The Early Effects of COVID-19 on Plastic Surgery Residency Training: The University of Washington Experience.

Plastic surgeons have the unique perspective of working with all types of patients and care teams from almost all specialties in surgery and medicine, which creates unique challenges in times of distress. As the initial epicenter of coronavirus disease 2019 cases in the United States, the University of Washington program was required to rapidly develop strategies to deal with the escalating crisis. All aspects of the program were affected, including the need to triage the urgency of plastic surgery care, safe staffing of plastic surgery teams, and the role of plastic surgery in the greater hospital community. In addition, as a residency training program, limiting the impact of resident education and maintaining a sense of community and connection among members of the program developed into important considerations. The authors hope that the narrative of their experience will provide insight into the decisions made in the University of Washington health care system but also remind others that they are not alone in dealing with the challenges of this pandemic.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs.

BACKGROUND: With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown. OBJECTIVE: We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training. METHODS: PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed. RESULTS: In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001). CONCLUSIONS: A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Educational Exposure to Transgender Patient Care in Plastic Surgery Training.

BACKGROUND: Gender dysphoria is estimated to occur in up to 0.9 percent of the U.S. POPULATION: With increasing awareness and decreasing stigma surrounding transgender issues, it is predicted that more patients will begin to seek medical and surgical transition. This study aims to determine the current state of transgender-related education in U.S. plastic surgery residency programs and to evaluate trainee perceptions regarding the importance of such training. METHODS: Plastic surgery trainees from a representative sample of 21 U.S. training programs were asked to complete a cross-sectional eight-question survey between November of 2015 and January of 2016. Respondents were queried regarding demographics, transgender curricular exposure (didactic versus clinical), and perceived importance of training opportunities in transgender patient care. RESULTS: A total of 322 residents or fellows responded to the survey (80 percent response rate) from four U.S. Census regions. Sixty-four percent of respondents had education on or direct exposure to transgender patient care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to chest and genital surgery. Overall, the majority of respondents believed that training in gender-confirming surgery is important, and 72 percent endorsed the necessity for gender-confirming surgery fellowship training opportunities. CONCLUSIONS: A significant number of plastic surgery trainees are exposed to transgender patient care, although exposure type is variable. The majority of trainees endorsed the importance of residency and fellowship training in gender-confirming surgery. To better serve the transgender population, formal fellowship training in gender-confirming surgery should be offered.

Validated Assessment Tools and Maintenance of Certification in Plastic Surgery: Current Status, Challenges, and Future Possibilities.

BACKGROUND: The transition to the Next Accreditation System is well underway, and a shift toward competency-based assessment in the form of milestones is now the standard. A significant effort has been completed by the Plastic Surgery Milestones Working Group to develop specific milestones and assessment tools for plastic surgery training. METHODS: The history of the development toward competency-based assessment was reviewed. Data regarding the trends and regulations associated with board certification and the role of maintenance of certification were reviewed. RESULTS: The work of the Plastic Surgery Milestones Working Group has sparked interest in assessment and created an opportunity for further development. The efforts toward validating assessment tools by our colleagues working in other surgical specialties serve as a suitable roadmap for further progress. Board certification is an integral part of successful practice and should be regarded as an expectation. Despite the burdens associated with maintenance of certification, it serves a valuable function in ensuring optimal patient care and is often retrospectively seen as an important component of practice. CONCLUSIONS: The competency-based milestones are the new standard, and work on this new methodology of assessing plastic surgery trainees is expected to continue. Accurate assessment is critical to the pathways for board certification and maintenance of certification, which serve important roles for all parties involved in the delivery of medical care.

Implementing Assessment Methods in Plastic Surgery.

BACKGROUND: Principles of effective assessment have become increasingly popular topics in graduate medical education. Changes in the structure of plastic surgery training demand a thorough understanding of the state-of-the-art in assessing surgical trainees. Moreover, the authors' understanding of different domains and methods of assessment and the available tools continues to grow. METHODS: The authors reviewed the available literature regarding assessment in graduate medical education, specifically as it pertains to plastic surgery. In addition, the authors present principles of effective assessment and report on the currently available assessment methods. RESULTS: Assessment is multifaceted and impacts everyone, not just the individual learner. For assessments to be useful, they need to possess validity and reliability. Moreover, there is a necessary pragmatism limiting different methods and tools for assessing learners. Some types of assessment are universally familiar and include examples such as written examinations and procedural logs. Other emerging areas that are actively being researched involve simulation, nontechnical skills, and procedure-specific technical assessments. CONCLUSION: Updating the thoroughness and multidimensionality with which plastic surgery trainees are assessed is an evolving area and one that is ripe for continued research.

Reconstruction of the traumatized thumb.

