Updates in Cleft Care.

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

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.

Comparison of Long-term Surgical Outcomes and Microsurgical Skills between Independent and Integrated Plastic Surgery Trainees.

We compared the surgical skills and outcomes of microsurgical fellows who completed an independent versus integrated plastic surgery residency. Methods: We reviewed outcomes of abdominal wall reconstructions performed autonomously by microsurgical fellows at our institution from March 2005 to June 2019; outcome measures included hernia recurrence, surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. The microsurgical skills were prospectively evaluated using the validated Structured Assessment of Microsurgical Skills at the start and end of the fellowship, in an animal laboratory model and clinical microsurgical cases. Multivariable hierarchical models were constructed to evaluate study outcomes. Results: We identified 44 fellows and 118 consecutive patients (52% women) who met our inclusion criteria. Independent fellows performed 55% (n = 65) of cases, and 45% were performed by integrated fellows. We found no significant difference in hernia recurrence, surgical site occurrences, surgical site infections, 30-day readmission, unplanned return to the operating room, or length of stay between the two groups in adjusted models. Although laboratory scores were similar between the groups, integrated fellows demonstrated higher initial clinical scores (42.0 ± 4.9 versus 37.7 ± 5.0, P = 0.04); however, the final clinical scores were similar (50.8 ± 6.0 versus 48.9 ± 5.2, P = 0.45). Conclusions: Independent and integrated fellows demonstrated similar long-term patient outcomes. Although integrated fellows had better initial microsurgical skills, evaluation at the conclusion of fellowship revealed similar performance, indicating that fellowship training allows for further development of competent surgeons.

No Association of Sirolimus with Wound Complications in Children With Vascular Anomalies.

INTRODUCTION: Sirolimus has demonstrated effectiveness as a treatment option for several types of vascular anomalies; however, it has a potential side effect of delayed surgical wound healing. The purpose of this study was to evaluate the association of sirolimus with postoperative complications in the pediatric vascular anomaly population. METHODS: A retrospective cohort study was performed for children with a vascular anomaly who underwent excision or debulking of the anomaly from 2015 to 2020. Patient demographics, vascular anomaly characteristics, operative variables, sirolimus dosing information, and perioperative outcomes were collected. Univariate analysis was performed to compare outcomes based on the administration of sirolimus. RESULTS: Forty-seven patients with vascular anomalies underwent 57 surgical procedures (36 without perioperative sirolimus, 21 with perioperative sirolimus). The median age at the time of surgery was seven years (IQR 1.7-14.0). The most common anomalies were lymphatic and venolymphatic malformations. Of the patients administered perioperative sirolimus, the median preoperative and postoperative sirolimus levels were comparable (preoperative 6.9 ng/mL (IQR 4.9-10.1), postoperative 6.5 ng/mL (IQR 4.7-9.4)). The rate of postoperative complications (sirolimus 19%, without sirolimus 11%; p = 0.45) and wound complications (sirolimus 14%, without sirolimus 6%; p = 0.26) were comparable between the cohorts. CONCLUSION: Our results suggest sirolimus may not significantly increase perioperative complication rates in pediatric patients undergoing resection of their vascular anomaly. LEVEL OF EVIDENCE: Level III.

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.

Did the COVID-19 Pandemic Impact the Caliber of Trainees Taken During Match 2021? A Survey of General Surgery Residency Program Directors.

BACKGROUND: The cancellation of clinical rotations (CRs) and implementation of virtual interviews (VIs) profoundly affected the residency selection process leading up to the 2021 NRMP Match. The authors investigated how these changes influenced the caliber of applicants taken by general surgery (GS) residency programs from the perspectives of program directors (PDs). METHODS: A 14 question, web-based electronic survey was emailed to PDs of ACGME-accredited GS residency programs. Questions sought program characteristics and PDs' perspectives regarding potential differences in subjective characteristics and clinical skills demonstrated by their 2021 Match class relative to previous resident classes. RESULTS: A total of 75 PDs (27.2%) responded to our survey. Most respondents observed no changes in residents' fit with their program (72.0%), communication skills (68.0%), responsiveness to clinical instruction and feedback (73.3%), work ethic (73.3%), and rotation evaluations (68.0%). Only 21.3% of PDs believed that VIs negatively impacted their ability to accurately assess applicant intangibles. Conversely, 56.0% of PDs reported that the cancellation of CRs in 2020 negatively affected residents' clinical competency at the start of residency. At 1-year following the 2021 NRMP Match, 30.7% of PDs reported that the clinical skills exhibited by their 2021 Match class were poorer than previous resident classes. DISCUSSION: Our findings suggest that VIs limited selection committees' ability to accurately assess applicant's subjective characteristics to a lesser degree than previously described in the literature. Canceled CRs adversely affected the 2021 Match Class's clinical skills at the start of residency and at 1 year following the 2021 NRMP Match.

