization scores remained moderate but stable, while personal accomplishment declined over the study year (−0.27, 95%CI −0.48 to −0.05, t(6) = −3.04, p<.05, d=−1.15). PGY-2 and PGY-3 cohorts had the highest burnout scores year-round.
Conclusions: This is the first Canadian study to analyze a formalized wellness program and burnout within plastic surgery residency. Our wellness program was feasible and well received by our residents. Despite high satisfaction, PGY-2 and 3 cohorts had the highest burnout scores. Personal accomplishment scores significantly declined over the year, suggesting that feelings of incompetence and achievement relate to burnout, and residents may require additional support in this domain. However, wellness initiatives should be tailored to resident and program context.
Prognostic Factors Associated with Survival in Patients Diagnosed with Primary Osteosarcoma of the Bone: A Systematic Review and Meta-Analysis
Natasha Barone, Emily Volfson, Vincent Dinh, Annie Switzer, Sevan Hopyan, Karen Wong Riff, Kristen Davidge
Toronto, ON
Purpose: Prognostic factors (PFs) associated with overall survival (OS) may help inform preoperative risk-stratification and preference-sensitive surgical decisions; however, they have not been comprehensively synthesized. We performed a systematic review and meta-analysis of epidemiologic- and tumour-related PFs associated with OS of pediatric and adult patients with primary osteosarcoma.
Methods: A protocol was registered a priori on OSF, PRISMA guidelines were followed. Medline, Embase, Cochrane Central and SCOPUS were searched from inception until 08/10/2025. Two independent reviewers screened the literature for studies of PFs, extracted data using the CHARMS-PF checklist, and assessed risk of bias (ROB) using QUIPS. Random effect meta-analyses of pooled adjusted hazard ratios (HR) with 95% CIs were performed for each PF-outcome pair. Heterogeneity was measured (I2, τ2). High ROB studies were removed on sensitivity analyses. Publication bias and certainty of evidence (GRADE) were assessed.
Results: Of 6584 articles screened, 75 articles with 37957 patients were included. Worse OS was associated with age ≥40 years (HR:2.09[1.47-2.99], p 8cm (HR:1.43[1.25-1.65].
Conclusions: Several PFs were associated with OS in primary osteosarcoma, thereby providing a clearer understanding of PFs of OS, which can improve risk-stratification and support preference-sensitive surgical decision-making.
Use of Partially Injured Donors in Nerve Transfer Surgery: A Subgroup Analysis
Raahulan Rathagirishnan, Molly McIntyre, Gerald Wolff, Kirsty Boyd
Ottawa, ON
Purpose: The standard of care for nerve transfer surgery is to utilize donor nerves with full strength and optimal function to maximize successful outcomes in peripheral nerve injuries. However, in significant brachial plexus injuries where suitable full-strength donors are limited, the exploration of partially injured donor nerves warrants investigation. This study evaluates the role and efficacy of these donors in nerve transfer surgeries, addressing the current literature gap regarding their potential contributions to functional recovery.
Method: A cohort analysis was performed on all nerve transfers conducted at a single institution from 2011 to 2025. Donor nerves with a Medical Research Council (MRC) grade less than 5 and/or abnormal electromyography (EMG) results were analyzed. Primary outcomes included the number of patients achieving MRC strength grades of 3 or greater and 4 or greater, the number of patients with no change in MRC grade, and the average change in MRC grade. Secondary outcomes assessed complications and donor function morbidity.
Results: Among 484 peripheral nerve surgeries, preliminary data from 2020 to 2025 identified 21 transfers using downgraded donor nerves. The mean patient age was 52.6 years, with 80.9% male. Notably, 65% achieved MRC grade 3 or greater strength, while 63% reached MRC 4 or greater. 10.5% percent exhibited no change in MRC grade. The average change of MRC was 1.75. One patient experienced donor nerve morbidity, and one had a deterioration of their initial condition.
Conclusions: Preliminary findings suggest that partially injured donor nerves may provide functional improvement when optimal donor options are limited, highlighting their potential role in complex brachial plexus injuries.
Reconsidering Treatment for Non-Melanoma Skin Cancer in Frail Patients: Are We Operating Too Much?
Tara Behroozian, Achilles Thoma, Josephine D'Abbondanza
Hamilton, ON
Purpose: Plastic surgeons are increasingly tasked with managing high volumes of non-melanoma skin cancer (NMSC), driven by an aging population and rising incidence of cutaneous malignancies. Frail patients often present with comorbidities, associated with higher risks of operative complications. Accounting for patient outcomes and the demands of a strained healthcare system, is it worthy treating NMSC in frail, elderly patients? This study aims to (1) review current guidelines, (2) present a practical decision-making framework to guide operative versus non-operative management in older adults, and (3) illustrate its application through common clinical scenarios.
Method: We conducted a narrative review of current clinical practice guidelines for NMSC management, including those from Cancer Care Ontario, the National Comprehensive Cancer Network, and the International Society of Geriatric Oncology. Additional literature on geriatric assessment, perioperative risk, and prognosis estimation tools was reviewed to develop a clinical framework for use by plastic surgeons.
Results: Existing guidelines provide tumour-specific management recommendations but lack age- or frailty-based criteria. Geriatric medicine literature emphasizes integrating frailty, comorbidities, and life expectancy into surgical decision-making. We developed a three-step clinical framework to guide surgical decision-making: (1) cancer risk stratification; (2) patient perioperative risk stratification and prognosis assessment using validated tools, including the FRAIL scale or mFI-5; and (3) individualized treatment selection ranging from surgical intervention to watchful waiting. Applying the framework to real-life clinical scenarios demonstrated which patients benefited from surgery and which were better managed conservatively.
Conclusions: A frailty-informed approach to NMSC in plastic surgery practice may reduce overtreatment and minimize operative complications. Future research will aim to develop evidence- and consensus-based geriatric-focused guidelines in NMSC management.
Patient-Reported Outcomes Following Single-Digit Replantation Versus Revision Amputation: A HAND-Q–Based Comparative Study
Ophelie Doucet, Bruno Mastropasqua, Sabrina Le, Lou-An Lê-Berthier, Kim-Anne Do
Montreal, QC
Purpose: The objective of this study is to compare long-term patient-reported functional outcomes, measured using HAND-Q scores, following single-digit replantation versus revision amputation in the context of ongoing controversy surrounding individualized treatment selection.
Methods: A retrospective cohort study was conducted including adult patients referred to the University of Montreal Regional Hand Replantation Center and deemed candidates for replantation, who underwent either successful single-digit replantation or revision amputation, performed immediately or secondarily, between 2018 and 2024. Thumb amputations and multiple-digit injuries were excluded. At a minimum of one year after treatment, outcomes were assessed using six HAND-Q scales: Appearance, Function, Life Impact, Psychological Function, Symptoms, and Satisfaction with Hand Surgeon. Raw HAND-Q scores were converted to Rasch-transformed interval-level scores (0-100) using published conversion tables. Independent-samples t-tests were used to compare outcomes between treatment groups.
Results: The cohort of 38 patients included had a mean age of 40 years, was predominantly male (68%), and included 17 (44.7%) successful single-digit replantation and 21 (55.3%) single-digit revision amputation, with injuries distributed across finger flexor tendon zone I (44.7%) and zone II (55.3%). Significantly longer occupational therapy duration (6.18 vs 2.93 months) and higher rates of cold intolerance (94.11% vs 57.14%) were found in the replantation group. Comparative analysis demonstrated numerically favorable HAND-Q scores in the replantation group for Hand Function (87.93 vs 79.55), Life Impact (87.93 vs 79.55), and Satisfaction with Hand Surgeon (94.0 vs 81.25); however, none of these differences reached statistical significance.
Conclusions: Long-term reported functional and psychosocial outcomes were comparable after single-digit replantation and revision amputation. Treatment decisions should remain individualized, incorporating patient priorities, while considering costs, duration of occupational therapy, periods of invalidity, and prevalence of cold intolerance.
Recipient Nerve Evaluation for Nerve Transfers in Tetraplegia: Is Surface Electrical Stimulation a Reliable Alternative to Electrodiagnostics in Determining the Presence of Lower Motor Neuron Injury Preoperatively?
Noah Oiknine, Catherine Dansereau, Philippe Ménard, Géraldine Jacquemin, Elie Boghossian, Dominique Tremblay
Montreal, QC
Purpose: Accurate assessment of lower motor neuron (LMN) integrity in nerve transfer (NT) candidates with tetraplegia is essential to determine whether recipient targets are time-dependent or time-independent. Although electrodiagnostic studies (EDX) are commonly used preoperatively, their reliability remains debated. This study evaluates the reliability of preoperative surface electrical stimulation (SES) for characterizing LMN integrity by comparing it with intraoperative direct nerve stimulation (DNS), with the aim of determining NT time sensitivity preoperatively.
