Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations.

OBJECTIVE: Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS: Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS: A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence.

OBJECTIVE: To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication. DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded. INTERVENTION: Modified pharyngeal flap with through-and-through dissection of the soft palate. MAIN OUTCOME MEASURE(S): Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale. RESULTS: The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours. CONCLUSIONS: This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

Lymphatic Malformation Architecture: Implications for Treatment With OK-432.

PURPOSE: Herein, the authors aim to describe their findings of novel architectural types of lymphatic malformations (LM) and explain the relationship between these architectures and OK-432 treatment outcomes. METHODS: A retrospective review was conducted of all patients diagnosed with a LM treated with OK-432 at the Vascular Anomalies Clinic at BC Children's Hospital from December 2002 to January 2012. RESULTS: Twenty-seven patients were included in the study. Sixty percent of lesions were present by 2 years of age with the majority located in the head and neck (59%). The average number of sclerotherapy procedures was 1.4 per patient. Treatment under fluoroscopic guidance revealed 3 new LM architectures: open-cell microcystic, closed-cell microcystic, and lymphatic channel. Response to treatment was complete or good for 14/19 macrocystic and for 1/2 mixed lesions. Open-cell microcystic LMs gave a complete or good response for 3/3, which was attributed to OK-432 freely communicating between cysts. Closed-cell microcystic LM had localized cysts that did not allow OK-432 to freely communicate and were associated with partial responses, 2/2. The lymphatic channel had a partial response. There were 2 minor complications and 1 instance of recurrence. CONCLUSIONS: The identification of 3 new LM architectures expands the current accepted classification to include: open-cell microcystic, closed-cell microcystic, and lymphatic channels. The majority of complete responses to OK-432 were found with macrocystic lesions. Open-cell microcystic lesions respond better to OK-432 than closed-cell microcystic lesions, and lymphatic channels may respond to OK-432. These key architecture-response relationships have direct clinical implications for treatment with OK-432 sclerotherapy.

What Technique Results in the Lowest Rate of Velopharyngeal Insufficiency in Patients With Submucous Cleft Palate? A Systematic Review and Meta-Analysis.

Objective: To determine which surgical technique offers the lowest rate of velopharyngeal insufficiency (VPI) without the need for further operative intervention, in pediatric patients with nonsyndromic submucous cleft palate (SMCP). Methods: This systematic review and meta-analysis included articles reporting on nonsyndromic pediatric patients treated surgically during childhood for SMCP, with data on postoperative speech outcomes and/or recommendations for secondary surgery. Main outcome measures included rates of unfavorable speech outcomes defined as persistent VPI requiring secondary surgery and speech outcome data. Results: 15 articles met our inclusion criteria, reporting on 383 children who underwent surgical treatment; 343 patients were included in studies reporting recommendations for secondary surgery. There was 1 randomized comparative trial, 4 comparative studies, and 10 single cohort studies. Eight articles used validated speech assessment tools. Our model showed the proportion of patients recommended for secondary surgery varied between techniques, ranging from 0.0% (CI 0.0, 1000) in pharyngeal flap to 17.8% (CI 8.9, 32.5) in straight line repair techniques, but there was no statistically significant difference between treatments (P = .33). Speech improvement ranged from 44.4% to 100%, with 9 studies recommending secondary surgery for some of their patient series. Conclusions: Although not of statistical significance, pharyngeal flap yields the lowest rate of reoperation as a primary technique for pediatric patients with nonsyndromic SMCP. Delayed repair age inherent to SMCP may render operations that rely on a functional levator muscle with less favorable outcomes. The absence of standardized surgical techniques, speech outcomes, speech therapy, and assessment make comparative analysis and recommendation difficult. We advocate for standardized speech assessment tools to improve future quantitative assessment of cleft surgery outcomes and a randomized controlled trial to better elucidate the preferred first-line technique.

