The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial.

Importance: Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective: To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants: This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions: Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures: Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results: Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance: Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration: ClinicalTrials.gov Identifier: NCT03638947.

Patient-Reported Social, Psychological, and Urologic Outcomes After Adult Buried Penis Repair.

OBJECTIVE: To assess changes in hygiene, urination, and sexual activity after surgery for adult-acquired buried penis. MATERIALS AND METHODS: The study included men who underwent buried penis repair from 2011 to 2015. Patients were asked pre- and postoperative questions on hygiene, urinary difficulties, sexual difficulties, and difficulties with activities of daily living (modified Post-Bariatric Surgery Quality of Life Questionnaire). Postoperative satisfaction was assessed at a minimum of 6 months. Pre- and postoperative data were compared with chi-squared analyses. RESULTS: Of 14 eligible patients, 12 completed postoperative questionnaires. Buried penis repair required debridement of penile skin with split-thickness skin grafting to penis (n = 11; 92%), escutcheonectomy (n = 12; 100%) and abdominoplasty (n = 10; 83%), scrotoplasty (n = 7; 59%), and securing the supra-penile dermis to the pubic dermal or periosteal tissue (n = 12, 100%). The average length of follow-up was 31 months (±20 months). Mean age was 50 (±10.5 years) and mean body mass index was 55 (±13.7 kg/m2). Wound complications (all Clavian Grade 1) occurred in 9 of 12 patients. Patients reported improvement in hygiene (100%), urination (91%), and sexual function (41%); 92% of patients reported they would choose to have the surgery again; and 83% felt that surgery had led to a positive change in their lives. The ability to perform most activities of daily living, as assessed by the Post-Bariatric Surgery Quality of Life Questionnaire, improved significantly. Over 90% of men had lost additional body weight at last clinical follow-up. CONCLUSION: Buried penis repair positively impacts social, psychological, and functional outcomes for patients. Wound complications should be expected but are easily managed.

The American Association of Plastic Surgeons Recent History, with a Review of the Past.

The American Association of Plastic Surgeons was founded in 1921 and is the oldest of the plastic surgery societies. It was born out of the enthusiasm of reconstructive surgeons who had recently increased in numbers and expanded the scope of their activities as a result of the challenges posed by battle-injured soldiers during World War I. Early meetings were small, focused exclusively on the head and neck, and often included live surgical demonstrations. The Association has grown in size and scope with time, but it has maintained its academic focus. This article focuses on the most recent 15 years of the Association's history, as prior publications have chronicled the history of the organization up to 2000. The organization has remained robust in the new millennium, with the national meetings being its most prominent activity. The format of the meetings has continually been improved to remain relevant and of interest to the membership and other attendees. The organization continues to support the development of young academic plastic surgeons through the Academic Scholars Program. It has established new programs such as the Constable Fellowship to support international exchange and has also sponsored two consensus conferences to help define standards of care in plastic surgery-related issues. The Association annually recognizes significant contributors to the field through the variety of awards that it bestows as well. The mission of the American Association of Plastic Surgeons is to provide scholarly leadership in plastic surgery, and the organization continues to successfully accomplish this mission.

A novel supermicrosurgery training model: the chicken thigh.

BACKGROUND: Supermicrosurgery is an increasingly important technique in reconstructive surgery. It requires a more technically refined skill set compared with standard microsurgery. All currently available biologic training models involve the use of live rats. A nonliving model would be more accessible and cost-effective for practice. We have developed such a model using chicken thighs purchased from a local grocery store. METHODS: The ischiatic neurovascular bundle was identified in 20 chicken thighs and dissected distally to the end of the specimen. The vessel diameters were measured at several points along the artery, vein, and their respective branches. Vessels with diameters in the 0.3-0.8-mm range were then divided and supermicrosurgical anastomoses were attempted. RESULTS: The branching pattern of the ischiatic artery and vein were anatomically consistent with intermediate and terminal secondary and tertiary branches consistently in the range of 0.3-0.8 mm. In all specimens, at least one 0.3-mm vessel could be identified, though additional intramuscular dissection was sometimes required. It was demonstrated that supermicrosurgical anastomoses could be successfully performed using these branches. CONCLUSIONS: This study introduces a novel, convenient, and economical model for supermicrosurgery utilizing easily obtained chicken thighs. The chicken thighs have an anatomically consistent vascular branching pattern, and vessels of appropriate sizes for training can be easily identified and isolated. Surgeons looking to develop or refine supermicrosurgical skills may find this nonliving, biologic model very useful.

Academic plastic surgery: faculty recruitment and retention.

BACKGROUND: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. METHODS: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. RESULTS: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. CONCLUSIONS: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

An old controversy revisited-one versus two venous anastomoses in microvascular head and neck reconstruction using anterolateral thigh flap.