BACKGROUND: The goals of thumb reconstruction include the restoration of thumb length, strength, position, stability, mobility, sensibility, and aesthetics. It is a rare event when all of these objectives can be achieved, and prioritization should be based on the goals and functional demands of the patient. METHODS: In this article, the authors review the most common reconstructive strategies for all types of traumatic thumb defects. RESULTS: Replantation is approached first as the primary option for most amputations. Nonreplantable injuries are organized using a simple classification adapted from Lister, dividing thumb amputations into four functional categories: soft-tissue deficit with acceptable length, subtotal amputation with borderline length, total amputation with preservation of the carpometacarpal joint, and total amputation with destruction of the carpometacarpal joint. Within each category, relevant microsurgical and nonmicrosurgical reconstructive techniques are discussed, with a focus on appropriate technique selection for a given patient. Evidence and outcomes data are reviewed where available, and case examples from our own experience are provided. CONCLUSIONS: Given that available options now range from simple gauze dressings to complex microsurgical reconstruction, preservation of reconstructive flexibility is essential and should be facilitated by judicious preservation of intact structures. The divergence of available reconstructive pathways underscores the importance of knowing one's patients, understanding their motivation, and assessing their goals. Only in properly matching the right reconstruction with the right patient will a mutually satisfactory result be achieved.

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture.

PURPOSE: To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture. METHODS: Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests. RESULTS: Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed. CONCLUSIONS: The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Metacarpal fractures: treatment and complications.

Metacarpal fractures comprise between 18-44 % of all hand fractures. Non-thumb metacarpals account for around 88 % of all metacarpal fractures, with the fifth finger most commonly involved [19]. The majority of metacarpal fractures are isolated injuries, which are simple, closed, and stable. While many metacarpal fractures do well without surgery, there is a paucity of literature and persistent controversy to guide the treating physician on the best treatment algorithm. The purpose of this article is to review non-thumb metacarpal anatomy and treatment protocols for nonoperative management of stable fractures, and compare existing literature on surgical techniques for treatment of acute fractures and complications.

Academic plastic surgery: faculty recruitment and retention.

BACKGROUND: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. METHODS: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. RESULTS: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. CONCLUSIONS: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

Skin graft loss resulting from collagenase clostridium histolyticum treatment of Dupuytren contracture: case report and review of the literature.

Treatment of Dupuytren disease with collagenase clostridium histolyticum is increasingly used among hand surgeons. Although it is generally safe and efficacious, complications related to enzymatic fasciotomy occur. Postapproval surveillance and communication among hand surgeons continues to refine the indications, contraindications, and complications recognized in the treatment of Dupuytren disease with enzymatic therapy. Major treatment-related adverse events previously reported include flexor tendon rupture and complex regional pain syndrome. We report a patient who experienced total loss of a well-established volar ring finger skin graft following collagenase injection and propose a potential mechanism of vulnerability. This case may illustrate the susceptibility of type I collagen, which is uniformly present in a healed skin graft bed, to degradation with collagenase. We propose a cautious approach when considering treatment of a Dupuytren cord with collagenase in the presence of an overlying skin graft, regardless of the age of the graft.

Thumb reconstruction.

Thumb reconstruction aims to restore the cardinal thumb traits and actions including mobility, stability, sensibility, length, and appearance. The level of thumb loss is divided into thirds: distal (tip to interphalangeal [IP] joint), middle (IP joint to metacarpal neck), and proximal (metacarpal neck to carpometacarpal joint). Distal third reconstruction usually requires only soft tissue restoration. Many options exist for middle third reconstruction, including increasing thumb ray length (metacarpal lengthening, osteoplastic reconstruction, toe transfer) and increasing relative length (phalangization). Proximal third reconstruction is best accomplished with toe transfer, pollicization, or on-top plasty (pollicization of a damaged index finger).

Joint arthritis and soft-tissue problems of the hand.

The hand, by virtue of its position in space, complex anatomical composition, and characteristic biomechanical properties, is subject to a host of disease processes and traumatic injuries. This article reviews the presentation, evaluation, treatment, and outcomes of treatment in hand infections, high-pressure injection injuries, Dupuytren disease, and arthritis.

Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy.

BACKGROUND: In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. METHODS: Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). RESULTS: At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. CONCLUSIONS: Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Soft tissue reconstruction of the hand.

There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage.

MOC-PSSM CME article: Metacarpal fractures.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Identify the fracture patterns and types of metacarpal fractures. 2. Recognize when surgery is indicated for a given fracture. 3. Discuss the pathophysiology of Bennett's fractures and treatment. 4. List surgical treatment options and their relative advantages and disadvantages. 5. Be familiar with pediatric metacarpal injuries and when surgery is indicated. BACKGROUND: Metacarpal fractures are among the most common injuries seen in the emergency room and a staple for the hand surgeon. Knowledge of the types of fractures that occur and the appropriate treatment options is critical core knowledge for the hand surgeon. With the advent of superior implants and intraoperative fluoroscopy, powerful treatment options exist for metacarpal fractures and are at the disposal of the informed hand surgeon. METHODS: Closed reduction and cast immobilization, Kirschner wires, lag screws, plate fixation, and other techniques are all available to the hand surgeon. Bone grafting in highly comminuted fractures also deserves consideration. RESULTS: The majority of metacarpal fractures can be treated closed and do well with compliant hand therapy. Those fractures requiring operative intervention likewise do well, provided that the appropriate technique is used for the situation. For example, long oblique shaft fractures are optimally treated with lag screws, whereas short oblique fractures do better with Kirschner wires or plate fixation. When the correct therapy is tailored to the injury, most metacarpal fractures can be treated with predictably good outcomes. CONCLUSIONS: Metacarpal fractures are common occurrences in the office of the hand surgeon. The different types of injury patterns must be recognized by the surgeon and appropriate treatment then executed to serve both the patient and hand surgeon optimally.