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.

Treatment Outcomes of Manual Lymphatic Drainage in Pediatric Lymphedema.

BACKGROUND: Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain. METHODS: A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire. RESULTS: Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain. CONCLUSIONS: MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.

Extremity anomalies associated with Robinow syndrome.

Robinow syndrome, a rare genetic disorder, is characterized by skeletal dysplasia with, among other anomalies, extremity and hand anomalies. There is locus heterogeneity and both dominant and recessive inheritance. A detailed description of associated extremity and hand anomalies does not currently exist due to the rarity of this syndrome. This study seeks to document the hand anomalies present in Robinow syndrome to allow for improved rates of timely and accurate diagnosis. A focused assessment of the extremities and stature was performed using clinical examination and standard photographic images. A total of 13 patients with clinical and molecular diagnosis consistent with dominant Robinow syndrome or recessive Robinow syndrome were evaluated. All patients had limb shortening, the most common of which was mesomelia; however, rhizomelia and micromelia were also seen. These findings are relevant to clinical characterization, particularly as Robinow syndrome has classically been defined as a "mesomelic disorder." A total of eight distinct hand anomalies were identified in 12 patients with both autosomal recessive and dominant forms of Robinow syndrome. One patient did not present with any hand differences. The most common hand findings included brachydactyly, broad thumbs, and clinodactyly. A thorough understanding of the breadth of Robinow syndrome-associated extremity and hand anomalies can aid in early patient identification, improving rates of timely diagnosis and allowing for proactive management of sequelae.

Craniofacial phenotypes associated with Robinow syndrome.

Robinow syndrome is characterized by mesomelic limb shortening, hemivertebrae, and genital hypoplasia. Due to low prevalence and considerable phenotypic variability, it has been challenging to definitively characterize features of Robinow syndrome. While craniofacial abnormalities associated with Robinow syndrome have been broadly described, there is a lack of detailed descriptions of genotype-specific phenotypic craniofacial features. Patients with Robinow syndrome were invited for a multidisciplinary evaluation conducted by specialist physicians at our institution. A focused assessment of the craniofacial manifestations was performed by a single expert examiner using clinical examination and standard photographic images. A total of 13 patients with clinical and molecular diagnoses consistent with either dominant Robinow syndrome (DRS) or recessive Robinow syndrome (RRS) were evaluated. On craniofacial examination, gingival hyperplasia was nearly ubiquitous in all patients. Orbital hypertelorism, a short nose with anteverted and flared nares, a triangular mouth with a long philtrum, cleft palate, macrocephaly, and frontal bossing were not observed in all individuals but affected individuals with both DRS and RRS. Other anomalies were more selective in their distribution in this patient cohort. We present a comprehensive analysis of the craniofacial findings in patients with Robinow Syndrome, describing associated morphological features and correlating phenotypic manifestations to underlying genotype in a manner relevant for early recognition and focused evaluation of these patients.

A Novel Sand Dollar and Staves Technique for Unilateral Lambdoid Craniosynostosis.

BACKGROUND: Unilateral lambdoid synostosis (ULS) is the rarest form of craniosynostosis. Due to the associated cranio-caudal shift seen in ULS, surgical correction is technically challenging from a morphological standpoint. Herein, the authors present a novel "Sand-Dollar and Staves" technique for the repair of ULS. METHODS: A zigzag coronal incision is performed, and an anteriorly-based pericranial flaps are elevated. Prefabricated cutting guides are placed and the calvarium is marked. To treat the flattening on the ipsilateral side, a wedged suturectomy is performed with additional barrel staves. A large circle centered over the bulging on the contralateral side is cut out above the open lambdoid suture. This piece is barrel staved in a radial fashion, leaving the center intact and creating a Sand-Dollar appearance. This disk is then flattened and trimmed. The modified Sand-Dollar is fixed using an absorbable plating system. While gentle pressure is applied to the Sand-Dollar piece as it is being secured, the ipsilateral side demonstrates compensatory filling. Results are evaluated using the Whitaker Classification. RESULTS: Four patients underwent surgical correction with this technique. The procedure was performed at mean age of 11.7 months. The mean operative time was 2.5 hours. Intraoperative blood loss was 50 to 100 ml. Total hospitalization time was 2 to 3 days. No post-operative complications were encountered. Whitaker scores ranged from 1 to 1.5. The mean follow-up was 10 months. CONCLUSION: The Sand-Dollar and Staves procedure is a novel, single-stage approach for the management of ULS with decreased operative time, blood loss, and hospital stay with satisfactory aesthetic outcomes.

Cleft Care Packages and the Impact on Postoperative Care Following a Primary Cleft Lip Repair.