Methods: This prospective study included consecutive tetraplegic patients who underwent upper extremity (UE) NTs between March 2024 and March 2025. The five-zone spinal cord injury classification described by Bryden et al was expanded to incorporate responses to preoperative SES and intraoperative DNS. Recipient nerves were classified as zone 3, 4, or 5 preoperatively and intraoperatively. SES performance was assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), with true positives defined as concordant zone 5 classifications by SES and DNS.
Results: Five patients (9 UEs) undergoing 23 UE NTs were included. Eighteen recipient nerve/motor point targets were evaluated using both SES and DNS. All patients were motor complete by ASIA classification (A: 40%, B: 60%). SES and DNS classifications were concordant in 15/18 targets (83%). SES demonstrated a sensitivity of 57%, specificity of 100%, PPV of 100%, and NPV of 79%.
Conclusions: Preoperative SES is highly specific and does not falsely classify time-dependent (zone 3 or 4) recipients as time-independent (zone 5). A PPV of 100% indicates that recipients identified as zone 5 by SES can be confidently considered time-independent preoperatively. Lower sensitivity suggests that some recipients classified as time-dependent by SES may have intact LMNs.
Validation Study: Movement Sonification of the Hand as a Rehabilitation Tool
Alexander Platt, Martin Giuffre, Emma Yanko, Ryan Hoeve, Maleka Ramji, Aaron Knox, Justin Yeung
Calgary, AB
Purpose: Hand injuries frequently result in functional impairment, with adherence to rehabilitation remaining a barrier to recovery. Movement sonification, the conversion of movement data into audible sound, may improve accessibility, engagement, and feedback during hand rehabilitation, improving patient outcomes. The purpose of this study was to validate a novel, web-based movement sonification interface that maps single-digit finger motion to real-time auditory feedback. To ensure the reliability and clinical readiness of this technology, this study determined whether 1. Users can accurately perceive and predict the relationship between joint movement and auditory feedback, and 2. That sonification mapping is intuitive.
Methods: Nineteen healthy adults (mean age 32 years; 10 males, 9 females) with no prior exposure to movement sonification participated. Using Google's MediaPipe hand-tracking technology via webcam, participants interacted with a web-based program that mapped fourth digit PIP joint flexion and extension to musical pitch changes (low pitch for extension, high pitch for flexion). Construct, face, content, and predictive criterion validity were assessed through structured surveys after participants viewed demonstration videos and explored the program independently.
Results: Construct validity was 89%, with participants correctly identifying the relationship between fourth digit PIP movement and pitch changes. Both face and content validity were 100%, with all 19 participants recognizing the sound-movement relationship and that only the fourth digit produced sound. Predictive criterion validity demonstrated high accuracy, with participants correctly matching hand configurations to sounds (95%) and predicting sounds from muted videos (95%).
Conclusions: Results demonstrate excellent construct, face, content, and predictive criterion validity. This supports the feasibility of using this movement sonification interface in future studies to determine its impact on hand injury rehabilitation outcomes.
Augmented reality-based hand tracking application for monitoring ulnar nerve recovery
Sasha Letourneau, Hannan Minhas, Ethan Peters, Juliana Larocerie-Salgado, Stahs Pripotnev, Caitlin Symonette
London, ON
Purpose: Clinical digital tools have garnered considerable interest given their potential to standardize clinical measurements, improve accessibility for remote communities through virtual assessment and enable patient-driven “self-tracking” as motivation for therapy adherence. Interestingly, despite its prevalence, ulnar neuropathy has been neglected as a focus for digital assessment. Thus, we developed a web application using open-source augmented reality (AR) frameworks which provides real-time abducted hand tracing (AHT) measurements: https://digits-hand-measurement-tool.vercel.app/hand-tracker. Used to track ulnar-innervated intrinsic function, AHTs represent valid, clinical adjuncts to electrodiagnostic studies and other clinical assessments (eg pinch strength), which are not amenable to remote monitoring. This study assessed intra-instrument reliability of AR-based AHTs and their accuracy relative to paper-based AHT measurements among patients with ulnar neuropathy.
Methods: Adults with ulnar neuropathy had photos taken of their affected hand in maximal abduction immediately followed by AHT on paper while the patient maintained the same hand pose. Hand photos were used to collect five sets of AR-based measurements for intra-instrument reliability assessment using intraclass correlation coefficients (ICC). Absolute AR-based measurements between each digit were compared to paper-based AHTs using paired t-tests.
Results: Among ten participants with ulnar neuropathy (mean age 60.3 years, 80% left-sided injury), AR-based measurements demonstrate excellent intra-instrument reliability between all digits (ICC>0.99). AR-based and paper-based AHTs measurements between all digits were significantly different (p < 0 .05). Lowest mean absolute difference was between D4–5 (6.1mm±4.7mm, p < 0 .05) and highest between the D1–2 (15.0mm±4.7mm, p < 0 .05).
Conclusions: Excellent intra-instrument reliability of AR-based measurements suggests potential, for instance, for a remote monitoring application that could flag clinical changes over time necessitating intervention. While ongoing developments are underway to improve accuracy, further studies should correlate AR-based measurements to other metrics of ulnar nerve function.
A comparison of human upper extremity and porcine forelimb perfusate proteome over 24 h of ex vivo machine perfusion
Nina Hadzimustafic
Montreal, QC
Purpose: Upper extremity (UE) transplant is a treatment option for limb loss. Cold ischemia time of a UE is limited to 4–6h due to the high metabolic activity of skeletal muscle. Ex vivo machine perfusion has emerged as a potential alternative to cold storage of the UE. Liquid chromatography-mass spectrometry (LCMS) based proteomics can aid in profiling global protein expressions.
Methods: Three human UEs and three porcine forelimbs were perfused for 24h; perfusate samples were collected at 0h, 12h, and 24h for LCMS. LCMS measured intensities of expressed proteins. 5649 proteins were detected in the human UE, while 6479 proteins were detected in the porcine forelimb perfusate samples over 24h. ANOVA analysis was conducted to determine changes over 24h; human and porcine protein results were compared.
Results: 326 of 5649 proteins identified in the human perfusate had significant fold change from 0 to 24h (p 0.05).
Conclusions: Several protein groups showed significant changes over 24h perfusion, with a plateau in changes after 12h. Results in human UE were mirrored by porcine forelimb, re-affirming the porcine model as promising for further ex vivo limb perfusion studies.
Real World Evidence of Near Infrared Spectroscopy Supporting Clinical Evaluation: Reducing Rates of Flap Tip Necrosis in Oncologic Reconstructive Surgery
Myriam Verly, Bianief Tchiloemba, Sara Cho, Cynthia Kahl, Golpira Elmi Assadzad, Claire Temple-Oberle
Calgary, AB
Purpose: We previously demonstrated that near-infrared spectroscopy (NIRS) correlates with skin flap necrosis (SFN). This prospective study aimed to evaluate whether clinical decision making supported by NIRS can guide targeted, intra-operative flap-tip revision and reduce post-operative SFN.
Method: Consecutive patients undergoing oncologic resection with immediate flap reconstruction were enrolled. Each flap was assessed intraoperatively using standard clinical examination and NIRS imaging. Flap tips demonstrating concerning perfusion by either modality were revised when technically feasible. Patients were followed for 30 days to assess SFN.
Results: Forty-seven patients (26 female, 21 male) underwent 63 flaps between 2020 and 2021. Diagnoses included melanoma (22), breast cancer (13), non-melanoma skin cancer (7), sarcoma (4), and glioblastoma (1). Flap types included random subdermal (33), axially based regional (12), perforator-based (12), and free flaps (6). Anatomical locations included the torso (34), lower extremity (14), upper extremity (8), and head and neck (7). SFN occurred in 4/63 flaps (6.3%). One flap developed a small area of necrosis in an area identified as concerning by NIRS where revision was not technically feasible. The remaining three cases had reassuring intraoperative findings and developed only minor necrosis that resolved with conservative management. In comparison to our previously published NIRS blinded-cohort study, SFN rates were decreased from 18% to 6.3% (p =0.04). These cohorts were similar across age (p=0.35), gender (p=0.22), oncologic diagnosis (p=0.19), flap type (p=0.52), comorbidities (0.05) and history of radiation (0.11).
Conclusions: In real-world practice, integrating NIRS with clinical judgment was associated with a reduced rate and severity of SFN compared with historical assessment alone. Accordingly, NIRS may be a valuable adjunct for intraoperative flap evaluation.
Efficacy and safety of abdominal flap-based breast reconstruction in women aged 60 and over: A systematic review
Karanvir Raman, Sara Morel, Rahul Thareja, Caroline Esmonde-White, Rawan ElAbd, Charles Arcand, Tyler Safran, Joshua Vorstenbosch
Montreal, QC
Purpose: Despite representing over half of all breast cancer diagnoses, patients aged 60 and older account for only 3% of autologous breast reconstructions. This gap reflects patient hesitancy and surgeon concerns about complications and overall benefit. However, emerging evidence suggests that age alone should not exclude patients from microvascular reconstruction.
