Trans-tarsal Stair-Step Technique for Lateral Extension of the Transconjunctival Incision: A Technical Note and Case Series.

Background: The transconjunctival approach paired with lateral canthotomy is a commonly used technique for widened exposure of the orbital floor and infraorbital rim. A major drawback of this approach is the severance of lateral canthal ligament fibers, which predisposes to potential postoperative eyelid malpositioning. To avoid these suboptimal aesthetic outcomes, a modification of this approach has been proposed in which the lower eyelid is mobilized with a paracanthal, trans-tarsal stair-step incision. In this pilot study, we describe our experience with the trans-tarsal stairstep incision for lateral extension of the transconjunctival incision and report its outcomes in a Western population. Methods: All patients who underwent facial fracture operative fixation at a single institution by a single senior surgeon were included. Clinical variables were extracted. Patients were stratified by incision type. Results: Compared with patients who underwent subtarsal incision (n = 20) and transconjunctival incision with lateral canthotomy (n = 4), patients who received the trans-tarsal stair-step incision (n = 10) had no incision-related complications or requirements for revision. The most common complications found in the comparison groups were ectropion and hypertrophic or irregular scarring, and 4 patients required revision. Conclusions: Our initial experience with the transconjunctival approach with the trans-tarsal stair-step incision shows promising outcomes. Further study may promote greater utilization of this technique in Western countries.

Partial hand replantation using free microsurgical replantation with staged heterotopic banking of amputated parts: towards improving long term outcomes.

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the "Three R's" - Recovery, Rehabilitation, and Revision over the first year of recovery.

Evaluation of Health Literacy in Plastic Surgery Using a Crowdsourced Patient Survey.

Little is known about the levels of health literacy (HL) among plastic and reconstructive surgery (PRS) patients compared with the general population. This study aimed to characterize HL levels in patients interested in plastic surgery and identify potential risk factors associated with inadequate levels of HL among this population. Methods: Amazon's Mechanical Turk was used to distribute a survey. The Chew's Brief Health Literacy Screener was used to evaluate the level of HL. The cohort was divided into two groups: non-PRS and PRS groups. Four subgroups were created: cosmetic, noncosmetic, reconstructive, and nonreconstructive groups. A multivariable logistic regression model was constructed to assess associations between levels of HL and sociodemographic characteristics. Results: A total of 510 responses were analyzed in this study. Of those, 34% of participants belong to the PRS group and 66% to the non-PRS group. Inadequate levels of HL were evidenced in 52% and 50% of the participants in the non-PRS and PRS groups, respectively (P = 0.780). No difference in HL levels was found in the noncosmetic versus cosmetic groups (P = 0.783). A statistically significant difference in HL levels was evidenced between nonreconstructive versus reconstructive groups after holding other sociodemographic factors constant (0.29, OR; 95% CI, 0.15-0.58; P < 0.001). Conclusions: Inadequate levels of HL were present in almost half of the cohort, which highlights the importance of adequately assessing HL levels in all patients. It is of utmost importance to evaluate HL in clinical practice using evidence-based criteria to better inform and educate patients interested in plastic surgery.

Misconceptions, Myths, and Mystery: A Cross-sectional Survey Study on Public Knowledge and Values of Microsurgery.

