Resident Exposure and Involvement in Core Procedural Competencies within Pediatric Plastic Surgery.

Introduction: The implementation of competency-based residency training in plastic surgery is underway. Key competencies in plastic surgery have been previously identified, however, within the domain of pediatrics, data suggest limited exposure throughout training for Canadian graduates. This study aims to identify the exposure and involvement of residents in core pediatric cases. Methods: We performed a retrospective, multicenter review of plastic surgery resident case logs (T-Res, POWER, New Innovations) across 10 Canadian, English-speaking training programs between 2004 and 2014. Case logs were coded according to the 8 core pediatric competencies previously identified by a modified Delphi technique. Results: A total of 3061 of 59 405 cases (5.2%) logged by 55 graduating residents were core pediatric procedures with an average of 55.6 ± 23.0 cases logged per resident. The top 3 most commonly logged procedures were cleft lip repair, cleft palate repair, and setback otoplasty. The number of cases per program varied widely with the most at 731 and least at 85 logged cases. Roles across procedures have wide variation and residents are most commonly identified as the assistant rather than surgeon or co-surgeon. Conclusion: These findings highlight variability both within and across residency programs with a paucity of exposure and involvement in pediatric plastic surgery cases. This may present a conflict between current recommendations for residency-specific procedural competencies and true clinical exposure. Further curriculum development and simulation may be of benefit.

Introduction: La formation des résidents fondée sur les compétences est en voie d'être adoptée en chirurgie plastique. Les compétences clés sont d'ailleurs déjà établies, mais dans le domaine de la pédiatrie, les données indiquent que les diplômés canadiens y sont peu exposés pendant leur formation. La présente étude vise à déterminer l'exposition et la participation des résidents aux cas fondamentaux en pédiatrie. Méthodologie: Les chercheurs ont procédé à une analyse multicentrique rétrospective des registres de cas des résidents en chirurgie plastique (T-Res, POWER, New Innovations) de dix programmes de formation anglophones canadiens entre 2004 et 2014. Ils ont codé ces registres en fonction des huit compétences pédiatriques fondamentales préalablement déterminées par une technique Delphi modifiée. Résultats: Au total, 3 061 des 59 405 cas enregistrés (5,2 %) par 55 résidents de dernière année étaient des interventions pédiatriques fondamentales, et chaque résident a enregistré une moyenne de 55,6 ± 23,0 cas. Les trois interventions les plus enregistrées étaient la réparation de la fissure labiale, la réparation de la fissure palatine et l'otoplastie. Le nombre de cas enregistrés variait énormément d'un programme à l'autre, le plus élevé étant de 731 et le plus bas, de 85. Les rôles au cours des interventions étaient très variables, et les résidents étaient davantage qualifiés d'assistants que de chirurgiens ou de cochirurgiens. Conclusion: Ces observations font ressortir la variabilité des pratiques à la fois au sein des programmes de résidence et entre eux et démontrent le peu d'exposition et de participation des résidents aux cas de chirurgie plastique pédiatrique. Elles peuvent révéler un conflit entre les recommandations actuelles en matière de compétences interventionnelles des résidents et la véritable exposition clinique. Il pourrait être utile de voir à l'élaboration plus poussée du programme et des simulations.

Large-Volume Fat Grafting to the Breast With External Expansion Assist.