Methods: A PRISMA-compliant systematic review was conducted to summarize outcomes of autologous abdominal flap-based breast reconstruction in women aged ≥60. Two reviewers extracted patient demographics, flap type, reconstructive details, and all available postoperative outcomes. Complications were categorized as breast-related, donor-site, or systemic. Efficacy outcomes were synthesized narratively given heterogeneous reporting of patient- and physician-based scoring systems.
Results: Complication-related and patient-reported outcomes were extracted from 28 observational studies (n=2023 patients). Pooled donor-site complications included abdominal hernia (5.16%), wound complications (10.42%), hypertrophic scarring (16.42%), hematoma (1.56%), seroma (6.80%), umbilical necrosis (2.94%), infection (11.94%), fat necrosis (2.99%), and cellulitis (4.65%). Breast-related complications included partial flap loss (3.42%), total flap loss (1.81%), infection (5.67%), fat necrosis (7.04%), flap necrosis (7.66%), wound dehiscence (2.88%), hematoma (3.23%), seroma (6.25%), arterial thrombosis (5.06%), and venous thrombosis (10.13%). Revision surgery due to immediate flap-related complications occurred in 7.54% of cases. Across studies, women 60 and older demonstrated excellent improvements in psychosocial and physical well-being following reconstruction.
Conclusions: Age ≥60 is not a contraindication to abdominal flap-based breast reconstruction. Major complication rates and patient-reported outcomes in this cohort are comparable to those of younger patients, though older adults may face a modest increase in donor-site morbidity. Risk assessment should instead rely on more accurate stratifiers such as frailty rather than chronological age.
Risk Factors for Postoperative Collection Formation in Top Surgery: Is Testosterone Actually to Blame?
Gavin Raner, Aaron Grant, Caitlin Symonette, Tanya DeLyzer
London, ON
Purpose: The main postoperative complication of bilateral mastectomy for gender affirmation (“top surgery”) is hematoma formation requiring reoperation for evacuation. Some centers require patients to stop testosterone before surgery due to the theoretical risk of erythrocytosis causing increased bleeding. Testosterone cessation, however, can cause detransition symptoms and worsen dysphoria. This study aims to identify factors that may increase the risk of postoperative hematoma formation after top surgery. This is one of the first studies to investigate testosterone dosage as a continuous variable in this context.
Method: This single-center retrospective chart review enrolled all top surgery patients of the senior authors from January 1, 2018 to December 31, 2024. Investigated factors included: testosterone use/amount, cigarette use/amount, operative approach, surgery duration, perioperative NSAID use, mass of excised tissue, intraoperative blood loss, and demographics. Primary outcomes were hematoma and seroma formation. Secondary outcomes included hypertrophic scarring, tissue necrosis, infection, and need for revision. Statistical analyses included Fisher's test and logistic regressions.
Results: 236 charts were screened and 116 met inclusion criteria. Ten reported postoperative hematoma (9 on testosterone; P=1); 3 required surgical evacuation (all on testosterone; P=1). Seven developed a seroma (all on testosterone, P=0.593). Independently, only cigarette use was significantly associated with postoperative hematoma (P=0.0294). Multivariate logistic regression on age, BMI, smoking, surgical approach, and testosterone dose showed the circumareolar approach was significantly associated with postoperative hematoma (P=0.0334).
Conclusions: Testosterone was not shown to increase hematoma or seroma formation after top surgery, and may not require perioperative suspension. Circumareolar top surgery patients and smokers, however, may benefit from being counselled on a potentially higher risk for postoperative hematoma or seroma formation.
The Impact of Obesity on Mortality and Length of Stay in Severe Burn Injury
Amir Khorrami, Sara Sheikh-Oleslami, Anthony Papp, Aman Sharma
Vancouver, BC
Purpose: The relationship between obesity and outcomes after severe burn injury remains controversial. While an “obesity paradox” has been described in trauma and critical illness, evidence in burn patients is conflicting. This study evaluates the association between body mass index (BMI), mortality, and hospital length of stay in adults with severe burns.
Methods: A retrospective, single-centre cohort study was conducted of adult patients (≥18 years) admitted with severe burns (total body surface area [TBSA] ≥20%) between October 2019 and July 2024 to Vancouver General Hospital. Patients were stratified by BMI into normal weight, overweight, and obese categories. Demographics, burn characteristics, and outcomes were compared using Wilcoxon rank-sum and Fisher's exact tests. Mortality was analyzed using multivariable logistic regression. Secondary outcomes included hospital length of stay.
Results: Eighty-two patients met the inclusion criteria (59 male, 23 female). There were no significant differences between BMI groups with respect to age, TBSA, or inhalation injury. Overall mortality was 15% (12/82). Mortality was significantly higher in overweight patients (24.2%) compared with normal weight (6.3%) and obese patients (12.5%). However, numeric BMI was not independently associated with mortality on multivariable logistic regression. Among survivors, higher BMI was associated with a trend toward shorter hospital length of stay, though this did not reach statistical significance.
Conclusion: An obesity paradox was not observed in this cohort of patients. While overweight status was associated with higher mortality, BMI was not an independent predictor of death. Increased BMI may be associated with shorter hospital stay among survivors. Further multi-centre studies are needed to clarify the this correlation.
Release of Immature Neutrophils Links Burn Severity, Not Size, to Mortality and Generalizes Across Critical Illness
Sarthak Sinha, Edna Ayerim Mandujano-Tinoco, Eren Kutluberk, Patrick Mulder, Nicolás Collao, Keerthana Chockalingam, Alex Pun, Rkia Dardari, Myriam Verly, Frankie Fraulin, Robertson Harrop, Nicole Rosin, Vincent Gabriel, Jeff Biernaskie
Toronto, ON
Purpose: To identify cell-specific immune programs linking burn size, inhalation injury, and mortality, and to develop a biomarker panel of fatal trajectories that generalizes across critical illness.
Method: We profiled 73,014 peripheral blood immune cells by single-cell mRNA-sequencing from 4 adult burn patients (day 14) and 5 healthy donors, and projected bulk transcriptomic signatures of TBSA, inhalation injury, and mortality onto this atlas. Clinical associations were tested using multivariable logistic regression in the American Burn Association's National Burn Repository. We derived a 5-gene neutrophil signature and evaluated mortality prediction in independent blunt trauma (n=158) and ICU COVID-19 (n=103) cohorts.
Results: Burn injury was characterized by emergency hematopoiesis with expansion of hematopoietic progenitors, immature neutrophils, and plasmablast/plasma cell states, alongside depletion of naïve T cells and dendritic cell compartments. Larger burns (>20% TBSA) preferentially activated humoral programs (plasmablast/plasma cell enrichment) with relative suppression of CD8⁺ T-cell programs. In adjusted clinical models, inhalation injury was a stronger independent predictor of death than TBSA (adjusted OR 1.9 vs 1.1) and shared greater cellular overlap with non-survivor transcriptional programs, converging on neutrophils. A 5-gene immature neutrophil panel (OLFM4, RETN, LCN2, ARG1, BTNL3) predicted burn mortality with AUC >0.9 at 4.7–6 days post-burn and generalized to trauma (AUC 0.81) and COVID-19 (AUC 0.75). Cytomorphology supported this phenotype, with increased band forms and larger neutrophil size in a fatal burn trajectory.
Conclusions: Immature neutrophil surges are a conserved marker of fatal trajectories in burns and generalize across critical illnesses. A parsimonious 5-gene panel may enable early risk stratification beyond conventional severity metrics.
Exploring Associations Between Facial Anthropometry and Patient-Reported Perceptions of Appearance and Health-Related Quality of Life in Cleft Lip and/or Palate: A Cross-Sectional Analysis Using the CLEFT-Q
Alexandra D'Souza, Eileen Tang, Jessie Howard, Kariym Joachim, Karen Wong Riff
Toronto, ON
Purpose: Facial anthropometric measurements objectively characterize surgical and aesthetic outcomes in individuals with cleft lip and/or palate (CL/P). The degree to which these measurements correlate with patients’ perceptions of appearance and health-related quality of life (HRQoL) is unclear. An understanding of this relationship is essential to aligning clinical assessment with patient experience. This study evaluated the association between facial anthropometric measures and patient-reported outcome (PRO) measures of appearance and HRQoL using the CLEFT-Q.
Method: CL/P patients aged 8–29 years completed select CLEFT-Q scales assessing appearance (Face, Lips, Cleft Lip Scar, Nose, Nostrils, Teeth, Jaws), speech (Speech Function, Speech Distress), and HRQoL (Psychological, Social, School Function). Participants also completed the Appearance Distress scale from the FACE-Q Craniofacial Module. Fourteen clinically relevant anthropometric variables were derived from standardized two-dimensional clinical photographs. Multivariable regression models were used to examine relationships between anthropometric measurements and PRO scores.