BACKGROUND: The necessity of a second venous anastomosis in free tissue transfer is controversial. We review a single surgeon's 8-year experience of head and neck reconstruction using free anterolateral flap reconstruction to assess the need for a second venous anastomosis. PATIENTS AND METHOD: Three hundred and fifteen cases were included in the study after selecting only for anterolateral thigh flap, head, and neck reconstruction, and those that used superior thyroid artery as recipient. The selection criteria were designed to create as homogeneous a group as possible to decrease confounding factors. RESULTS: The group with single anastomosis required more frequent take-backs than the group with dual anastomoses (19% vs 10.8%, P = 0.055). The trend persisted when only take-backs for venous insufficiencies were compared (8.2% vs 2.5%, P = 0.039). When flaps with single anastomosis developed venous congestion, they were more likely to require operative salvage for venous insufficiency than those with dual anastomoses (35.5% vs. 6.3%, P = 0.037). No difference was found in postoperative complications and flap survival. CONCLUSION: Our data suggest that flaps with single venous anastomosis are more likely to require take-back for flap salvage than those with dual anastomoses.

Assessing the plastic surgery workforce: a template for the future of plastic surgery.

BACKGROUND: The American Society of Plastic Surgeons (ASPS) formed the Plastic Surgery Workforce Task Force to study the size of the plastic surgery workforce and make recommendations about future workforce needs. The ASPS member workforce survey and two supplementary surveys of plastic surgery academic chairs and senior residents were developed to gain insights on current and projected demand for plastic surgery procedures and to find out more about plastic surgeons' current daily practice patterns and plans for the future. METHODS: The ASPS member workforce survey was mailed to 2500 randomly selected ASPS active members practicing in the United States, and a second mailing was sent to 388 unique members who practice in an academic setting; a total of 1256 surgeons responded (43.5 percent response rate). The survey of academic chairs was distributed to 103 attendees at the annual meeting of the Association of Academic Chairmen of Plastic Surgery, and 74 returned the survey (71.8 percent response rate). The survey of senior residents was e-mailed to 183 graduating residents, of whom 65 responded (35.5 percent response rate). RESULTS: Useful demographic information regarding the current plastic surgery workforce was obtained from these surveys. In addition, insight into current trends in practice composition and procedural demand was gained. CONCLUSIONS: The rapid growth of the U.S. population, combined with a significant number of plastic surgeons approaching retirement and an unchanged number of plastic surgery residency training positions, will lead to a discrepancy between the demand for plastic surgery procedures and the supply of appropriately trained physicians. Without an increase in the number of plastic surgeons trained each year, there will be a significant shortage in the next 10 to 15 years.

Integrated plastic surgery residency applicant survey: characteristics of successful applicants and feedback about the interview process.

BACKGROUND: Integrated plastic surgery residency training is growing in popularity, bringing new challenges to program directors and applicants. The purpose of this study was to identify characteristics of successful applicants and to obtain feedback from applicants to improve the integrated plastic surgery residency training application and interview process. METHODS: An anonymous survey assessing applicant academic qualifications, number of interviews offered and attended, and opinions about the application and interview process was distributed electronically to the 2006 integrated plastic surgery residency training applicant class. The number of interviews offered was used as an indicator of potential applicant success. RESULTS: A 38 percent survey participation rate (139 of 367) was achieved. United States Medical Licensing Examination Step 1 score correlated with number of interview invitations (p < or = 0.001). Successful Alpha Omega Alpha designation (p < or = 0.001), high class rank (p = 0.034), presence of a plastic surgery residency program at the participant's school (p = 0.026), and authorship of one or more publications (p < or = 0.001) were associated with receiving greater number of interview invitations. Geographic location was an important consideration for applicants when applying to and ranking programs. Applicants desired interviews on weekdays and geographic coordination of interviews. CONCLUSIONS: Integrated plastic surgery residency training is highly competitive, with the number of interview invitations correlating with academic performance and, to a lesser extent, research. Applicant feedback from this survey can be used to improve the application and interview process.

Maximizing the aesthetic result in panniculectomy after massive weight loss.

BACKGROUND: Plastic surgical consultation for abdominal contouring following massive weight loss is becoming increasingly prevalent, especially with the popularity of surgical weight loss procedures. The authors reviewed their experience with a novel panniculectomy technique that generally combines horizontal and vertical tissue excision to generate the best contour possible while providing effective relief of symptoms related to a dependent abdominal panniculus. METHODS: A retrospective chart review was conducted of 100 consecutive patients who underwent panniculectomy using the authors' technique over a 5-year period. Demographic and procedural data were collected, and outcome measures were analyzed. RESULTS: Eighty-seven women and 13 men with an average weight loss of 133 lb underwent abdominal panniculectomy. A total of 37 ventral hernias were repaired concomitantly. Mean clinical follow-up was 16 months. Hospital length of stay averaged 4 days, and the most common complications were blood transfusion requirement (n = 39), fluid collections (n = 32), tissue necrosis requiring debridement (n = 18), and contour irregularities requiring revision (n = 15). Overall, 56 patients had a completely uncomplicated recovery. Greater amounts of tissue resection were associated with higher rates of transfusion (p < 0.01). CONCLUSIONS: The panniculectomy technique described can be performed safely and reproducibly. It yields an excellent abdominal contour and is effective in alleviating many symptoms of the dependent abdominal panniculus. It also provides exposure for improved evaluation and repair of concomitant ventral hernia defects.

