Impact and Implementation of Plastic Surgery Interest Groups: National Survey of Plastic Surgery Interest Group Leadership

Background: Plastic surgery interest groups (PSIGs) provide an invaluable opportunity to enhance medical students' exposure to and knowledge of plastic surgery. Despite this, there have been no studies that provide information on the formation of these groups as well as the aspects that make for a productive PSIG. Methods: An anonymous survey was distributed by email via RedCAP to US medical students who hold leadership positions within their medical school's PSIG. Participants were asked baseline medical school information, the structure of their interest group, and perspectives on the most impactful and challenging components of their interest group. Results: Sixteen members (27.6%) of PSIG leadership completed the survey. Eighty percent reported having a membership of greater than 20 students. Fifty percent of the PSIGs were led by advisors who were medical school or hospital-affiliated faculty. Sixty-nine percent of groups were allocated a predetermined amount of money to fund activities and events throughout the academic year. Based on member feedback, groups reported that interactions with plastic surgery faculty, mentorship opportunities, and research opportunities were the most impactful and beneficial components of their PSIG. Forty-four percent reported that the biggest challenge faced by their PSIG was having a small active member group, followed by a lack of funding. Conclusion: Our study provides an in-depth look at the current structure and impact of PSIGs in the United States. It also provides a framework for medical schools that wish to start a PSIG and suggestions for established groups who wish to revitalize their PSIG structure.

Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation

BACKGROUND

Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures.

METHODS

A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information.

RESULTS

The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers' fractures were found to be independently associated with unplanned reoperation.

CONCLUSIONS

Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.

In the Age of Social Media, How Does the Public Choose a Plastic Surgeon? A Crowdsourcing Analysis of Major Deciding Factors

BACKGROUND

Patients consider many factors when selecting a plastic surgeon. Previous studies have demonstrated the importance of board certification and reputation in this decision. Despite this, there is a paucity of knowledge on the role that cost of procedure, social media, and surgeon training have on the decision-making process.

METHODS

The authors' study used a population-based survey administered by Amazon Mechanical Turk. Adults 18 years and older and residing in the United States were asked to rank the importance of 36 factors from 0 (least important) to 10 (most important) when selecting a plastic surgeon.

RESULTS

A total of 369 responses were analyzed. The mean age of respondents was 36.9 years (SD, 10.9 years), and 174 participants (47.2%) were female. Of those surveyed, 216 (55.0%) had previously undergone plastic surgery, and all respondents were considering plastic surgery either at the time of survey or in the future. The most common first step for respondents in identifying a plastic surgeon was a web-based search (32.2%). The top three most important factors in selecting a plastic surgeon were surgeon's experience with the desired procedure (7.48), surgeon's board certification (7.38), and surgeon's years in practice (7.36). The three least important factors were the surgeon's race (5.43), number of social media posts (5.62), and television appearances (5.64).

CONCLUSIONS

The authors' survey provides insight into the role that different elements play in the decision of selecting a plastic surgeon in the United States. Understanding how patients select a plastic surgeon can help surgeons optimize these elements in their practices.

Trends of Autologous Free-Flap Breast Reconstruction and Safety during the Coronavirus Disease 2019 Pandemic

BACKGROUND

 Autologous free-flap breast reconstruction (ABR) is a valuable surgical option for patients following mastectomy. The coronavirus disease 2019 (COVID-19) pandemic has led to a myriad of factors that have affected access to care, hospital logistics, and postoperative outcomes. This study aims to identify differences in patient selection, hospital course and severity, and postoperative outcomes for patients who underwent ABR during and prior to the COVID-19 pandemic.

METHODS

 Patients undergoing ABR from the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database were analyzed to compare sociodemographics, hospital course, and outcomes over the first postoperative month. Multivariable logistic regression was used to identify factors predictive of complications based on the operative year.