BACKGROUND: Microsurgery is a foundational plastic surgery principle. However, public unawareness of microsurgery and its associated rigorous training in the United States may contribute to current misconceptions and undervaluing of plastic and reconstructive surgeons. This study aims to characterize public knowledge of microsurgery. METHODS: A cross-sectional survey was conducted from August to September 2021 using Amazon Mechanical Turk to assess baseline public knowledge of microsurgery. A multivariable logistic regression model was constructed to evaluate the association between baseline knowledge and demographic characteristics. Significance was set to a p < 0.05. RESULTS: A total of 516 responses were analyzed. The mean age was 36.7 years (standard deviation, 16.04 years; white, 84%; non-Hispanic, 70%). Of those surveyed, 52% agreed that general surgeons perform microsurgery, while only 28% agreed that plastic and reconstructive surgeons perform microsurgery. When asked if head and neck reconstruction, breast reconstruction, and finger replantation required microsurgery, only 28, 41, and 41% of respondents agreed, respectively. When controlled for sociodemographic factors, Hispanics had significantly more odds to mistake that head and neck reconstruction did not require microsurgery (odds ratio [OR] 95% CI 0.49; 0.30-0.80; p = 0.004) and less odds to consider plastic and reconstructive surgeons for reconstruction (OR 0.51; 95% CI 0.32-0.84; p = 0.008). Females had 1.63 more odds of considering plastic and reconstructive surgeons for reconstruction (95% CI 1.09-2.43; p = 0.017). Low-educated participants had significantly more odds to consider general surgeons as those who performed reconstructive microsurgery (OR 8.70; 95% CI 1.09-69.40; p = 0.041). CONCLUSION: Misconceptions of microsurgery as a foundational principle of plastic surgery persist and correlate with undervaluing the specialty. Knowledge differs by ethnicity, level of education, and gender. Therefore, patient counseling should use culturally appropriate elements to demystify microsurgery, build value, and better inform risks and benefits.

Plastic Surgery Residency Applicants' Perceptions of a Virtual Interview Cycle.

BACKGROUND: The 2020 to 2021 residency application cycle marked the first year of fully virtual integrated plastic surgery interviews. The virtual format was a double-edged sword for applicants with several advantages, such as reduced costs and time lost from travel, and disadvantages as the novel format introduced new stressors on top of an already demanding process. Concerns included unfair interview invitation distribution, interview "hoarding," and assessing "fit" virtually. In this study, the authors aimed to understand applicants' experiences of the 2020 to 2021 virtual plastic surgery interview cycle. METHODS: A survey was sent to 330 applicants in the 2020 to 2021 integrated plastic surgery application cycle. The survey included questions about participant demographics, preinterview preparation, virtual interview experiences, and postinterview process. Statistical comparisons were performed on responses using IBM SPSS Statistics version 25.0 (IBM, Armonk, N.Y.). RESULTS: Eighty-nine participants responded to the survey, representing a 27 percent response rate. Applicants received an average of 13.3 interview invitations (range, 0 to 45) and attended an average of 11.4 interviews (range, 0 to 30). Almost half (48.2 percent) did not feel interview invitations were distributed equitably, and more than half (68.2 percent) reported that there should be a limit on the number of interview invitations an applicant can accept. The majority of respondents (88.1 percent) reported spending $500 or less on virtual interviews. Half (50.6 percent) participated in virtual subinternships, of which 30.4 percent became significantly less interested in a program afterward. CONCLUSIONS: The inaugural virtual interview cycle had several advantages and disadvantages. Lessons learned from this year could be utilized toward building a more equitable, fair, and effective potential virtual cycle in years to come.

Morphologic Differences in Sagittal Synostosis with Age before Surgery.

BACKGROUND: It is important to determine whether sagittal synostosis-associated scaphocephaly is static in the presurgical period, or whether there are morphologic differences with time to include in surgical decision-making. The authors' purpose was to perform cross-sectional analysis of cranial morphology before any surgical intervention in children with sagittal synostosis younger than 9 months compared to matched controls. METHODS: The authors performed morphometric analysis on computed tomographic scans from 111 untreated isolated sagittal synostosis patients younger than 9 months and 37 age-matched normal controls. The authors divided the patients into three age groups and performed statistical comparison between sagittal synostosis and controls for each group. RESULTS: Sagittal synostosis cephalic indices were stable and lower in patients than in controls across groups. Total cranial volume was equivalent, but sagittal synostosis patients had a greater posterior volume than controls at all ages and a smaller middle fossa volume at older ages. Pterional width was greater in sagittal synostosis patients than in controls for each age group. Frontal bossing vectors were most severe in the youngest age groups and least in the older group. Occipital protuberance was consistent across the age groups. CONCLUSIONS: Upper parietal narrowing and occipital protuberance were the consistent deformities across age groups, with the most parietal constriction seen in older patients. Frontal bossing was not consistent and was more severe in the younger patients. The authors did not detect significant pterional constriction, and the appearance of constriction is relative to adjacent morphology and not absolute. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative. METHODS: An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps. RESULTS: This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications. CONCLUSION: This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.

