Unmatched. What's Next? Is a Preliminary Year of Residency or Research Fellowship Better for Reapplicants to Plastic Surgery?

Background: Plastic and reconstructive surgery is one of the most competitive residency programs, and given the increased number of applicants for a relatively fixed number of positions, successfully matching is a challenge. Match rates have declined since 2018, with a match rate of ~55% in 2022. Two common options before reapplying are a preliminary year of residency (preliminary year) or a research fellowship. This study investigated which option is more beneficial for reapplicants seeking a successful match. Methods: This retrospective study included all applicants to an integrated plastic and reconstructive surgery residency from 2015 to 2023. Two cohorts based on reapplication strategy (research fellowship or preliminary year) were created. Demographic, applicant, and match data were collected. Pearson chi-squared, Fisher exact, and Wilcoxon rank sum testing were performed. Results: In total, 125 reapplicants were included. Seventy-one (56.8%) reapplicants pursued a preliminary year, and 29 (23.2%) completed a research fellowship. Research fellowship reapplicants had a greater mean number of first author publications (8.8 versus 3.2, P < 0.001), non-first author publications (11.3 versus 5.9, P = 0.021), poster presentations (9.7 versus 6.0, P = 0.028), and oral presentations (11.8 versus 6.4, P < 0.001). Research fellowship reapplicants were more likely to match into plastic and reconstructive surgery (PRS) than preliminary year reapplicants, with 72.4% (n = 21) of research fellowship reapplicants matching into PRS compared with 39.4% (n = 28) of preliminary year reapplicants (P = 0.003). Conclusions: Research fellowship reapplicants demonstrated greater research productivity and were almost twice as likely to match into PRS compared with preliminary reapplicants.

A Day in the Life of a Surgical Instrument: The Cycle of Sterilization.

Surgeons must be confident that the instruments they use do not pose risk of infection to patients due to bioburden or contamination. Despite this importance, surgeons are not necessarily aware of the steps required to ensure that an instrument has been properly sterilized, processed, and prepared for the next operation. At the end of an operation, instruments must be transported to the sterile processing unit. There, instruments are decontaminated before being sterilized by heat, chemical, or radiation-based methods. Following this, they are stored before being brought back into use. This review highlights the intricacies of the processing of surgical instruments at the conclusion of an operation so that they are ready for the next one.

Picture Perfect: Standardizing and Safekeeping Clinical Photography in Plastic Surgery.

Plastic surgery relies heavily on clinical photography to document preoperative and postoperative changes, visualize surgical approaches, and evaluate outcomes. However, the contemporary landscape of plastic surgery photography faces challenges, including a lapse in standards due to the prevalence of smartphones, social media platforms, and security concerns related to data storage and cyberattacks. In this comprehensive review, the authors aim to provide plastic surgeons with practical guidelines for achieving standardized, high-quality clinical photography while navigating the evolving landscape of technology, security, and ethical considerations. We explore the security challenges associated with storing clinical photographs, emphasizing the legal obligations under the Health Insurance Portability and Accountability Act (HIPAA). We also discuss various storage options, including HIPAA-compliant cloud services, electronic medical records, and emerging technologies like blockchain and artificial intelligence.

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.

Indocyanine Green Angiography Overpredicts Postoperative Necrosis Compared to Multispectral Reflectance Imaging.

BACKGROUND: Sufficient perfusion is foundational to successful reconstructive surgery. Various technologies have been developed to help determine whether tissue is adequately perfused, or whether it will be prone to necrosis postoperatively. Indocyanine green (ICG) angiography is one such method that uses fluorescence and analyzes tissue perfusion. Multispectral reflectance imaging (MSRI) is an alternative technology that analyzes optical properties of oxygenated and deoxygenated hemoglobin to determine tissue viability. Because tissue in low-perfusion states may still survive because of sufficient oxygenation, the authors hypothesized that compared to MSRI, ICG angiography overpredicts necrosis, potentially resulting in unnecessary resection of viable tissue. This study expands on preliminary work to investigate this hypothesis. METHODS: This was a prospective cohort of patients undergoing prepectoral direct implant reconstruction at a single institution. Each patient was examined intraoperatively with both ICG angiography and MSRI. Decisions to resect tissue were made in conjunction with MSRI and ICG images collected purely for data analysis. Patients were followed postoperatively for at least 2 months for signs of postoperative necrosis. RESULTS: Fifty-three cases were included. ICG angiography accurately predicted viability in 40 of 40 patients (100%) and incorrectly predicted necrosis in 11 of 13 patients (84.6%). Simultaneously, MSRI predicted necrosis in zero patients and accurately predicted viability in 51 of 53 patients (96.2%). There was no statistically significant difference in demographic data among patients predicted to experience necrosis by means of ICG angiography versus those predicted to have entirely viable tissue. CONCLUSION: This study suggests that ICG angiography is prone to overpredicting postoperative necrosis in comparison to MSRI. CLINICAL RELEVANCE STATEMENT: This study suggests that multispectral reflectance imaging may benefit practicing plastic surgeons in determining the likelihood of postoperative necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