RESULTS

 In total, 3,770 breast free flaps were stratified into two groups based on the timing of reconstruction (prepandemic and pandemic groups). Patients with a diagnosis of disseminated cancer were significantly less likely to undergo ABR during the COVID-19 pandemic. On univariate analysis, there were no significant differences in postoperative complications between the two groups. When controlling for potentially confounding sociodemographic and clinical risk factors, the COVID-19 group was significantly more likely to undergo reoperation compared with the prepandemic group (p < 0.05).

CONCLUSION

 When comparing outcomes for patients who underwent ABR prior to and during the COVID-19 pandemic, we found a significant increase in the odds of reoperation for those who had ABR during the pandemic. Debridement procedures and exploration for postoperative hemorrhage, thrombosis, or infection increased in the prepandemic group compared to the COVID-19 group. Notably, operative times decreased.

Posttraumatic Penile Replantation with Minimal Skin Necrosis

Penile amputation is a surgical emergency where practical and timely perioperative management is crucial for ensuring a successful outcome. Tenuous viability of penile and scrotal skin has been well described in the literature, with a putative mechanism attributed to the transection of distal branches of the external pudendal artery. Although the perforasomes critical to penile replantation have been debated, this case report details a patient who successfully recovered sensation and function with minimal necrosis after penile replantation. Surgically, this was facilitated by intentional drain placement, aggressive debridement beyond the zone of injury, and planned redundancies with dorsal artery/vein anastomoses via interposition grafts of the dorsal penile vessels alone.

Comparison of Complication Risks Following Lower Extremity Free Flap Reconstruction Based on Seven Pre-Operative Indications: Analysis of the ACS-NSQIP Database

Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011–2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort ( p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication ( p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring.

Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons

PURPOSE

Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula.

METHODS

This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (<5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach.

RESULTS

Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing, & compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions.

CONCLUSIONS

There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.

Readability, Understandability, Usability, and Cultural Sensitivity of Online Patient Educational Materials (PEMs) for Lower Extremity Reconstruction: A Cross-Sectional Study

Background: Lower extremity reconstructive surgery is an evolving field wherein patients rely on accessible online materials to engage with their perioperative care. This study furthers existing research in this area by evaluating the readability, understandability, actionability, and cultural sensitivity of online health materials for lower extremity reconstruction. Methods: We identified the 10 first-appearing, educational sites found by searching the phrases “leg saving surgery”, “limb salvage surgery,” and “leg reconstruction surgery”. Readability analysis was conducted with validated tools, including Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed with Patient Education and Materials Assessment Tool (PEMAT), while cultural sensitivity was measured with Cultural Sensitivity Assessment Tool (CSAT). A Cohen's κ value was calculated (PEMAT and CSAT analyses) for inter-rater agreement. Results: The mean SMOG reading level for websites was 13.12 (college-freshman reading level). The mean PEMAT understandability score was 61.8% and actionability score was 26.0% (κ = 0.8022), both below the 70% acceptability threshold. The mean CSAT score was 2.6 (κ = 0.73), exceeding the 2.5 threshold for cultural appropriateness. Conclusion: Online PEM for lower extremity reconstruction continue to fall below standards of readability, understandability, and actionability; however, they meet standards of cultural appropriateness. As patients rely on these materials, creators can use validated tools and positive examples from existing PEM for greater patient accessibility.

A Critical Assessment of the Transgender Health Care Workforce in the United States and the Capacity to Deliver Gender-Affirming Bottom Surgery

BACKGROUND

Gender-affirming surgery is a critical component of transgender health care, but access information is limited. The study aim was to assess workforce capacity to perform gender affirming bottom surgeries (GABSs) in the United States.

METHODS

A questionnaire was administered via email, phone call, or fax from February to May 2020 to 86 practices identified as performing GABS by searching 10 Web-based databases with standardized keywords. Questions assessed training capacity, surgical capacity, and surgeon experience.