Comparison of Various Modalities Utilized for Preoperative Planning in Microsurgical Reconstructive Surgery.

BACKGROUND: The benefits of preoperative perforator imaging for microsurgical reconstruction have been well established in the literature. METHODS: An extensive literature review was performed to determine the most commonly used modalities, and their applicability, advantages and disadvantages. RESULTS: The review demonstrated varioius findings including decreases in operative time and cost with the use of CT angiography to identification of perforators for inclusion in flap design with hand-held Doppler ultrasound. Modalities like MR angiography offer alternatives for patients with contrast allergies or renal dysfunction while maintaining a high level of clarity and fidelity. Although the use of conventional angiography has decreased due to the availability of less invasive alternatives, it continues to serve a role in the preoperative evaluation of patients for lower extremity reconstruction. Duplex ultrasonography has been of great interest recently as an inexpensive, risk free, and extraordinarily accurate diagnostic tool. Emerging technologies such as indocyanine green fluorescence angiography and dynamic infrared thermography provide real-time information about tissue vascularity and perfusion without requiring radiation exposure. CONCLUSION: This article presents an in-depth review of the various imaging modalities available to reconstructive surgeons and includes hand held Doppler ultrasound, CT angiography, MR angiography, conventional angiography, duplex ultrasonography, Indocyanine Green Fluorescence Angiography and Dynamic Infrared Thermography.

Virtual Interviews for the Integrated Plastic Surgery Residency Match: The Program Director Perspective.

Interviews for the integrated plastic surgery residency match took place in a virtual format for the 2020-2021 application cycle. Current literature lacks the perspectives of program directors (PDs) on virtual interviews compared with traditional in-person interviews. METHODS: Following institutional review board approval, an anonymous 17-question survey was distributed by email to 82 program directors of integrated plastic surgery residency programs in the United States. Participants were asked baseline program information, the number of positions and interview invites offered, and their perspectives on various aspects of the virtual interview process. RESULTS: Sixty-two (75.6%) PDs completed the survey. Thirty-seven percent reported increasing the number of interview offers per available residency spot. On a five-point Likert scale (1, not well at all; 5, extremely well), PDs showed no significant differences in their ability judge an applicant's professionalism (3.1 ± 1.1), interpersonal and communication skills (3.2 ± 1.1), and "fit" with their program (2.9 ± 0.9) during virtual interviews (P = 0.360). Sixty-eight percent reported being satisfied (15.3% extremely satisfied, 52.5% somewhat satisfied) with the virtual interview process, though 76.3% preferred in-person interviews. CONCLUSIONS: This study is the first to provide insight into PDs' impressions of virtual residency interviews. Although most reported being satisfied with the virtual interview process, the majority still preferred in-person interviews. Further long-term studies evaluating the pros and cons of each interview modality may provide more information on whether virtual interviews could become a sustainable alternative to the traditional in-person residency interview.

Timing of Ossification of the Anterior Skull Base in Syndromic Synostosis.

The anterior skull base undergoes a progressive ossification after birth. This has implications on the epidural dissection of early trans-craniofacial osteotomy procedures such as monobloc advancements. Our purpose was to determine the rate of ossification in syndromic synostosis patients relative to a normal cohort to establish when maturation of the anterior skull base is complete. The authors analyzed CT scans from 35 patients with Crouzon, Apert or Pfeiffer syndrome, and 84 patients without any craniofacial anomaly between the ages of 0 and 6 years. The non-ossified anterior skull base area was measured using 3D Slicer. The authors compared the sizes of the defects at different ages between the three syndromes and with the control group using Mann-Whitney test. Significance was set at P < 0.05. All patients less than 12 months of age had a measurable defect anterior to the cribriform whereas patients greater than five years of age had full ossification of the anterior skull base with no evidence of defect. The relationship of defect size and age at scan was non-linear, with most defects closing rapidly in the first six months. The temporal closure pattern of the defect was similar between the three syndromes and the control group with no significant difference. Our findings indicate that syndromic children undergo skull base maturation at the same rate as non-syndromic cases, with the majority ossified by three years of age. Anterior skull base surgeries performed before three years should optimize visualization of this area during dissection.

