What COVID Restrictions Have Taught Us About Visiting Subinternships.

BACKGROUND: Integrated plastic surgery applicants complete among the highest number of visiting audition rotations of any specialty. In the 2021 match, we observed that the elimination of audition rotations and in-person interviews drastically increased the number of applicants who matched at their home program. We sought to evaluate the effect of applicants participating in one selective visiting subinternship rotation on home program match rates. METHODS: Top 50 plastic surgery residency programs were identified by 2021 Doximity rankings. Publicly available, online plastic surgery match spreadsheets were used to collect available information including matched applicants' medical school, the institution at which they matched, whether they matched at their home institution, and whether they had previous communication with their matched program including research year or visiting subinternship completed. RESULTS: Fourteen percent of applicants matched at their home institution in 2022, comparable with recent prepandemic rates of 14.1% and 16.7%, versus 24.1% in 2021. The largest effect was observed among the top 25 programs. Separately, approximately 70% of applicants provided self-reported information on whether they completed a subinternship. Among the top 50 programs, 39.0% of applicants completed an audition rotation at the institution at which they eventually matched. CONCLUSIONS: The allowance of medical students to perform only one visiting subinternship in the 2022 match cycle normalized home match rates to the prepandemic baseline, possibly driven by a large proportion of students matching at their visiting rotation institution. Perhaps from both a program and applicant standpoint, 1 away rotation may provide sufficient exposure for eventual match success.

Application of Trapezoid Orbital Septum Membrane Flap in Double-Eyelid Blepharoplasty.

BACKGROUND: For a long time, to achieve the natural shape of double-eyelid crease, multiple techniques of double-eyelid plastic surgery have been developed. We describe the trapezoid orbital septum membrane flap in blepharoplasty to achieve a dynamic double-eyelid crease and avoid a depressed static scar. METHODS: The authors developed a trapezoid orbital septum membrane flap in double-eyelid blepharoplasty. The flap base is fixed on the pretarsal plate with the distal end of the flap positioned between the superior and inferior edges of the incision. Layer-by-layer contraposition suturing is then performed. RESULTS: One hundred ninety-one cases of double-eyelid blepharoplasty were performed by a senior surgeon using the trapezoid orbital septum flap method. Patients were followed for 6 to 17 months. Twelve cases were revised secondarily. Patients were satisfied with the palpebral folds, which showed a dynamic crease followed with movements of the eyelids. CONCLUSIONS: The authors introduce a trapezoid orbital septum flap in upper eyelid blepharoplasty. The flap relies on the elasticity of the orbital septum flap as the levator aponeurosis extension segment to produce a natural crease without a depressed static scar.

Epidemiological Investigation of Facial Soft Tissue Injury in Chinese Preschool Children.

OBJECTIVE: The aim of this study was to analyze the epidemiological characteristics of pediatric facial soft tissue injuries of Chinese preschool-aged children in Hangzhou Plastic Surgery Hospital. METHODS: Medical records of preschool-aged children's facial injuries, 6 years and younger, from January 2017 to December 2019 were collected. Sex; age; time of injury; length of stay; causes of injury; location, type, length, and depth of wound; anesthesia methods; and treatment and evaluation of postoperative scars were analyzed. RESULTS: There were 10,862 cases (male, 6780 cases; female, 4082 cases) in the group. The ratio of male to female was 1.66:1. Mean age was 3.4 (±1.6) years; the youngest was 1 month old. The time of injury occurred frequently between 9:00 and 13:00 and 16:00 to 21:00, with the most common incident time being between 19:00 and 20:00. Collision injury was the main cause of injury (9822 [90.43%]). The most frequently injured area was the forehead (4874 [44.87%]). The main form of injury was laceration wound (9721 [89.45%]). The depth of injuries was mainly middle layer (adipose or muscular layer) (6299 [57.99%]). The length of injuries was 1.7 (±0.9) cm, ranging from 0.2 to 10.5 cm. Furthermore, 9110 cases were repaired by plastic surgeries and 1 or more antiscar measures. After 6-month to 2-year follow-up, 9 cases of animal scratch or bite, lip penetrating wound, or bumping teeth were infected and 26 cases had scar hyperplasia. The others achieved satisfactory results, and the scars were not obvious. CONCLUSION: Preschool-aged children's facial injuries have predictable patterns of occurrence, and targeted preventive measures can reduce the incidence rates. After facial injury, children should present for timely plastic surgery treatment and accept combined antiscarring measures to minimize postoperative scarring.

