Pediatric Hand Fractures and Congenital Differences: An Analysis of Data From the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery.

PURPOSE: Pediatric patients with hand trauma and congenital differences are treated across multiple surgical subspecialties. The purpose of this study was to assess operative trends over an 11-year period using the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases to better understand which surgeons were caring for pediatric hand fractures and birth differences in the first 2 years of their practice. METHODS: We queried the American Board of Orthopaedic Surgery and the American Board of Plastic Surgery databases for surgical procedures performed by applicants for the oral examinations between 2004 and 2014. Candidates self-identified as general orthopedic surgeon, pediatric orthopedic surgeon, hand surgeon (orthopedic and plastic), and general plastic surgeon. This included a total of 2,453 Board applicants. A total of 6,835 surgeries for birth differences or hand trauma were identified and reviewed for patients <18 years of age. RESULTS: There were 5,759 trauma and 1,076 congenital difference surgeries. A total of 4,786 (70%) surgeries were performed by orthopedic surgeons. Fellowship-trained hand surgeons (orthopedic and plastic) performed 3,809 (56%) surgeries. Pediatric orthopedic surgeons performed 608 (9%) surgeries. Over the 11 years, general orthopedic surgeons performed 4.2 fewer surgeries per year, whereas surgeons in hand orthopedics and pediatric orthopedics performed 10.8 and 4.7 additional surgeries per year. There were 3.1 fewer general orthopedic surgeons per year, whereas there were 3.6 and 1.4 additional surgeons in hand orthopedics and pediatric orthopedics each year, respectively. The number of surgeries and the number of surgeons submitting surgeries did not significantly change for those in general plastics or hand plastics. CONCLUSIONS: This analysis of early practice patterns over 11 years demonstrates that the increasing numbers of surgeons in pediatric orthopedics and hand orthopedics are performing more surgeries compared with other fields. CLINICAL RELEVANCE: The care of children with hand injuries and congenital differences is evolving, with direct implications for residency and fellowship education.

Clinical Practice Patterns and Evidence-Based Medicine in Secondary Cleft Rhinoplasty: A 14-Year Review of Maintenance of Certification Tracer Data From the American Board of Plastic Surgery.

OBJECTIVE: To evaluate evolving practice patterns in secondary cleft rhinoplasty. DESIGN: Retrospective review of data submitted during Maintenance of Certification (MOC). SETTING: Evaluation of MOC data from the American Board of Plastic Surgery. PARTICIPANTS: Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns. INTERVENTIONS: Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period. MAIN OUTCOME MEASURES: Practice patterns were compared to EBM trends during the study period. RESULTS: A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007). CONCLUSIONS: These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data.

BACKGROUND: Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. OBJECTIVES: The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. METHODS: A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. RESULTS: There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. CONCLUSIONS: Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015.

From Residency to Lifelong Learning.

The residency training experience is the perfect environment for learning. The university/institution patient population provides a never-ending supply of patients with unique management challenges. Resources abound that allow the discovery of knowledge about similar situations. Senior teachers provide counseling and help direct appropriate care. Periodic testing and evaluations identify deficiencies, which can be corrected with future study. What happens, however, when the resident graduates? Do they possess all the knowledge they'll need for the rest of their career? Will medical discovery stand still limiting the need for future study? If initial certification establishes that the physician has the skills and knowledge to function as an independent physician and surgeon, how do we assure the public that plastic surgeons will practice lifelong learning and remain safe throughout their career? Enter Maintenance of Certification (MOC). In an ideal world, MOC would provide many of the same tools as residency training: identification of gaps in knowledge, resources to correct those deficiencies, overall assessment of knowledge, feedback about communication skills and professionalism, and methods to evaluate and improve one's practice. This article discusses the need; for education and self-assessment that extends beyond residency training and a commitment to lifelong learning. The American Board of Plastic Surgery MOC program is described to demonstrate how it helps the diplomate reach the goal of continuous practice improvement.

Immune system dysregulation preceding a case of laboratory-confirmed zoster/dermatitis on board the International Space Station.

A case report detailing, for the first time, a case of laboratory-confirmed zoster in an astronaut on board the International Space Station is presented. The findings of reduced T-cell function, cytokine imbalance, and increased stress hormones which preceded the event are detailed. Relevance for deep space countermeasures is discussed.

Severe Spaceflight-Associated Neuro-Ocular Syndrome in an Astronaut With 2 Predisposing Factors.

