Rise Above the Competition: How Do Plastic Surgery Residency Applicants with NCAA Experience Fare in the Residency Match?

BACKGROUND: The integrated plastic surgery residency match continues to be highly competitive. Every year, some candidates are former NCAA athletes. While it is challenging to balance academic and athletic responsibilities, participation in NCAA sports may be predictive of continued success. OBJECTIVES: This study aimed to evaluate the impact of participation in collegiate athletics on applicant anticipated rank and academic success. METHODS: All applications received from 2017 to 2020 at a single institution were reviewed for participation in NCAA athletics (Division I-III). Our primary outcome of interest was applicant anticipated rank by letter of reference writers. Applications were also examined for demographic information, membership in AOA, number of research publications, and USMLE board certification examination scores. RESULTS: After reviewing 885 applications, 61 applicants (6.89%) were former NCAA athletes. Former NCAA involvement was associated with the highest effect on anticipated ranking (- 0.22, p=0.001). Former NCAA involvement demonstrated the highest odds of receiving an anticipated ranking in the top 5 (OR 1.83, p=0.025). We found no significant difference in research productivity between the two groups, including first authorships or USMLE Step 1 board certification exam scores. A significant difference was seen in race distribution, with forty-five (80.4%) of athlete applicants identifying as Caucasian, while 430 (56.5%) of non-athletes identified as Caucasian (p=0.012). CONCLUSION: Former athletes applying to become integrated plastic surgery residents overcome the challenges of balancing athletic and academic pursuits with a higher anticipated rank in the integrated plastic surgery match while having comparable academic achievement. Former collegiate athletes have demonstrated greater success in and after residency. Former NCAA participation demonstrated the highest odds of receiving a top-5 rank. Former NCAA applicants showed no difference in academic productivity LEVEL OF EVIDENCE V: Case series study. 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 Relationship Between Neuropsychiatric Diagnoses and Revision Surgery After Breast Reconstruction.

BACKGROUND: A neuropsychiatric diagnosis (ND) has the potential to affect patient satisfaction after breast reconstruction. However, literature regarding the interplay between neuropsychiatric diagnoses and revision operations after reconstruction remains sparse. In this study, we aim to determine whether neuropsychiatric diagnoses result in increased revision operations and healthcare utilization of plastic surgery resources after alloplastic and autologous breast reconstruction. METHODS: We retrospectively reviewed 200 patients from 2010 to 2019 who underwent postmastectomy alloplastic or autologous breast reconstruction by a single surgeon at our institution. We evaluated for the presence of neuropsychiatric diagnoses, type of neuropsychiatric diagnoses, number of revisions, and number of postreconstruction plastic surgery appointments. Continuous variables were compared using independent samples t tests, and categorical variables were compared using χ 2 tests. RESULTS: Of the 196 patients who met inclusion criteria, the majority underwent at least one revision (65.3%). The presence of an ND did not predict a higher number of revision operations ( P = 0.512) nor was the timing of the diagnosis (preoperative vs postoperative) significantly associated with the number of revision procedures ( P = 0.156). The patients who had a ND at any point during the reconstructive process had a significantly higher number of plastic surgery appointments and a longer duration of follow-up compared with the patients without any neuropsychiatric diagnoses ( P = 0.009 and P = 0.040, respectively). Complications did not impact the number of revision operations ( P = 0.780). CONCLUSIONS: Neuropsychiatric diagnoses do not significantly influence the number of revision operations after breast reconstruction. However, neuropsychiatric diagnoses result in increased healthcare utilization of plastic surgery resources that may lead to increased healthcare costs.

Targeted Muscle Reinnervation in the Hand: Treatment and Prevention of Pain After Ray Amputation.

Targeted muscle reinnervation (TMR), originally developed as an experimental technique for prosthetic control, has been shown to be safe and effective for the treatment and prevention of postamputation pain. Targeted muscle reinnervation involves coaptation of residual nerve ends to nearby motor nerve branches of healthy but expendable muscles proximal to an amputation. It has been shown to prevent and reduce residual limb pain and phantom limb pain after major upper and lower extremity amputation. However, the use of this technique has not been described distal to the forearm because bioprosthetic use is not a consideration at that level. The aim of this article was to (1) present 2 cases of TMR performed in the setting of ray amputation, and (2) provide technical strategies for maximizing success and efficiency.