OBJECTIVE: To provide caregivers with all the resources needed to care for a surgical site following a primary cleft lip repair and evaluate its efficacy on postoperative care. SETTING/PARTICIPANTS: Caregivers of infants ages 3 to 6 months with a cleft lip and/or palate undergoing a primary repair at the Texas Children's Hospital. METHODS: Packages were given to caregivers at discharge following repair. Packages included instructions and supplies needed for surgical site care. At discharge an advanced practice provider obtained informed consent and a questionnaire that established baseline knowledge of surgical site care. Following the questionnaire, the advanced practice provider demonstrated how to care for the site using the package provided. Assessment of scar healing, nasal stent compliance, and ease of care was evaluated at postoperative follow up. RESULTS: Thirty-two families were enrolled in this study. Our data supports that caregivers who are provided resources to care for the site had increased comfort level, preparedness, and compliance rates following a primary cleft lip repair. Eighty-four percent of respondents strongly agreed that the package provided aided in preparedness for site care with 100% of respondents recommending the resources to future families undergoing a cleft lip repair. CONCLUSIONS: Caregivers feel comfortable and equipped with their ability to care for their child's repaired cleft lip when given the appropriate instructions and supplies. In addition, they would recommend the packages to future families following a repair. Empowering families to be proactive in postoperative care will potentially lead to better outcomes in cleft care.

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.

A Systematic Review of Wellness in Plastic Surgery Training.

BACKGROUND: Physician and resident wellness has been increasingly emphasized as a means of improving patient outcomes and preventing physician burnout. Few studies have been performed with a focus on wellness in plastic surgery training. OBJECTIVES: The aim of this study was to systematically review what literature exists on the topic of wellness in plastic surgery training and critically appraise it. METHODS: A PubMed search was performed to identify journal articles related to wellness in plastic surgery residency. Seventeen studies (6 cohort and 11 cross-sectional) met inclusion criteria and were appraised with the Newcastle-Ottawa Quality Assessment Scale (NOQAS) to determine the quality of the studies based on selection, comparability, and outcome metrics. RESULTS: Critical assessment showed that the studies were highly variable in focus. Overall, the quality of the data was low, with an average NOQAS score of 4.1. Only 2 studies focused on plastic surgery residents, examining work hours and social wellness, respectively; they were awarded NOQAS scores of 3 and 4 out of 10. CONCLUSIONS: The results of this systematic review suggest that little research has been devoted to wellness in surgery training, especially in regard to plastic surgery residents, and what research that has been performed is of relatively low quality. The available research suggests a relatively high prevalence of burnout among plastic surgery residents. Evidence suggests some organization-level interventions to improve trainee wellness. Because outcomes-based data on the effects of such interventions are particularly lacking, further investigation is warranted.

Algorithm for Temple Reconstruction With Consideration of Anatomic and Defect Characteristics.

The temple is an intriguing region of the face with unique anatomic features, such as the temporal hairline, concave contour, and close proximity to vital structures like the frontal branch of the facial nerve. However, cancerous skin lesions can plague this sun-exposed region and, when excised, it can result in large and significant defects. Reconstruction in this area is a formidable challenge for surgeons, as it requires comprehensive knowledge of temple morphology and the use of creative techniques in order to minimize disruption of surrounding functional and aesthetic structures. In this study, we describe our experience with temple reconstruction in patients of varying defect size and depth. Based on these defect characteristics, anatomic and aesthetic principles of the temple, we propose a surgical algorithm for temple reconstruction to aid surgeons in achieving optimal results.

Chicken or the Egg: A Case Report of Endoscopic-Assisted Treatment of Concomitant Sagittal Craniosynostosis With Calcified Cephalohematoma.

Nonsyndromic craniosynostosis results in premature fusion of cranial sutures and is rarely found in the context of other craniofacial abnormalities. Here the authors present the case of a 3-month-old male infant with a rare presentation of sagittal craniosynostosis and concomitant calcified cephalohematoma repaired by endoscopic-assisted sagittal strip craniectomy with good cosmetic and functional outcomes. The authors discuss the advantages of endoscopic repair of craniosynostosis when found in the presence of a cephalohematoma and the need for further research to investigate a possible causal relationship between these 2 pathologies.

Access to Multidisciplinary Care for Patients With 22q11.2 Deletion Syndrome: Identifying Breakdowns in the Screening Process.