The history of the Association of Academic Chairmen in Plastic Surgery: 1985 to 1990.

BACKGROUND: Program directors in plastic surgery had met annually as a committee of the American Association of Plastic Surgeons since the early 1970s. In 1984, Dr. Ronald Berggren, then chairman of the committee, asked Dr. Elvin Zook to head a subcommittee charged with exploring the desirability and feasibility of a separate program director's organization. The subcommittee enthusiastically supported the concept, leading to the founding of the Association of Academic Chairmen in Plastic Surgery. METHODS: All available documents related to the development and functioning of the organization since 1985 were reviewed. RESULTS: The early years of the Association of Academic Chairmen in Plastic Surgery led to the definition of the organization as one that provided significant input on key issues facing the plastic surgery community, such as the Certificate of Added Qualification in Hand Surgery. A variety of significant contributions grew out of the early years of the organization, including the plastic surgery match and the use of the central application process. In addition, the meetings provide updates for program directors to aid them in dealing with the ever-changing environment of graduate medical education. CONCLUSIONS: The Association of Academic Chairmen in Plastic Surgery grew out of a committee of the American Association of Plastic Surgeons into a vital organization that made significant contributions to plastic surgery resident education in its early years of existence.

The history of the Association of Academic Chairmen in Plastic Surgery: 1990 to 2004.

BACKGROUND: The Association of Academic Chairmen in Plastic Surgery was founded in 1985 to provide a forum for program directors in plastic surgery to discuss issues of common interest. The formation and early years of the organization have already been discussed. From 1985 to 2004, the organization continued to mature and address issues of interest to the training of plastic surgeons. METHODS: All available documents related to the development and functioning of the Association of Academic Chairmen in Plastic Surgery were reviewed. RESULTS: Discussions within the organization spawned the development and refinement of the integrated and coordinated models for plastic surgery resident education. Defined curricula for integrated programs have been developed to complement those developed for independent programs. The meetings of the organization have provided forums for the discussion of key issues relevant to plastic surgery program directors, including the funding of graduate medical education, the desirability of departmental status, training in aesthetic surgery, the "Gen X" resident, and workforce issues. They have also provided updates on interspecialty issues that have developed with otolaryngology and dermatology. In addition, the meetings have provided information to aid program directors in dealing the changing Residency Review Committee requirements including the competencies and work hours. CONCLUSION: The Association of Academic Chairmen in Plastic Surgery continued to mature from 1985 and 2004 and served as a vital resource for program directors in plastic surgery.

Biologic enhancement of wound healing.

Manipulation of the healing process through wound supplementation with agents that are natural contributors to the healing process is an appealing concept. Early experimental studies evaluating wounds supplemented with inflammatory mediators used materials extracted from cell preparations and generated encouraging results. Recombinant technology has allowed the production of larger volumes of these mediators that can be used more practically and safely in the clinical setting. Several clinical trials involving inflammatory mediators as wound supplements are reviewed, and the results of many of the studies are encouraging. Wound supplements are considered drugs, and therefore, they must be demonstrated to be safe and efficacious before they can receive approval for human use by the FDA. It is extremely expensive to carry out the experimental studies required for FDA approval. Because of the expense involved, Regranex is the only supplement that has been tested thoroughly enough to receive FDA approval for use in humans. It is hoped that additional agents will be demonstrated to be safe and efficacious in human trials so that they might become available in the United States in the near future.

Wound dressings.

There are currently hundreds of dressings on the market to aid in wound management. Before selecting a dressing for a particular wound, a practitioner must assess carefully the needs of the wound to understand which dressing would provide maximal benefit. Frequently, there is not one clear best choice, and it is crucial that the pros and cons of each dressing modality be understood. This article has provided a framework to assist in dressing assessment.

Acute wound healing an overview.

The ability to heal an injury is a biologic necessity for all organisms, with mammals lagging in proficiency when compared with lower life forms that have the ability to regenerate differentiated structures. Technology and increased scientific knowledge have established a coordinated interplay that has improved the ability to manage wounds in a logical manner, and, on occasion, to accelerate the healing process. Insight into the complex chain of events leading to the formation of scar is a necessity for every individual who attempts wound management.