Venous Flaps for Revascularization and Soft-Tissue Coverage in Traumatic Hand Injuries: A Systematic Review of the Literature.

BACKGROUND: The use of the venous flap for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. First described in 1981, Nakayama et al demonstrated that a vein and overlying skin, or a venous flap, may be transposed from one area of the body to another with complete survival of the graft. The aim of this study was to conduct a systematic review of the literature to determine predictors of venous flap survival in traumatic hand injuries. METHODS: A literature search of PubMed, MEDLINE, and Cochrane Library was performed with emphasis on venous flap use in traumatic hand injuries. MeSH terms included: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand, and thumb. RESULTS: Forty-three articles were collected that contained data on 626 free venous flaps. Most patients were males (73.9) and injured their right hand (52.3%). The forearm was the most commonly used venous flap donor site (83.6%), and most of the skin paddles were 10 to 25 cm2 (41.1%). Arterial inflow was used in 93.1% of the flaps. Most venous flaps (79.6%) healed without superficial tissue loss or necrosis. Ninety-two (14.7%) flaps had partial loss while 36 (5.8%) flaps did not survive. CONCLUSION: The use of venous flaps for concomitant revascularization and soft tissue coverage of the hand permits good results with limited morbidity. The overall flap survival rate is nearly 95%. Younger patients whose flaps have arterial inflow and skin paddles of medium size (10-25 cm2) have the best chance for survival.

A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures.

BACKGROUND: Evidence supports short-term perioperative prophylaxis for facial fractures. It is unknown, however, whether there is any professional consensus on how to manage these injuries. No multidisciplinary evaluation of the prophylactic antibiotic prescribing patterns for neither operative nor nonoperative facial fractures has been performed. AIM: To evaluate the prophylactic antibiotic prescribing patterns of multiple specialties in operative and nonoperative facial fractures. METHODS: A 14 question anonymous online-based survey was distributed to members of the American Society of Maxillofacial Surgeons (ASMS) and the American Association of Facial Plastic Surgeons to evaluate current practices. RESULTS AND CONCLUSIONS: 205 respondents, including 89 plastic surgeons, 98 otolaryngologists, 12 oral and maxillofacial surgeons, and 7 with double board certification practicing throughout the United States with ranging experience from 11 to 30 years. As expected, preoperative, perioperative, or postoperative prophylactic antibiotics are either "always" or "sometimes" prescribed, 100% of the time with more varied practice upon further inspection. A total of 85.1% either "always" or "sometimes" use antibiotics while awaiting surgery. Dentate segment fractures are the most frequent type of facial fractures to receive prophylactic antibiotics for both operative (90.5%) and nonoperative (84.1%) fractures. Duration of antibiotic use is more varied with the majority providing 3 to 7 days despite current evidence. First generation cephalosporins alone are prescribed by 49% of respondents, which may not adequately cover oral flora. There is no multidisciplinary consensus for prophylactic antibiotics for specific operative fracture types or nonoperative facial fractures, an area with little published evidence.

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study.

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes.

