A Unique Case of Intrauterine Pressure Injury.

ABSTRACT: The authors present a review of the literature regarding pressure injuries (PIs) in neonates and a case of a newborn who developed a PI following a prolonged labor process and fetal malposition. A girl born at 35 weeks' gestation to a 34-year-old gravida 7 para 6 mother with a medical history of untreated gestational diabetes, preeclampsia, and COVID-19 was delivered via cesarean section after failure to progress through labor. The premature infant was found to have a 3.2 × 2.3-cm PI at the nape of the posterior neck. Premature infants have a histologically proven, age-dependent decreased thickness of their stratum corneum, epidermis, and dermis, which places them at increased risk of developing PIs that can be painful and lead to infection. In the present case, the neonate's congenital PI was successfully treated with medical-grade honey for approximately a month.

The Experience of Virtual Interviews in Resident Selection: A Survey of Program Directors in Surgery.

BACKGROUND: MATCH 2021 was short of the classic "in-person" component. Herein, we assess the impact of virtual interviews (VIs) on resident selection, from the perspectives of program directors (PDs) across all surgical specialties. MATERIALS AND METHODS: We conducted a cross-sectional survey-based study of ACGME-accredited US residency program directors (PDs) of all surgical specialties. The survey was designed based on a review of relevant literature and inquired about the strengths, limitations, and overall utility of VIs. RESULTS: A total of 365 PDs responded to our survey. Almost all respondents (90%) found VIs to be less expensive than in-person interviews, while only 34% agree that VIs were less time-consuming. Only a median of 5% of interviews was complicated by technical difficulties. Most PDs found it more challenging to assess applicants' fit (75%), personality and communication skills (71%), and commitment to specialty (60%). Only 14% found VIs to be overall better for assessing residency applicants. In future cycles, most PDs are planning to host both virtual and in-person interviews (57%), while 35% and 8% will host exclusive in-person and virtual interviews, respectively. CONCLUSIONS: VIs are a novel way of dealing with the restrictions imposed by COVID-19. Despite their cost and time benefit, they present particular challenges in evaluating residency applicants. A combination of both virtual and in-person interviews will likely be implemented in the coming cycles.

Smile Train: A Sustainable Approach to Global Cleft Care.

ABSTRACT: Smile Train, the largest global cleft nonprofit organization, employs a model of establishing partnerships with treatment centers and medical professionals in low- and middle-income countries (LMICs). Having a presence in over 90 countries throughout its history, the organization provides support for cleft lip and palate repair as well as comprehensive cleft care (CCC) for patients with clefts. With the goal of reducing disparities in access to quality surgical, anesthesia, and medical care, Smile Train strengthens partners with training, education, equipment, and patient support grants. Furthermore, safety and quality protocols have been put in place as guidelines for each partner center, and partnerships with other nongovernmental agencies were created to increase safety in the operating rooms. The founder of Smile Train desired to apply technology wherever possible to build sustainability within the treatment centers and surgeons supporting their own community. Smile Train's model, aimed at increased sustainability, is supplemented by technological advancements to assist in the safety and quality of cleft care services provided in LMIC treatment centers. Examples include centralized online data record keeping for every patient, virtual simulations and training, and mobile applications to enhance care. Recently, Smile Train's focus is expanding CCC with nutrition, oral health, speech, and nursing care programs to improve functional and psychosocial outcomes for patients following their procedure. Despite the challenges imposed by the COVID-19 pandemic, Smile Train continues to provide safe, efficacious, and CCC alongside their partners in LMICs further investing tremendous efforts towards the livelihood of children with clefts globally.

Late Presenting Multi-Suture Craniosynostosis.

ABSTRACT: The authors provide the case of a 6-year-old male who presented late with multi-suture craniosynostosis and chronically elevated intracranial pressures (ICPs). He was surgically managed with frontal orbital advancement. This particular case illustrates the significant bleeding and unique bony pathology that can occur in patients with high ICP with concomitant venous collateralization. At 1-month follow-up, he demonstrated significant improvement with maintained expansion and no signs of elevated ICP despite delayed intervention. Frontal orbital advancement serves as an effective method for cranial vault expansion and correction of frontal deformities caused by craniosynostosis.

Fascicular Turnover Flap: An Approach for Facial Nerve Reconstruction.