Results: Fifty-nine participants were included. Greater symmetry of upper lip vermillion height was associated with more favorable outcomes across several domains, including Face, Psychological, Social, School Function, and Appearance Distress. Horizontal lip length symmetry was associated with School Function, while increased upper lip projection was associated with higher ratings of lip appearance. Improved symmetry of nasal alar base height corresponded with higher Face scale scores. Increased nasal width and tip projection were associated with lower School Function scores. Other associations across appearance-related domains demonstrated similar directional trends but did not reach statistical significance.
Conclusions: Objective facial measurements and PROs represent distinct yet interrelated dimensions of outcome assessment in CL/P. Anthropometric data provide important clinical benchmarks, while PROs capture the psychosocial impact of facial differences. Ongoing network-based analyses aim to further characterize how objective and subjective factors interact to shape patient perceptions of appearance and well-being.
The utility of video-assisted technology to improve learning outcomes among surgical residents during cleft palate surgery: A quality improvement study
Kathryn Minkhorst, Katie Garland
London, ON
Background: Cleft palate repair surgery poses difficulties in education for learners due to its limited visibility. Surgical education relies heavily on observation, in order to teach surgical steps and relevant anatomy. We will aim to improve visualization cleft palate repair surgery with video-assisted observation using a loupe mounted camera and have designed a quality improvement study to analyze the success of this intervention.
Methods: For bilateral cleft palate surgeries, implement traditional (direct) observation on one side and video-assisted loupe-mounted observation on the contralateral side. Learners will then complete a survey through Qualtrics to share their experience with the two learning environments. All responses are anonymous.
Results: To date, six of ten eligible residents have participated in cleft surgery using video assisted observation. All the residents reported better intra-operative visualization leads to improved learning. After direct observation, most respondents were somewhat satisfied with their view. Comparatively during the video-observation most residents were somewhat dissatisfied with their view, and they were dissatisfied with the quality of the video. Although many residents commented they were able to see more of the surgery with the video assistance, the quality of the video, inference of operating room lights, shakiness and difficulty assisting were all listed as pitfalls.
Conclusions: Although all residents expressed the importance of visualization to their learning, and were only somewhat satisfied with direct visualization, the video-observation quality was not high enough to not provide significant benefit. We plan to improve the set up in the future to hopefully overcome these pitfalls and allow for more benefit to be had from video-observation.
A 21-Year Provincial Perspective on Necrotizing Fasciitis Epidemiology
Austin McGrath, Sarvesh Logsetty, Justin Gawaziuk, Rae Spiwak, Lisa Moore, Jordan Nantais
Winnipeg, MB
Purpose: Necrotizing fasciitis (NF) is a devastating infection with morbidity and mortality rates from 20%–30%. The purpose of this study is to identify the provincial incidence and mortality rates of this disease process using 21 years of prospectively collected data.
Methods: We performed a retrospective study of patients with NF admitted to two tertiary hospitals from 2004–2024. A total of 589 patients (324 males and 285 females) met inclusion criteria via ICD-10 codes and confirmation by operative report mentioning fascial involvement. Data was collected on factors including age, sex, regional health authority (RHA), comorbidities, in-hospital mortality, and microbiology.
Results: The mean age of patients who survived was 48.5, and those who died was 62.4. Provincially there was a significantly higher rate of comorbidities in those who died (cardiovascular disease 66.7% vs 44.5% and renal disorders 31.9% vs 12.2%). Multifocal presentation was significantly higher in those that died (13.9% vs 4.1%). The incidence of NF provincially was 1.95 per 100,000 annually, compared to 5.81 in the Northern RHA. Although the overall provincial mortality rate was 12.2%, those in the Northern RHA did not have a greater rate of mortality.
Conclusion: In this study, the standardized annual incidence of NF is approximately 3 times higher than the most recently reported Canada-wide data. While our province makes up less than 4% of the country's population, there was on average 30 NF cases per year over a 21-year span, making up 15%–33% of the country's annual cases. Surprisingly, the mortality rates throughout the province were equivalent regardless of distance from a tertiary center.
From The Groin Flap to SCIP: The Vascular Anatomy of the Femoral Triangle and Advancement of Plastic Surgery.
Chantal Valiquette, Steven McCabe, Syena Moltaji
Toronto, ON
Purpose: The purpose of this presentation is to review the evolution of flaps based on vessels originating from the femoral triangle, to show how this is interconnected with advancements in Plastic Surgery, and to highlight some of those individuals who developed our knowledge.
Method: We reviewed the literature, focussing on articles that discussed vascular anatomy, flap physiology, and surgical technique. We selected a chronologic sequence of publications that reveal the evolution of flaps originating in the femoral triangle.
Results: The vascular anatomy of the femoral triangle was clearly described by Manchot in the late 1800's. Gillies writing in 1935 and Bunnell in 1944 knew that vertical or oblique flaps originating from the inguinal region had improved survival based on improved blood supply. Jerome Webster, in 1937, clearly described tubed pedicle flaps with clear understanding of the longitudinal vessels originating from the femoral triangle. Shaw and Payne, working in the Second World War, first described the axial pattern flap based on the Superficial Inferior Epigastric Artery (SIEA) in 1946. In 1973 McGregor and Jackson illustrated a preference for flaps based on the Superficial Circumflex Iliac Artery (SCIA) introducing the workhorse groin flap. In the same year Daniel and Taylor performed the first free skin flap using the SIEA. Further understanding of perforator flaps resulted in Koshima describing the Superficial Circumflex Iliac Perforator (SCIP) flap in 2004. Both the SCIP and the SIEA can be elevated as thin flaps resulting in improved recipient site cosmesis.
Conclusion: The femoral triangle has been connected to some of the most important innovations in Plastic Surgery.
A qualitative exploration of factors influencing practice decisions among plastic surgery residents and early-career plastic surgeons in Canada
Sarah Hunt, Anna-Lisa Nguyen, Sarah Appleton
London, ON
Purpose: Canadian plastic surgery workforce trends are changing. This study aims to gain a richer understanding of factors that influence how plastic surgery residents and early-career plastic surgeons in Canada choose their eventual practice.
Methods: Plastic surgery residents and early-career plastic surgeons across Canada were recruited to participate in semi-structured interviews between February 2025 and 2026. Interview transcripts underwent thematic analysis by two independent reviewers. Final themes were identified via consensus coding.
Results: Twenty plastic surgery residents participated. Residents prioritized family, valuing spousal job opportunities and opinions, and living near family and friends. They also described living in communities they were familiar with, either through life or work experience, and communities compatible with their hobbies and interests. Among the early-career plastic surgeons who participated, many discussed choosing a job that fit their interests within subspecialties of plastic surgery, with the job responsibilities being prioritized over location. Early-career plastic surgeons also discussed the importance of residency mentors in shaping their career. Both residents and early-career plastic surgeons agree that finding a collegial working group is the most important workplace factor when choosing a practice.
Conclusions: Factors influencing practice decisions are multifaceted, with many important factors existing outside of the typical terms of contract negotiation.
Plagiarism in Manuscripts Submitted to the Plastic Surgery Journal: A Comprehensive Analysis of iThenticate Scores
Sara Sheikh-Oleslami, Marija Bucevska, Kathy Vuong, Mirko Gilardino, Jugpal Arneja
Vancouver, BC
Montreal, QC
Purpose: Plagiarism undermines scientific credibility. Many journals utilize plagiarism detection software, like iThenticate, to screen submissions. This study evaluates the relationship between iThenticate similarity scores and editorial decisions for manuscripts submitted to Plastic Surgery, and to examine post-rejection publication outcomes.
Methods: A retrospective, descriptive analysis was conducted of manuscripts submitted between 2021–2024. Collected variables included submission year, manuscript type, subspeciality, country, number of reviews completed, editorial decisions, and iThenticate similarity scores. Submissions with high scores (>20%) were examined to determine subsequent publication elsewhere. Retrieved published versions were screened to compare similarity scores before and after publication.
Results: 1042 manuscripts were submitted. Most were Original Articles (58%), followed by Case Reports (21%) and Review Articles (10%). The mean similarity score across all submissions was 17.8% ± 12.7%, ranging from 18.1% (2021) to 14.7% (2024). 31.7% of submissions exceeded 20% similarity and were disproportionately rejected, with a final rejection rate of 77%. Accepted manuscripts had lower similarity scores than rejected manuscripts (13.5% vs 19.8%, p<0.0001). Among 233 rejected high-similarity manuscripts, 122 (52%) were likely published elsewhere. Of 107 retrieved published versions, all (100%) demonstrated lower similarity after publication (mean reduction 29% to 11%); 92% fell below the 20% threshold, while 8% retained >20% similarity. Authorship modification occurred in 23.6% of published manuscripts.
Conclusions: Higher similarity scores were strongly associated with rejection, supporting iThenticate as an effective screening tool when paired with contextual editorial judgment. Post-rejection publication trends suggest that many authors revise substantially prior to resubmission, although a minority of manuscripts retain elevated similarity after publication, underscoring variability in journal standards. These findings highlight the need for harmonized plagiarism policies and targeted author education.