Application of External Nasal Skin Stretching in Asian Rhinoplasty.

ABSTRACT: Asian nasal characteristics include a low dorsum, short nose, and thick skin envelope, usually requiring lengthening and elevating the nose during rhinoplasty ( Facial Plast Surg Clin North Am 2007;15(3):293-307, v). The increase in rhinoplasty popularity has resulted in a greater prevalence of complications. In a severely short and contracted nose, an extensively scarred or contracted soft tissue envelope results in weak laxity and extensibility of the nasal skin. For these patients, the essential component of rhinoplasty is to improve skin texture and obtain a sufficient nasal skin soft tissue envelope. Tissue expanders have previously been utilized to expand nasal skin and soft tissue ( Plast Reconstr Surg 2006;118(6):1447-1452; Facial Plast Surg 2019;35(1):68-72). However, nasal anatomical characteristics have limited the clinical application of tissue expanders. This article introduces a simple, noninvasive, and easily adopted method of external nasal skin stretching, which was first proposed by the senior author. This approach has been accepted by rhinoplasty surgeons in China and widely used in clinic. The approach can improve skin laxity, yield extra nasal soft tissue, and create adequate soft tissue coverage of the reconstructed nasal framework to reduce the difficulty of surgery with a reliable clinical effect.

The Impact of COVID-19 on Plastic Surgery Home Program Match Rates.

BACKGROUND: Historically, integrated plastic surgery is one of the most competitive specialties in the residency match. In the 2020-2021 residency application cycle, plastic surgery programs were forced to adjust how they select applicants because of the COVID-19 pandemic disrupting visiting subinternships. We hypothesize that a higher proportion of plastic surgery applicants matched at their home institution during the 2020-2021 application cycle secondary to the implementation of COVID-19-related restrictions. METHODS: Between March 24 and 27, 2021, we used publicly available, online plastic surgery-specific spreadsheets to analyze plastic surgery applicant information over the course of 3 application cycles (2018-2019, 2019-2020, and 2020-2021) for the top 50 plastic surgery programs. We collected data corresponding to the matched plastic surgery applicants' medical school, the institution at which they matched, and whether they had previous communication with their matched program. RESULTS: Our search yielded information on 128 applicants from the 2019 match cycle, 129 applicants from the 2020 match cycle, and 133 applicants from the 2021 application cycle. In 2019 and 2020, 15 (11.7%) and 22 (17.1%) plastic surgery applicants matched at their home program, respectively. In 2021, 32 (24.1%) of plastic surgery applicants matched at their home program (P = 0.032). When stratified by reputation rank, home program match rates among programs ranked 1-25 in 2021 had a large increase over the 2020 match cycle (28.4% vs 16.7%), whereas the home match rates of programs ranked 26-50 in 2021 (17.3%) held level with that of 2020 (17.6%). Conversely, for those not matched to their home programs, only 20 (19.8%) in 2021 reported having had any prior contact with their matched programs compared with 54 (50.5%) in 2020 (P < 0.001). CONCLUSIONS: The 2020-2021 plastic surgery application cycle matched a significantly higher proportion of applicants at their home institution. With the temporary discontinuation of visiting subinternships during the 2020-2021 application cycle, it is likely that both plastic surgery programs and applicants compensate for this loss of in-person exposure by turning to home applicants and home institutions, respectively.

Comparable Effects on Healing between Autologous Diabetic Adipose-Derived Stem Cells and Allogeneic Normal Counterparts.