ABSTRACT: Facial nerve injuries are a common complication associated with parotidectomy. These functionally debilitating injuries are conventionally treated with nonvascularized nerve grafting; however, this reconstructive modality produces moderate donor site morbidity and has limited efficacy for repairing large defects. In addition, nonvascularized nerve grafts are highly susceptible to radiotherapy and require a well-vascularized wound bed to produce adequate therapeutic results. The fascicular turnover flap, described by Koshima et al, utilizes a single fascicle to bridge two nerve endings that are in series with no donor site morbidity. Although studies have demonstrated this technique's efficacy, there is a paucity of data regarding its use in patients undergoing facial nerve reconstruction. Herein, we describe our early clinical experience using the fascicular turnover flap to reconstruct branches of the facial nerve in patients undergoing extensive parotidectomy. Our patients underwent successful reconstruction of the nerve defects produced by parotidectomy using the fascicular turnover flap. Despite postoperative radiotherapy, both patients demonstrated complete functional recovery at six months postoperatively. Although formal head-to-head studies are needed to compare the outcomes of this technique versus conventional nerve grafting for facial nerve reconstruction, our preliminary experiences suggest that the fascicular turnover flap is a viable modality of reconstruction with great potential.

Two-Stage Treatment of a Large Premaxillary Defect.

ABSTRACT: Bilateral cleft lip and palate (CLP) patients commonly require surgical management to treat maxillary hypoplasia following the primary repair. Rarer is the CLP patient who also presents with a missing premaxillary segment. Here the authors present the case of a 19-year-old female with a history of bilateral CLP who demonstrated significant maxillary hypoplasia in addition to a large premaxillary defect. To correct this deformity, LeFort I advancement with fibular reconstruction of the maxilla and dental implant placement was performed as a single surgical procedure. The authors discuss the advantages of undergoing this single-staged operation. By utilizing virtual surgical planning (VSP) and incorporating a multidisciplinary team within the operating room, the patient was able to successfully undergo maxillary reconstruction and dental implant placement in a single operation.

Distraction Osteogenesis: Mandible and Maxilla.

Mandibular and maxillary deformities commonly require surgical intervention. Prior to distraction osteogenesis, traditional modalities involving single-staged translocation and rigid fixation were used to correct these craniofacial anomalies. Distraction osteogenesis has evolved as a compelling alternative for treating aesthetic and functional dentofacial defects. The process of distraction osteogenesis involves three phases-latency, activation, and consolidation-which allow for appropriate translation of the affected craniofacial skeleton. This review will cover the role of distraction for managing congenital and acquired deformities of the mandible and maxilla. This novel technique can be performed at numerous anatomical sites along the craniofacial skeleton to treat a variety of anomalies, which serves as a testament to its adaptability and efficacy. Importantly, distraction osteogenesis also has the ability to simultaneously increase bone length and the overlying soft tissue envelope. This advantage results in larger advancements with reduced relapse rates and improved patient satisfaction. While complications remain a concern, it stands to reason that the measurable benefits observed underscore the power and versatility of distraction osteogenesis.

Pediatric Fronto-Orbital Skull Reconstruction.

Craniofacial surgery in children is a highly challenging discipline that requires extensive knowledge of craniofacial anatomy and pathology. Insults to the fronto-orbital skeleton have the potential to inflict significant morbidity and even mortality in patients due to its proximity to the central nervous system. In addition, significant aesthetic and ophthalmologic disturbances frequently accompany these insults. Craniosynostosis, facial trauma, and craniofacial tumors are all pathologies that frequently affect the fronto-orbital region of the craniofacial skeleton in children. While the mechanisms of these pathologies vary greatly, the underlying principles of reconstruction remain the same. Despite the limited data in certain areas of fronto-orbital reconstruction in children, significant innovations have greatly improved its safety and efficacy. It is imperative that further investigations of fronto-orbital reconstruction are undertaken so that craniofacial surgeons may provide optimal care for these patients.

Reconstructing Severe Lower Extremity Skin Necrosis in a Pediatric Patient.

ABSTRACT: Purpura fulminans can result in significant full-thickness wounds, posing a challenge in the pediatric population, given the paucity of donor sites for reconstruction. The authors present the case of an 11-month-old patient for whom a split-thickness skin allograft (TheraSkin) was successfully implemented as a temporizing measure for a large leg wound.