BACKGROUND: Large-volume autologous fat transfer (AFT) to the breast with external expansion has emerged as an alternative to alloplastic augmentation or reconstruction in appropriate patients. OBJECTIVES: Report the authors' technique for this procedure and experience with 49 consecutive patients of a single surgeon's practice from 2013 to 2021. METHODS: The authors performed a retrospective analysis of consecutive patients undergoing fat grafting to the breast with preexpansion. Patients were included if they had a clinical problem amenable to correction with large-volume fat injection and adequate donor sites, and were willing to undergo preexpansion. Data was collected through chart review and deidentified. Demographics, diagnosis, radiation status, volume grafted, complications, and adjunct procedures were recorded. RESULTS: Forty-nine patients underwent external expansion with AFT by a single surgeon. Twenty-three patients (47%) had hypoplastic indications, including tuberous breast deformity (n = 9) and Poland syndrome (n = 1). Seventeen patients (35%) had indications for secondary breast revision of previously placed implants. Nine patients (18%) utilized the procedure for primary oncologic breast reconstruction. A total of 71 procedures were performed, with an average of 1.45 procedures per patient. The average volume of fat grafted per breast was 372 mL for hypoplasia, 240 mL for secondary breast revision, and 429 mL for oncologic reconstruction. Concurrent procedures included implant exchange, implant removal, mastopexy, and breast reduction. Follow-up ranged from 1 to 84 (average = 20) months. CONCLUSIONS: The authors' experience shows promising results with external expansion and large-volume fat grafting to the breast.

The Macrotextured Implant Recall: Breast Implant-Associated-Anaplastic Large Cell Lymphoma Risk Aversion in Cosmetic and Reconstructive Plastic Surgery Practices.

BACKGROUND: The recall of Allergan Biocell (Irvine, CA) devices due to the association between anaplastic large cell lymphoma (ALCL) and macrotextured breast implants means that plastic surgeons are faced with the challenge of caring for patients with these implants in situ. Cosmetic and reconstructive surgeons have been contacting affected patients to encourage them to follow up and discuss the most appropriate risk-reduction strategies. OBJECTIVES: The aim of this study was to evaluate patient concerns about the risk of breast implant-associated ALCL (BIA-ALCL) and to compare management differences between cosmetic and reconstructive patients. METHODS: A retrospective review was performed of 432 patients with macrotextured implants who presented to clinic after being contacted (121 reconstructive and 311 cosmetic). These records were analyzed for their presenting concerns, surgery wait times, and management plans. Statistical analysis was performed to compare the cohorts, and odds ratios (ORs) were computed to determine the association between patient concerns and their choice of management. RESULTS: After consultation, 59.5% of the reconstructive cohort and 49.5% of the cosmetic cohort scheduled implant removal or exchange. The reconstructive population had a higher rate of ALCL concern (62.7%); however, both cohorts had a significant OR, demonstrating an expressed fear of ALCL likely contributed to their subsequent clinical management (OR cosmetic, 1.66; OR reconstructive, 2.17). CONCLUSIONS: Although the risk of ALCL appears to be more concerning to the reconstructive population, both cohorts were equally motivated to have their implants removed. Informing patients about their ALCL risk is crucial to ensure a patient-supported risk reduction plan.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training.

North American residency programs are transitioning to competency-based medical education (CBME) to standardize training programs, and to ensure competency of residents upon graduation. At the centre of assessment in CBME are specific surgical procedures, or procedural competencies, that trainees must be able to perform. A study previously defined 31 procedural competencies for aesthetic surgery. In this transition period, understanding current educational trends in resident exposure to these aesthetic procedures is necessary. The aim of this study was to characterize aesthetic procedures performed by Canadian plastic surgery residents during training, as well as to describe resident performance confidence levels and degree of resident involvement during those procedures. Case logs were retrieved from all 10 English-language plastic surgery programs. All aesthetic procedures were identified, and coded according to previously defined core procedural competencies (CPCs) in the aesthetic domain of plastic surgery. Data extracted from each log included the procedure, training program, resident academic year, resident procedural role, and personal competence. From July 2004 to June 2014, 6113 aesthetic procedures were logged by 55 graduating residents. Breast augmentation, mastopexy, and abdominoplasty were the most commonly performed CPCs, and residents report high levels of competence and surgical role in these procedures. Facial procedures, in particular rhinoplasty, as well as nonsurgical CPCs are associated with low exposure and personal competence levels. Canadian plastic surgery residents are exposed to most of the core aesthetic procedural competencies, but the range of procedures performed is variable. With the implementation of CBME, consideration should be given to supplementation where gaps may exist in aesthetic case exposure.