Objectif: Déterminer les techniques chirurgicales qui offrent le plus bas taux d'insuffisance vélopharyngée (IVP) sans autre intervention opératoire chez les patients pédiatriques présentant une fissure palatine sous-muqueuse (FPSM) non syndromique. Méthodologie: La présente analyse systématique et méta-analyse incluait des articles rendant compte de patients pédiatriques non syndromiques ayant reçu un traitement chirurgical pendant l'enfance à cause d'une FPSM, y compris des données sur l'élocution postopératoire ou les recommandations en vue d'une opération secondaire. Les principales mesures de résultats incluaient les taux d'élocution défavorables définis comme une IVP persistante exigeant une opération secondaire et les données sur les résultats de l'élocution. Résultats: Au total, 15 articles respectaient les critères d'inclusion et rendaient compte de 383 enfants qui ont subi un traitement chirurgical; 343 patients ont participé à des études qui recommandaient une opération secondaire. Ces articles incluaient une étude comparative randomisée, quatre études comparatives et dix études de cohortes uniques. Huit faisaient appel à des outils d'évaluation de l'élocution validés. Le modèle des auteurs démontrait que la proportion de patients chez qui on recommandait une opération secondaire variait selon les techniques, soit de 0,0 % (IC, 0,0, 100,0) pour la technique de lambeau pharyngien à 17,8 % (IC, 8,9, 32,5) pour la technique de réparation linéaire, mais il n'y avait pas de différence significative entre les traitements (p=0,33). L'amélioration de l'élocution oscillait entre 44,4 % et 100 %, neuf études recommandant une opération secondaire pour certains patients de leur série. Conclusions: Même si ce résultat n'avait pas de signification statistique, le lambeau pharyngé est associé au taux de réopération le plus faible lorsqu'il est utilisé comme technique primaire chez les patients pédiatriques ayant une FPSM non syndromique. En raison de l'âge tardif de réparation inhérent à la FPSM, les opérations qui reposent sur le muscle élévateur fonctionnel peuvent donner des résultats moins favorables. Il peut être difficile de procéder à une analyse comparative et de formuler des recommandations à cause de l'absence de techniques chirurgicales standardisées, de résultats sur l'élocution, d'orthophonie et d'évaluation. Les auteurs préconisent des outils d'évaluation de l'élocution standardisés pour améliorer la future évaluation quantitative des résultats de l'opération de la fissure palatine et la tenue d'une étude contrôlée randomisée pour mieux déterminer la technique de première ligne à favoriser.

Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.

Objectif : Les fractures de main de l'enfant sont des situations fréquemment rencontrées dans les services d'urgence. Cette étude a été menée pour évaluer l'épidémiologie, la gestion et les résultats, où les soins ont été transmis et par qui, et pour offrir des suggestions d'utilisation des ressources concernant les fractures pédiatriques arrivant dans un hôpital canadien pour enfants. Méthodes : Les dossiers des patients âgés de 0 à 18 ans arrivés au service des urgences de l'hôpital pour enfants de Colombie-Britannique avec une fracture métacarpienne ou phalangienne entre le 1er nov. 2016 et le 31 janvier 2021 ont été analysés. Résultats : Un total de 524 fractures de la main a été identifié chez 499 patients. Plus de 60 % des fractures concernaient des garçons. Le nombre de fractures était maximum à l'âge de 11 ans pour les filles et de 12 ans pour les garçons. Les fractures ouvertes représentaient seulement 4,0 % de toutes les fractures. Approximativement 40 % des fractures concernaient la plaque de croissance épiphysaire avec les fractures Salter-Harris II constituant globalement le diagnostic le plus fréquent. La gestion a été principalement non chirurgicale : 75 % des fractures ont été gérées par immobilisation seule et 23 % des fractures ont été gérées par réduction fermée au chevet des patients et immobilisation. La majorité des réductions fermées pour fracture a été réalisée par le médecin des urgences avec un taux de succès de 82 %. Seulement 2,3 % de toutes les fractures ont nécessité une intervention chirurgicale. Conclusions : Les fractures de la main sont des blessures pédiatriques fréquentes et constituent une proportion importante des visites aux urgences. La majorité des fractures ne nécessite pas de chirurgie et est bien gérée avec seulement une immobilisation ou une réduction fermée suivie d'une immobilisation par le médecin des urgences. Le traitement non chirurgical obtient des résultats très encourageants. Un certain pourcentage de ces fractures simples relèverait probablement d'une gestion en soins primaires uniquement et ne nécessitent pas l'intervention d'un spécialiste.

Management of congenital midline cervical cleft.

Congenital midline cervical cleft (CMCC) is a rare developmental defect of the anterior neck normally characterized by an atrophic mucosal plaque with a cranial nipple-like skin tag, a short caudal sinus, and may be attached to a subcutaneous fibrous cord of variable length. Clinically, patients present at an early age with, white females being the most commonly affected population. In addition to aesthetic concerns, CMCC can prevent full extension of the neck, result in micrognathia and torticollis, predispose patients to infection, and can coexist with other clefting defects or cysts. Fewer than 50 cases have been published in the English-language literature. Herein, we report a case of CMCC that also presented with a mild contracture of the right sternohyoid muscle. The embryopathogenesis, histopathology, diagnosis, and treatment of this rare condition are also discussed.