Safety and Effectiveness of Prepectoral and Subpectoral Alloplastic Breast Reconstruction: A Longitudinal Prospective Study
Gina Zhang, Hannah Wells, Peter Lennox, Christopher Doherty, Peter Davison, Jenna-Lynn Senger, Sheina Macadam, Nancy Van Laeken, Esta Bovill, Kathryn Isaac
Vamcouver, BC
Purpose: For immediate breast reconstruction (IBR), the optimal plane for implant placement is debated between subpectoral (SPBR) and prepectoral (PPBR) placement. This study evaluates the safety and effectiveness profiles of PPBR and SPBR using surgical and patient-reported outcomes.
Method: This prospective cohort study is inclusive of patients who underwent total mastectomy and alloplastic IBR from March 2021 to November 2024. Patient records were reviewed to acquire demographics, oncological, and surgical details. At 3-months post-operatively, safety outcomes were recorded. Patient-reported outcomes (PROs) were collected at baseline, 6-month, 12-month, and 18-month post-operative timepoints using the BREAST-Q survey. To evaluate the association of plane placement with complications, logistic regression propensity score models were employed with sensitivity analyses.
Results: 473 patients were included in this analysis. 278 underwent PPBR and 195 underwent SPBR, with the majority as staged reconstructions (82%, n = 387). There were no observed differences in rates of device loss [PPBR 11.9%, SPBR 8.7%], reoperation [PPBR 15.8%, SPBR 16.4%], readmission [PPBR 12.2%, SPBR 12.3%], infection [PPBR 16.2%, SPBR 15.9%], seroma [PPBR 13.3%, SPBR 16.9%], and MFN [PPBR 12.9%, SPBR 13.8%]. In the logistic regression propensity score models, the risk of reoperation did not differ between the two groups for the first-stage expander insertion (OR = 0.76, 95% CI = 0.42–1.41, p = 0.816). The risk of implant loss, reoperation, and readmission was higher for the SPBR group undergoing single-stage implant placement of the second-stage implant insertion (OR=2.67, 95%=CI 1.16–7.11, p=0.014). A total of 140 patients consented for completion of PROMs. At baseline and 12-month post-operatively, there were no differences in psychosocial, sexual, and general satisfaction scores.
Conclusion: Both SPBR and PPBR are safe and effective techniques with comparable outcomes for surgical and patient-reported outcomes.
Patient-Reported Outcomes After Autologous Versus Contemporary Implant-Based Breast Reconstruction: A Rapid Review Using BREAST-Q.
Riley Smith, Aaron Grant
St. John's, NL
Purpose: Autologous breast reconstruction (ABR) has historically demonstrated superior patient-reported outcomes (PROs) compared with implant-based reconstruction (IBR). However, advances in implant technology and technique—including smooth cohesive silicone implants, pre-pectoral placement, and direct-to-implant (DTI) reconstruction—raise the possibility that contemporary IBR may narrow previously observed satisfaction differences. This rapid review synthesizes recent evidence comparing ABR and modern IBR using the BREAST-Q to assess whether PROs have shifted with these innovations.
Methods: A structured PubMed search (January 2020–June 2025) identified studies reporting BREAST-Q outcomes following ABR or IBR. Eligible studies included postmastectomy patients and reported outcomes in at least one BREAST-Q domain. Data extraction and risk-of-bias assessment using the Newcastle–Ottawa Scale were completed in Covidence. Weighted means, pooled mean differences (MD), standardized mean differences, and 95% confidence intervals were calculated to compare reconstruction modalities.
Results: Eleven studies met inclusion criteria (N = 5328; 2631 ABR; 2563 IBR). All studies reporting data collection years captured outcomes after 2015, reflecting adoption of smooth implants, pre-pectoral reconstruction, and DTI techniques. In contrast, prior meta-analyses—despite recent publication—largely relied on pre-innovation datasets. Pooled analyses demonstrated significantly higher BREAST-Q scores for ABR across all domains, including satisfaction with breasts (MD 9.01).
Conclusions: Despite substantial improvements in implant design and surgical technique, contemporary evidence continues to demonstrate higher patient-reported outcomes with autologous reconstruction. By incorporating the most modern dataset reflecting current practice, this review provides the most up-to-date comparison of ABR versus IBR satisfaction.
Evaluating the Feasibility of Implementing a Program for Immediate Lymphatic Reconstruction at Time of Axillary Lymph Node Dissection
Jonathan Chan, Jaimie Lee, Maya Lee, Peter Davison, Jenna-Lynn Senger, Esta Bovill, Melina Deban, Kathryn Isaac
Vamcouver, BC
Purpose: Immediate lymphatic reconstruction (ILR) is a surgical intervention done at the time of axillary lymph node dissection (ALND) to lower the risk of breast cancer-related lymphedema (BCRL). We sought to evaluate the feasibility of a coordinated ILR scheme involving plastic surgeons and surgical oncologists in a provincial lymphedema program.
Methods: We performed a retrospective chart review of patients receiving either ALND with ILR or ALND-only at Vancouver Coastal Health and Providence Health Care in Vancouver, BC between January 2024 and May 2025. Patients with pre-existing lymphedema, distant metastasis, documented allergy to blue dye, or who were pregnant were excluded.
Results: Out of 110 patients reviewed, 53 received ALND with ILR and 57 received ALND alone. The median age at surgery was 60 years. Median operative time for ILR was 95 min, with a range of 60 to 180 min. There was a median of 2 anastomoses per case. Anastomosis was most often performed with intussusception (62%) or end-to-end (28%), with the most common recipient veins being the thoracoepigastric (24%), lateral pectoral (21%), and thoracodorsal (19%). Early axillary surgical complications included a decreased range of motion and paresthesia in the ipsilateral arm. The median follow-up time to date is 297 days [IQR 197–397].
Conclusions: Implementing a program integrating ILR at the time of ALND is feasible, and long-term outcomes from the program's prospective analysis are forthcoming.
Clinical Validation of Machine Learning-Based Prediction Tools in Delivery of Breast Reconstruction
Taylor Bootsma, Peter Davison, Jenna-Lynn Senger, Nancy Van Laeken, Sheina Macadam, Esta Bovill, Kathryn Isaac
Vancouver, BC
Purpose: Machine-learning (ML) prediction tools may support decision-making in immediate breast reconstruction (IBR), including prediction of post-mastectomy radiation therapy (PMRT) and reconstructive complications. However, independent evaluation is limited. This study prospectively assessed the performance of two ML-based calculators: the Chen model for predicting need for PMRT and the Naoum model for predicting reconstructive complications.
Methods: Patients undergoing mastectomy with IBR for breast cancer or hereditary risk were prospectively recruited. The Chen model was evaluated for its ability to predict PMRT recommendation using preoperative variables. The Naoum model was evaluated for prediction of infection or skin necrosis requiring surgical intervention and overall reconstructive failure, defined as expander or implant removal, within 90 days postoperatively. Model outputs were treated as continuous probabilities and assessed using receiver operating characteristic (ROC) analysis and area under the curve (AUC). Sensitivity and specificity were calculated at Youden index–derived thresholds.
Results: A total of 77 patients were recruited, with 58 in the PMRT prediction cohort and 77 in the complication cohort. PMRT was recommended for 43% (n=25) of patients. Complications were recorded for 8% (n=6) of patients with infection or necrosis, and 5% (n=4) for overall failure. The PMRT-risk model demonstrated excellent discrimination (AUC 0.96, 95% CI 0.92-1.00), with sensitivity of 0.92 and specificity of 0.88 at a 45% threshold. The complication model showed fair discrimination for infection or necrosis (AUC 0.68, 95% CI 0.47-0.89) and fair-to-good discrimination for overall failure (AUC 0.75, 95% CI 0.53-0.98). Performance was limited by low event rates and short follow-up.
Conclusions: The PMRT-risk calculator performed well using preoperative data alone. The complication model demonstrated modest performance for early complications. These findings support ML tools for preoperative counselling while highlighting the need for context-specific validation.
The Role of Cannabis in Recurrent Adolescent Gynecomastia: A Case Series
Mark Ashamalla, Kathryn McDermid, Rebecca Courtemanche, Kathy Vuong, Jugpal Arneja
Vancouver, BC
Purpose: Gynecomastia is common among adolescent males and may recur after surgical excision. Cannabis has been proposed as a potential endocrine-disrupting factor, though evidence remains conflicting. This case series examines postoperative gynecomastia recurrence in adolescents who used cannabis to explore a possible association.
Method: A retrospective case series was conducted of adolescent males who underwent gynecomastia excision by the senior author between May 2009 and May 2025 at BC Children's Hospital. Patients were included if they reported cannabis use after their initial operation and later required reoperation for recurrence. Clinical, operative, pathology, and follow-up data were extracted and narratively summarized.