The 22q11.2 deletion syndrome affects approximately 1 in 4000 live births and involves cardiac defects, immunodeficiency, and endocrine disruption. The complexity of diagnosis and multifaceted care often leads to fragmented management in the short and long term. With the purpose of developing an effective multidisciplinary program, the authors aimed to identify the deficiencies in current screening and referral processes among the teams required in the care for patients with 22q11.2 deletion syndrome. A retrospective chart review was conducted at our institution between 2001 and 2016. Patients with confirmed 22q11.2 deletion diagnoses between the ages of 0 and 28 were included. A list of 15 relevant specialties that should evaluate patients with 22q11.2 deletion syndrome was created according to established guidelines. Patient medical and demographic information were collected and analyzed. A total of 270 patients were included. Mean age at diagnosis was 3.3 years. On average, patients visited 6 of 15 departments (1-14). Only 8.8% of patients visited >10 specialties. The majority were seen by Cardiology, Allergy and Immunology, Genetics, and Speech (57.4-87.8%). A minority were seen by Hematology and Oncology, Sleep Therapy, and Physical Therapy (13.3-16.3%). Only 34.1% encountered plastic surgery. Negative correlation (-0.128; P = 0.035) was demonstrated between patients' age at diagnosis and number of specialty teams encountered. This study highlights the current underutilization of services required to manage patients with 22q11.2 deletion syndrome. While screening guidelines have been established, implementation can be challenging as it requires efficient care coordination between teams. Moving forward, the authors believe that a multidisciplinary clinical approach to streamline patient care is necessary.

American Cleft-Palate Craniofacial Association Annual Meeting: International Medical Graduate's Perspective as a First-Time Attendee.

In the United States, plastic surgery continues to be one of the most competitive fields to match into for medical graduates. However, the process is even more difficult for international medical graduates (IMGs) mostly due to their unknown academic backgrounds and unfamiliarity with US health-care system. While many IMGs pursue of research to publish articles in peer-reviewed journals and obtain letters of recommendations as a means to prove one's potential, networking with well-known plastic surgeons in US plastic surgery programs via national meetings is of utmost importance. These conferences provide the perfect opportunity to learn about the multidisciplinary US health-care system, expand one's network of mentors and colleagues, and demonstrate one's research experience. This article describes my experience as a first-time attendee in the American Cleft-Palate Craniofacial Association 76th Annual Meeting, with the aim to encourage other IMGs interested in applying to plastic surgery residency programs to actively pursue and attend national plastic surgery society meetings.

Oculocardiac Reflex as a Late Presentation of Orbital Floor Fracture.

Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and radiographically, complicate prompt diagnosis. The oculocardiac reflex may be the only indication of fracture with entrapped orbital contents, but, unfortunately, the reflex has variable onset patterns and can mimic common diagnoses. Therefore, the authors present the case of a 14-year-old male with a right orbital floor fracture, who presented with delayed symptoms secondary to an oculocardiac reflex. The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits. After admission to the hospital due to progressive symptoms, a CT scan showed concerns for a subacute orbital blowout fracture. The patient underwent orbital floor exploration with findings of scarred orbital fat herniating into a healing fracture site. Repositioning of the fat into the orbit resulted in immediate resolution of the patient's symptoms. Awareness of the presenting characteristics of the oculocardiac reflex can lead to prompt diagnosis and maximize clinical outcomes.

Asymmetric Multisutural Craniosynostosis: an Algorithm of Early Intervention to Prevent Evolving Deformity.

BACKGROUND: Asymmetric multisutural craniosynostosis (AMC) is characterized by fusion of a midline suture combined with unilateral fusion of at least 1 nonmidline suture. Due to its rarity, complexity, and high rate of reoperation, the purpose of this study is to evaluate outcomes of our staged approach to AMC. METHODS: Patients treated for craniosynostosis between January 2004 and December 2013 were identified retrospectively. Only patients with AMC and a minimum follow-up of 2 years were included. The 3-staged algorithm includes: extended strip craniectomy of fused sutures; postoperative helmet molding; and fronto-orbital advancement versus a touch-up procedure. Morphologic, aesthetic, and functional outcomes were evaluated. RESULTS: Nine patients (6.8% of cases) were treated for AMC (mean follow-up: 4.1 years). Sixty-seven percent of patients (6 of 9) demonstrated signs of elevated intracranial pressure. Patients were divided into 2 groups: "Group A" included patients treated according to the staged algorithm (n = 5); "Group B" included those treated by traditional techniques (n = 4). Group A underwent their first calvarial vault procedure earlier than those from Group B (2.7 vs. 13.2 months; P < 0.02). Postoperatively, no Group A patients had developmental delay, signs of elevated intracranial pressure, or reoperation. Three of 5 patients (60%) were rated Whitaker Classification II and the others (40%) rated Whitaker Classification III. CONCLUSIONS: Asymmetric multisutural synostosis results in a complex and evolving deformity involving the entire craniofacial complex. However, when asymmetric multisutural synostosis is approached in stages with early intervening helmet therapy, acceptable functional and appearance-related outcomes can be obtained with minimal complications. LEVEL OF EVIDENCE: III.