The Presence of Ghost Publications Among Canadian Plastic Surgery Residency Applicants: How Honest Are Canadians?

Background: Physicians with history of unprofessional behaviour during their medical training are shown to be 3 times more likely to have board disciplinary action later in their career. One realm in which unprofessional behaviour takes place is the phenomenon of unverifiable publications or "ghost publications." To that end, this study aims to assess the rate of ghost publications among a recent cohort of Canadian Plastic Surgery residency applicants to determine if this phenomenon is geographic in nature. Methods: The current study was a retrospective, cross-sectional observational study; a review of all residency applications submitted to a single Canadian Plastic Surgery residency program from 2015 to 2018 was performed and all their listed publications were verified for accuracy. The review was conducted by a third party librarian and a research coordinator blinded to the authors identifying information. "Ghost publication" was defined as any publication listed as "published," "accepted," or "in-press" that did not exist in the literature. Results: A total of 196 applications of 186 applicants were submitted over the span of 4 years. A total of 362 publications listed as peer-reviewed articles, belonging to 114 applications were extracted and reviewed. Among the 362 publications listed as peer-reviewed articles, 2 could not be found in the literature (0.55%). Additionally, 42 citations were found with 48 minor differences than what was cited. Conclusions: The rate of ghost publications among recent applicants to a Plastic Surgery residency program is low (less than 1%). Future studies should investigate methods to further improve and instill the value of professionalism in our future plastic surgery trainees.

Historique: Il est démontré que les médecins qui adoptent un comportement non professionnel pendant leur formation risquent trois fois plus de recevoir des sanctions disciplinaires de leur ordre pendant leur carrière. Le phénomène des publications non vérifiables, ou publications fictives, représente l'un des volets du comportement non professionnel. La présente étude vise à évaluer la fréquence de publications fictives dans une récente cohorte de candidats canadiens à la résidence en plasturgie pour déterminer si ce phénomène est de nature géographique. Méthodologie: Dans la présente étude d'observation transversale et rétrospective, toutes les candidatures en résidence déposées à un seul programme de résidence canadien en plasturgie entre 2015 et 2018 ont été examinées, et l'exactitude de toutes les publications présentées a été vérifiée. Un tiers bibliothécaire et un coordonnateur de recherche ne connaissant pas les données nominatives des auteurs ont effectué l'analyse. Une publication fictive désignait toute publication présentée comme « publiée ¼, « acceptée ¼ ou « sous presse ¼, mais qui n'existait pas dans les revues scientifiques. Résultats: Au total, 196 demandes de 186 candidats ont été déposées sur une période de quatre ans. Les chercheurs ont extrait et examiné 362 publications présentées comme des articles dotés d'un comité de lecture, cités par 114 candidats. De ces 362 publications, les chercheurs n'en ont pas trouvé deux dans les revues scientifiques (0,55 %) et ont relevé 42 citations comportant 48 différences mineures par rapport à la version originale. Conclusions: Les récents candidats à un programme de résidence en plasturgie s'approprient peu de publications fictives (moins de 1 %). De prochaines études devraient porter sur des méthodes pour améliorer et inculquer la valeur du professionnalisme chez les futurs résidents en plasturgie.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis.

BACKGROUND: Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids. METHODS: We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality. RESULTS: A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found. CONCLUSIONS: Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