Results: Among 119 adolescents who underwent gynecomastia excision, 11 reported cannabis use at any point, and three (27%) used cannabis postoperatively and later required reoperation for recurrence. All patients had normal endocrine evaluations and no systemic health changes aside from one individual with notable BMI reduction. Case 1 developed recurrent bilateral gynecomastia two years after initial excision and reported weekly cannabis use. Case 2 experienced recurrent unilateral gynecomastia at age 19, having discontinued cannabis six months before reoperation. Case 3 developed contralateral gynecomastia three years after initial surgery and reported monthly cannabis use before recurrence. Pathology at second operation confirmed fibrofatty or fibroglandular tissue in all three cases consistent with gynecomastia, and postoperative course after reoperation were unremarkable.
Conclusions: These findings suggest a potential association between postoperative cannabis use and recurrent adolescent gynecomastia. While causality cannot be inferred, these findings highlight the importance of discussing cannabis use during preoperative counseling and follow-up. Larger prospective studies are needed to clarify this relationship.
Electrolysis in Gender-Affirming Genital Surgery: An Observational Study Pilot
Frédérique Leroux, Michelle Cappadona, Blair Peters, Michelle Bonapace-Potvin
Montreal, QC
Purpose: Preoperative genital hair removal is required for safe and effective gender-affirming genital surgery and prevention of postoperative complications. Despite its importance, electrolysis remains a major barrier due to its time-intensive nature, procedural pain, high cost, and inconsistent insurance coverage. These factors delay access to phalloplasty and vaginoplasty and may worsen gender dysphoria and psychological distress. The number and duration of genital electrolysis sessions required before phalloplasty or vaginoplasty remain unreported, leaving care fragmented. This study quantifies treatment burden within access, pain, and financial barriers to care.
Method: We retrospectively reviewed the ten most recent phalloplasty and ten most recent vaginoplasty cases (2024–2025) performed within our transgender health program. Patients underwent preoperative genital electrolysis by an in-house electrologist. Variables included surgical type, treatment site, session number, total treatment hours, and urethral lengthening status. Descriptive statistics summarized treatment information.
Results: Among transmasculine patients undergoing phalloplasty, the mean number of electrolysis sessions was 29.3 (range 11–55), with a mean total treatment time of 25.45 h (range 5.50–54.25). Patients undergoing radial forearm free flap (RFFF) preparation required fewer sessions and treatment hours than those treated for anterolateral (ALT) thigh flaps. Among transfeminine patients undergoing vaginoplasty, the mean number of electrolysis sessions was 34.5 (range 7–80), with a mean total treatment time of 29.43 h (range 6.5–48). Considerable variability reflected differences in hair density, tolerance, and anatomy.
Conclusions: Preoperative electrolysis for genital gender-affirming surgery entails a substantial and variable treatment burden. Procedural pain and high costs further delay surgical access and exacerbate inequities in care. These findings identify electrolysis as a key bottleneck and support integrated institutional services, standardized protocols, improved pain management, and consistent insurance coverage.
Enhancing Gender-Affirming Surgical Education: A Cross-Canada Initiative in Plastic Surgery
Solana Husein, Kathleen Armstrong, Claire Temple Oberle
Vamcouver, BC
Purpose: Gender-affirming surgery (GAS) plays an important role in the care of transgender and gender-diverse (TGD) individuals, with well-documented benefits for quality of life. However, there remains a shortage of trained providers in this field, with potential roots in variable training experiences across Canada. This study aims to map the current state of GAS training in Canada and identify steps towards developing a standardized national curriculum.
Methods: This mixed-methods national study comprised a cross-sectional survey of curricular experts from all 12 Canadian plastic surgery (PS) residency programs and semi-structured interviews with senior PS trainees. Questions assessed structure, administrative valuation, and implementation of GAS training. Interviews explored trainee confidence and perspectives regarding GAS procedures. Quantitative and qualitative data were analyzed using descriptive statistics and thematic coding between 2 coders, respectively.
Results: Eight of 12 programs responded, representing all provinces except British Columbia. Most programs (87.5%) reported providing formal GAS training; however, structure and intensity varied substantially, ranging from longitudinal mixed-modality curricula to single-year or incidental exposure. Only two programs (25%) reported defined GAS-specific core competencies, both aligned with Royal College recommendations. While most respondents reported neutral-to-positive perceptions of residents meeting core competencies, perceived adequacy of training varied, and fewer than half (37.5%) expressed confidence in residents’ ability to independently perform GAS procedures for TGD patients. Data collection is ongoing; final results will be presented at CSPS 2026.
Conclusion: This study highlights significant variability and limitations in GAS training across Canada. Recommendations are being developed to support the creation of a unified national curriculum, aimed at equipping all plastic surgeons with necessary skills to care for TGD patients, regardless of subspecialization.
The Bow and Arrow Technique for Large Volume Fluid Aspiration
Merry Faye Graff, Brett Ponich, Alexander Platt, Claire Temple-Oberle
Calgary, AB
Purpose: Post-operative seromas are a common and often frustrating complication that can delay healing and affect clinician workflow. While some preventive methods have been described, symptomatic seromas are commonly treated with repeated needle aspirations. Standard techniques can be uncomfortable for both the clinician and the patient, as they often involve repeated needle entries, multiple syringe exchanges for large-volume, high-force suction, and a sharp, rigid instrument pointed near the patient. To overcome these drawbacks, we describe a straightforward, low-cost aspiration technique that uses commonly accessible clinic supplies.
Methods: This method involves a 50-mL syringe, a 10-mL syringe, a 21-gauge winged infusion set, protective gloves, and a sterile towel. The 10-mL syringe is taken apart so that its plunger can rest behind the 50-mL syringe. To aspirate, the needle is inserted, the 50-mL syringe plunger is fully pulled back, and the 10-mL plunger is rested behind it, analogous to nocking an arrow onto a bowstring. This generates sustained negative pressure and continuous drainage. We demonstrate this technique to aspirate an axillary and groin seroma as well as to drain expander breast implants.
Results: The described technique uses readily available clinic supplies and is effective for large-volume fluid aspiration. Sustained negative pressure enables continuous drainage and facilitates manual manipulation, which is advantageous in the setting of loculated seromas. Compared with standard syringe-based aspiration, this approach reduces the need for repeated needle punctures and decreases physician fatigue during prolonged or high-volume drainage.
Conclusions: In a high-volume outpatient practice or busy ward, this aspiration technique offers an efficient, reproducible, and cost-effective approach to managing symptomatic post-operative seromas or large-volume drainage while minimizing physician fatigue.
Keloid Scar Tissue Hyaluronome: Concerted mRNA and Protein-Level Alterations in Gene Expression Yield Treatment-Relevant Mechanistic Insight
Jay Shah, Ayushi Bhatt, Britney Messam, Kathleen Hill, Eva Turley, Caitlin Symonette
Toronto, ON
Purpose: Hyaluronan (HA) plays a molecular weight-dependent role in scar formation, and although not an established treatment for keloid scars, several studies suggest clinical benefit. This study explored mechanistic rationale for these effects by investigating expression of genes involved in HA production and metabolism (ie, the hyaluronome) at mRNA and protein levels in keloid tissue.
Methods: An exploratory review of Gene Expression Omnibus (GEO) microarray datasets comparing mRNA expression in keloid-and non-keloid tissue was performed. Protein expression of selected hyaluronome components was subsequently evaluated using immunofluorescence in patient keloid tissue samples. Differential protein expression between keloid-and non-keloid tissue was assessed using Mann-Whitney U tests (W) with false discovery rate (FDR) correction.
Results: Four studies, comprising eight datasets were included. At the mRNA level in keloids, HA synthases and associated receptors were generally downregulated, whereas hyaluronidases and extracellular binding proteins were upregulated. HAS1, VCAN, LAYN, and TSG6 protein expression, and HA abundance were assessed in seven patient keloid samples. Significant increases in keloid compared to non-keloid tissue were observed for epidermal (W = 714, p 0.60, 95% CI 0.06 to 1.14) and dermal (W = 754.5, p 0.76, 95% CI 0.21 to 1.31) HAS1 expression, epidermal LAYN expression (W = 628, p 0.69, 95% CI 0.14 to 1.24), and epidermal HA abundance (W = 668.5, p 0.73, 95% CI 0.18 to 1.27).
Conclusions: Altered hyaluronome expression explored at the mRNA level and validated at the protein level suggests state of HA disequilibrium in keloid tissue, characterized by aberrant production and metabolism. We hypothesize that supplemental HMW-HA, and targeting hyaluronome components, may promote more typical wound healing patterns.
A Cross-Sectional Study of Oral Health Burden in Facial Paralysis Patients
Inaam Chattha, Christine Novak, Ronald Zuker, Heather Baltzer, Kevin Zuo
Toronto, ON
1-Purpose: Facial paralysis (FP) affects perioral muscles needed for mastication, speaking and bolus control, yet its impact on oral health is understudied. This study evaluated oral health in FP patients using a validated patient reported outcome measure for oral health.