Introduction : La mise en place d'un drain est habituelle après de nombreuses procédures de chirurgie plastique pour l'évacuation des excès de sang et de liquide. L'acide tranexamique (TXA) est un agent antifibrinolytique qui a une efficacité démontrée sur la réduction des saignements et de la production de fluides au niveau des sites chirurgicaux; il peut être administré par voie orale, par voie intraveineuse ou en application locale. L'objectif de cette étude était d'évaluer l'effet du TXA topique sur le retrait du drain après reconstruction mammaire autologue à base abdominale (ABABR). Méthodes : Un examen rétrospectif des dossiers des patients ayant subi une ABABR entre août 2018 et novembre 2019 a été effectué. Dans une cohorte, une solution de TXA à 2,5 % a été appliquée localement sur la paroi abdominale avant sa fermeture. Les drains ont été retirés quand la production est devenue inférieure à 30 mL/jour pendant 2 jours consécutifs. Le critère d'évaluation principal était le nombre de jours jusqu'au retrait du drain. Les critères de jugement secondaires étaient notamment : la production quotidienne du drain chez les patients hospitalisés, les taux d'hémoglobine postopératoires, les transfusions sanguines et les complications survenues dans les 30 jours postopératoires. Résultats : Quatre-vingt-trois patients ont été inclus, dont 47 dans le groupe contrôle et 36 dans le groupe TXA. Les drains ont été retirés significativement plus tôt chez les patients qui avaient reçu du TXA (16 jours contre 23 jours, P = 0,02). De plus, un nombre significativement inférieur de patients a nécessité des transfusions sanguines postopératoires dans le groupe TXA (2 contre 14, P = 0,005). Les complications abdominales ont été moins nombreuses dans le groupe TXA avec significativement moins de complications de cicatrisation (22 % contre 49 %, P = 0,01). Il n'y a pas eu de différence concernant la perte du lambeau cutané ou les événements thromboemboliques systémiques. Conclusion : L'utilisation topique de TXA dans l'ABABR permet un retrait plus précoce du drain abdominal, moins de transfusions sanguines et moins de complications de la plaie abdominale inférieure sans augmentation du risque de perte du lambeau cutané ou d'événements indésirables pour le patient.

Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications-A Retrospective Review of 174 Patients.

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection (P = .005), epidermolysis (P = .031), and seroma (P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity (P = .024), history of smoking (P = .049), and the number of perforators harvested (P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.

Introduction : La reconstruction mammaire autologue reste une option chirurgicale appréciée après une mastectomie. Toutefois, elle ne va pas sans complications. Des angio-TDM préopératoires sont souvent effectués dans le cadre de la planification chirurgicale et les données morphométriques (comme la répartition du tissu adipeux et musculaire) peuvent être mesurées. Cette étude a eu pour but d'évaluer si les données morphométriques de la TDM prédisent les complications abdominales au site donneur chez les patientes subissant une reconstruction mammaire autologue à partir de tissus abdominaux. Méthodes : Une étude de cohorte rétrospective a été effectuée avec des patients ayant subi une reconstruction mammaire autologue à base abdominale entre 2013 et 2018. Parallèlement aux caractéristiques opératoires et de la population, les variables morphométriques préopératoires suivantes ont été évaluées : tissu adipeux sous-cutané, tissu adipeux viscéral, surface de muscle squelettique et surface transversale index, du grand droit et du psoas, densité osseuse. Une comparaison statistique aux complications du site donneur abdominal a été réalisée au moyen d'une analyse de régression logistique pour chaque changement de 100 unités. Résultats: Cent-soixante-quatorze patientes ont été incluses dans l'étude. Le tissu adipeux viscéral a été associé de manière significative avec le développement d'une infection (P = 0005), d'une épidermolyse (P = 0031 et d'un sérome (P = 0,04). Le tissu adipeux sous-cutané, l'indice de muscle squelettique, la surface musculaire transversale et la densité osseuse n'ont pas été associées à des complications abdominales du site donneur. L'obésité (P = 0024), les antécédents de tabagisme (P = 0049) et le nombre de perforantes collectées (P = 0035) ont significativement augmenté la probabilité du retard de guérison abdominales. Conclusions: Cette étude démontre que l'augmentation de tissu adipeux viscéral, mesurée par angio-TDM, est significativement associée à une augmentation du risque de complications abdominales au site donneur. Les données morphométriques de l'angio-TDM et l'identification des caractéristiques des patients à risque élevé peuvent aider à orienter les conseils préopératoires et à mieux renseigner sur les risques chirurgicaux.

Osteoarthritis Increases the Frequency and Duration of Postoperative Hand Clinic Visits after Carpal Tunnel Release.