HISTORIQUE: Les chéloïdes auriculaires récalcitrantes sont celles qui se manifestent de nouveau après un traitement. Il est démontré que leur risque de récurrence est plus élevé. Il n'y a pas de consensus au sujet de leur traitement. Les chercheurs procèdent à la première analyse systématique et méta-analyse sur les données probantes relatives au traitement des chéloïdes auriculaires récalcitrantes. MÉTHODOLOGIE: Les chercheurs ont fouillé les bases de données MEDLINE, EMBASE, CINAHL et EBM Reviews au moyen de mots-clés précis. Ils ont utilisé des critères d'inclusion et d'exclusion préétablis pour évaluer l'admissibilité des articles. Ils ont extrait les données relatives au nombre de chéloïdes récalcitrantes, à la modalité thérapeutique, à la récurrence et à la durée minimale du suivi. Ils ont stratifié les articles retenus d'après le traitement utilisé et leur ont attribué une qualité de preuve (QdP) en fonction des directives de l'Oxford Centre for Evidence-Based Medicine. Ils ont procédé à une méta-analyse pour évaluer le taux de récurrence, d'après des intervalles de confiance à 95 % par modalité thérapeutique. RÉSULTATS: Les chercheurs ont relevé 887 articles uniques et en ont retenu 13. De ce nombre, 11 avaient une QdP III et deux, une QdP IV. Ils ont constaté un taux de récurrence de 9 % (IC à 95 %, 3 % à 25 %) après une excision et une curiethérapie adjuvante, de 14 % (IC à 95 %, 12 % à 17 %) après une excision et une thérapie de compression adjuvante, de 17% (IC à 95 %, 3 % à 56 %) après une excision et une radiothérapie externe adjuvante, et de 18 % (IC à 95 %, 4 % à 53 %) après une excision et des injections adjuvantes de stéroïdes. Ils n'ont constaté aucune différence statistiquement significative. CONCLUSIONS: Les données relatives au traitement des chéloïdes auriculaires sont hétérogènes, et peu d'études sont de qualité. À l'analyse, l'excision avec curiethérapie adjuvante présente le taux de récurrence le plus faible. Les faibles intervalles de confiance liés à la curiethérapie et à la thérapie de compression pourraient inciter les chirurgiens à recommander avec conviction l'une de ces deux modalités thérapeutiques aux patients.

Recalcitrant Anaphylaxis Associated with Fibrin Sealant: Treatment with "TISSEEL-ectomy".

Here, we present the case of an adolescent male who developed a severe allergic reaction 10 minutes after application of TISSEEL fibrin sealant to control bleeding during a gynecomastia revision surgery. Conventional treatments of acute hypersensitivity were ineffective. After a "tisseel-ectomy," the patient's condition improved and symptoms resolved. Besides oral tranexamic acid, and topical and local anaesthesia, no other medications besides TISSEEL were administered preceding the allergic reaction. After TISSEEL was identified as the allergen upon its removal, his clinical status improved. The patient had been exposed to TISEEL 15 months before the anaphylactic episode. This case can aid in decision-making for surgical re-exposure to fibrin sealants in the setting of acute anaphylaxis.

A Randomized Controlled Trial of Virtual Reality in Awake Minor Pediatric Plastic Surgery Procedures.

BACKGROUND: Virtual reality has been used to alleviate pain and anxiety in a variety of medical procedures. The authors sought to explore the effects of virtual reality in common awake minor plastic surgery procedures where children may experience discomfort. METHODS: A randomized controlled trial compared virtual reality to standard-of-care distraction among children aged 6 to 16 years undergoing awake minor plastic surgery procedures at a quaternary children's hospital. Primary outcome was change in Faces Pain Scale-Revised pain score, and secondary outcomes included change in Venham Situational Anxiety Scale score, procedure duration, administration of local anesthetic, and pain/anxiety management satisfaction. RESULTS: Mean pain and anxiety scores were similar in both groups (p = 0.60 and p = 0.18, respectively), and procedure duration was shorter with virtual reality (22 minutes versus 29 minutes; p = 0.002). Duration remained shorter in a linear regression model accounting for procedure type (p = 0.01). Similar proportions of children received additional local anesthetic after the initial dose (virtual reality, n = 6; standard of care, n = 9; p = 0.19) and median pain management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.41). Median anxiety management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.05). Younger children reported more "fun" than older children with virtual reality (p = 0.02). Surgeons reported interest "using virtual reality again" in 83 percent of cases. CONCLUSIONS: The use of virtual reality for awake pediatric plastic surgery reduced procedure time but not pain or anxiety compared to standard of care in children aged 6 to 16 years. Virtual reality was safe and well-liked and should be considered as an additional tool. Increased efficiency may allow more cases to be performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Medico-legal Closed Case Trends in Canadian Plastic Surgery: A Retrospective Descriptive Study.