A Second Drain Decreases Seroma Formation in Prepectoral Immediate Breast Reconstruction with an Acellular Dermal Matrix.

Seroma formation is the most common complication after mastectomy. While the exact pathophysiology behind seroma development has not been entirely elucidated, seromas are associated with negative outcomes in breast reconstruction. The utilization of drains is one method to combat seroma. However, the current state of plastic surgery is divided as to whether one drain or two drains is optimal in reducing seroma formation. We hypothesized that using two drains instead of one drain would reduce the risk of seroma more so than one drain. Methods: This was a retrospective cohort study of patients who underwent prepectoral direct to implant reconstruction at a single institution by a single surgeon. Each patient underwent reconstruction with either one or two drains. Patients were followed postoperatively for rates of seroma formation. Seroma were classified as either minor or major. Secondary variables including drain duration, infection, and necrosis were also analyzed. Results: A total of 99 breasts and 71 patients experienced breast reconstruction with two drains, and 163 breasts corresponding to 135 patients received reconstruction with one drain. In the two drain cohort, 14 (14.1%) developed a seroma, with 11 (11.1%) being minor seromas and three (3.03%) being major seromas. In comparison, out of the one drain cohort, 41 (25.2%) developed a seroma, with 35 (21.5%) being a minor seroma and six (3.68%) being classified as major. Conclusion: This study suggests that two drains decreases the rate and risk of seroma formation compared to one drain in prepectoral breast reconstruction with an acellular dermal matrix.

Is systematic lymph node dissection mandatory or is sampling adequate in patients with stage I non-small-cell lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Is systematic lymph node dissection (SLND) mandatory or is sampling adequate in stage I non-small-cell lung cancer (NSCLC)? Two hundred and eleven papers were identified, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and the results of these papers are tabulated. There are 7 retrospective cohort reviews, 3 meta-analyses and 2 randomized controlled clinical trials (RCTs) to answer the clinical question. Four of the 7 retrospective studies demonstrated that the total number of resected lymph nodes and the number of lymph node stations sampled affected the accuracy of staging in patients with early-stage NSCLC and had an impact on overall survival and disease-free survival. Two RCTs, 1 meta-analysis and 1 cohort study revealed no significant benefit in overall survival and disease-free survival in patients undergoing SLND. One meta-analysis, which contained only 1 RCT, revealed significantly better 3- and 5-year survival with SLND. One further meta-analysis revealed improved survival with SLND in cohort studies but no significant difference in the 4 RCTs included. Two further studies identified specific subgroups of patients in whom LN sampling could be justified and SLND avoided. We conclude that there is no significant difference in the recurrence rate when performing either SLND or LN sampling in patients with stage I NSCLC. While retrospective cohort studies implied survival benefit with SLND, this was not borne out in RCTs and meta-analyses. However, there may be a potential survival benefit for patients who are upstaged by SLND identifying mediastinal nodal involvement.

Human Exposure to Radioactivity From Tobacco Smoke: Systematic Review.

INTRODUCTION: Tobacco has been known to contain radioactive polonium and lead for 50 years but the literature is divided as to the public health significance. I review the data on tobacco radioactivity and its internalization by smokers. METHODS: Data sources: Reports of lead-210 and polonium-210 content of tobacco leaf, cigarettes, cigarette smoke, and human respiratory tissues, published between 1964 and September 2017. Study selection: Any identified study that reported values for lead-210 and polonium-210 content. Data extraction: Data quality was addressed by comparative review of analytic methods. RESULTS: The data about radiation content of tobacco and smoke are robust. Early reports suggesting microsievert lifetime doses of inhaled radioactivity to smokers were not borne out. The results remain sensitive to pharmacological assumptions around absorption and redistribution of inhaled radionuclides, and radiobiological assumptions about interaction with human tissues. CONCLUSIONS: Literature on tobacco radioactivity has not fully contended with pharmacological and radiobiological uncertainty, and is therefore divided as to health significance. This does much to explain regulatory inaction over the last half century. Before radiation safety law can offer a vehicle for tobacco control, more must be learnt about the pharmacology and radiobiology of inhaled radionuclides in tobacco smoke. IMPLICATIONS: This work makes it apparent that the study of tobacco smoke radioactivity has been scientifically stagnant for the last 40 years. The field cannot advance until we improve understanding of the pharmacology and radiobiology of inhaled radionuclides in tobacco smoke. Despite this, a subset of contemporary authors is still suggesting individual health risks about 1000 times higher than can be supported by internationally accepted models.

