The Utility of an Open-Access Surgical Simulator to Enhance Surgeon Training.

BACKGROUND: Smile Train, an international children's charity committed to improving cleft care around the world, empowers local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. As part of their sustainable model, Smile Train developed a web-based, interactive virtual simulator to improve surgical training of cleft procedures for surgeons around the world, replicating the anatomical and technical steps involved in cleft surgery. This study evaluated the simulator as a tool for enhancing surgical training. METHODS: A pre-test and questionnaire addressing cleft care, surgical knowledge, and confidence level was administered to surgeons-in-training at an academic institution. Participants completed 3 simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels. RESULTS: Sixteen surgeons-in-training participated in this study. The mean score on the knowledge examination increased after reviewing the modules for both junior residents (33.1%-64.4%) and senior residents (46.9%-70.8%). Reviewing the modules increased participants' confidence in the knowledge of cleft anatomy, understanding of surgical procedures, and ability to follow along meaningfully while assisting in operations. CONCLUSIONS: The Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons-in-training. Virtual simulation is a valuable resource for improving understanding and competence of the craniofacial surgeon while serving as an educational resource to other members of the comprehensive cleft care team, patients, and families.

Speech Outcomes After LeFort I Advancement Among Cleft Lip and Palate Patients.

BACKGROUND: Velopharyngeal insufficiency (VPI) results from incomplete closure of the velopharyngeal (VP) sphincter with oral pressure consonants during speech. Maxillary hypoplasia is common among cleft children and often requires LeFort I advancement. This results in anterior movement of the soft palate with the bony maxillary segment. Consequently, the size of the VP sphincter is increased and may result postoperative VPI or worsening of prior VPI. To better counsel our patients and their families of the risk of VPI after LeFort I advancement, we chose to evaluate our own cohort. METHODS: We conducted an institutional review board-approved prospective review of all cleft children presenting to Texas Children's Hospital who underwent LeFort I advancement after previous palatoplasty between 2013 and 2016 in a three-surgeon, consecutive patient series. Data collected included age, sex, ethnicity, cleft type, prior secondary speech surgery, presence of preoperative fistula, planned distance of advancement, orthognathic surgery performed, and any concurrent procedures performed. Primary outcomes measured included preoperative and postoperative VP function and hypernasality as measured by a certified speech pathologist. RESULTS: Velopharyngeal function was unchanged in 67% of our cohort after LeFort I advancement. Of those patients, 83% had evidence of VPI preoperatively, and 17% had normal speech preoperatively. Twenty-two percent of the patients displayed worsening VP function after surgery, and 6% displayed evidence of improvement. Velopharyngeal function was unable to be assessed in 6% of patients. Nasality ratings worsened in 39% of patients, were unchanged in 39%, and improved in 22%. Of the patients with incompetent VP function after surgery, 50% already received or are currently scheduled for secondary speech surgery, 25% declined secondary surgery, and 25% are pending scheduling. CONCLUSIONS: Although VP function remains unchanged in a majority of patients after LeFort I advancement, VPI should be carefully screened for after surgery. If detected, secondary operations to correct speech should be strongly considered.

What are the ethical and legal considerations when your patient refuses the standard of care?

In medical practice, physicians are sometimes faced with patients who reject the gold-standard treatment for a condition. In this hypothetical clinical scenario, we present the case of a patient who refuses Mohs micrographic surgery for management of infiltrative basal cell carcinoma and instead requests off-label therapy with imiquimod. We discuss the treating dermatologist's options in response to this patient's request and the ethical considerations surrounding the case. We conclude that the physician has the right to refuse to provide treatment that deviates from standard clinical practice but that the physician should counsel the patient on all options, provide thorough informed consent, offer contact information for the patient to pursue a second opinion or a radiation oncology referral, and ensure safe transfer of care should the patient desire treatment with a different provider.

Insurance Appeals for Pediatric Reconstructive Surgery: A Micro Cost Analysis and How-to Guide.