2-Methods: A cross-sectional study was conducted at a tertiary academic FP centre (November 2024 to November 2025) and included consecutive adult patients with FP of all durations and etiologies. Study participants completed the Oral Health Impact Profile-14 (OHIP-14) to assess oral health burden (scores 0 to 4 with higher scores indicating worse oral health). Clinical data was extracted from medical records.
3- Results: This study included 93 patients (mean age 49.8±14.2 years; 61% female). The median duration of FP was 1.5 years, and Bell's palsy was the most common FP etiology (55%). Most patients had synkinesis (71%) compared with flaccid paralysis (29%). The mean OHIP-14 score was 24.6±12.8, indicating worse oral health compared to population values of 1 to 4. Females reported significantly worse oral health than males (26.1 vs 21.1; p=0.04). Female sex was independently associated with higher OHIP-14 scores on linear regression analysis, adjusting for age, paralysis duration and laterality. Patient age and FP duration were not associated with higher OHIP-14 scores and no difference was observed between synkinesis and flaccid paralysis. Questions about embarrassment and self-consciousness due to FP-related oral health were the most distressing. Out of the seven OHIP-14 domains, psychological discomfort was most affected, whereas physical disability was least affected.
4- Conclusion: FP substantially impacts oral health, supporting the need for routine, longitudinal, multidisciplinary oral health assessment of patients.
Pediatric Scaphoid Non-Unions Across the Diagnostic Continuum: Incidence, Risk Factors, and Pathways in 967 Suspected Injuries
Vincent Dinh, Camille Zeitouni, Abhishek Achunair, James Jarvis, Sasha Carsen, Kevin Cheung
Ottawa, ON
Purpose: The perceived risk of scaphoid non-union drives risk-averse management in children with suspected fractures. Existing evidence, however, is derived almost exclusively from adult literature and small case series with confirmed fracture cohorts. The risk of non-union in suspected and occult fractures is unknown. This study evaluates the incidence, risk factors, and pathways to pediatric scaphoid non-union across the full spectrum of suspected injuries.
Method: A retrospective review was performed for all children referred with suspected scaphoid fractures to a tertiary pediatric center (2017–2024). Clinical, radiographic, and management data were collected. Non-union was defined as persistent fracture without radiographic healing at ≥3 months post-injury. Univariate linear and logistic regression identified predictors of non-union, with sensitivity analyses assessing alternative definitions of non-union and delayed presentation.
Results: Nine hundred and sixty-seven children with suspected or confirmed scaphoid fractures were reviewed. Of these, 354 scaphoid fractures and 30 non-unions were identified (3.1% overall; 7.8% of fractures). Non-union was significantly associated with increasing age (β = 0.020 per year), male sex (OR 6.56), waist (OR 12.87) and proximal pole fractures (OR 17.80), and delayed presentation ≥3 weeks (OR 7.50) (all p < 0 .05). Two-thirds of non-unions followed delayed presentation or inadequate early management. 0.5% of the cohort developed non-union despite guideline-concordant acute care, with no non-unions identified among patients with two normal radiographs.
Conclusions: Most pediatric scaphoid non-unions arose from delayed presentation or preventable early management failures, reframing non-union as a systems-level issue. Early immobilization, repeat imaging, and timely referral represent key interventions to reduce non-union risk.
Improving Access to Hand Surgeon Consultation Through a Streamlined Emergency Hand Trauma Decanting Clinic
Emily Volfson, Rebeca Yakubov, Kaitlyn Soro, Jin Xuetong, Chloe Wong, Daniel Antflek, Heather Baltzer
Toronto, ON
Purpose: Hand and wrist trauma contributes substantially to emergency department (ED) utilization. A rapid referral triage system was implemented at the Toronto Western Hospital enabling patients with isolated, stable hand and wrist injuries to bypass conventional outpatient referral processes and receive expedited hand surgeon assessment. This study evaluated the effectiveness of this model.
Methods: 591 patients were reviewed with hand/wrist trauma (mean age 41.4 years [SD 17.3], 63.6% male). Patients were managed through the rapid referral triage system (n=336), contemporary non-rapid care in 2024–2025 (n=47), or a historical non-rapid pathway from 2019 (n=208). Multivariable negative binomial regression was used to assess the association between care pathway and time to consultation.
Results: Injuries included fractures (n=311), soft tissue (n=164), tendon (n=40), ligamentous (n=34), nerve (n=18), chronic conditions (n=18), and amputations (n=6). Median time to consultation was shorter for rapid patients (3 days [IQR 1-4]) than contemporary non-rapid (10 days [IQR 5-15]) and historical care (7 days [IQR 4-11]; p < 0 .0001). After adjusting for age, sex, and diagnosis, rapid care was 66% shorter for time to consultation versus historical care, while contemporary non-rapid care did not differ significantly. Increasing age and tendon injuries were associated with longer consultation times with sensitivity analyses.
56 patients underwent surgery, including 64% managed through the rapid pathway and 27% non-rapid historical control. Most operative indications included fractures (n=34) and nerve injuries (n=10). Time from ED presentation to surgery did not differ significantly between pathways.
Conclusions: The rapid referral pathway substantially reduced time to hand surgeon consultation without delaying operative intervention. Most surgical patients were managed through the rapid pathway, supporting effective operative capture and expedited surgical decision-making.
AI Burn Injury Assessment Tools for First Responders: A Qualitative Evaluation
Lisa Kirby, Alexander Perry, Adam Nichols, Rakesh Joshi, Hannah O Chan, Collin Hong, Joshua N Wong
Edmonton, AB
Purpose: Acute burn assessments in prehospital settings are challenging due to variable exposure and training across first responders. Artificial intelligence (AI)-enabled decision-support tools may help address these shortcomings but successful implementation will depend on alignment with end-user workflows and operational constraints. Few studies have examined the needs of first responders for such tools and the feasibility of implementation into practice. This study characterized first responders’ workflows during acute burn assessment and elicited user-derived feedback and implementation considerations for an AI-driven burn assessment application.
Method: Using purposive sampling first responders participated in qualitative, semi-structured interviews comprising two phases: (i) workflow mapping and challenges encountered during burn assessment and (ii) a think-aloud evaluation of a prototype AI burn assessment tool. Interviews were audio-recorded, transcribed verbatim, and analysed using inductive thematic analysis.
Results: In total, 20 first responders were interviewed. This cohort included paramedics, firefighters, and emergency department physicians. Participants emphasized that tools must be rapid, intuitive, and require minimal data entry, with outputs that support triage/transfer decision-making and link to province-specific protocols and referral resources. Key feasibility barriers included time pressures, difficulty obtaining comprehensive and high-quality images in the field, and concerns regarding privacy, medicolegal liability, and local governance of clinical photography and data storage.
Conclusions: These findings generated a set of actionable design and implementation recommendations for AI-enabled burn assessment tools intended for prehospital and emergency settings. Incorporating these requirements may improve usability, regulatory acceptability, and ultimately adoption.
Can Artificial Intelligence Support Remote Burn Triage? An Image-Based Diagnostic Accuracy Study
Ayeh Aldulaymi, Vidya Shankaran, Loujane Zwai, Amjad Zwai
Saskatoon, SK
1. Purpose: Accurate burn depth assessment is essential for appropriate patient management. However, it remains a challenge to physicians, particularly in remote settings where specialist access is limited1–3. Artificial intelligence (AI) has shown promise in burn evaluation, yet large language models (LLMs) have not been formally assessed for this task. We evaluated ChatGPT's diagnostic accuracy in classifying burn depth from images.
2. Method: Five hundred burn images with confirmed diagnoses were analyzed. ChatGPT classified burn depth and provided one-line management advice. Diagnostic accuracy, sensitivity, specificity, and misclassification patterns were assessed.
3. Results: In 500 burn images, ChatGPT classified burn depth with an overall accuracy of 65.6% (95% CI 61.3-69.6). ChatGPT generated out-of-scope responses (ex. not a burn/dermatitis) for 11.0% of cases (95% CI 8.5-14.0), restricting analysis to images with an explicit first/second/third prediction increased accuracy to 73.7% (95% CI 69.4-77.6, n=445). Class-wise performance showed sensitivity of 71.1% for first-degree, 61.7% for second-degree, and 59.1% for third-degree burns, with high specificity for third-degree burns (97.1%). The most common errors were adjacent-class misclassifications, particularly first-degree upgraded to second-degree (n=39) and third-degree downgraded to second-degree (n=26).
4. Conclusions: ChatGPT demonstrates moderate diagnostic accuracy comparable to non-specialist clinicians1–3 but inferior to dedicated AI models8–10. While potentially useful as a triage adjunct in teleburn care11–13, LLMs require clinician oversight and further validation before clinical adoption.
Lower Limb Salvage Using an Orthoplastic Approach: Outcomes and Secondary Surgeries in a Cohort of 114 Free Flap Cases
Sharanya Menon, Hollie Power, Adil Ladak, Peter Kwan, Justin Lee
Edmonton, AB
PURPOSE: Lower extremity (LE) free-flap reconstruction is associated with higher complication, however evolution of microsurgery and the adoption of an orthoplastic approach have improved limb salvage outcomes. This study investigates outcomes and secondary surgical burden following LE free-flap reconstruction at a Canadian tertiary trauma center after implementation of an orthoplastic extremity reconstruction program.