Canadian Plastic Surgery Resident Operative Experience in Hand Surgery.

PURPOSE: Core procedural competencies (CPCs) in hand surgery have been previously described. However, it is unknown whether plastic surgery residents receive sufficient operative experience with these procedures. This study aimed to determine whether Canadian plastic surgery residents are receiving adequate exposure to CPCs in hand surgery during residency training. METHODS: Hand surgery case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014 were reviewed from 3 databases. For each CPC in hand surgery, perceived resident role and self-competence scores were collected and analyzed. Core procedural competencies encompass core essential procedural competencies (CEPCs) and nonessential procedural competencies. RESULTS: There were 55 graduating plastic surgery residents included in the study. A total of 14,909 procedures were logged for 42 CPCs, with an average of 271 procedures/resident. When grouped by subdomain within hand surgery, procedures with the most exposure were related to traumatic finger injuries (29%) and neuropathies (22%). The least common procedures were related to flap reconstructions (0.3%) and muscle release (0.1%). Many residents reported receiving no operative experience (range, 2% to 100%) or between 1 and 10 cases of CEPCs (range, 7% to 50%). Most graduating residents (58% to 72%) did not feel competent independently performing 60% of the most common procedures. There were weak to moderate correlations between role and self-competence, and between postgraduate year and self-competence. CONCLUSIONS: Currently, many plastic surgery residents graduate from training programs with little to no exposure for over half of the CEPCs in hand surgery. CLINICAL RELEVANCE: Given the great diversity in hand surgery CPCs, it is difficult for residents to gain adequate operative experience during their residency in all of the CPCs.

Variable Experience in Microsurgery and Flap-Based Procedures Among Canadian Plastic Surgery Residents.

TITLE: Variable experience in microsurgery and flap-based procedures among Canadian plastic surgery residents. OBJECTIVE: Plastic surgery residencies are transitioning toward a competency-based education model. It is not known whether trainees can realistically achieve proficiency in microsurgical techniques during their training. This study aims to define the operative experience in the core microsurgical flap procedures among Canadian plastic surgery residents. DESIGN: Microsurgical core procedural competencies (CPCs) have been described. A retrospective review was conducted, evaluating case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014. Perceived role and competence scores were also collected and analyzed. SETTING: University of Toronto, Toronto, ON, Canada; University of British Columbia, Vancouver, BC, Canada. RESULTS: Among 27 microsurgical CPCs, 2082 procedures were logged and each resident performed an average of 37.9 (±21.7) procedures. Anterolateral thigh flaps, radial forearm-based flaps, and digit replants were the most common; however, 10.9% to 14.5% of residents did not have any operative experience with these flaps. Most residents reported zero operative experience with many of the CPCs (10.9%-100%). Co-Surgeon (50%) and First Assistant (30%) were the most common roles. None of the graduating residents reported feeling competent enough to independently perform 50% of the microsurgery CPCs. There was no difference in perceived roles when programs with ≥5 residents were compared against programs with fewer trainees. There were weak to moderate correlations between role and self-perceived competence, and between Post Graduate Year and self-perceived competence. CONCLUSIONS: There is wide variation in resident operative experience in microsurgical CPCs. Many residents graduate with little to no experience in many of the core procedures. Identifying areas of deficiency may help guide curriculum development in the new competency-based education model.

Why Do We Need Anatomical Implants? the Science and Rationale for Maintaining Their Availability and Use in Breast Surgery.

The choice between anatomical and round implants is an important decision in breast augmentation surgery; however, both have their place and the decision between them that should be made on a patient-by-patient basis, taking into account the patient's desires, anatomy, and surgical history. In some individuals, there are clear indications for using either anatomical or round devices, and there is good evidence that aesthetic outcomes are better with anatomical implants in some instances. When both types are an option, anatomical devices may offer increased flexibility and, despite a longer learning curve needed to properly manage them, they are associated with positive long-term outcomes and high levels of patient satisfaction. Concerns about implant rotation can be minimized with proper patient selection and surgical technique, and the overall complication rate may favor anatomical over round devices in appropriate patients. Breast implant-associated anaplastic large-cell lymphoma is an important issue, and while rare, it must be considered in the context of the entire patient risk profile. Both anatomical and round implants remain key elements of a complete surgical toolbox in breast augmentation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Burn Care and Surgical Exposure amongst Canadian Plastic Surgery Residents: Recommendations for Transitioning to a Competency-Based Medical Education Model.

With the ongoing implementation of a competency-based medical education (CMBE) model for residency programs in North America, emphasis on the duration of training has been refocused onto ability and competence. This study aims to determine the exposure of burn-related core procedural competencies (CPCs) in Canadian Plastic Surgery Residents in order to enhance curricular development and help define its goals. A retrospective review of burn-related resident case logs encompassing all 10 English-speaking plastic surgery residency programs from 2004 to 2014 was performed, including analysis of personal competence scores and resident role by Postgraduate Year (PGY)-year. Case logs of a total of 55 graduating plastic surgery residents were included in the study. Overall, 4033 procedures in burn and burn-related care were logged, accounting for 6.8% of all procedures logged. On average, each resident logged 73 burn procedures, 99% of which were CPCs. The most frequently performed procedure was harvest and application of autograft, allograft, or xenograft, while emergent procedures such as escharotomy and compartment release were performed on average less than one time per resident. Personal competence scores as well as role of the resident (surgical responsibility) increased as PGY-year progressed during residency. Canadian plastic surgery residency programs provide adequate exposure to the majority of the scope of burn care and surgery. However, infrequently encountered but critical procedures such as escharotomy and fasciotomy may require supplementation through dedicated educational opportunities. CMBE should identify these gaps in learning through facilitation of resident competency evaluation. With consideration for the amount of exposure to burn-related CPCs as identified, plastic surgery residency programs can work toward achieving competency in all aspects of burn care and surgery prior to the completion of residency.

Toward the Assessment of Core Procedural Competencies among Canadian Plastic Surgery Residents.

BACKGROUND: Plastic surgery residency training programs are working toward integrating competency-based education into program curriculum and training, a key component of which involves establishing core procedural competencies. This study aims to determine the exposure of graduating Canadian plastic surgery residents to established core procedural competencies. METHODS: A retrospective review of case log procedure data using three databases (T-Res, POWER, and New Innovations) from graduating residents at all 10 Canadian English-speaking plastic surgery training programs between 2004 and 2014 was completed. Case logs were coded according to 177 core procedural competencies identified as "core" by the Delphi method among an expert panel of Canadian plastic surgeons. RESULTS: A total of 59,405 procedures were logged by 55 graduating residents across Canada between 2004 and 2014 (average, 1080 ± 352 procedures per resident). Of 13 plastic surgery domains, 44 percent of all procedures were within either hand, upper extremity, and peripheral nerve (28.3 percent) or nonaesthetic breast (16.1 percent). The most frequently performed core procedural competencies (average case logs per resident) included breast reduction (65.3 ± 33.9); open carpal tunnel release (46.7 ± 34.2); breast reconstruction, implant-based (39.6 ± 20.5); and wound management (35.7 ± 28.6). Sixty-two of 177 procedures were logged on average less than once in 5 years of residency, including escharotomy, temporal parietal fascia flap, Guyon canal release, and soft-tissue fillers. CONCLUSION: This study identifies areas of exposure and underexposure to plastic surgery core procedural competencies, and can help focus surgical education on areas of greater need for surgical skills training and acquisition.

Breast Cancer Genetics for Plastic Surgeons.

Multidisciplinary genetic clinics offer counseling and testing to those who meet criteria for familial breast cancer, and plastic surgeons become integral to this process when risk-reducing surgery and postmastectomy reconstruction are deemed appropriate. As reconstructive surgeons, it is important that plastic surgeons are aware of the risks and issues associated with the genetic variants that cause patients to present for prophylactic or therapeutic surgery.