REPRODUCTIVE HORMONE PATTERNS IN MALE AND FEMALE COWNOSE RAYS ( RHINOPTERA BONASUS) IN AN AQUARIUM SETTING AND CORRELATION TO ULTRASONOGRAPHIC STAGING.

Reproductive management of cownose rays ( Rhinoptera bonasus) under professional care plays an important role in conservation of the species, but hormone and ultrasonographic analyses of their 12-mo reproductive cycle have not been documented previously. Plasma reproductive hormone concentrations (17B-estradiol, progesterone, testosterone, and androstenedione) were measured monthly via radioimmunoassay for 1 yr in an aquarium-managed population of adult females ( n = 15) and males ( n = 5). Ultrasounds of the uterus were performed each month at the time of sample collection to identify gestation stage (0-5) based on a previously developed in-house staging system. Stages were correlated to hormone concentrations to track progression through pregnancy. Thirteen females were reproductively active, and each produced one pup in March-June, similar to timing for free-ranging populations. Female estradiol increased steadily throughout gestation from stages 0 to 5, while progesterone, testosterone, and androstenedione were increased only in early gestation (stages 1 and 2). Unlike month of year, gestation stage strongly predicted hormone concentration, but specific values to predict parturition date were not identified. Male testosterone and progesterone were higher in March-June (mating season) than July-January, while estradiol and androstenedione did not exhibit a seasonal pattern. Aquarium-managed cownose rays have similar reproductive patterns to what is reported in wild populations. Ultrasonographic monitoring with serial hormone analysis and accurate mating records will provide the most useful information for managing a reproductive population of cownose rays in an aquarium setting.

Hybrid model intermediate between a laboratory and field study: A humane paradigm shift in feline research.

OBJECTIVES: Non-surgical contraceptives are under development to provide accessible, affordable and humane alternatives for the management of free-roaming cat populations. The objective of this project was to develop a research approach for promising non-surgical contraceptives using outbred cats in a simulated free-roaming setting, meeting high standards for both animal welfare and scientific rigor. METHODS: A facility, specially constructed with indoor and outdoor living areas, was approved and regulated as both an animal shelter and a United States Department of Agriculture research facility. Thirty female and five male cats, healthy but at high risk of euthanasia, were recruited from animal shelters and private homes. Guided by a detailed protocol, cats were housed in this facility for up to 18 months after acclimatization. Cats were administered the study product or a placebo, and then entered into a breeding trial. Cats were adopted at the end of the study. A range of methods was used to provide enrichment and balance a natural environment with the need for detailed daily monitoring. RESULTS: Primary study results related to contraceptive safety and efficacy are published separately. Achieving a research model that is an intermediate step between a laboratory and an uncontained free-roaming cat colony was complex. Significant learnings shared in this current publication span: the selection of cats; acclimatization to a simulated colony environment; cat behavioral training during the study and in preparation for adoption; disease management; contract staff and volunteer support; and cat behavior throughout a breeding study. CONCLUSIONS AND RELEVANCE: This model inspires continued movement away from the paradigm of breeding cats for research and instead sources existing cats at risk for euthanasia. The housing and management of the cats elevates research animals' quality of life and provides positive post-study outcomes. While not appropriate for every feline research scenario, this hybrid model (between a laboratory and field study) proved to be a practical, humane and reliable scenario for research requiring a simulated real-world environment.

Pharmacokinetics of a Single Dose of Oral and Intramuscular Meloxicam in African Penguins ( Spheniscus demersus).

Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that has been used orally and intramuscularly in numerous avian species, but not studied to date, in African penguins ( Spheniscus demersus). The study describes the pharmacokinetic parameters of meloxicam after oral and intramuscular administration to African penguins. Several pilot studies were conducted initially where meloxicam (1, 0.5, and 0.25 mg/kg) was given intramuscularly to 4 birds, and orally (1 mg/kg) to 2 birds. Based on pilot study results, one group of 8 penguins was given meloxicam 0.5 mg/kg intramuscularly and one group of 8 penguins was given 1 mg/kg orally. Blood samples were collected at baseline and at 11 time intervals per group after administration of meloxicam. Meloxicam time to maximum plasma concentration (Tmax), maximum concentration (Cmax), and half-life (t1/2) after intramuscular administration were 1.00 hour, 8.03 µg/mL, and 31.87 hours, respectively, while oral administration produced a Tmax, Cmax, and t1/2 of 12.00 hours, 10.84 µg/mL, and 28.59 hours, respectively. Based on plasma meloxicam concentrations found to be therapeutic in other bird species and humans, the recommended dosage and frequency for African penguins is 1 mg/kg orally every 48 hours and 0.5 mg/kg intramuscularly every 24 hours. Further studies are needed to determine the multiple-dose pharmacokinetics of meloxicam in African penguins.

The role of surgical resection in Unicentric Castleman's disease: a systematic review.

INTRODUCTION: Castleman's disease is a rare benign lymphoproliferative disorder of unknown etiology. The disease occurs in two clinical forms with different prognoses, treatments and symptoms: a unicentric form (UCD), which is solitary, localized, and a multicentric form characterized by generalized lymphadenopathy and systemic symptoms. This article aims to review the current literature to consolidate the evidence surrounding the curative potential of surgical treatment to the unicentric type. MATERIAL AND METHODS: A systematic review of English-language literature was performed and databases (Medline, Pubmed, the Cochrane Database and grey literature) were searched to identify articles pertaining to the treatment of unicentric form of Castleman's disease. Each article was critiqued by two authors using a structured appraisal tool, and stratified according to the level of evidence. RESULTS: After application of inclusion criteria, 14 studies were included. There were no prospective randomized control studies identified. One meta-analysis including 278 patients with UCD reported that resective surgery is safe and should be considered the gold standard for treatment. Seven retrospective studies enhance this standpoint. Radiotherapy (RT) has been used in six studies with controversial results. CONCLUSIONS: We conclude that surgical resection appears to be the most effective treatment for Unicentric Castleman's Disease of the thoracic cavity. Radiotherapy can also achieve clinical response and cure in selected patients.

Effectiveness of GonaCon as an immunocontraceptive in colony-housed cats.

Objectives Non-surgical contraceptive management of free-roaming cat populations is a global goal for public health and humane reasons. The objectives of this study were to measure the duration of contraception following a single intramuscular injection of a gonadotropin-releasing hormone-based vaccine (GonaCon) and to confirm its safe use in female cats living in colony conditions. Methods GonaCon (0.5 ml/cat) was administered intramuscularly to 20 intact female cats (queens), and saline was administered to 10 queens serving as sham-treated controls. Beginning in late February, 4 months after injection, all cats were housed with fertile male cats in a simulated colony environment. Time to pregnancy, fetal counts and vaccine-elicited injection-site reactions were evaluated. Results All control cats (n = 10/10) and 60% (n = 12/20) of vaccinated cats became pregnant within 4 months of the introduction of males. Two additional vaccinates became pregnant (70%; n = 14/20) within 1 year of treatment. Average fetal counts were significantly lower in vaccinated cats than in control cats. Vaccinates had a significantly longer ( P = 0.0120) median time to conception (212 days) compared with controls (127.5 days). Injection-site reactions ranging from swelling to transient granulomatous masses were observed in 45% (n = 9/20) of vaccinated cats. Conclusions and relevance A single dose of GonaCon provided contraception lasting for a minimum of 1 year in 30% (n = 6/20) of treated cats. The level of contraception induced by this GonaCon dose and vaccine lot was not sufficiently effective to be recommended for use in free-roaming cats.

The role of sympathectomy in long QT syndrome.

Long QT syndrome (LQTS) is an uncommon and potentially fatal cardiac channelopathy. Treatment options can be medical with ß-blockers or surgical with implantable cardioverter defibrillator (ICD) implantations and left cardiac sympathetic denervation (LCSD). Purpose of this paper is through a literature review to identify the management algorithm and the role of sympathectomy in LQTS.

Arterial Thoracic Outlet Syndrome Treated Successfully with Totally Endoscopic First Rib Resection.

Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. TOS may be classified as either neurogenic TOS (NTOS) or vascular TOS: venous TOS (VTOS) or arterial TOS (ATOS), depending on the specific structure being affected. The basis for the surgical treatment of TOS is resection of the first rib, and it may be combined with scalenectomy or cervical rib resection. Herein, we describe a case of arterial thoracic outlet syndrome which was successfully treated with totally endoscopic video-assisted thoracoscopic surgery (VATS) first rib resection.

Short and long-term impact of parathyroid autotransplantation on parathyroid function after total thyroidectomy.

The most common complication of total thyroidectomy is parathyroid insufficiency. Acute, transient, post-operative hypoparathyroidism increases length of hospitalization, morbidity and cost associated with total thyroidectomy. While permanent hypoparathyroidism poses a significant medical burden with lifetime medication, regular follow up and considerable disease burden related to chronic renal failure and other sequelae. Parathyroid autotransplantation has been demonstrated to result in biochemically functional grafts, leading to the procedures' common use during total thyroidectomy. The clearest indications for parathyroid auto transplantation are inadvertently removed or devascularized parathyroid glands. Some centers utilize routine autotransplantation to reduce the risk of permanent hypoparathyroidism. Novel fluorescence techniques to aid in parathyroid detection during thyroid surgery are under evaluation. This review aims to define the role and impact of parathyroid autotransplantation undertaken during total thyroidectomy.

Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) causes neurologic symptoms in 95% of cases and vascular symptoms in 5% of cases. Surgical resection is curative. Endoscopic-assisted transaxillary first rib resection has been previously reported. In this study we report a totally endoscopic video-assisted thoracoscopic surgery (VATS) approach using tailored endoscopic instruments. METHODS: Ten patients (8 women; average age, 32.3 ± 5.6 years) with TOS underwent VATS first rib resection following failure of symptom improvement with physiotherapy. Symptoms were: unilateral neurogenic (n = = 7), bilateral neurogenic (n = = 2), and bilateral arterial compression (n = = 1). Three standard VATS ports were utilized. The parietal pleura and periosteum overlying the first rib were stripped avoiding injury to the neurovascular bundle. The rib was transected with an endoscopic rib cutter and resected completely in a piecemeal fashion using endoscopic bone nibblers. All periosteal remnants were trimmed releasing the neurovascular bundle completely. RESULTS: Patients were discharged within 72 hours following surgery. One patient had the contralateral side treated 18 months later and another patient is awaiting the second surgery. At follow-up, 9 patients had complete resolution of their main symptoms. One patient with neurogenic TOS developed mild functional and sensational loss of the non-dominant hand that improved within 8 months with physiotherapy. CONCLUSIONS: VATS first rib resection for TOS provides, unlike the classic approaches, a superior, magnified, and well-illuminated view of the thoracic inlet. It allows good posterior trimming of the first rib, release of brachial plexus, and an aesthetically pleasing result, especially in female patients.

Comparison of hematology, plasma biochemistry, and blood gas variables between 2 venipuncture sites in Southern Stingrays (Dasyatis americana).

BACKGROUND: The Southern Stingray (Dasyatis americana) is a batoid elasmobranch frequently exhibited in zoological institutions. Blood is commonly collected from the caudal hemal arch at the tail base in stingrays for the purpose of health assessment and clinical pathology tests. An alternative site that allows a dorsal or ventral approach without necessitating puncture of a cartilaginous structure has been identified between the cartilaginous pectoral fin rays (ceratotrichia). OBJECTIVES: The purpose of the study was to compare CBC, plasma biochemistry analytes, and blood gas variables between blood samples collected from the caudal and pectoral fin vasculature sites of the Southern Stingray. METHODS: Fifteen captive Southern Stingrays (10 females, 5 males) from 4 zoo and aquarium facilities were sampled. Lithium heparinized blood samples were collected from the caudal and pectoral venipuncture sites of each animal. Values from estimated total and differential leukocyte counts, plasma biochemistry analytes, and blood gas variables were compared. RESULTS: There were no statistically significant differences between venipuncture sites for the measured analytes except for CK activity, which was statistically significantly higher in the pectoral site samples. Levels of agreement between sites were good or moderate for 22 analytes and poor for ALT, AST, CK, pO2 , lactate, monocytes, and eosinophils. CONCLUSIONS: The good agreement between sampling sites for the majority of the measured analytes and the lack of differences that would alter clinical interpretation support the use of the pectoral site as an alternative to the traditional caudal fin venipuncture site in Southern Stingrays.