METHODS: A retrospective review was conducted of all patients undergoing free-flap reconstruction distal to the hip between 2017–2024 by one of three surgeons at a tertiary trauma center. Patients of all ages and indications with minimum 6-month follow-up were included. Data collected included demographics, etiology, operative details, complications, and secondary surgeries. The primary outcome was total flap loss. Secondary outcomes included secondary amputation, secondary surgeries, limb salvage, and return to ambulation.
RESULTS: 114 free-flaps were performed, primarily for acute trauma (52%), malignancy (22%) and infection (7%). Mean age was 48 years (65% male). Defects primarily involved the distal leg (36%) and foot (32%). Fasciocutaneous flaps accounted for 94% of reconstructions; ALT (68%) and SCIP (11%) flaps. Total flap failure occurred in 4% of cases. The limb salvage rate was 90%, and 89% of salvaged limbs achieved independent ambulation. 11% of patients underwent secondary amputations most commonly due to infected non-union, chronic osteomyelitis and malignancy recurrence. Secondary flap refinement surgery was required in 17% of patients, and 29% required secondary orthopedic surgeries. Chronic osteomyelitis was a risk factor for amputation.
CONCLUSIONS: An orthoplastic approach enables high rates of limb salvage and functional recovery but is associated with a high rate of secondary surgeries. These findings can be used to inform preoperative patient counseling.
Building an International Cleft Registry: Using Patient-Reported Outcomes to Support Comprehensive Care in Resource-Limited Communities
Eileen Tang, Kariym Joachim, Julieta Villca Guzmán, Yolanda Ricela Flores Santivañez, Hugh Brewster, Neeti Daftari, Danaka Robertson, Mariyana Ivanova, Claudia Vidal, Mirta Palomares Aguilera, Phanomwan Yoodee, Alexandra D'Souza, Jessie Howard, Karen Wong
Toronto, ON
Purpose: In low- and middle-income countries (LMICs), systemic constraints often hinder standardized outcome assessment. Patient-reported outcomes (PROs) offer a practical solution as they rely solely on patient input. Using this framework, Transforming Cleft (TC) supported implementation of CLEFT-Q data collection in four international sites. SickKids has partnered with TC to expand these efforts into a centralized multicentre registry to support quality improvement and locally driven research. The aim of this study is to assess the development of this prospective registry and to pilot its use for outcomes research at a single Bolivian site.
Method: A REDCap database was created with appropriate translations for each site. Data were collected in four cleft centers in Bolivia, Bulgaria, Chile, and Thailand alongside SickKids. All patients aged 8–29 years with cleft lip and/or palate receiving care at these sites are eligible for inclusion. Data collected include CLEFT-Q scales, patient demographics, and treatment history. Preliminary results from the Fundacion Ayninakuna cleft center in Bolivia were discussed with local stakeholders.
Results: Sites have enrolled 385 participants into the registry. In 200 Bolivian patients recruited thus far, the mean age was 14.6 ± 4.7 years, 38% were female, and 96% had cleft lip and palate. Average scores for CLEFT-Q appearance scales were considerably lower than those for speech and health-related quality of life scales. Discussions with local stakeholders highlighted themes to contextualize these results and enabled identification of site-specific future directions to improve patient outcomes.
Conclusions: This study demonstrates how implementation of standardized data collection including PROs at a single resource-limited site can drive epidemiological, quality improvement, and longitudinal outcomes studies. The information from this registry will support ongoing efforts to improve cleft care outcomes globally.
The Impact of Transversus Abdominus Plane block versus Quadratus Lumborum Block on Quality of Recovery after DIEP flap breast reconstruction: A Randomized Controlled Trial
Raahulan Rathagirishnan, Jacob Hardy, Yonatan Fortinsky, Patrick Wong, Simon Frank, Jing Zhang
Ottawa, ON
Purpose: Autologous reconstruction using Deep Inferior Epigastric Perforator (DIEP) flap remains as a mainstay in breast cancer care. For postoperative analgesia, the transversus abdominus plane (TAP) block is a common option. Recently, Quadratus lumbar (QL) blocks has emerged as an alternative pain control for lower abdominal surgeries. Our study aimed to compare the efficacy of TAP block versus QL block on the quality of recovery in DIEP flap-based breast reconstruction.
Method: This is a double-blind randomized controlled trial. Patients undergoing breast reconstruction with DIEP flaps were included in the study. Quality of Recovery-15 (QoR-15) survey was used for patient satisfaction scores, and visual analog scales and post-operative analgesic use was collected. Chi-square and t- tests were utilized to analyze categorical and continuous variables respectively.
Results: 46 participants were included and randomized to the TAP and QL block arms. There was statistically significant improvement in mean QoR-15 scores in the QL group in comparison to the TAP group (84.09 vs 94.09, p = 0.04). Total oral morphine equivalents were significantly decreased in the QL group (227.5mg vs 135.1mg, p = 0.04). Visual analog scores were similar in both groups up until the 16th hour scores, where there's statistically significant increase in pain scores in the TAP group (3.67 vs 1.91, p = 0.005 at the 16th hour, and 3.64 vs 1.82, p = 0.001 24th hour).
Conclusions: This randomized trial study proves that QL block is associated with improved postoperative quality of recovery and reduced opioid requirements compared with TAP block in patients undergoing DIEP flap breast reconstruction. Further larger scale, multi-center based RCT study is planned to better elucidate the application of the QL block in such type of breast reconstruction.
Comparing Plastic Surgery Training Models: A Cross-National Review
Maxime Berthout, Gabriel Bensimon, Nayan Bhindi, Giulia Pieracci, Claudia Boucher, Temir Kenbayev, Chanel Beaudoin-Cloutier, Émilie Mailhot, Céline Roberge
Quebec City, Canada
Montreal, QC
Melbourne, Australia
Purpose: Plastic surgery training structures differ widely across countries in duration, autonomy, and educational philosophy. Understanding these differences provides valuable insight into how varying systems cultivate surgical independence, technical mastery, and professional development. This review compares national training models to identify opportunities for cross-learning and the evolution of competency-based education.
Method: A narrative comparative review was conducted using official publications and peer-reviewed literature from the Royal College of Physicians and Surgeons of Canada (RCPSC), Accreditation Council for Graduate Medical Education (ACGME), Royal College of Surgeons (UK), and Royal Australasian College of Surgeons (RACS). Domains analyzed included training structure, assessment methods, research integration, and trainee autonomy.
Results: Training duration ranged from five years in Canada to eight years in the United Kingdom. Canada employs a Competence by Design framework, while the United States uses milestone-based evaluations within the ACGME model. The UK and Australia retain apprenticeship-style systems with formal summative examinations (FRCS(Plast), FRACS). Research expectations are highest in Canada and the U.S., whereas graded autonomy and mentorship most strongly influence the development of surgical confidence and independent practice across all systems.
Conclusions: Distinct training philosophies among Canada, the United States, the UK, and Australia produce surgeons with varying balances of technical autonomy, academic focus, and procedural depth. Recognizing and integrating best practices across systems may enhance global competency standards and strengthen surgical education.
Concussions in Facial Trauma Patients: A Retrospective Study
Aneesh Karir, Spencer Ferbers, Jessica Lancaster, Fatima Saqib, Sydnee Tuckett, David Hedden, Jennifer Giuffre, Leif Sigurdson, Tom Hayakawa, Edward Buche
Winnipeg, MB
Purpose: There is a paucity of literature regarding the incidence of concussions in facial trauma. Prompt identification of concussion is crucial for patient recovery. The purpose of this retrospective study is to evaluate the relationship between facial trauma and concussion symptoms.
Methods: We evaluated 74 patients who presented to a facial trauma clinic at a Level 1 trauma center in British Columbia (2019–2021). Patients with facial trauma were evaluated according to injury type, epidemiological, and demographic characteristics in the context of symptoms indicating clinically significant concussions.
Results: 95% of patients presenting to a facial trauma clinic at a Level 1 trauma center had a clinically significant concussion symptom that affects quality of life. This was stratified according to mild/moderate/severe concussions. Zygoma/zygomatic arch fractures had the highest mean concussion scores. Surgery cases with general anesthesia had worse mean concussion scores than no surgery or intervention under local anesthesia cases. Male patients were on average younger than female patients. Male patients had on average worse symptoms than female patients. The worst concussion score was for the 20–30 age range. Of any symptom, knowing the “irritable” symptom score was the biggest predictor of concussion score, followed by “anxiousness.” The more subjective symptoms appear to be more powerful predictors of concussion scores.
Conclusions: The severity of concussion scores increased significantly with fractures, particularly with zygoma/zygomatic arch fractures in facial trauma patients. Facial trauma is related to clinically significant concussion symptoms that affect quality of life.
