Preference Signaling and the Integrated Plastic Surgery Match: A National Survey Study

OBJECTIVE

Rooted in economics market strategies, preference signaling was introduced to the Plastic Surgery Common Application (PSCA) in 2022 for integrated plastic surgery residency applicants. This study surveyed program and applicant experience with preference signaling and assessed how preference signals influenced likelihood of interview invitations.

DESIGN

Two online surveys were designed and distributed to all program directors and 2022-2023 applicants to integrated plastic surgery. Opinions regarding the utility of preference signaling were solicited, and the influence of preference signals on likelihood of interview offers was assessed.

SETTING

All integrated plastic surgery programs.

PARTICIPANTS

All 88 program directors and 2022-2023 applicants to integrated plastic surgery.

RESULTS

A total of 45 programs and 99 applicants completed the survey (response rates, 54.2% and 34.2%, respectively). Overall, 79.6% of applicants and 68.9% of programs reported that preference signals were a useful addition to the application cycle. Programs reported that 41.4% of students who sent preference signals received interview offers, compared to 84.6% of home students, 64.8% of away rotators, and 7.1% of other applicants; overall, students who signaled were 5.8 times more likely to receive an interview offer compared to students who were not home students and did not rotate or signal. After multivariable adjustment, programs with higher Doximity rankings, numbers of away rotators, and numbers of integrated residents per year received more preference signals (all p < 0.05).

CONCLUSIONS

Applicants and programs report that preference signaling was a useful addition to the integrated plastic surgery application cycle. Sending preference signals resulted in a higher likelihood of interview offers among nonrotators. Preference signaling may be a useful tool to reduce congestion in the integrated plastic surgery application cycle.

Porous Polyethylene Versus Autologous Costochondral Reconstruction for Microtia: Incidence and Analysis of Secondary Procedures

OBJECTIVE

To examine the frequency of autologous and alloplastic ear reconstructions for patients with microtia in the United States, and describe post-index procedure rates associated with each method.

DESIGN

Retrospective cohort study.

SETTING

Claims data from 500 + hospitals from IBM® MarketScan® Commercial and Multi-State Medicaid databases.

PATIENTS/PARTICIPANTS

A total of 649 patients aged 1 to 17 years with International Classification of Diseases, ninth/tenth revision (ICD-9/10) diagnoses for microtia, congenital absence of the ear, or hemifacial microsomia.

INTERVENTIONS

Alloplastic or autologous ear reconstruction between 2006 and 2018.

MAIN OUTCOME MEASURE

Post-index procedures performed within 1 year following the index repair, analyzed across the study period and separately for each half of the study period (2006-2012, 2012-2018).

RESULTS

A total of 486 (75%) qualifying patients received autologous and 163 (25%) received alloplastic reconstruction. Secondary procedure rates were significantly higher in the autologous group at 90 days (P = .034), 180 days (P < .001), and at 365 days (P < .001). Alloplastic reconstruction accounted for 23.2% of reconstructions in the first half of the study period compared with 26.7% in the second half (P = .319). One-year secondary procedure rates in the autologous group were not significantly different between both halves of the study period (69.7% vs 67.1%, P = .558), but were significantly lower in the second half for the alloplastic group (44.9% vs 20.2%, P = .001).

CONCLUSIONS

In these databases, autologous reconstruction is more common than alloplastic reconstruction. Autologous reconstruction is staged, with most undergoing a secondary procedure between 3 months and 1 year postoperatively. Secondary procedure rates decreased over time in patients undergoing alloplastic reconstruction.

Cost of Cleft Team Care at an Academic Children's Hospital

BACKGROUND

The financial burden of cleft-craniofacial team care is substantial, and high costs can hinder successful completion of team care.

SOLUTION

Collaboration with multiple stakeholders including providers, insurers, and patient guardians, as well as hospital administrators, is critical to increase patient retention and improve final clinical outcomes.

WHAT WE DO THAT IS NEW

At our cleft and craniofacial center, charges for a team care visit fall into one of three categories-hospital fees, professional fees, or external fees. There are four types of hospital fees depending on (1) whether the patient is new or returning, and (2) whether the patient saw ≤4 or ≥5 providers. To further elucidate the financial burden (out-of-pocket costs) directly borne by families of children with cleft lip and/or palate, we conducted a retrospective review of billing records of team care visits made between September 2019 and March 2020. Out-of-pocket costs for a single team care visit (on a commercial insurance plan) ranged from $4 to approximately $1220 and had a median (IQR) of $445 ($118, $749).

Family-Centered Pediatric Plastic Surgery Care

Our multidisciplinary cleft palate and craniofacial center was established in 1978 and manages more than 5,000 active patients from birth to skeletal maturity. Over the past four years we have implemented a complex family-centered reorganization, with the goal of improving care and patient retention. Through our implementation of a familycentered approach, we have also decreased treatment burden, need for secondary procedures and cost of care. 1-12.

Too much or too little? A systematic review of postparetic synkinesis treatment

Synkinesis is a negative sequela of facial nerve recovery. Despite the need for effective treatment, controversy exists regarding optimal management and outcome reporting measures. The goals of this study were to evaluate the current synkinesis literature and compare the effectiveness of treatment modalities. A search of biomedical databases was performed in May 2019. Full-text English language articles of cohort studies or randomized controlled trials on synkinesis treatment were eligible for inclusion. Reviews, animal studies, and those without assessment of treatment effect were excluded. We found 592 unique citations; 33 articles were included in the final analyses. Nine studies focused on botulinum toxin (BTX-A), 7 on surgery, 5 on physical therapy (PT), and 12 on multimodal therapy. The Sunnybrook Facial Grading System was the most frequently used outcome measure (17 studies, 51.5%). All treatment modalities improved outcomes. Chemodenervation studies showed an average improvement of 17.8% (range 11-33.3%) in the respective outcome measures after treatment. PT improved by 29.7% (range 14.6-41.2%), surgery by 16.6% (range 4.7-41%), and combination therapy by 20.4% (range 5.13-37.5%). Only 21 studies (63.6%) provided data on adverse outcomes. There is lack of high-evidence level data for robust comparisons of postparetic synkinesis treatments; however, this condition is likely effectively treated nonsurgically and requires the support of a specialized multidisciplinary team. Adoption of standardized patient evaluation and outcome reporting methods is necessary for robust comparative effectiveness studies.

Survey of North American Multidisciplinary Cleft Palate and Craniofacial Team Clinic Administration

OBJECTIVE

This study aims to provide an understanding of the ways cleft palate (CP) and craniofacial teams address billing, administration, communication of clinical recommendations, appointment scheduling, and diagnosis-specific protocols.

DESIGN

An online clinic administration survey was developed using data from an open-ended telephone questionnaire. The online survey was distributed by e-mail to the American Cleft Palate-Craniofacial Association (ACPA) nurse coordinator electronic mailing list, used regularly by the ACPA and its members to communicate with teams. The response was 34.1% (42/123). Two incomplete records were excluded, as were any inconsistent responses of 3 teams submitting duplicate records.

RESULTS

Six (15.8%) of 38 teams do not charge for clinic visits. For all other teams, some or all providers bill individually for services (68.4%) or a single lump sum applies (10.5%). Patients of 34 (89.5%) of 38 teams occasionally or often neglect to schedule or attend follow-up appointments. Twenty-six (66.7%) of 39 team directors were plastic surgeons. Phone is a common method of contacting families for scheduling (60.0%) and appointment reminders (82.5%). Most teams' providers (90.0%) routinely communicate findings to each other during postclinical conference. Most teams saw patients with isolated cleft lip (43.6%), cleft lip and palate (64.1%), or isolated CP (59.0%) annually.

CONCLUSIONS

The breadth of strategies team clinic administration strategies warrants further exploration of the variations and their effects on patient-centered outcomes including the quality of life, satisfaction, cost, and resource utilization.

Incidence of Palatal Fistula at Time of Secondary Alveolar Cleft Reconstruction

OBJECTIVE

We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature.

DESIGN

An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015.

MAIN OUTCOME MEASURES

Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured.

RESULTS

We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89).

CONCLUSIONS

Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.

Primer on State Statutory Mandates of Third-Party Orthodontic Coverage for Cleft Palate and Craniofacial Care in the United States

Provision and timing of orthodontic treatment is a crucial part of comprehensive cleft palate and craniofacial care. Some states statutorily mandate orthodontic coverage for the medically necessary care of cleft palate and craniofacial anomalies. However, application of the medically necessary standard varies broadly. Disputes over medical necessity lead to orthodontic coverage denials and surgical intervention delays. Provider-friendly statutory definitions of medical necessity enable patients and providers to avoid such hurdles. The objective of this study is to evaluate state mandates and highlight language favorable to patients and providers.

Side-To-Side Nerve Bridges Support Donor Axon Regeneration Into Chronically Denervated Nerves and Are Associated With Characteristic Changes in Schwann Cell Phenotype

BACKGROUND

Chronic denervation resulting from long nerve regeneration times and distances contributes greatly to suboptimal outcomes following nerve injuries. Recent studies showed that multiple nerve grafts inserted between an intact donor nerve and a denervated distal recipient nerve stump (termed "side-to-side nerve bridges") enhanced regeneration after delayed nerve repair.

OBJECTIVE

To examine the cellular aspects of axon growth across these bridges to explore the "protective" mechanism of donor axons on chronically denervated Schwann cells.

METHODS

In Sprague Dawley rats, 3 side-to-side nerve bridges were placed over a 10-mm distance between an intact donor tibial (TIB) nerve and a recipient denervated common peroneal (CP) distal nerve stump. Green fluorescent protein-expressing TIB axons grew across the bridges and were counted in cross section after 4 weeks. Immunofluorescent axons and Schwann cells were imaged over a 4-month period.

RESULTS

Denervated Schwann cells dedifferentiated to a proliferative, nonmyelinating phenotype within the bridges and the recipient denervated CP nerve stump. As donor TIB axons grew across the 3 side-to-side nerve bridges and into the denervated CP nerve, the Schwann cells redifferentiated to the myelinating phenotype. Bridge placement led to an increased mass of hind limb anterior compartment muscles after 4 months of denervation compared with muscles whose CP nerve was not "protected" by bridges.

CONCLUSION

This study describes patterns of donor axon regeneration and myelination in the denervated recipient nerve stump and supports a mechanism where these donor axons sustain a proregenerative state to prevent deterioration in the face of chronic denervation.

Transcaruncular Approach for Treatment of Medial Wall and Large Orbital Blowout Fractures

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm(2); the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm(2). Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).