Combination of a fillet flap, free tissue transfer, and autologous tissue grafts in pelvic reconstruction following retroperitoneal sarcoma: a case report.

The resection of large pelvic tumors is challenging due to their infiltrative nature into multiple structures and organ systems. In this report, we describe the use of multiple vascularized and nonvascularized spare parts to reconstruct a pelvic defect in a patient with a uniquely large pelvic sarcoma invading the spinal canal. A 39-year-old Caucasian female who presented with a large retroperitoneal sarcoma where the tumor encased the left ureter, kidney, colon, and external iliac vessels and invaded the L3-S1 vertebral bodies. An extensive hemipelvectomy and reconstruction was performed over two days. A free thigh and leg fillet flap together with ipsilateral fibula flap, based on the superficial femoral artery and venae comitantes, was used for spinal reinforcement as well as abdominal and pelvic wall reconstruction. The postoperative course was uneventful without complications, no flap compromise or wound healing problems. After a follow-up period of 4 months, the patient had no complications and returned to activities of daily living with mild limitations. The success of this flap procedure shows the practicality and usefulness of using the full spectrum of tissue transfer for the purposes of a large pelvic reconstruction.

Is the SMAS Flap Facelift Safe? A Comparison of Complications Between the Sub-SMAS Approach Versus the Subcutaneous Approach With or Without SMAS Plication in Aesthetic Rhytidectomy at an Academic Institution.

BACKGROUND: For treating the aging face, a facelift is the surgical standard. A variety of techniques have been described. The purpose of the current study is to evaluate the safety of the sub-SMAS facelift compared to the subcutaneous facelift with or without SMAS plication. METHODS: A retrospective chart review was conducted on all patients who underwent facelift surgery between 2003 and 2011. Patients included in the study were seeking elective improvement of facial appearance. All charts were reviewed to identify the presence of hematoma, seroma, deep venous thrombosis, skin loss, unfavorable scar, wound infection, or motor and sensory deficit following the operation. The primary outcome was overall complication rate. RESULTS: A total of 229 facelifts were included; 143 patients underwent a subcutaneous facelift with or without SMAS plication and 86 underwent a sub-SMAS facelift. For the subcutaneous facelifts, 88% of the patients were female with a mean age of 62 years. For the sub-SMAS dissections, 88% of the patients were female with a mean age of 59 years. The overall complication rate was 29.4% (n = 42) for patients who underwent a subcutaneous facelift compared to 24.4% (n = 21) for patients with a sub-SMAS facelift (p = 0.4123). Analysis of each individual complication failed to yield any statistically significant difference between the two groups. CONCLUSIONS: In the present study, sub-SMAS facelift complication rates were not statistically different compared to those of subcutaneous facelift with or without SMAS plication. These data suggest that sub-SMAS dissection can be performed with similar safety compared to the traditional subcutaneous facelift, with the potential additional advantage of the SMAS flap elevation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Facelift complications related to median and peak blood pressure evaluation.

BACKGROUND: Hematoma remains the most challenging complication of facelifting and has been associated with male sex, hypertension, aspirin use, smoking, and high body mass index. Patients who underwent a facelift were studied to determine rates of hematoma and other complications and to identify predictive and protective factors, including meticulous analysis of perioperative blood pressure. METHODS: Charts of patients who underwent a facelift from 2003 to 2011 at our institution were retrospectively reviewed. Demographic, clinical, and procedural data were collected. All postoperative complications were recorded. Data from continuous blood pressure monitoring in the operating and recovery rooms were obtained from a perioperative database and stratified by median and peak values. Logistic regression was used for data analysis. RESULTS: Of the 229 patients included, the majority were female (88.2 %), mean age at presentation was 62 years, and 35.8 % had hypertension. Postoperative complications occurred in 60 patients (26.2 %). The most common complication was unfavorable scar (7.4 %), followed by hematoma (6.5 %). Male sex (P = 0.02), history of hypertension (P = 0.04), preoperative systolic blood pressure (SBP) greater than 160 mmHg (P = 0.04), and operating room peak SBP greater than 165 mmHg (P = 0.04) were predictive factors for hematoma. Recovery room peak SBP greater than 150 mmHg (P = 0.09) was also associated with hematoma. On multivariate analysis, only male sex and preoperative SBP greater than 160 mmHg remained independent risk factors for hematoma. CONCLUSIONS: This study is unique in that it compares the rate of hematoma to continuous blood pressure data in the operating and recovery rooms stratified by median and peak values. Meticulous control of perioperative SBP is recommended for a safe facelift. History of hypertension, increased SBP at admission, and increased perioperative peak SBP are predictors for postoperative hematoma. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.