To enhance patient safety and prevent medico-legal complaints, we need to understand current trends and impacts. We aimed to characterize Canadian plastic surgery medico-legal patterns in many dimensions. METHOD: This retrospective descriptive analysis of Canadian Medical Protective Association data between January 1, 2013 and December 31, 2017 included closed regulatory body complaints and civil-legal actions involving plastic surgeons. We excluded class action legal cases and hospital complaints. We collected data on patient allegations, procedure types, healthcare-related patient harms, and peer expert criticisms. The primary outcome of interest was physician medico-legal outcome. RESULTS: We found 414 cases that met the inclusion criteria: 253 (61.1%) cases involved cosmetic procedures and 161 (38.9%) noncosmetic procedures. The annual incidence among plastic surgeon members of regulatory body complaints and civil-legal actions was 12.1% and 6.7%, for a combined incidence of 18.8%. The most common allegations were deficient clinical assessment, inadequate informed consent, delayed or misdiagnosis, and inadequate monitoring. Leading contributing factors were physician-patient communication breakdown, deficient clinical judgments, and inadequate documentation. The top procedural complications included cosmetic deformity, poor scarring, upper extremity stiffness or deficit, major structural injury, and mental health disorder. Less than half of cases (198/414, 47.8%) had unfavorable medico-legal outcomes for the surgeon. Patients were compensated in 86/198 (43.4%) of civil-legal cases. CONCLUSIONS: Plastic surgeons experience more medico-legal complaints for cosmetic versus noncosmetic procedures. To minimize medico-legal risks, plastic surgeons should focus on strong physician-patient communication, patient education/consent, thorough clinical assessment, minimizing potentially preventable complications, and maintaining relevant documentation.

Outcomes and Complications of the Mustardé Otoplasty: A "Good-Fast-Cheap" Technique for the Prominent Ear Deformity.

BACKGROUND: The Mustardé otoplasty is a commonly used procedure for the correction of the prominent ear deformity. Complication rates related to suture extrusion and long-term outcomes are variable in the literature. The study's purpose was to examine the efficacy and safety of the Mustardé otoplasty and its resource utilization, using an "iron triangle" methodology incorporating quality, time, and cost. METHODS: Retrospective data were collected on patients under 18 years who underwent primary Mustardé otoplasty between 2009 and 2018. Patient demographics, intraoperative details, complications, follow-up, and satisfaction were collected and analyzed. RESULTS: There were 119 Mustardé otoplasties performed on 68 patients, with a median follow-up of 72 weeks (24-476 weeks). In total, 51 of the 68 patients underwent bilateral procedures. The median operative time was 95 minutes (31-133 minutes), translating to a facility case cost of $2046. A total of 24 complications were reported in 17 patients. Minor complications included the following: suture extrusion (n = 20), hematoma (n = 1), and suture abscess (n = 1). Major complications included reoperation (n = 2). The series had a revision rate of 1.7% (n = 2). No additional procedures were documented at other hospitals in the province. The majority (97%) of ear outcomes demonstrated both patient and surgeon satisfaction. CONCLUSIONS: The Mustardé otoplasty demonstrated a high efficacy in the correction of the prominent ear, with low reoperation rates and high patient and surgeon satisfaction. The procedure demonstrated intriguing results in resource utilization, with brief operative times, a "knife and fork" supply chain, and minimal overall case costs. This technique qualifies as a good, fast, and cheap outpatient otoplasty option.

What Is Driving Paradigm Shifts in Plastic Surgery and Is Cosmetic Surgery Keeping Up?

BACKGROUND: Cosmetic surgery represents 20 to 30 percent of total plastic surgical volume. The authors hypothesize that with current capitalization and market share, cosmetic surgery should be proportionally represented in scientific innovation. METHODS: All journals that may contain articles relevant to plastic surgery were selected from the 2016 edition of Journal Citation Reports. The authors identified, reviewed, and analyzed the 100 top-cited plastic surgery clinical articles using the Science Citation Index Expanded (1900 to 2017) as a proxy for innovation. RESULTS: The top-100 articles were cited a median of 329.5 times (range, 240 to 1709 times). Sixteen journals were represented, led by Plastic and Reconstructive Surgery (45 percent) and Annals of Surgery (15 percent). Fifty-six percent were reconstructive, 13 percent were breast, 11 percent were pediatric/craniofacial, 11 percent were cosmetic, and 9 percent were hand/peripheral nerve articles. Only 11 percent of articles represented level of evidence I or II, with the majority (79 percent) of articles being level IV. Sixty-seven percent of publications originated from United States. The 11 cosmetic articles originated from different subspecialties: injectables, fillers, and fat grafting (n = 7); contouring (n = 2); facial cosmetic (n = 1); and general cosmetic (n = 1). CONCLUSIONS: Cosmetic innovation is not keeping up with reconstructive innovation; it is unknown why cosmetic surgery is lacking. The authors offer several speculations as to why there is a gap in cosmetic surgical research and, by proxy, innovation.

Do Microsurgical Outcomes Differ Based on Which Specialty Does the Operation? A NSQIP Analysis.