Background: Carpal tunnel syndrome affects up to 6% of the general population, and surgical intervention is often required to ameliorate symptoms. Osteoarthritis (OA) is a common condition that often coexists with carpal tunnel syndrome. We hypothesized that patients with preexisting OA use more healthcare resources after carpal tunnel release (CTR) than patients without arthritis. Methods: This was a retrospective cohort study at a single academic center between January 1, 2018 and November 1, 2021. Patients who underwent CTR were included. Preoperative carpal tunnel symptoms, diagnostic tests, medications, and concomitant OA were abstracted. Hand, wrist, and basal joint arthritis were specified. The primary outcome was healthcare utilization represented by duration and frequency of hand clinic and occupational therapy (OT) follow-up. In total, 312 hands were included. Multivariable analysis was performed. Results: The average duration of hand clinic follow-up among patients without arthritis was 25.3 days compared with 87.1 days for patients with any arthritis (P = 0.0375) and 172 days for patients with wrist arthritis (P = 0.012). The average number of postoperative surgeon visits was increased in patients with hand arthritis, with an average of 2.3 visits versus 1.34 visits for patients without arthritis (P = 0.003). Both the number of OT visits and the duration of OT follow-up did not differ between cohorts. Conclusion: After CTR, patients with preexisting OA use more healthcare resources than patients without OA.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study.

BACKGROUND: Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures. METHODS: We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications. RESULTS: A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age. CONCLUSION: The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.

Analysis of clinically significant seroma formation in breast reconstruction using acellular dermal grafts.

With a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation-defined by the need for a drainage procedure-to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups-AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)-we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.

Insurance Status Predicts Hand Therapy Adherence Following Flexor Tendon Repair: A Retrospective Cohort Study".

BACKGROUND: Many patients are not adherent to hand therapy rehabilitation following surgical repair of traumatic flexor tendon injuries, which can negatively affect surgical outcomes and long-term hand function. We aimed to identify the factors that predict patient non-adherence to hand therapy following flexor tendon repair surgery. METHODS: This retrospective cohort study included 154 patients who underwent surgical repair of flexor tendon injuries at a level I trauma center between January 2015 and January 2020. A manual chart review was performed to collect demographic data, insurance status, injury characteristics, and details of the postoperative course including health care utilization. RESULTS: Factors significantly associated with occupational therapy no-shows included Medicaid insurance (OR, 8.35; 95% CI, 2.91 to 24.0; p < 0.001), self-identified Black race (OR, 7.28; 95% CI, 1.78 to 29.7; p = 0.006), and current cigarette smoker status (OR, 2.69; 95% CI, 1.18 to 6.15; p = 0.019). Patients without insurance attended 73.8% of their OT visits and patients with Medicaid attended 72.0% of their visits, which were significantly lower rates than those with private insurance 90.7% (p=0.026 and p=0.001, respectively). Patients with Medicaid were 8 times more likely to seek emergency department care postoperatively than patients with private insurance (p=0.002). CONCLUSIONS: Significant disparities in hand therapy adherence following flexor tendon repair surgery exist between patients with different insurance statuses, races, and tobacco use. Understanding these disparities can help providers identify at-risk patients to improve hand therapy utilization and postoperative outcomes.

Making Headway in Surgical Education at Home and Abroad: Use of an Inexpensive Three-Dimensional Learning Model to Improve Plastic Surgery Resident Confidence in Mohs Defect Assessment and Closure Planning.

BACKGROUND: The development of simulation, particularly low-cost models, has become a focus of interest within plastic surgery education. Current simulators for Mohs reconstruction are either expensive or not reusable. The authors hypothesize that using a Styrofoam head model during an interactive teaching session will positively affect plastic surgery trainee comfort in designing Mohs reconstructive options. METHODS: A cohort of integrated plastic surgery residents at a single institution performed a preactivity questionnaire to obtain baseline comfort in defect assessment and design for five Mohs defects. They subsequently underwent an interactive learning session and were instructed to design flaps on life-size Styrofoam heads with feedback from the senior author (M.L.B.). A postactivity questionnaire was completed to assess improvement in comfort in defect assessment and flap design. Three attending surgeons then compared trainee designs with the senior author's design to assess accuracy. All surveys were based on a five-point Likert scale. RESULTS: When analyzing all defects, average postactivity scores increased by 0.63 (SD, ±0.24) ( P = 0.008). Junior residents ( n = 8) had a greater increase in average score responses [mean, 1.07 (0.5 to 1.75)] compared with senior residents ( n = 9) [mean, 0.27 (0 to 1)] ( P < 0.001). When assessed by senior-level surgeons, senior residents had significantly greater accuracy in design for each defect ( P < 0.05) except cheek advancement flap ( P = 0.08). CONCLUSION: Participation in an interactive educational activity using a Styrofoam head model demonstrated significant improvements in trainee assessment and design of reconstructive options for Mohs defects.