Emergency Restructuring of a General Surgery Residency Program During the Coronavirus Disease 2019 Pandemic: The University of Washington Experience.

Seattle, Washington, is an epicenter of the coronavirus disease 2019 epidemic in the United States. In response, the Division of General Surgery at the University of Washington Department of Surgery in Seattle has designed and implemented an emergency restructuring of the facility's general surgery resident care teams in an attempt to optimize workforce well-being, comply with physical distancing requirements, and continue excellent patient care. This article introduces a unique approach to general surgery resident allocation by dividing patient care into separate inpatient care, operating care, and clinic care teams. Separate teams made up of all resident levels will work in each setting for a 1-week period. By creating this emergency structure, we have limited the number of surgery residents with direct patient contact and have created teams working in isolation from one another to optimize physical distancing while still performing required work. This also provides a resident reserve without exposure to the virus, theoretically flattening the curve among our general surgery resident cohort. Surgical resident team restructuring is critical during a pandemic to optimize patient care and ensure the well-being and vitality of the resident workforce while ensuring the entire workforce is not compromised.

National Database Reported Outcomes Following Craniosynostosis Reconstruction.

BACKGROUND: While there has been ample interest and literature published regarding craniosynostosis surgical technique, there are few reports on adverse hospital and health system outcomes. The purpose of this study was to describe rate of and risk factors for complications, and adverse outcomes following craniosynostosis reconstruction. METHODS: This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database and identified all patients undergoing craniosynostosis repair from 2012 to 2016. Univariate logistic regression analysis was used to identify significant associations between preoperative risk factors and adverse outcomes. Multivariate logistic regression analysis was then used to identify independent risk factors and causes of prolonged operative times, transfusions, reoperation, prolonged length of hospital stays, and readmission. RESULTS: There were 3924 patients included who underwent craniosynostosis repair, of whom 1732 underwent frontoorbital advancement and 2192 underwent cranial vault remodeling. Transfusion was the most common NSQIP reportable outcome, occurring for 66.5% of all patients. The incidence of reoperation was 2.4% and readmission was 3.0%. CONCLUSION: This study provides a large descriptive analysis of craniosynostosis repair throughout the United States. Largely nonmodifiable patient risk factors lead to worse health system metrics, with young age, gastrointestinal comorbidities, American Society of Anesthesiologist scores of 3 and greater, reoperation, and a prolonged length of stay as independent risk factors for readmission. This analysis can be used to identify the standard of practice in synostosis care and enhance the implementation of ancillary care services to provide safe and cost-effective care for patients undergoing craniosynostosis repair.

The Facial Adipose System: Its Role in Facial Aging and Approaches to Volume Restoration.

BACKGROUND: Volume loss in facial adipose tissue plays a critical role in the aesthetics of facial aging. Furthermore, the facial adipose system is a complex network of distinct compartments, and a detailed understanding of these compartments is essential for optimal facial volume restoration. OBJECTIVE: To review the facial adipose system, age-related changes, and the role of volume restoration products for facial rejuvenation. METHODS: Publications including deceased donors' dissection studies and more recent studies using computed tomography were reviewed to provide an up-to-date understanding of the facial adipose system anatomy and age-related changes. Current volume restoration treatment options including hyaluronic acid, calcium hydroxylapatite, and poly-L-lactic acid are discussed. RESULTS: Facial aging is associated with volume loss in superficial and deep adipose compartments, including those of the forehead, cheek, lip, chin, and jowl areas. Volume restoration products can be used to address the age-related changes of the facial adipose compartments. CONCLUSION: Understanding the complex network of facial adipose compartments and their age-related changes allows for the optimal use of injectable volume restoration products for facial rejuvenation that can be customized to the anatomical needs of each patient.

A randomized, controlled clinical study to investigate the safety and efficacy of acoustic wave therapy in body contouring.