BACKGROUND: Because plastic surgeons do not "own" a specific anatomic region, other surgical specialties have increasingly assumed procedures historically performed by plastic surgery. Decreased case volume is postulated to be associated with higher complication rates. Herein, we investigate whether volume and surgical specialty have an impact on microsurgical complications, specifically surgical site infection (SSI) and reoperation rates. METHODS: The 2005-2015 National Surgical Quality Improvement Program participant use file was queried by Current Procedural Terminology code for breast and head/neck microsurgeries. Multivariate logistic regression was performed to compare the outcomes between surgical specialties. A cumulative frequency variable was introduced to investigate the effect of case volume on complication rates. RESULTS: We captured 6,617 microsurgical cases. Multivariate logistic regression revealed that although the rate of SSI was lower in plastic surgery compared with otolaryngology for head and neck reconstructions (13.3% versus 10.5%) and compared with general surgery for breast reconstructions (5.4% versus 4.7%), there was no significant difference between specialties (P = 0.13; P = 0.96). Increased case volume is negatively correlated with complications. CONCLUSIONS: Plastic surgery is at risk given case cannibalization by other specialties. We conclude that surgical specialty does not affect the rates of SSI and reoperation. We demonstrate a correlation between lower volumes and increased complications, implying that, once a specialty has amassed critical case experience, complication rates may decrease, and outcomes can be equivalent or superior. Case breadth and volumes should be maintained to preserve skills, optimize outcomes, and maintain the specialty as it currently exists.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

BACKGROUND: There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors. METHODS: A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation. RESULTS: We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood. CONCLUSIONS: The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

HISTORIQUE: Les données à grande échelle sur les complications de la chirurgie plastique font défaut. Une description des taux de référence et des résultats cliniques des patients permettrait de mieux déterminer comment améliorer les soins aux patients et réaliser des économies dans les systèmes de santé. Dans le présent article, les chercheurs recensent les complications les plus fréquentes en chirurgie plastique, dégagent les interventions aux taux de complication élevés et examinent les facteurs de risque prédictifs. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective des données de chirurgie plastique tirées du programme national d'amélioration de la qualité chirurgicale de l'American College of Surgeons entre 2012 et 2016. Ils ont calculé les taux de complications de toute la cohorte et de chaque intervention recensée. Ils ont analysé les interventions microchirurgicales en sous-groupe, où ils ont utilisé des modèles de régression logistique multivariée pour déterminer les facteurs de risque d'infection des plaies opératoires (IPO) et de réopérations s'y rapportant. RÉSULTATS: Les chercheurs ont dénombré 108 303 patients qui avaient subi une intervention en chirurgie plastique, dont 6 264 (5,78 %) avaient souffert d'au moins une complication. Les réopérations (3,31 %), suivies des IPO (3,11 %) étaient les résultats à la plus forte incidence. Les cas de microchirurgie représentaient 6 148 (5,68 %) de toutes les occurrences, et 1211 (19,33 %) ont souffert d'au moins une complication. Tout comme dans l'ensemble de la cohorte, les réopérations (12,83 %) et les IPO (5,66 %) étaient des complications courantes. La plus longue durée de l'opération était un facteur de risque indépendant fréquent, prédicteur d'une réopération ou d'une IPO (p<0,001). Ainsi, 23,3 % des microchirurgies duraient plus de dix heures, ce qui s'associait à une plus forte augmentation du risque de réopération. CONCLUSIONS: Le taux de complications demeure relativement faible en chirurgie plastique, mais est significativement plus élevé en microchirurgie. La longue durée des opérations représente un facteur de risque courant. On pourrait explorer les approches à deux équipes et les opérations échelonnées, car une forte proportion des microchirurgies sont vulnérables à un accroissement des complications.

Axillary osmidrosis in Apert syndrome: management with an arthroscopic shaver technique.

Apert syndrome is a congenital condition characterized by craniosynostosis, syndactyly, and maxillary hypoplasia. Previous authors have outlined the management of craniofacial and extremity anomalies associated with this syndrome; however, there is a paucity of literature regarding the treatment of the cutaneous manifestations of Apert syndrome. Axillary osmidrosis, a chronic skin condition characterized by an excessive, axillary malodor resulting from apocrine gland dysfunction, can be particularly severe in patients with Apert syndrome. Herein, we describe a pediatric patient with Apert syndrome and severe axillary osmidrosis managed by an arthroscopic shaver technique of axillary glandular debridement and aspiration.