"The Impact of Neighborhood and Socioeconomic Disparities on Distal Radius Fracture Follow-Up Adherence: A Retrospective Cohort Study".

BACKGROUND: The aims of this retrospective cohort study were to assess if the Area Deprivation Index (ADI), a novel neighborhood-level socioeconomic disparities metric, is associated with follow-up non-adherence, and secondarily, determine the individual-level socioeconomic factors associated with follow-up non-adherence after treatment of distal radius fractures (DRF). METHODS: We included all patients who underwent non-operative and operative management of DRF at an academic level I trauma center between 2019 and 2021. A manual chart review was performed to collect data on ADI, sociodemographic factors, injury characteristics, conservative and surgical interventions, and healthcare utilization. RESULTS: There was a significant, weak negative Spearman-ranked correlation between ADI state deciles and clinic attendance rates (rs(220) = -.144; [95% CI: -.274, -.009] p = .032). Socioeconomic factors associated with significant differences in clinic attendance rates were having a spouse or partner (protective) (p = .007), Medicaid insurance (p = .013), male sex (p = .023), and current smokers (p = .026). Factors associated with differences in no show rates were having spouse or partner (OR .326; [95% CI: .123 - .867] p = .025), Medicaid insurance (OR 7.78; [95% CI: 2.15 - 28.2] p = .002), male sex (OR 4.09; [95% CI: 1.72 - 9.74] p = .001), and cigarette use (OR 5.07; [95% CI: 1.65 - 15.6] p = .005). CONCLUSIONS: ADI has a weak, negative correlation with clinic attendance rates following DRF treatment. Significant disparities in clinic follow-up adherence exist between patients with different marital status, insurances, sexes, and cigarette use.

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

BACKGROUND: There is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one's perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age. OBJECTIVES: The authors hypothesized that covering the lower third of the face with a mask will make a person appear younger. METHODS: One hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients' age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis. RESULTS: Masked patients on average appeared 6.17% younger (mean difference = 3.16 years, P < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, P = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age (P = 0.0617) and patients BMI > 35 (P = 0.5084). CONCLUSIONS: The mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.

Fractures of the Carpal Bones.

Diagnosis and proper initial management of acute fractures of the carpal bones is critical because of the limited blood supply of many bones of the wrist and the role of the carpus in optimizing hand function. Pathology is correctly diagnosed by a focused history and examination. Injuries may be missed with a cursory examination and routine wrist radiographs. Together, fractures of the scaphoid and triquetrum make up nearly 90% of carpal bone fractures. Relative frequency, mechanism of injury, diagnosis, and management principles are covered for each of the bones of the wrist.

Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures.

BACKGROUND: Opioid overprescribing is a nationwide problem contributing to the current epidemic. This study evaluated opioid consumption, physician prescribing, and patient satisfaction with pain control following outpatient plastic surgery procedures. METHODS: Patients completed a questionnaire during their first postoperative visit. The authors queried about procedure type, quantity of opioids prescribed and consumed, days to opioid cessation, prescription refills, pain scores, use of nonopioid analgesics, and satisfaction with pain control. RESULTS: One hundred seventy patients were included. On average, 26 tablets were prescribed and 13 were consumed. Eighty percent of patients stopped opioids by postoperative day 5. Patients rated their worst pain at 6.1 and follow-up pain at 1.9. Approximately 50 percent of patients consumed nonopioid analgesics. Ninety-six percent of patients were satisfied with their pain control. Similar findings were observed across procedure subcategories. The number of pills prescribed was not correlated with satisfaction but was predictive of worst pain level (p = 0.014). Reduction mammaplasty and abdominoplasty patients consumed the most opioids at 17 and 18.6 pills, respectively; however, first-stage alloplastic breast reconstruction had the largest percentage of patients consuming opioids at the time of follow-up (25 percent) and requiring refills (7 percent). Patients who underwent revision of their reconstructed breast reported the earliest opioid cessation, rated their pain the lowest, and were prescribed the most excess tablets. CONCLUSIONS: Plastic surgeons are prescribing almost double the amount of opioids consumed by patients after outpatient plastic surgery procedures. The results of this study may help guide prescribing practices.