Importance: Understanding potential predisposing factors associated with spaceflight-associated neuro-ocular syndrome (SANS) may influence its management. Objective: To describe a severe case of SANS associated with 2 potentially predisposing factors. Design, Setting, and Participants: Ocular testing of and blood collections from a female astronaut were completed preflight, inflight, and postflight in the setting of the International Space Station (ISS). Exposure: Weightlessness throughout an approximately 6-month ISS mission. Mean carbon dioxide (CO2) partial pressure decreased from 2.6 to 1.3 mm Hg weeks before the astronaut's flight day (FD) 154 optical coherence tomography (OCT) session. In response to SANS, 4 B-vitamin supplements (vitamin B6, 100 mg; L-methylfolate, 5 mg; vitamin B12, 1000 µg; and riboflavin, 400 mg) were deployed, unpacked on FD153, consumed daily through FD169, and then discontinued due to gastrointestinal discomfort. Main Outcomes and Measures: Refraction, distance visual acuity (DVA), optic nerve, and macular assessment on OCT. Results: Cycloplegic refraction was -1.00 diopter in both eyes preflight and +0.50 - 0.25 × 015 in the right eye and +1.00 diopter in the left eye 3 days postflight. Uncorrected DVA was 20/30 OU preflight, 20/16 or better by FD90, and 20/15 OU 3 days postflight. Inflight peripapillary total retinal thickness (TRT) peaked between FD84 and FD126 (right eye, 401 µm preflight, 613 µm on FD84; left eye, 404 µm preflight, 636 µm on FD126), then decreased. Peripapillary choroidal folds, quantified by surface roughness, peaked at 12.7 µm in the right eye on FD154 and 15.0 µm in the left eye on FD126, then decreased. Mean choroidal thickness increased throughout the mission. Genetic analyses revealed 2 minor alleles for MTRR 66 and 2 major alleles for SHMT1 1420 (ie, 4 of 4 SANS risk alleles). One-week postflight, lumbar puncture opening pressure was normal, at 19.4 cm H2O. Conclusions and Relevance: To the authors' knowledge, no other report of SANS documented as large of a change in peripapillary TRT or hyperopic shift during a mission as in this astronaut, and this was only 1 of 4 astronauts to experience chorioretinal folds approaching the fovea. This case showed substantial inflight improvement greater than the sensitivity of the measure, possibly associated with B-vitamin supplementation and/or reduction in cabin CO2. However, as a single report, such improvement could be coincidental to these interventions, warranting further evaluation.

Practice Profile of Practicing Plastic Surgeons: A 20-year Review of Plastic Surgery Statistics.

Background: Evaluation of practice patterns by American Board of Plastic Surgery (ABPS) diplomates allows for a greater understanding as to how the field is progressing. Understanding evolving procedural trends can give insight into plastic surgeons' subspecialty focus and influence resident training to prepare them for future practice. Methods: American Society of Plastic Surgeons member only projections for aesthetic and reconstructive procedures were reviewed from 1999 to 2018 in 5-year increments to identify shifts in frequency between the beginning (1999-2003) and end (2014-2018) of the timeframe. Tracer utilization for all four ABPS modules were also examined between 2014 and 2018. Descriptive statistics were performed to identify significant changes (P < 0.05) in subspecialty focus and procedure trends. Results: Annual procedure incidence between 2014 and 2018 was compared with that between 1999 and 2003. The annual number of procedures more than doubled from 3,244,084 to 6,628,082. Among reconstructive procedures, there was a statistically significant increase in the number of breast reconstruction, breast implant removal, and maxillofacial surgery procedures, and a statistically significant decrease in the number of procedures focused on reconstruction of birth defects, burn injuries, and hand anomalies. In aesthetic surgery, significant increases were seen in the number of augmentation mammoplasty, abdominoplasty, and mastopexy procedures, with significant decreases in the number of blepharoplasty and rhinoplasty procedures. Conclusions: Understanding the changing practice patterns of ABPS diplomates is essential to define the direction that our specialty is taking over time, and to guide program directors in plastic surgery on areas of focus for appropriate training of plastic surgeons.

A Fourteen-year Review of Practice Patterns and Evidence-based Medicine in Operative Metacarpal Fracture Repair.

The American Board of Plastic Surgery has been collecting practice data on metacarpal fracture operative repair since 2006 as part of its Continuous Certification process. These data allow plastic surgeons to compare their surgical experience to national trends. Additionally, these data present the opportunity to analyze those trends in relation to evidence-based medicine. METHODS: Data on metacarpal fracture operative repair from May 2006 to December 2014 were reviewed and compared with those from January 2015 to March 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine. RESULTS: In total, 1160 metacarpal fracture repair cases were included. Outpatient (as opposed to inpatient) operative repairs have been trending upward, from 50% to 61% (P < 0.001). Most repairs were performed under general anesthesia (68%), and there was a decrease in the use of regional anesthesia between our two cohorts (14%-9%; P = 0.01). An open reduction with internal fixation was the most popular technique (51%), and a decrease in the use of closed reduction with splinting was observed (16%-10%; P = 0.001). Stiffness was the most commonly reported adverse event. Topics addressed in evidence-based medicine articles but not tracer data included interosseous wiring, which has shown success in spiral shaft fracture treatment with minimal complications, and nonoperative management. CONCLUSION: As evidence-based recommendations continue to change with additional research inquiry, tracer data can provide an excellent overview of the current practice of metacarpal fracture repair and how effectively physicians adapt to remain aligned with best practices.

Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair.

BACKGROUND: As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States. METHODS: Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles. RESULTS: Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics. CONCLUSIONS: This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.

Performance on the Plastic Surgery In-Service Examination Can Predict Success on the American Board of Plastic Surgery Written Examination.

BACKGROUND: Originally developed for resident self-assessment, the Plastic Surgery In-Service Examination has been administered for over 45 years. The Accreditation Council for Graduate Medical Education requires that at least 70 percent of graduates pass the American Board of Plastic Surgery Written Examination on their first attempt. This study evaluates the role of In-Service Exam scores in predicting Written Exam success. METHODS: In-Service Exam scores from 2009 to 2015 were collected from the National Board of Medical Examiners. Data included residency training track, training year, and examination year. Written Exam data were gathered from the American Board of Plastic Surgery. Multivariate analysis was performed and receiver operating characteristic curves were used to identify optimal In-Service Exam score cut-points for Written Exam success. RESULTS: Data from 1364 residents were included. Residents who failed the Written Exam had significantly lower In-Service Exam scores than those who passed (p < 0.001). Independent residents were 7.0 times more likely to fail compared with integrated/combined residents (p < 0.001). Residents who scored above the optimal cut-points were significantly more likely to pass the Written Exam. The optimal cut-point score for independent residents was the thirty-sixth percentile and the twenty-second percentile for integrated/combined residents. CONCLUSIONS: Plastic Surgery In-Service Exam scores can predict success on the American Board of Plastic Surgery Written Exam. Residents who score below the cut-points are at an increased risk of failing. These data can help identify residents at risk for early intervention.

Evolving Trends in Textured Implant Use for Cosmetic Augmentation in the United States.

BACKGROUND: Breast implants have evolved for decades. In 2011, the U.S. Food and Drug Administration identified an association between textured breast implants and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The purpose of this study was to identify the trends of textured implant use since that time. METHODS: Maintenance of Certification tracer data were queried between 2011 and 2015 for cosmetic breast augmentation cases submitted by American Board of Plastic Surgery diplomates. A nested random effects logistic regression analysis was used to identify associations between variables. RESULTS: Eleven thousand seven hundred sixteen breast augmentations were performed by 880 unique surgeons. The overall proportion of cases using textured implants increased steadily from 2.3 percent in 2011 to 13.0 percent in 2015 (p < 0.001). The proportion of surgeons whose cases included both textured and smooth implants increased (from 6.2 percent to 24.3 percent), as did those using only textured implants (from 0.4 percent to 4.4 percent) (p < 0.001). Significance remained after controlling for form-stable implants, suggesting an alternative motivation for use of textured implants. Subglandular cases (20.5 percent) were more likely to use a textured implant than submuscular (8.4 percent) or dual-plane (7.8 percent) (p < 0.001) cases. CONCLUSIONS: Maintenance of Certification tracer data represent a random sampling of American Board of Plastic Surgery-certified plastic surgeons spanning the gamut of practice settings. Despite ongoing education regarding the association of BIA-ALCL with textured implants, American Board of Plastic Surgery diplomates have trended toward increased use of textured implants for cosmetic breast augmentation since 2011. This finding does not appear to be driven by the introduction of anatomical implants during the study period.

The Importance of Patient Satisfaction: A Blessing, a Curse, or Simply Irrelevant?

New regulations require that physician performance must be evaluated and graded in both objective and subjective ways. This represents a novel factor in American health care delivery driven by the reality that the United States spends more than any other nation on health care yet still lags behind in key outcome measures. Patient satisfaction has been established as a core component of physician rankings and reimbursement. In fact, it already has acted as both a powerful motivator and stressor. Patient feedback has driven hospital administrators' agendas to improve facilities and provide relative luxuries to inpatients, and individual providers have been tempted to ignore sound medical judgment by relenting to patient requests to increase their satisfaction scores. Unfortunately, there is little high-level evidence to support that patient satisfaction will improve medical outcomes, and there are plenty of contradictory data in smaller studies. Part of the difficulty of these studies may lie in the diversity of patient expectations, which are dependent on the disease process and the inherently subjective and labile nature of people's responses. Reliable tools are needed that will take into account what constitutes a superior quality of patient care in a more systematic, meaningful, and validated way.

Breast reconstruction following mastectomy.