Screening pediatric surgical patients during the COVID-19 pandemic.

ABSTRACT: SARS-CoV-2 has profoundly affected the way healthcare is delivered and has created significant strain on medical facilities globally. As a result, hospitals have had to continuously adapt in order to provide optimal patient care while minimizing the risk of SARS-CoV-2 transmission, particularly in the surgical setting. Texas Children's Hospital developed a set of protocols for surgical screening and clearance of patients in the context of the COVID-19 pandemic. These screening protocols were designed to mitigate the risk of exposing patients and healthcare providers to SARS-CoV-2 and have evolved significantly as a result of the emerging changes in medicine, technology, and governmental regulations. In this article, we share the reasoning behind the development, implementation, and successive modification of our institutional screening protocols.

The Virtual Interview Experience for MATCH 2021: A Pilot Survey of General Surgery Residency Program Directors.

BACKGROUND: Virtual interviews (VIs) for the 2020 residency application season were mandated as a result of the COVID-19 pandemic. We aimed to determine the perspectives of general surgery (GS) program directors (PDs) on the benefits and drawbacks of VIs. METHODS: A 14-item survey was emailed to all GS PDs from programs identified on the American Council for Graduate Medical Education website. Program directors were asked about the cost-time benefit of VIs, its ability to assess candidates, and their thoughts on the future of VIs for evaluating residency applicants. RESULTS: 60 PDs responded corresponding to a response rate of 21%. While 93% agreed/strongly agreed that VIs were less expensive, only 35% found VIs to be less time-consuming. 75% and 67%, respectively, disagreed/strongly disagreed that VIs allowed for an easier assessment of an applicant's fit, and personality and communication skills. Almost one-half of our survey respondents suggested that VIs made the selection committee rely more heavily on objective applicant data. Almost two-thirds of GS PDs suggested that they would adopt both VI and in-person interview formats for future application cycles. The median [interquartile range] cost saved through the implementation of VIs was US$ 4500 [1625 - 10 000]. CONCLUSION: Remarkably, VIs have been swiftly imbibed by all residency programs and many aspects of the VI experience were positive. While MATCH 2021 has definitely proved to be one of its kind, the implementation of VIs has been met with overall broad success and a promising future awaits this novel modality of resident selection to GME programs in the United States.

Elevated Intracranial Pressure After Primary Surgical Correction of Sagittal Suture Craniosynostosis.

Study Design: A Case Report. Objective: Craniosynostosis is a craniofacial condition defined by premature fusion of at least one cranial suture. Resynostosis or secondary craniosynostosis of a previously patent adjacent suture following primary repair is a relatively common complication. While studies have assessed the rates of secondary craniosynostosis and subsequent reoperation, extremely limited data regarding reoperation techniques is available. Methods: We present a unique case of a pediatric patient with sagittal craniosynostosis who previously underwent a modified pi procedure and later developed resynostosis of the sagittal suture and secondary synostosis of the bicoronal sutures. We subsequently performed total cranial vault reconstruction with virtual surgical planning (VSP). Results: At his 31-month postoperative follow-up, he displayed normal head shape and denied any clinical signs of elevated intracranial pressures with a normal ophthalmological exam. Conclusions: The reoperation was successful with no significant postoperative complications noted. Performing geometric expansion with VSP to manage fusion of a previously open suture following primary treatment of sagittal synostosis should be considered within the armamentarium of operative options.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.

Barriers to care in juvenile localized and systemic scleroderma: an exploratory survey study of caregivers' perspectives.