Appropriateness of the Use of Magnetic Resonance Imaging in the Diagnosis and Treatment of Wrist Soft Tissue Injury.

BACKGROUND: When diagnosing wrist soft tissue injury, the authors hypothesize that magnetic resonance imaging is used injudiciously and is associated with unnecessary cost. METHODS: A retrospective review was conducted of patients aged 20 to 60 years who underwent magnetic resonance imaging for possible wrist soft tissue injury at a tertiary care center between 2009 and 2014. Treatment recommendation was classified as nonoperative, operative, or equivocal. If the magnetic resonance imaging-directed treatment recommendation differed from the pre-imaging recommendation, it was noted that the imaging influenced patient care (impact study). The cost estimate of an impact study was calculated by dividing the total studies performed by the number of studies that impacted the treatment recommendation and multiplying this value by the institutional wrist magnetic resonance imaging cost ($2246 in 2016). RESULTS: One hundred forty patients were included. Magnetic resonance imaging affected treatment recommendation in 28 percent of patients. Independent predictors of impact on treatment recommendation were "question specific injury" (OR, 9.46; 95 percent CI, 3.18 to 28.16; p < 0.001) and "question scapholunate injury" (OR, 2.88; 95 percent CI, 1.21 to 6.88; p = 0.02). The only independent predictor of surgery was ordering physician (hand surgeon) (OR, 3.69; 95 percent CI, 1.34 to 10.13; p = 0.01). The cost of an impact study ordered by a non-hand surgeon versus a hand surgeon was $13,359 versus $6491, respectively. CONCLUSIONS: The provider must carefully consider the pretest probability of ordering a study that will affect treatment recommendation. Injudicious screening with magnetic resonance imaging ($15,565) incurred a cost nearly seven times the cost of the one imaging scan ($2246) before impacting one treatment recommendation. In the current era of cost containment and bundled payment, diagnostic test probability must be appreciated to guide physician ordering practices.

Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone.

BACKGROUND: The lateral arm flap is used for composite defects in need of vascularized soft tissue, skin, and bone. From its original description, the distal humeral metaphysis can be included with the flap, supplied by the periosteal extensions of the posterior branch of the radial collateral artery. We sought to reexplore the anatomy of the lateral arm to determine its utility as a donor site for vascularized bone. METHODS: Twelve fresh, silicone-injected cadaver dissections were performed. Arteriovenous anatomy, pedicle length and diameter, and anatomic variability as well as photo documentation was recorded. RESULTS: The distal extent of the deltoid, lateral intermuscular septum and lateral humeral epicondyle were identified before the dissection. A septocutaneous perforator was consistently located 10 cm proximal to the lateral humeral epicondyle, which could be used for a skin paddle to monitor. Harvest of a 1.5 cm × 2 cm corticocancellous bone graft was performed. Average pedicle length was 9.1 ± 1.1 cm, and average pedicle diameter was 1.74 ± 0.52 mm. The inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm were consistently identified and preserved. CONCLUSION: The predictable anatomy of the lateral distal humerus make it an ideal donor site for small segments of vascularized bone.

Erratum: Opioid Prescribing and Consumption Trends in Outpatient Plastic Surgery: Erratum.

[This corrects the article DOI: 10.1097/01.GOX.0000533930.73173.70.].

Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury.

INTRODUCTION: Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury. METHODS: We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI). RESULTS: Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians (P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years (P = .01), within 6 weeks of symptom onset (P = .03), to question a specific anatomic injury (P = .0001), or by a board-certified hand surgeon (P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs. CONCLUSIONS: MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms.