Who is in Your Waiting Room? Social Determinants of Health and Adverse Childhood Experiences in Pediatric Surgery Clinics.

BACKGROUND: Social determinants of health (SDoH) influence overall health, although little is known about the SDoH for pediatric patients requiring surgical services. This study aims to describe SDoH for pediatric surgical patients attending out-patient, community, and outreach clinics, as well as demonstrate the feasibility of identifying and addressing SDoH and Adverse Childhood Experiences (ACEs) when appropriate. METHODS: A cross-sectional study using surveys evaluating SDoH that were distributed to families attending pediatric surgical clinics over a two-year period. The pilot survey used validated questions and was later refined to a shorter version with questions on: Barriers to care, Economic factors, Adversity, Resiliency and Social capital (BEARS). Data was analyzed with descriptive and inferential statistics. RESULTS: 851 families across 13 clinics participated. One third of families reported not having a primary health care provider or being unable to turn to them for additional support. One in four families were found to have a household income less than the Canadian after-tax low-income threshold (<$40,000 CAD). Two-thirds of families answered questions about ACEs, and those with more ACEs were more likely to report a low income. Forty percent of families rarely or only sometimes had adequate social support. CONCLUSION: This survey tool enabled discussions between families and care providers, which allowed clinicians to appropriately follow-up with families and refer them to social work for further support when indicated. Addressing concerns around SDoH within a busy surgical clinical is feasible and may positively affect long-term health outcomes and equitable resource allocation. LEVEL OF EVIDENCE: IV.

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.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions.

BACKGROUND: The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions. METHODS: Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined. RESULTS: DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria. CONCLUSION: The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions.

BACKGROUND: The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales. METHODS: Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity. RESULTS: 1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores. CONCLUSION: The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

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.

Do Microsurgical Outcomes Differ Based on Which Specialty Does the Operation? A NSQIP Analysis.

BACKGROUND: Because plastic surgeons do not "own" a specific anatomic region, other surgical specialties have increasingly assumed procedures historically performed by plastic surgery. Decreased case volume is postulated to be associated with higher complication rates. Herein, we investigate whether volume and surgical specialty have an impact on microsurgical complications, specifically surgical site infection (SSI) and reoperation rates. METHODS: The 2005-2015 National Surgical Quality Improvement Program participant use file was queried by Current Procedural Terminology code for breast and head/neck microsurgeries. Multivariate logistic regression was performed to compare the outcomes between surgical specialties. A cumulative frequency variable was introduced to investigate the effect of case volume on complication rates. RESULTS: We captured 6,617 microsurgical cases. Multivariate logistic regression revealed that although the rate of SSI was lower in plastic surgery compared with otolaryngology for head and neck reconstructions (13.3% versus 10.5%) and compared with general surgery for breast reconstructions (5.4% versus 4.7%), there was no significant difference between specialties (P = 0.13; P = 0.96). Increased case volume is negatively correlated with complications. CONCLUSIONS: Plastic surgery is at risk given case cannibalization by other specialties. We conclude that surgical specialty does not affect the rates of SSI and reoperation. We demonstrate a correlation between lower volumes and increased complications, implying that, once a specialty has amassed critical case experience, complication rates may decrease, and outcomes can be equivalent or superior. Case breadth and volumes should be maintained to preserve skills, optimize outcomes, and maintain the specialty as it currently exists.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

BACKGROUND: There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors. METHODS: A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation. RESULTS: We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood. CONCLUSIONS: The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

HISTORIQUE: Les données à grande échelle sur les complications de la chirurgie plastique font défaut. Une description des taux de référence et des résultats cliniques des patients permettrait de mieux déterminer comment améliorer les soins aux patients et réaliser des économies dans les systèmes de santé. Dans le présent article, les chercheurs recensent les complications les plus fréquentes en chirurgie plastique, dégagent les interventions aux taux de complication élevés et examinent les facteurs de risque prédictifs. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective des données de chirurgie plastique tirées du programme national d'amélioration de la qualité chirurgicale de l'American College of Surgeons entre 2012 et 2016. Ils ont calculé les taux de complications de toute la cohorte et de chaque intervention recensée. Ils ont analysé les interventions microchirurgicales en sous-groupe, où ils ont utilisé des modèles de régression logistique multivariée pour déterminer les facteurs de risque d'infection des plaies opératoires (IPO) et de réopérations s'y rapportant. RÉSULTATS: Les chercheurs ont dénombré 108 303 patients qui avaient subi une intervention en chirurgie plastique, dont 6 264 (5,78 %) avaient souffert d'au moins une complication. Les réopérations (3,31 %), suivies des IPO (3,11 %) étaient les résultats à la plus forte incidence. Les cas de microchirurgie représentaient 6 148 (5,68 %) de toutes les occurrences, et 1211 (19,33 %) ont souffert d'au moins une complication. Tout comme dans l'ensemble de la cohorte, les réopérations (12,83 %) et les IPO (5,66 %) étaient des complications courantes. La plus longue durée de l'opération était un facteur de risque indépendant fréquent, prédicteur d'une réopération ou d'une IPO (p<0,001). Ainsi, 23,3 % des microchirurgies duraient plus de dix heures, ce qui s'associait à une plus forte augmentation du risque de réopération. CONCLUSIONS: Le taux de complications demeure relativement faible en chirurgie plastique, mais est significativement plus élevé en microchirurgie. La longue durée des opérations représente un facteur de risque courant. On pourrait explorer les approches à deux équipes et les opérations échelonnées, car une forte proportion des microchirurgies sont vulnérables à un accroissement des complications.

A Cross-Sectional Analysis of the BC Children's Hospital Cleft Palate Program Waitlist.

OBJECTIVE: A 2016 review of the BC Children's Hospital Cleft Palate - Craniofacial Program (CPP) revealed that one-third of patients met the program's care recommendations and half met the American Cleft Palate-Craniofacial Association guidelines. This study reviews patients on the CPP waitlist and determines median wait times and missed clinical assessments as well as identifies how wait times are influenced by medical complexity, specialized speech service needs, vulnerability, and distance from clinic. DESIGN: Cross-sectional. SETTING: BC Children's Hospital Cleft Palate-Craniofacial Program. PATIENTS: Five hundred seventy-six waitlisted patients. MAIN OUTCOME MEASURES: Additional wait time after recommended appointment date. Correlation of additional wait time with diagnosis, number of specialists required, speech services needed, vulnerability, and distance from the clinic. Missed plastic surgery, speech, and orthodontic assessments according to CPP team recommendations and ACPA guidelines. RESULTS: Patients had a median additional wait time of 11 months (interquartile range: 5-27). Longer additional wait times were associated with a craniofacial diagnosis (P = .019), a need for formal speech assessments or evaluations (P < .001), or a requirement to see multiple specialists (P < .001). Vulnerability and distance from clinic did not affect wait times. Plastic surgery assessments were not available at the preschool and preteen time points for 45 (8%) patients, 355 (62%) patients were unable to access speech assessments, and 120 (21%) were unable to complete an orthodontic assessment. CONCLUSION: Patients wait up to an additional year to be seen by the CPP and miss speech, orthodontic, and surgical assessments at key developmental milestones. Additional resources are required to address these concerns.

OBJECTIF: Une analyse du programme de chirurgie labiofaciale et crâniofaciale (PCLC) du BC Children's Hospital réalisée en 2016 a révélé que le tiers des patients respectaient les recommandations du programme et la moitié, les lignes directrices de l'American Cleft Palate-Craniofacial Association (ACPA). La présente étude visait à passer en revue les patients sur la liste d'attente du PCLC, à déterminer la liste d'attende médiane et les évaluations cliniques ratées et à établir l'effet de la complexité médicale, des besoins en orthophonie, de la vulnérabilité et de la distance de la clinique sur les temps d'attente. MÉTHODOLOGIE: Transversale. CONTEXTE: Programme de chirurgie labiofaciale et crâniofaciale du BC Children's Hospital. PATIENTS: 576 sur la liste d'attente. PRINCIPALES MESURES DE RÉSULTATS: Temps d'attente supplémentaire après la date recommandée du rendez-vous. Corrélation du temps d'attente supplémentaire avec le diagnostic, le nombre de spécialistes requis, les besoins en orthophonie, la vulnérabilité et la distance de la clinique. Évaluations ratées en chirurgie plastique, en orthophonie et en orthodontie en fonction des recommandations de l'équipe du PCLC et des lignes directrices de l'ACPA. RÉSULTATS: Les patients devaient subir un temps d'attente supplémentaire médian de 11 mois (plage interquartile de 5 à 27). Des temps d'attente supplémentaires plus longs s'associaient à un diagnostic crâniofacial (P = 0,019), à la nécessité de subir une évaluation officielle en orthophonie (P < 0,001) ou à la nécessité de consulter de multiples spécialistes (P < 0,001). La vulnérabilité et la distance de la clinique n'avaient pas d'incidence sur les temps d'attente. Les évaluations en chirurgie plastique n'étaient pas disponibles pour 45 patients (8 %) pendant la période préscolaire et à la préadolescence, alors que 355 patients (62 %) n'avaient pas eu accès à une évaluation en orthophonie et 120 (21 %), en orthodontie. CONCLUSION: Les patients attendent jusqu'à une année supplémentaire avant d'être vus par le PCLC et ratent des évaluations en orthophonie, en orthodontie et en chirurgie lors d'étapes importantes de leur développement. Des ressources supplémentaires s'imposent pour corriger ces lacunes.

Is there a role for computed tomography scanning in microtia with complete aural atresia to rule out cholesteatoma?

OBJECTIVE: To determine if radiologic imaging is necessary to rule out cholesteatoma in patients with congenital aural atresia. METHODS: A retrospective chart review of patients attending the BC Children's Hospital Microtia Clinic from January 1, 1990 through April 17, 2017 was undertaken. Patients with complete atresia of the external canal were included in the study. Available radiologic imaging and clinical records were examined for the presence or absence of cholesteatoma. RESULTS: Of the 125 charts reviewed, 102 met criteria for inclusion in the study and 79 had three-dimensional imaging completed. None of these 102 patients had radiologic or clinical evidence of cholesteatoma. CONCLUSION: Computed tomography and/or magnetic resonance imaging remains an essential modality in the work-up of selected patients with microtia/atresia. It may be unnecessary in the follow-up of certain patients to rule out a congenital cholesteatoma. This imaging avoidance may reduce exposure to radiation, the potential need for general anaesthesia, and unnecessary financial cost.

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.

CLEFT-Q: Detecting Differences in Outcomes among 2434 Patients with Varying Cleft Types.

BACKGROUND: Measuring the patient perspective is important in evaluating outcomes of cleft care. Understanding how treatment outcomes vary depending on cleft type may allow for better planning of treatments, setting of expectations, and more accurate benchmarking efforts. The CLEFT-Q is a patient-reported outcome measure for patients with cleft lip and/or palate. METHODS: The 12 CLEFT-Q scales measuring appearance (i.e., face, nose, nostrils, lips, cleft lip scar, teeth, and jaws), function (i.e., speech), and health-related quality of life (i.e., psychological, school, social, and speech-related distress) were field tested in a cross-sectional study in 30 centers in 12 countries. Patients with cleft lip and/or cleft palate aged 8 to 29 years were recruited from clinical settings. Differences in CLEFT-Q scores by cleft subtypes were evaluated using one-way analysis of variance or Kruskal-Wallis H tests, with Tukey or Dunn procedure with Bonferroni corrections post hoc analyses, respectively. Scores are presented using radar charts to visualize all outcomes simultaneously. RESULTS: The field test included 2434 patients. Scores on all CLEFT-Q scales varied significantly with cleft subtype. Patients with unilateral or bilateral cleft lip and/or palate scored lower on all appearance scales compared with patients with cleft palate or unilateral incomplete cleft lip. Scores on the speech function and speech-related distress scales decreased with each progressive group in the Veau classification. Patients with complete bilateral cleft lip and palate scored lowest on the social, school, and psychological scales. CONCLUSIONS: Patient-reported outcomes measured with the CLEFT-Q vary significantly with cleft type. Visualizing multiple outcomes simultaneously with radar charts allows for an understanding of a patient's overall status in a single graph.

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.

A Review of Validated Quality-of-Life Patient-Reported Outcome Measures in Pediatric Plastic Surgery.

BACKGROUND: There has been an exponential increase in the number of patient-reported outcome measures in plastic surgery. The authors reviewed the reliability, validity, and practicality of the most frequently used patient-reported outcome measures in pediatric plastic surgery research. METHODS: A review of the literature from January of 2010 to June of 2015 was conducted to identify patient-reported outcome measures in pediatric plastic surgery. Patient-reported measures used in five articles with two validation studies were included for analysis and classified as generic, disease-specific, and mental health. The type of validation used and reliability scores were compared across each class of outcome measure. The practicality of each measure was determined by the frequency of use and the number of items and cost. RESULTS: Of the 173 unique patient-reported outcome measures identified, 14 were included for analysis and classified as generic (n = 7), disease-specific (n = 4), and mental health (n = 3). The majority of all measures used construct validity. Disease-specific measures had the highest distribution of domains related to physical functioning, the same domain also found to have the highest reliability scores. A patient-reported outcome measure's frequency of use was not associated with its number of items or cost. CONCLUSIONS: This review found that generic patient-reported outcome measures were used most often, construct validity was used most frequently, physical functioning domains had the highest reliability, and the number of items or cost of a patient-reported outcome measure was not related to its frequency of use. Considered together, this information may inform the future development or selection of patient-reported outcome measures in pediatric plastic surgery.

Multidisciplinary Cleft Palate Program at BC Children's Hospital: Are We Meeting the Standards of Care?

OBJECTIVE: To characterize current Cleft Palate Program (CPP) practices and evaluate the timeliness of appointments with respect to patient age and diagnosis based on American Cleft Palate-Craniofacial Association (ACPA) population guidelines and CPP patient-specific recommendations. DESIGN: A retrospective review of CPP patient appointments from November 6, 2012, to March 31, 2015, was done. Data were analyzed using descriptive and inferential statistics. SETTING: The study was conducted using data from the CPP at BC Children's Hospital. PATIENTS: A total of 1214 appointments were considered in the analysis, including syndromic and nonsyndromic patients of 0 to 27 years of age. MAIN OUTCOME MEASURES: Percentage of patients meeting follow-up targets by ACPA standards and CPP team recommendations. RESULTS: Our results showed patients 5 years and younger or nonsyndromic were more likely to be seen on time (P < .001). No relationship between the timeliness of an appointment and specific patient diagnoses or distance to clinic was found. With the exception of nursing (97% of appointments were on time), all disciplines had less than 45% of appointments on time with 51% of appointments meeting ACPA guidelines for timeliness and 32% of all appointments meeting CPP recommendations. CONCLUSION: Timely care for the cleft/craniofacial patient populations represents a challenge for the CPP. Although half of patients may meet the general ACPA guidelines, only 32% of patients are meeting the CPP patient-specific recommendations. To provide better patient care, future adjustments are needed, which may include improved resource allotment and program support.

OBJECTIF: Caractériser les pratiques du programme sur la fente labiopalatine (PFL) et évaluer la rapidité des rendez-vous compte tenu de l'âge du patient et du diagnostic en fonction des lignes directrices en population de l'American Cleft Palate-Craniofacial Association (ACPA) et des recommandations aux patients du PFL. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des rendez-vous des patients du PFL entre le 6 novembre 2012 et le 31 mars 2015. Ils ont analysé les données au moyen de statistiques descriptives et inférentielles. LIEU: L'étude a été réalisée à l'aide des données du PFL du BC Children's Hospital. PATIENTS: Les chercheurs ont évalué 1 214 rendez-vous dans l'analyse, incluant les patients syndromiques et non syndromiques de 0 à 27 ans. PRINCIPALES MESURES: Pourcentage de patients qui respectaient les cibles de suivi fixées par les normes de l'ACPA et les recommandations du PFL. RÉSULTATS: Les résultats ont démontré que les patients de cinq ans et moins et les patients non syndromiques étaient plus susceptibles d'être vus dans les délais fixés (P < .001). Il n'y avait pas de lien entre le moment d'un rendez-vous et le diagnostic exact du patient ou la distance de la clinique. À l'exception des soins infirmiers (où 97 % des rendez-vous avaient lieu dans les délais fixés), toutes les disciplines tenaient moins de 45 % de leurs rendez-vous dans les délais fixés. Ainsi, 51% de ces rendez-vous respectaient les lignes directrices de l'ACPA en matière de rapidité et 32 % de tous les rendez-vous, les recommandations du PFL. CONCLUSIONS: Au sein du PFL, il était difficile d'offrir des soins rapides à la population de patients ayant une fente labiopalatine ou craniofaciale. Même si la moitié des patients peut respecter les directives générales de l'ACPA, seulement 32 % d'entre eux respectent les recommandations du PFL. Pour mieux soigner les patients, il faudra apporter des correctifs, qui pourraient inclure une meilleure répartition des ressources et un meilleur soutien du programme.

Spontaneously Resolved Macrocystic Lymphatic Malformations: Predictive Variables and Outcomes.

INTRODUCTION: Lymphatic malformations are benign, low-flow vascular malformations that typically present at or near birth. Due to morbidity associated with operative treatment, nonoperative treatment with injection of sclerosant has become the mainstay of therapy. Over the past 15 years, several patients at our centre with macrocystic (>2 cm cyst size) lymphatic malformations have seen their lesions resolve spontaneously while awaiting treatment. In this study, we review features of these patients that may contribute to spontaneous resolution. METHOD: A retrospective chart review was conducted from our Vascular Anomalies Clinic database (1999-2014) of all macrocystic lymphatic malformations; characteristics of patients with spontaneous resolution were reviewed. RESULTS: Of 61 patients with macrocystic lymphatic malformations, 7 cases (11.5%; 4 females, 3 males) resolved spontaneously. Median age at malformation appearance was 2 years (range: 0-6.5 years), with median age at resolution of 4 years (range: 10 months-7 years). Median time from appearance to resolution was 24 months (range: 3-43 months), with a median follow-up time of 4 years (range: 1-15 years). All but 1 case was associated with local or upper respiratory tract infection antecedent to resolution. Six of the 7 lesions were located in the neck. CONCLUSION: Among the cases reviewed, there was a common theme of upper respiratory tract or local infection antecedent to spontaneous lesion resolution. Compared to the literature, our proportion of malformations presenting after birth and the proportion of malformations presenting in the neck region were higher than those of other series. Although side effects associated with treatment are generally mild and/or rare, risks related to sclerotherapy and the accompanying requirement for general anesthesia in pediatric populations nevertheless exist. As the median time from lesion appearance to resolution was 24 months, it may be reasonable to observe these malformations for up to 24 months before proceeding with treatment if the lesion does not impair function and disfigurement is not considerable, particularly if the lesion presents after birth and/or is located in the neck region.

HISTORIQUE: Les malformations lymphatiques sont des malformations vasculaires bénignes à faible débit généralement présentes à la naissance ou peu après. Étant donné la morbidité associée à l'opération, le traitement non opératoire par injection de sclérosant est devenu la norme. Depuis 15 ans, plusieurs patients ayant une malformation lymphatique macrokystique (kyste de plus de 2 cm) qui ont été suivis au centre des chercheurs ont vu leurs lésions disparaître d'elles-mêmes pendant l'attente d'un traitement. Dans la présente étude, les chercheurs analysent les caractéristiques de ces patients qui sont susceptibles de contribuer à cette résolution spontanée. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective des dossiers de la base de données de la clinique des anomalies vasculaires (1999-2014) afin d'en extraire toutes les malformations lymphatiques macrokystiques et ils ont examiné les caractéristiques des patients chez qui la malformation s'était résolue spontanément. RÉSULTATS: Chez les 61 patients présentant une malformation lymphatique macrokystique, sept cas se sont résolus spontanément (11,5 %; quatre filles, trois garçons). Ces derniers avaient un âge médian de deux ans (plage de 0 à 6,5 ans) à l'apparition de la malformation, et un âge médian de quatre ans (plage de dix mois à sept ans) à la résolution. La période médiane entre l'apparition et la résolution s'élevait à 24 mois (plage de trois à 43 mois), et la durée de suivi médian, à quatre ans (plage de un à 15 ans). Tous les cas, sauf un, s'associaient à une infection locale ou à une infection des voies respiratoires supérieures qui avait précédé la résolution. Six des sept lésions se situaient au niveau du cou. CONCLUSION: Parmi les cas étudiés, on constatait la présence d'une infection des voies respiratoires supérieures ou d'une infection locale avant la résolution spontanée de la lésion. Par rapport aux données contenues dans les publications, la proportion de malformations observées après la naissance et de malformations présentes dans la région du cou était plus élevée que dans les autres études. Même si les effets secondaires associés au traitement sont généralement légers ou rares, les populations pédiatriques courent tout de même des risques liés à la sclérothérapie et à l'anesthésie générale connexe. Puisqu'une période médiane de 24 mois s'écoulait entre l'apparition de la lésion et sa résolution, il peut être raisonnable d'observer ces malformations jusqu'à 24 mois avant le traitement si la lésion ne nuit pas à la fonction et ne défigure pas l'enfant de manière considérablement, particulièrement si elle se forme après la naissance ou si elle est située dans la région du cou.

Lymphatic Malformation Architecture: Implications for Treatment With OK-432.

PURPOSE: Herein, the authors aim to describe their findings of novel architectural types of lymphatic malformations (LM) and explain the relationship between these architectures and OK-432 treatment outcomes. METHODS: A retrospective review was conducted of all patients diagnosed with a LM treated with OK-432 at the Vascular Anomalies Clinic at BC Children's Hospital from December 2002 to January 2012. RESULTS: Twenty-seven patients were included in the study. Sixty percent of lesions were present by 2 years of age with the majority located in the head and neck (59%). The average number of sclerotherapy procedures was 1.4 per patient. Treatment under fluoroscopic guidance revealed 3 new LM architectures: open-cell microcystic, closed-cell microcystic, and lymphatic channel. Response to treatment was complete or good for 14/19 macrocystic and for 1/2 mixed lesions. Open-cell microcystic LMs gave a complete or good response for 3/3, which was attributed to OK-432 freely communicating between cysts. Closed-cell microcystic LM had localized cysts that did not allow OK-432 to freely communicate and were associated with partial responses, 2/2. The lymphatic channel had a partial response. There were 2 minor complications and 1 instance of recurrence. CONCLUSIONS: The identification of 3 new LM architectures expands the current accepted classification to include: open-cell microcystic, closed-cell microcystic, and lymphatic channels. The majority of complete responses to OK-432 were found with macrocystic lesions. Open-cell microcystic lesions respond better to OK-432 than closed-cell microcystic lesions, and lymphatic channels may respond to OK-432. These key architecture-response relationships have direct clinical implications for treatment with OK-432 sclerotherapy.