BACKGROUND: Adipose-derived stem cell (ASC) therapy is considered a promising strategy for improving impaired wound healing, especially in diabetics. Although the therapeutic potential of allogeneic ASCs from healthy donors is naturally limited, that of autologous ASCs from diabetic patients is questionable. The aim of this study was to investigate the impact of diabetic ASCs in the treatment of diabetic wounds. METHODS: Diabetic ASCs (DMA) and nondiabetic ASCs were isolated from db/db and C57BL/6J mice, and characterized by immunocytochemistry, proliferation, differentiation, and gene expression assays. The effects of both ASCs on healing were investigated using 36 male 10- to 12-week-old db/db mice. Wound size was measured semiweekly until day 28, and histologic and molecular analyses were performed at day 14. RESULTS: Both ASCs had fibroblast-like morphology and were CD44 + /CD90 + /CD34 - /CD45 - at passage 4. Compared with nondiabetic ASCs in vitro, DMA proliferative capability was restored by passage 4 ( P > 0.05). Although DMA osteogenesis was attenuated ( P < 0.01), both ASCs had similar adipogenesis and expressions of PPARγ/LPL/OCN/RUNX2 ( P > 0.05). In vivo experiments showed that, compared with phosphate-buffered saline control, both ASCs are comparable in improving wound healing ( P < 0.0001), angiogenesis ( P < 0.05), epithelial cell proliferation ( P < 0.05), and granulation tissue formation ( P < 0.0001). CONCLUSIONS: In both in vitro and in vivo murine models, DMAs have shown a comparable therapeutic capacity to normal ASCs in promoting diabetic wound healing by improving angiogenesis, reepithelialization, and granulation tissue formation. These results support clinical applications of autologous ASCs in diabetic wound treatments. CLINICAL RELEVANCE STATEMENT: This work has particular surgical relevance as it highlights a theoretical and clinical pathway to use diabetic patients' own ASCs to treat their wounds, bypassing any concerns of cross-host sourcing issues in regenerative medicine.

Improving Health Behaviors and Weight Parameters With Motivational Interviewing and the TEEEN Program in an Ethnically and Socioeconomically Diverse Pediatric Population.

Objective: Obesity affects 14.7 million children and adolescents in the United States. Children's health behaviors are affected by parental health practices. Therefore, pediatric obesity interventions should include parents. The objective of this study was to assess the changes in self-reported health behaviors in a diverse population attending the TEEEN program, with motivational interviewing of child-parent dyads as a key component, for 1 year. Methods: Here we assessed the changes in Family and Nutrition and Physical Activity (FNPA) screening tool scores, a tool that assesses obesogenic behaviors, in the context of MI of child-parent dyads in a racially, ethnically, and socioeconomically diverse population who attended the TEEEN (Teens, Empowerment, Education, Exercise, Nutrition) program, a nonclinic and family-based behavior program in Massachusetts, for 1 year. Results: Participation in the TEEEN program, which includes MI of child-parent dyads, was associated with a significant increase in the overall FNPA score (median change= 4 points, P = .007). We observed that 76.5% of children experienced a decrease in BMI% and BMI z-score. The change in BMI% (median= -0.9, P = .006) and change in BMI z-score (median= -0.2, P = .008) were statistically significant. Conclusion: Participation in the TEEEN program seemed to be beneficial based on aspects of the FNPA screening tool and changes in weight parameters. The FNPA screening tool enhanced-motivational interviewing of child-parent dyads shows promise as an approach to address obesogenic behaviors. This study provides a detailed framework for medical providers to address pediatric obesity in a nonclinic setting with less time constraints.

Disparate Responses in Match Outcome across Competitive Surgical Subspecialties to Pandemic Era Constraints: An Analysis of Impacts of Minimal Auditions.