Mandibular Fracture in a Hemifacial Microsomia Patient following Implant Failure and Hardware Infection: A Case Report.

Hemifacial microsomia (HFM) is a complex congenital condition with heterogeneous malformations of the facial skeleton that almost always involves mandibular hypoplasia. Here we introduce a unique case in which a patient with HFM had initially successful optimization of facial symmetry using a polyetheretherketone implant for mandibular augmentation. However, multiple factors associated with the intraoperative and postoperative course, including hardware failure and infection, led to diminished mechanical strength of the mandible, ultimately resulting in a mandibular fracture. In this unique case presentation of HFM, we discuss the various factors that contributed to mandibular weakness and increased susceptibility to fracture.

Arteriovenous Malformations of the Hand: Optimizing Outcomes with Palmar Arch Reconstruction.

BACKGROUND: Arteriovenous malformations are abnormal high-flow vascular anomalies that can greatly alter the structure of surrounding tissues. Treatment of symptomatic hand arteriovenous malformations must address the functional and aesthetic considerations of the hand. Nonsurgical treatment such as embolization continues to be plagued by complications such as digital ischemia and secondary need for amputation. In this study, the authors describe their experience treating hand arteriovenous malformations with wide resection and microsurgical reconstruction of the palmar arch. This technique aims to optimize postoperative function and minimize postoperative complications and recurrence. METHODS: Retrospective review identified five patients who underwent surgical excision of hand arteriovenous malformations performed by two of the senior authors (W.C.P. and M.M.) between 2002 and 2020. Four patients underwent reconstruction of the palmar arch, whereas one patient underwent ray amputation of the involved index finger only. One patient required concurrent free flap for soft-tissue coverage following resection. RESULTS: Mean age at the time of surgery was 34.6 years. After an average follow-up of 2.7 years, there were no postoperative complications, functional deficits, or recurrences. The patient who underwent ray amputation only was postoperatively noted to have pulsatile dorsal veins concerning for a persistent high-flow state, although no recurrent mass was seen at limited 1-year follow-up. CONCLUSIONS: Meticulous surgical excision with microvascular reconstruction is an acceptable technique for management of symptomatic hand arteriovenous malformations. Potential soft-tissue loss does not preclude aggressive resection. Wide excision with palmar arch reconstruction minimizes complications, optimizes functionality, and may prevent ischemia that could otherwise trigger recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Impact of the Virtual Format on Plastic Surgery Residency and Fellowship Interviews: A National Cross-Sectional Study.

BACKGROUND: The 2020 to 2021 residency and fellowship application cycles were profoundly affected by the introduction of virtual interviews. The authors investigated the impact the virtual format had on plastic surgery residency and fellowship interviews from the perspectives of program directors. METHODS: Surveys were sent to program directors of integrated plastic surgery residency and fellowship programs to ascertain their perspectives regarding the virtual format's impact on residency and fellowship interviews. Program directors were stratified into residency and fellowship cohorts, and comparative analysis was performed. RESULTS: Ninety-two program directors, 28 from integrated plastic surgery residency programs and 64 from fellowship programs, completed our survey (35 percent). Compared to in-person interviews, virtual interviews were reported to be more economical and time efficient by program directors of residency (100 percent and 46 percent, respectively) and fellowship programs (97 percent and 48 percent, respectively). Consequentially, 36 percent and 47 percent of residency and fellowship programs were able to interview more applicants, respectively. Program directors of residency and fellowship programs reported that virtual interviews hindered their ability to assess applicants' fit with the program (75 percent and 63 percent, respectively), personality and communication skills (75 percent and 64 percent, respectively), and commitment to the field, along with their ability to function as a trainee (57 percent and 50 percent, respectively). Overall, 71 percent of program directors of residency and 58 percent of program directors of fellowship programs preferred in-person interviews. The majority of residency (71 percent) and fellowship (56 percent) program directors intend to conduct both in-person and virtual interviews in future application cycles ( p = 0.12). CONCLUSIONS: Despite preferring in-person interviews, program directors intend to host both in-person and virtual interviews in future application cycles. It remains to be seen how virtual interviews will be used moving forward.

The Challenges of Upper Extremity Intramuscular Hemangioma: A Case Study and Systematic Review.