RESULTS

Thirty-two of 86 practices responded, 20 met the inclusion criteria. Practices were identified in 15 states, with an average 2.4 (SD, 1.3) surgeons performing GABS per year. States with the greatest number of total providers offering GABS were Illinois (n = 21), Texas (n = 10), and Massachusetts (n = 13). No significant correlation between number of GABS types offered and geographic population density (r = -0.40, P = 0.08), or between number of providers and geographic population density (r = 0.19, P = 0.44). Vaginoplasty was most frequently performed, with the longest waitlists and highest number of waitlist additions per month. Phalloplasty was the second most common procedure, and waitlist additions per month exceeded provider capacity to perform the procedure. Most surgeons performing GABS were plastic surgeons and urologists, whereas obstetricians/gynecologists performed the majority of hysterectomies.

CONCLUSIONS

This study demonstrated a shortage of providers with requisite training and experience to provide GABS. Although more robust studies are needed to better characterize the relationship between the number of patients seeking GABS and available providers, these findings indicate a need for improved training.

Comparison of Acellular Solutions for Ex-situ Perfusion of Amputated Limbs

INTRODUCTION

Hypothermic ex-situ machine perfusion (MP) has been shown to be a promising alternative to static cold storage (SCS) for preservation of solid organs for transplantation and vascularized composite allotransplantation. Perfusion with blood-based perfusion solutions in austere environments is problematic due to their need for appropriate storage and short shelf life, making it impractical for military and emergency use. Acellular perfusion has been shown to be effective, but the ideal perfusate solution for MP of amputated limbs is yet to be determined. The purpose of this study is to evaluate the efficacy of alternative perfusate solutions, such as dextran-enriched Phoxilium, Steen, and Phoxilium in ex-vivo hypothermic MP of amputated limbs in a porcine model.

MATERIALS AND METHODS

Amputated forelimbs from Yorkshire pigs (n = 8) were preserved either in SCS (n = 2) at 4°C for 12 hours or machine-perfused at 10°C for 12 hours with oxygenated perfusion solutions (n = 6) at a constant flow rate. The perfusates used include modified Steen-solution, Phoxilium (PHOX), or Phoxilium enriched with dextran-40 (PHODEX). The perfusate was exchanged after 1 and 6 hours of perfusion. Machine data were recorded continuously. Perfusate samples for clinical chemistry, blood gas analysis, and muscle biopsies were procured at specific timepoints and subsequently analyzed. In this semi in-vivo study, limb replantation has not been performed.

RESULTS

After amputation, every limb was successfully transferred and connected to our perfusion device. The mean total ischemia time was 77.5 ± 5.24 minutes. The temperature of the perfusion solution was maintained at 10.18 ± 2.01°C, and perfusion pressure at 24.48 ± 10.72 mmHg. Limb weight increased by 3% in the SCS group, 36% in the PHODEX group, 25% in the Steen group, and 58% in the PHOX group after 12 hours. This increase was significant in the PHOX group compared with the SCS group. All perfusion groups showed a pressure increase of 10.99 mmHg over time due to edema. The levels of HIF-1a decreased over time in all groups except the Steen and the PHODEX group. The biomarkers of muscle injury in the perfusate samples, such as creatine kinase and lactate-dehydrogenase, showed a significant difference between groups, with highest values in the PHODEX group. No significant differences were found in the results of the blood gas analysis.

CONCLUSION

With the exception of significantly higher levels of creatine kinase and lactate dehydrogenase, MP with dextran-enriched Phoxilium provides similar results as that of the commercially available perfusates such as Steen, without the need for cold storage, and at circa 5% of the cost of the Steen solution. Further large-scale replantation studies are necessary to evaluate the efficacy of dextran-enriched Phoxilium as an alternate perfusate solution.

Do Vertical Soft Tissue and Actual Bony Landmarks Correlate in Le Fort I Orthognathic Surgery?

PURPOSE

Vertical changes in Le Fort I orthognathic surgery are critical to the overall esthetic result. Three-dimensional planning enables vertical measurements from the rendered computed tomographic (CT) scan, but intraoperative points are ascribed partially from soft tissues landmarks. This study compared intraoperative soft tissue vertical measurements with pre- and postoperative CT-based values and attempted to validate intraoperative soft tissue landmarks for vertical positioning.

MATERIALS AND METHODS

In this retrospective single-cohort study, the authors examined orthognathic procedures performed by a single surgeon at their institution. Patients were excluded if measurements or pre- and postoperative CT scans were lacking. Demographic information and soft tissue perioperative data were tabulated. Clinical vertical measurements included the left medial canthus to the central incisor, the left medial canthus to the left canine, and the right medial canthus to the right canine. Bone measurements were calculated using pre- and postoperative cone-beam CT scans for the same clinical landmarks. Statistical analysis, including paired Student t test, was performed using SPSS.

RESULTS

Forty-two patients were identified (mean age, 23 yr; 57% female). The change in pre- and postoperative measurements was analyzed. There was no significant difference in the absolute value pre- and postoperatively between the 2 modalities (P < .2, .1, .1), but there was a significant difference between bony and soft tissue measurements (P < .01). Subset analysis showed differences in postoperative values between Class II and III cases.

CONCLUSIONS

These results show a nonlinear but predictable relation between intraoperative soft tissue (medial canthi and maxillary dentition) and CT-measured bony vertical measurements. Understanding this relation enables effective use of intraoperative measurements to reproducibly achieve the desired bony vertical position and allows adjustments to be made to optimize esthetics.

<b>A pre­liminary report on the impact of road kills on the herpetofauna species in Nilgiris, Tamil Nadu, India</b>

To know the situation of road hits of amphibians and reptile species, a survey was conducted during the period 02 June 2013 to 25 May 2014.  A total of 172 incidents of road kill of different species were noticed, representing 12 species of herpetofauna, including five amphibian species of the families Bufonidae, Dicroglossidae, Microhylidae and Rhacophoridae, and seven species of reptiles of the families Scincidae, Agamidae, Uropeltidae, Colubridae, Natricidae and Xenodermatidae.  Reptiles were the most affected group (60%), of which more than 79.61% of the road kills were snakes.  The most affected snake species were endemic Xylophis perroteti (64.63%). 

Road kills of the endemic snake Perrotet’s Shieldtail Plectrurus perrotetii, Dumeril, 1851 (Reptilia: Squamata: Uropeltidae) in Nilgiris, Tamil Nadu, India

Twenty seven road killed specimens of Plectrurus perrotetii were recorded in Emerald and its surrounding areas in the Nilgiris. Among the road kills, fourteen of them were females, seven were males and six are juveniles. Among the road kill female specimens of this species, it was observed that seven were gravid with fully developed young. Three to six developing young ones were observed

Effect of vehicular traffic on wild animals in Sigur Plateau, Tamil Nadu, India

The construction of a road, directly and indirectly, impacts on the ecosystems where the road is built.  Highways passing through national reserves/wildlife sanctuaries have an adverse impact on wild animals.  The present survey was conducted to estimate the road kills on the state highways passing through the Nilgiri north territorial forest division (19km) and Mudumalai Tiger Reserve (15km) in Sigur Plateau, Tamil Nadu, India.  The road kills were monitored three times a month between July 2013 and December 2013 (six months) and a total of 176 road kills belonging to 30 species were recorded.  Reptiles were the most affected taxa (39%), followed by mammals (33%) and birds (21%).  Amphibians were least affected by vehicular traffic and comprised 7% of the total kills.  According to road stretch category, the overall road kill was N=135 in the forested area and N=41 in human habitations.  A total of 812 food materials were encounterd  612km with average of  1.32 food materials / km. Conservation and management implications are essential to prevent the local extinction of wildlife.