OBJECTIVE: The Covid-19 pandemic eliminated nearly all visiting sub-internships. We seek to uncover match rate disparities across plastic surgery, otolaryngology, urology, and neurosurgery subspecialties with respect to in-person appraisals. These data aim to highlight the common practices as well as subtle differences that each subspecialty may be displaying in selecting their respective residency candidates. DESIGN: We accessed publicly available online spreadsheets between March 24 to 27 specific to the following surgical subspecialties: plastic surgery, otolaryngology, neurosurgery, and urology. We collected available information including the matched applicants' medical school, the institution at which they matched, and whether they had previous communication with their matched program. This data was then used to record whether the applicant matched at their home institution. SETTING: N/A PARTICIPANTS: N/A RESULTS: There was a statistically significant increase in the number of plastic surgery and otolaryngology applicants who matched at their home programs during the 2020 to 2021 application cycle. 12.1% and 17.2% of plastic surgery applicants matched at their home program in the 2018 to 2019 and 2019 to 2020 application cycles, compared to 25.0% during the 2020 to 2021 application cycle (p = 0.0345). Overall, 23.4% and 22.2% of otolaryngology applicants matched at their home program in the 2018 to 2019 and 2019 to 2020 application cycles, compared to 31.3% during the 2020 to 2021 application cycle (p = 0.0482). Neurosurgery and urology applicants did not demonstrate statistically significant differences in home match rates during the 2020 to 2021 application cycle (p = 0.164 and p = 0.105, respectively). CONCLUSIONS: Covid-19 related restrictions in the 2020 to 2021 match cycle led residency programs to utilize novel selection mechanisms to evaluate applicants. Without visiting sub-internships during the 2020 to 2021 match cycle, some programs appear to have intentionally favored candidates with whom they were previously acquainted. The significantly higher number of international medical graduates and non-senior medical graduates among neurosurgery and urology residencies, respectively, likely washed out the home matching effect among these specialties but does not discount the importance of in-person appraisals.

Comparison of Yield, Purity, and Functional Properties of Large-Volume Exosome Isolation Using Ultrafiltration and Polymer-Based Precipitation.

BACKGROUND: Mesenchymal stem cell-derived exosomes are known to produce effects similar to those of source cells and therefore represent a new approach in cell-free regenerative medicine. Their potential clinical application demands efficient isolation of stable and functional exosomes from a large volume of biological fluid. METHODS: Exosomes from adipose-tissue conditioned medium of the same volume were isolated using either (1) ultrafiltration with size exclusion or (2) ExoQuick-TC. The isolated exosomes were characterized by protein concentration, particle size, exosomal marker expression, RNA expression profiles, and roles in dermal fibroblast proliferation and migration. RESULTS: Both isolation methods produced exosomes within the size range defined for exosomes (50 to 200 nm) and common markers were enriched. Compared to the ExoQuick-TC precipitation method, the ultrafiltration method produced a significantly higher protein yield (p < 0.001) but a lower particle-to-protein ratio (p < 0.05); it also yielded higher RNA contents from the same fat tissue indicated by housekeeping genes, but with overall lower purity. The expression of several mRNAs and miRNAs related to tissue regeneration showed that there was no statistical difference between both methods, except miR-155 and miR-223 (p < 0.05). However, there was no difference in overall fibroblast proliferation and migration between exosomes isolated by these two methods. CONCLUSIONS: Ultrafiltration with size exclusion demonstrated higher yields, acceptable purity, and comparable biophysical properties and biological functions to the more expensive commercial precipitation method. Therefore, it may conceivably be translated into yield-efficient and cost-effective modalities for therapeutic purposes. CLINICAL RELEVANCE STATEMENT: Ultrafiltration with size exclusion may be amenable for exosome isolation from large-volume complex fluids such as tissue conditioned media for clinical application in future regenerative medicine.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review.

INTRODUCTION: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. METHODS: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. RESULTS: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. CONCLUSIONS: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.

Lateralization and Decreased Neck-Shaft Angle Reduces Scapular Notching and Heterotopic Ossification.

BACKGROUND: Lateralization of the glenosphere in reverse shoulder arthroplasty likely mitigates scapular notching; however, there is a paucity of data evaluating the effect of heterotopic ossification (HO) at the inferior aspect of the glenoid neck. METHODS: We retrospectively reviewed 107 consecutive reverse shoulder arthroplasty patients between April 2013 and April 2016. During the study period, the surgeon switched from a 2.5-mm lateral center of rotation and a 155° neck-shaft angle (NSA) to a 6- or 10-mm lateralized design with a 135° NSA. Preoperative and minimum 2-year postoperative patient-reported outcomes and range of motion were collected. Two-year postoperative radiographs were evaluated for scapular notching and HO. RESULTS: The lateralized center of rotation implant was 72% less likely to develop HO and 85% less likely to produce scapular notching than the medialized prosthesis. CONCLUSION: Implants with laterally offset glenospheres and 135° NSA may decrease postoperative HO and scapular notching. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

A Modification of the Active Compression Test for the Shoulder Biceps-Labrum Complex.

The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.