BACKGROUND: There is an increased demand for the reduction of localized adipose tissue by noninvasive methods. OBJECTIVE: The objective of this study was to determine the safety and efficacy of noninvasive lipolysis of excess adiposities overlying the lateral thigh region using acoustic wave therapy (AWT). This study incorporates 2 mechanical waves with varying properties in the same session: radial and planar AWT. METHODS AND MATERIALS: The treatment was performed using AWT on the lateral thigh areas of 15 female patients. The study was performed using the planar and radial pulse handpieces, with 8 sessions performed within 4 weeks. Follow-up visits were performed 1, 4, and 12 weeks after the last treatment. RESULTS: Reduction in both thigh circumference and subcutaneous fat layer thickness, measured through ultrasound, was observed. CONCLUSION: This study demonstrates that AWT is safe and efficacious for the treatment of localized adiposities in the saddlebag area. However, the results obtained were not statistically significant. Larger studies will be needed to further access the effects of AWT on thigh circumference reduction. Furthermore, the authors also found an improvement in the appearance of both cellulite and skin firmness after the treatments.

Bipolar and multipolar radiofrequency.

BACKGROUND: The increased demand for anti-aging treatments over the past decade has fueled the development of multimodality devices. This allows for more efficacious treatment of dermal defects, excess adiposity, and skin laxity. Radiofrequency (RF) devices are constantly evolving and consequently adding multiple indications for their use. In this article, the authors focus on bipolar and multipolar RF modalities. OBJECTIVE: The objective was to review, summarize, and evaluate the key studies of procedural therapies using bipolar and multipolar RF technologies. METHODS: Studies selected for evaluation had clear statements of purpose, patient selection, follow-up evaluations, previous and concurrent medications, treatment parameters, methods for evaluating results, and adverse effects. All studies were complete and published in peer-reviewed journals. RESULTS AND CONCLUSION: With their unique mechanism of action, bipolar and multipolar RF devices remain versatile treatment options associated with minimal downtime and pain compared with monopolar RF and other nonablative modalities. Proper patient selection and education along with an experienced treating physician is crucial in achieving patient satisfaction and results. It is important that larger studies are conducted to provide data on upcoming devices. Review of the literature provides a starting point for physicians seeking to treat patients safely and effectively with newer devices.

Use of multispectral digital skin lesion analysis for evaluation of nevi in children.

OBJECTIVE: We determine if the use of Multispectral Digital Skin Lesion Analysis for the evaluation of nevi in children and possible detection of malignancies. EVIDENCE REVIEW: Evidence gathered from a pivotal study involving 1,383 patients with 1,831-pigmented lesions. The isolated use of the pediatric population within this study was used to determine the specificity and sensitivity of such a device with comparison to a dermatologists evaluation. FINDINGS: For all lesions from the assessed pediatric population the biopsy ratio was equivalent for the Multispectral Digital Skin Lesion Analysis device as for the dermatologists when performing as independent reviewers. Furthermore analyzed data suggests that dermatologists who incorporate the Multispectral Digital Skin Lesion Analysis device perform better than they would independently or if they were to follow the device blindly without incorporating their own judgment. CONCLUSION AND RELEVANCE: An approach that integrates automated imaging technology like the Multispectral Digital Skin Lesion Analysis device, along with another diagnostic aid, with the end result being cost-effective, easy to use by even non-experts and comforting for the pediatric patient is likely to compete to be the new gold standard in successful early diagnosis and management of melanoma.

Radiofrequency: an update on latest innovations.

As the aging population in our society continues to grow, new technologies and procedures promising a more youthful appearance are continuously sought. The utilization of radiofrequency technology remains a novel method for the treatment of many aesthetic and medical dermatological indications. Innovative applications are constantly identified, expanding treatment options for various patient concerns including aging of the hands, cellulite, non-invasive lipolysis, and postpartum skin laxity. Non-invasive treatments are ideal for busy patients seeking minimal recovery time and so called lunch-time procedures. Furthermore, new developments in treatment devices enhance efficacy while decreasing patient discomfort.