There are numerous reconstructive options for patients undergoing mastectomy for breast cancer. These include autologous tissue transfer and implant reconstruction. Various factors play a role in determining the appropriate reconstructive course including the type of cancer resection and patient characteristics including comorbidities, smoking, body habitus, and patient preference. Patient education is an important component to minimizing the psychological trauma and emotional stress that accompanies treatment for breast cancer. All patients with breast cancer should be aware of their reconstructive options.

Uneventful versus Successful Reconstruction and Outcome Pathways in Implant-Based Breast Reconstruction with Acellular Dermal Matrices.

BACKGROUND: Meaningful data to help guide resource allocation for staged tissue expander/implant-based breast reconstruction are currently lacking. The authors seek to differentiate uneventful from successful reconstruction and identify common outcome pathways and factors that portend a deviation from an uneventful, two-stage, two-operation course. METHODS: A retrospective analysis of expander/implant reconstructions with or without acellular dermal matrix (2003 to 2009) was performed. Related postreconstructive events (including mastectomy flap necrosis, seroma, wound dehiscence, cellulitis, explantation, hematoma, and capsular revisions) were assessed for 2 years. Uneventful reconstruction was defined as exchange to breast implant within 2 years of tissue expander placement without complications, whereas successful reconstruction was defined as exchange to breast implant within 2 years with or without complications. Factors affecting reconstructive success were analyzed, and patterns of postreconstructive events were summarized as outcome pathways. RESULTS: Four hundred thirteen patients (295 with acellular dermal matrix and 118 without), with 602 breasts (432 with acellular dermal matrix and 170 without) underwent reconstruction. Forty-six percent of patients (48 percent with acellular dermal matrix and 40 percent without), experienced uneventful reconstruction. Reconstructive success was achieved in 337 patients (82 percent; 82.0 percent with acellular dermal matrix and 80.5 percent without), with reconstructive failure occurring in 58 patients. Multiple logistic regression analyses determined that cellulitis, seroma, and skin necrosis (OR, 15.8, 7.7, and 8.4, respectively) were highly predictive of reconstructive failure. The authors identified 10 distinct pathways experienced by tissue expander/implant patients that were characterized by specific postreconstructive events. CONCLUSION: The present study will facilitate discussions among patients, providers, and payers by providing a framework for understanding the myriad outcome pathways in implant-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outpatient Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Determine those patients appropriate for outpatient surgery. 2. Choose appropriate anesthetics. 3. Manage patients with cardiac disease. 4. Limit complications occurring intraoperatively. SUMMARY: This article provides continuing medical education information regarding the current state of practice concerning outpatient surgery. A thorough preoperative evaluation is necessary to identify comorbid conditions and patients at risk for pulmonary compromise. Guidelines are provided on the use of sedatives, analgesics, and reversal agents. The management of patients with coronary artery stents and/or cardiac rhythm management devices is discussed. Effective surgical team communication is crucial to ensure that everyone is aware of conditions that may require adjustments from the usual healthy patients. Lastly, suggestions are provided to avoid intraoperative problems such as drug reactions and pressure ulcers. As our aging population presents for an increasing number of procedures, plastic surgeons must ensure that patient safety is a priority.

Bioactive poly(L-lactic acid) conduits seeded with Schwann cells for peripheral nerve regeneration.

This study attempted to enhance the efficacy of peripheral nerve regeneration using our previously tested poly(L-lactic acid) (PLLA) conduits by incorporating them with allogeneic Schwann cells (SCs). The SCs were harvested, cultured to obtain confluent monolayers and two concentrations (1 x 10(4) and 1 x 10(6) SC/ml) were combined with a collagen matrix (Vitrogen) and injected into the PLLA conduits. The conduits were then implanted into a 12 mm right sciatic nerve defect in rats. Three control groups were used: isografts, PLLA conduits filled with collagen alone and empty silicone tubes. The sciatic functional index (SFI) was calculated monthly through four months. At the end of second and fourth months, the gastrocnemius muscle was harvested and weighed for comparison and the graft conduit and distal nerve were harvested for histomorphologic analysis. The mean SFI demonstrated no group differences from isograft control. By four months, there was no significant difference in gastrocnemius muscle weight between the experimental groups compared to isograft controls. At four months, the distal nerve demonstrated a statistically lower number of axons mm2 for the high and low SC density groups and collagen control. The nerve fiber density was significantly lower in all of the groups compared to isograft controls by four months. The development of a "bioactive" nerve conduit using tissue engineering to replace autogenous nerve grafts offers a potential approach to improved patient care. Although equivalent nerve regeneration to autografts was not achieved, this study provides promising results for further investigation.

Airway management of a patient with facial trauma.

Airway management in patients with facial trauma is usually challenging. In this case, we report the airway management of a patient who had multiple midface fractures and a two-inch tree limb implanted into his face.