BACKGROUND: Intramuscular hemangiomas are rare, benign vascular tumors, constituting 0.8 percent of all hemangiomas. Upper extremity intramuscular hemangiomas pose diagnostic and therapeutic challenges because of their rarity, invasive nature, and potential for neurovascular involvement. The authors report a comprehensive systematic review of upper extremity intramuscular hemangioma management and a challenging case report. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were used to identify articles describing upper extremity intramuscular hemangiomas through 2019. Patient demographics, clinical presentation, management, complications, and outcomes were reviewed. Based on operative timing, cases were categorized as either "primary" (excision performed at initial diagnosis) or "secondary" (excision performed after failure of conservative treatment). RESULTS: Eighteen articles encompassing 25 patients were included in the authors' systematic review. Of those, 18 underwent primary excision and seven underwent secondary excision. The majority involved the forearm or antecubital region. Complete excision, evaluated by gross examination or pathology, was reported in all primary cases and 71 percent of secondary cases. Primary excisions demonstrated smaller size of mass (19.4 cm 2 versus 165.3 cm 2 ) and superior reported functional outcomes (100 percent versus 33 percent). Complications were reported in 5 percent of the primary excisions compared to 71 percent of the secondary excisions, where one complication was a fatal hematoma. CONCLUSIONS: The literature concerning upper extremity intramuscular hemangioma is limited to mostly case reports and several case series with the potential risk of bias. With careful dissection and microsurgical technique, wide local excision followed by complete reconstruction can be successfully performed at initial diagnosis for upper extremity intramuscular hemangiomas. At early stages, smaller lesion size significantly reduces the risk of functional impairment and complications.

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.

Comparison of Outcomes of Abdominal Wall Reconstruction Performed by Surgical Fellows vs Faculty.

Importance: Concern regarding surgical trainees' operative autonomy has increased in recent years, emphasizing patient safety and preparation for independent practice. Regarding abdominal wall reconstruction (AWR), long-term outcomes of fellow autonomy have yet to be delineated. Objectives: To evaluate the long-term outcomes of AWRs performed by fellows and compare them with those of AWRs performed by assistant, associate, and senior-level professors. Design, Setting, and Participants: This retrospective cohort study included patients who underwent AWR for ventral hernias or repair of tumor resection defects at a 710-bed tertiary cancer center between March 1, 2005, and June 30, 2019. The analysis was conducted between January 2020 and December 2021. Exposure: Academic rank of primary surgeon. Main Outcomes and Measures: The primary outcome was hernia recurrence. Secondary outcomes were surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. Multivariable hierarchical models were constructed to identify predictive factors. Results: Of 810 consecutive patients, 720 (mean [SD] age, 59.8 [11.5] years; 375 female [52.1%]) met the inclusion criteria. Mean (SD) body mass index was 31.4 (6.7), and mean (SD) follow-up time was 42 (29) months. Assistant professors performed the most AWRs (276 [38.3%]), followed by associate professors (169 [23.5%]), senior-level professors (157 [21.8%]), and microsurgical fellows (118 [16.4%]). Compared with fellows and more junior surgeons, senior-level professors tended to operate on significantly older patients (mean [SD] age, 59.9 [10.9] years; P = .03), more patients with obesity (103 [65.6%]; P = .003), and patients with larger defects (247.9 [216.0] cm; P < .001), parastomal hernias (27 [17.2%]; P = .001), or rectus muscle violation (53 [33.8%]; P = .03). No significant differences were found for hernia recurrence, surgical site occurrence, surgical site infection, 30-day readmission rates, or length of stay among the fellows and assistant, associate, and senior-level professors in adjusted models. Compared with fellows, assistant professors (OR, 0.22; 95% CI, 0.08-0.64) and senior-level professors (OR, 0.20; 95% CI, 0.06-0.69) had lower rates of unplanned return to the operating room. Conclusions and Relevance: This cohort study provides evidence-based reassurance that providing fellows with autonomy in performing AWRs does not compromise long-term patient outcomes. These findings may incite efforts to increase appropriate surgical trainee autonomy, thereby empowering future generations of competent, independent surgeons.

Impact of the Virtual Interview Format on Urology Residency Interviews: A Survey of Program Directors.

INTRODUCTION: Our objective is to assess the impact of the virtual interview (VI) format on urology residency interviews during the COVID-19 pandemic from the perspectives of program directors (PDs). METHODS: An anonymous survey was sent to PDs of American Council for Graduate Medical Education-accredited urology residency programs. Questions were designed to evaluate how VIs affected programs' assessment of applicants, interview logistics, and overall perspectives regarding in-person and virtual interviews. RESULTS: A total of 42 PDs (31%) responded to our survey. VIs negatively affected programs' ability to assess applicants' fit with their residency program (71%), commitment to urology along with their ability to function as a resident (67%), and personality and communication skills (71%) when compared to in-person interviews. Fifty percent of PDs reported that they relied more heavily on objective metrics when ranking applicants, compared to prior years. VIs were more economical than in-person interviews for all participating programs, with each program saving an average of $3,135 in interview-related costs. Additionally, 33% of PDs reported that VIs were less time-consuming when compared to in-person interviews, with 26% of PDs reporting that they were able to interview more applicants. Only 19% of PDs reported that VIs were better than in-person interviews. Given the option, 60% of PDs intend on hosting both virtual and in-person interviews moving forward, while 9% and 31% of programs intend to exclusively host virtual and in-person interviews, respectively. CONCLUSIONS: PDs perceived VIs to be less reliable than in-person interviews for subjective evaluation of applicants; however, many PDs still desire to integrate VIs in future application cycles.