BACKGROUND: Juvenile localized scleroderma (LS) and systemic sclerosis (SSc) are rare pediatric conditions often associated with severe morbidities. Delays in diagnosis are common, increasing the risk for permanent damage and worse outcomes. This study explored caregiver perspectives on barriers they encountered while navigating diagnosis and care for their child's scleroderma. METHODS: In this cross-sectional study, caregivers of juvenile LS or SSc patients were recruited from a virtual family scleroderma educational conference and a juvenile scleroderma online interest group. The survey queried respondents about their child's condition and factors affecting diagnosis and treatment. RESULTS: The response rate was 61% (73/120), with 38 parents of LS patients and 31 parents of SSc patients. Most patients were female (80%) and over half were non-Hispanic white (55%). Most families had at least one person with a college education or higher (87%), traveled ≤ 2 h to see their rheumatologist (83%), and had private insurance (75%). Almost half had an annual household income ≥ $100,000 (46%). Families identified the following factors as barriers to care: lack of knowledge about scleroderma in the medical community, finding reliable information about pediatric scleroderma, long wait times/distances for a rheumatology/specialist appointment, balance of school/work and child's healthcare needs, medication side effects, and identifying effective medications. The barrier most identified as a major problem was the lack of knowledge about juvenile scleroderma in the medical community. Public insurance, household income less than $100,000, and Hispanic ethnicity were associated with specific barriers to care. Lower socioeconomic status was associated with longer travel times to see the rheumatologist/specialist. Diagnosis and systemic treatment initiation occurred at greater than one year from initial presentation for approximately 28% and 36% of patients, respectively. Families of LS patients were commonly given erroneous information about the disease, including on the need and importance of treating active disease with systemic immunosuppressants in patients with deep tissue or rapidly progressive disease. CONCLUSION: Caregivers of children with LS or SSc reported numerous common barriers to the diagnosis, treatment, and ongoing care of juvenile scleroderma. The major problem highlighted was the lack of knowledge of scleroderma within the general medical community. Given that most of the caregiver respondents to the survey had relatively high socioeconomic status, additional studies are needed to reach a broader audience, including caregivers with limited English proficiency, geographical limitations, and financial constraints, to determine if the identified problems are generalizable. Identifying key care barriers will help direct efforts to address needs, reduce disparities in care, and improve patient outcomes.

Interviewing Amidst a Pandemic: Perspectives of US Residency Program Directors on the Virtual Format.

COVID-19 imposed significant limitations upon the 2021 U.S. National Resident Matching Program (NRMP), most important of which is the replacement of traditional in-person interviews with a virtual format. To determine the strengths, limitations, and overall utility of virtual interviews (VIs) for residency applicant selection, a 14-question electronic survey was administered to programme directors (PDs) of all American Council for Graduate Medical Education (ACGME)-accredited residency programmes, from December 2020 through March 2021. PDs were asked about their experience with VIs and the ability to assess residency applicants using the virtual format. A total of 1123 PDs (30% response rate) representing 30 different specialities responded to our survey. Compared to in-person interviews, VIs made it more challenging to assess applicants' fit with the programme, emotional intelligence, commitment to speciality, and ability to function as a resident physician. Overall, only 15% of PDs believed that VIs were better than in-person interviews. Once travel restrictions are lifted and in-person interviews are possible, 67% of PDs plan on hosting dual-format residency interviews, while 26% and 5% of PDs will exclusively host in-person interviews and VIs, respectively. This result was significantly different between surgical and non-surgical programmes [35% of surgical PDs suggested they would offer in-person interviews exclusively, compared to 21% of non-surgical PDs, p < 0.0001]. Although proven to be cost and time-efficient, VIs were challenging in evaluating certain qualities of residency applicants. While this study was focused on U.S. residency matching, it provides important insights about the future of VIs in medical recruitment as a whole.

The Use of Biologic Wound Agents in Pediatric Reconstructions.

The indications for using biologic wound agents have expanded greatly since first being employed for acute burn management. The majority of the literature details the use of said agents in the adult population; however, there is little representation regarding their uses for reconstructing defects typically observed in the pediatric population. Ironically, children, and to a lesser extent adolescents, greatly benefit from their use given the reduced skin laxity and amount of surrounding tissue available for locoregional tissue transfer when compared with adults. Herein, we detail the use of acellular and cellular biologic wound agents in the pediatric population.

Overview of Biologic Agents Used in Skin and Soft Tissue Reconstruction.

Wound healing is a highly complex process mediated by cellular interactions at the microscopic level. Increased understanding of wound healing physiology has served as the foundation for translational research to develop biologic wound care technologies that have profoundly affected patient care. As the reader will see throughout this series in Seminars in Plastic Surgery , biologic wound technologies have broad applications and have greatly impacted the reconstructive ladder. Despite their frequent use, many surgeons lack familiarity with the myriad of products available on the market along with each product's relative advantages and shortcomings. This overview will discuss the classification of biologic wound agents used to reconstruct defects of the skin and soft tissue along with the advantages and disadvantages associated with their use.