BACKGROUND: When insurance coverage for pediatric reconstructive procedures is denied, a stressful and time-consuming appeals process ensues. This article discusses the results of a micro cost analysis performed to better understand the time and monetary burden that the insurance process places on our clinic and families. We also advise plastic surgeons on how to appeal insurance denials for necessary reconstructive procedures. METHODS: Our micro cost analysis focused on patients with congenital breast anomalies who were denied insurance coverage during the preservice insurance authorization process. We surveyed staff and family members to determine the steps involved in the insurance process and how long each person spent on each step. We combined this with average compensation data to calculate cost. RESULTS: For the 5 patients included in our analysis, the insurance process took an average of 7.4 hours of institutional time and cost $521.43 per patient. All patients were denied coverage during prior authorization and required a peer-to-peer, and all denials occurred because surgery was deemed cosmetic or not medically necessary. CONCLUSIONS: This analysis estimated the time and monetary cost of the insurance process in our department. Access to care was limited by prior authorization and the opinion of medical directors that these procedures are unnecessary or cosmetic. We encourage plastic surgeons to continue to perform patient-centered outcomes research in their practice to build on literature that proves the functional and psychosocial benefits of reconstructive procedures.

Safety Outcomes in Endoscopic Versus Open Repair of Metopic Craniosynostosis.

BACKGROUND: Premature fusion of the metopic suture leads to a range of clinical presentations, with more severe patients presenting characteristically with trigonocephaly. Endoscopic-assisted correction of craniosynostosis is emerging as an alternative to the gold-standard open cranial vault remodeling. While there are several documented benefits of endoscopic correction, the management of craniosynostosis varies widely in the literature with little consensus as to the preferred timing and surgical technique for repair. The purpose of this study was to investigate the safety outcomes of endoscopic versus open surgery at our institution. METHODS: This retrospective cohort study included all patients diagnosed with metopic craniosynostosis who underwent open or closed surgical management and received at least 6 months of follow-up. Data extraction was performed via chart review and included demographic information and safety outcome variables. RESULTS: During the study period, 17 patients who met our inclusion criteria were treated by the multidisciplinary craniofacial team at our institution. Eight patients underwent endoscopic surgery and 9 underwent open surgery. The mean age at surgery was significantly higher in the open surgery group than the endoscopic surgery group (13.7 months versus 2.3 months, respectively). Estimated blood loss, percent estimated blood volume lost, transfusion volume, procedure length, hospital length of stay, and intensive care unit (ICU) length of stay were all significantly higher in the open surgery group compared with the endoscopic group. CONCLUSIONS: In our patient population, endoscopic surgery for metopic craniosynostosis had an improved safety profile versus open surgery based on reduced procedure length, estimated blood loss, volume of blood transfusion, and length of stay in the ICU and hospital.

Shared Medical Appointments for Adolescent Breast Reduction.

Adolescents with macromastia face serious physical, emotional, and social burdens because of their large breast size. Studies have shown that reduction mammoplasty results in improvement in physical symptoms and quality of life for these patients. Shared medical appointments (SMAs), defined as individual patient-physician encounters that occur in a group setting, have been successfully applied to clinics for adult patients seeking breast reduction for this condition. We decided to apply the SMA model to our clinic for preoperative evaluation of adolescent patients with macromastia. The purpose of this article is to describe how our clinic implemented SMAs, evaluate changes in clinic efficiency, measure patient quality of life before surgery, and assess patient and provider satisfaction with the SMA model.From February to June 2016, our department instituted SMAs for preoperative evaluation of female adolescent patients with macromastia. We measured days from referral to appointment for 25 patients who attended SMAs and compared this with a retrospective cohort of 21 patients who attended traditional visits from 2013 to 2015.Clinic efficiency was measured in new patients per hour. During SMAs, we also administered the BREAST-Q, Pediatric Quality of Life Inventory, and patient and provider satisfaction surveys. Mean days between referral and office visit was reduced from 75.3 with traditional visits to 40.3 with shared appointments, although this finding was not statistically significant (P = 0.69). New patients per hour increased from 1.33 with traditional visits to 3 with SMAs, without reducing time spent on education or with the surgeon. The mean preoperative BREAST-Q scores were less than 40 for the 4 tested domains, and the mean (SD) total Pediatric Quality of Life Inventory score was 56.7 (14.8). Patients and the provider reported high satisfaction with SMAs, and the provider wishes to continue using SMAs in the clinic.In conclusion, SMAs resulted in high patient and provider satisfaction and increased clinic efficiency, without sacrificing time spent on education or with the surgeon. Low quality-of-life scores demonstrate a need for these patients to be evaluated and treated for their condition. Measuring patient-reported outcomes with validated surveys and improving clinic efficiency without sacrificing patient care have the potential to increase value at our institution.

Dermatological uses of rice products: Trend or true?

BACKGROUND: Rice has been used for cosmetic purposes for centuries and its benefits have been translated into modern-day skin careproducts. METHODS: Pubmed and google were searched with the terms "skin care" and "cosmetics" in conjunction with the words "rice", "rice bran", and "fermented rice bran". Resulting articles were analysed for potential benefits of ingredients contained within rice for skin care and summarised. RESULTS: Individual components of rice have been identified including phenolic compounds, betaine, squalene, tricin, and rice bran. These rice-derived ingredients have been found to be antiaging, anti-inflammatory, whitening, photoprotective, and moisturizing. Moreover, rice-derived ingredients have demonstrated benefits for dermatological conditions. Rice bran ash extract increases melanin synthesis and offers protection from radiation and skin injury. Fermented rice bran extract and rice bran broth baths have shown utility in atopic dermatitis treatments. Literature suggests that rice-derived ingredients are also safe, non-irritating, and hypoallergenic. CONCLUSION: Ingredients isolated from rice and its components have wide potential for use in skin care and cosmetic products.

A Rare Clinical Presentation of Metastatic Crohn's Disease.

A 31-year-old female with a history of systemic lupus erythematous, IgA nephropathy, and psoriasis presented with a one-month history of a painful, pruritic rash under the bilateral breasts and in the genital region. Cutaneous examination revealed a large, tender ulcer under the left breast with a shiny erythematous base and peripheral hypertrophic changes. Small ulcers were present on the bilateral inguinal folds, and the labia majora were edematous with multiple erythematous papules. Histological examination of the left breast revealed ulceration with granulomatous dermatitis, consistent with a diagnosis of metastatic Crohn's disease. Metastatic Crohn's disease is a rare cutaneous manifestation of Crohn's disease characterized by non-caseating granulomas in regions non-contiguous with the gastrointestinal tract. At the time of diagnosis, our patient reported no gastrointestinal symptoms aside from occasional blood-streaked stools from hemorrhoids. This case demonstrates the importance of considering the disease when a patient presents with intertriginous or genital lesions, even in the absence of systemic manifestations.

A review of N-acetylcysteine in the treatment of grooming disorders.

BACKGROUND: Pathologic grooming disorders can lead to clinically significant distress and functional impairment. Studies on treatment of these disorders with selective serotonin reuptake inhibitors (SSRIs) and anticonvulsants have led to inconsistent findings. N-acetylcysteine (NAC) has shown promise in treatment of obsessive-compulsive and related disorders. The objective of this article is to perform an updated review of NAC in the treatment of grooming disorders. METHODS: PubMed was searched from inception to October 2017 to identify literature on the use of NAC in the management of trichotillomania, onychophagia, and pathological skin picking. Case reports, case series, and randomized controlled trials were included. Data on study design, dosing regimens, comorbidities, concurrent treatment, and side effects were extracted from the included articles. RESULTS: Fifteen articles were included in this review, which consisted of 10 case reports, one case series, and four randomized controlled trials. Dosing of oral NAC ranged from 450 to 2,400 mg per day, and treatment periods lasted from 1 to 8 months. Side effects were uncommon, mild, and usually gastrointestinal in nature, with severe aggression reported in one child. CONCLUSIONS: While there are multiple reports of the safety and efficacy of NAC in the treatment of grooming disorders, there are currently few randomized controlled trials on this topic, and more research is needed to develop a formal treatment algorithm. While current data should be considered very preliminary, case reports have demonstrated mostly positive results and a lack of significant side effects. A trial of NAC may be a viable option for pathologic grooming disorders, especially in patients who have failed prior psychologic or pharmacologic treatment.

Social media in dermatology: clinical relevance, academic value, and trends across platforms.

Social media encompasses multiple sites for online communication that reach a large proportion of the global population. While the increase in number of publications investigating dermatology content on social media has paralleled the growth of social media in the past decade, there has not yet been an extensive review of past literature on this topic. Our objective is to summarize and analyze publications on the role of social media within the field of dermatology. Social media is frequently used by patients to solicit advice related to cutaneous concerns and even when seeking out a dermatologist, but it is underutilized among both clinicians marketing their practices and academicians collaborating with colleagues in the field. Social media has the potential to advance instruction for trainees in dermatology and facilitate new research methods. Patient-centered perspectives and advocacy groups have a larger presence overall on social media platforms than stakeholders in academic dermatology. Furthermore, specific platforms like Facebook, YouTube, and Twitter vary in originators of material, messaging strategies, and reliability of information with regards to certain dermatologic conditions and behaviors.

A systematic review of complications in prepectoral breast reconstruction.

The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high incidence of capsular contracture and complication rates. With the introduction of acellular dermal matrix (ADM), plastic surgeons are again considering the advantages of prepectoral implant placement. A systematic review was conducted to examine complication profiles in prepectoral breast reconstruction alone versus prepectoral with ADM or mesh. A systematic review of the PubMed database was performed from inception to March 2017 to identify literature on postmastectomy patients undergoing prepectoral breast reconstruction with and without ADM or mesh. Study characteristics, complication rates, and outcomes were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale, and complication profiles were analyzed using the random-effects model. Twenty-seven studies met criteria for inclusion out of 550 identified for review. For 1881 total breasts, the complication rate with ADM was 23.4%, while the rate without an additional implant material was 27.5%. The difference in the capsular contracture rate with and without ADM was 2.3% and 12.4%, respectively. The use of ADM in prepectoral breast reconstruction correlated with lower capsular contracture and overall complications rates; however, rates of implant loss, infection, and mastectomy flap necrosis were higher with the use of ADM. Results were variable across studies, and in general, the quality of evidence reported was low. Because the methodology for outcome assessment was inconsistent, there is a need for further investigation with comparative studies and standardized outcome reporting.

Prepectoral Breast Reconstruction.

Prepectoral breast reconstruction was first done in the early 1960s; however, while initial results were promising, high complication rates led surgeons to move toward submuscular implant placement. We soon came to find that submuscular implant placement was not without its own set of drawbacks. Surgeons have since revisited the efficacy of prepectoral breast reconstruction in light of new surgical and technological advances. Following these advancements, complication profiles for prepectoral breast reconstruction have drastically improved. Despite this change, surgeons recognize that prepectoral implant placement is not for everyone and patient selection is critical to success. As increasing numbers of these procedures continue to be done, we must now look to conduct direct comparisons between submuscular and prepectoral breast implant placement so that surgeons can make evidence-based decisions on patient selection and operative planning.

A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality.

BACKGROUND: A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners. METHODS: A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care. RESULTS: In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent). CONCLUSIONS: The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.

Medical Consultation Experience Questionnaire: Assessing perceived alliance and experienced confusion during medical consultations.

The Medical Consultation Experience Questionnaire (MCEQ) is a new, brief self-report instrument that can be used with both adult patients and parents of child patients to assess two dimensions of people's experiences interacting with medical practitioners: Alliance and Confusion. In contrast with existing measures, the MCEQ was expected to provide good discrimination across a full range of experience levels and to assess two distinct dimensions of experience with good factor validity. It was developed in a series of 7 preliminary studies (with 758 participants) and tested in 3 subsequent validation studies, which are the focus of the present report. Study 1 was an Internet sample of 199 parents of child patients, Study 2 was a hospital sample of 173 parents of child surgery patients, and Study 3 was an Internet sample of 204 adult patients. A confirmatory factor analysis specifying strict measurement invariance across the 3 groups produced a good fit. An item response theory analysis suggested that scales on the MCEQ provide good discrimination across a wide range of experience levels. The new scales measuring Alliance and Confusion each had a distinct pattern of convergent validity associations with criterion variables regarding alternate measures of consultation experience, treatment context, and patient-reported perception, behavior, and affect. Results support the validity of the MCEQ and suggest that Alliance and Confusion are two distinct and informative dimensions of medical consultation experience. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Soft Tissue Management in Facial Trauma.

The management of soft tissue injury after facial trauma poses unique challenges to the plastic surgeon, given the specialized nature of facial tissue and the aesthetic importance of the face. The general principles of trauma management and wound care are applied in all cases. The management of severe injuries to the face is discussed in relation to the location and the mechanism of injury. Facial transplants have arisen in the past decade for the management of catastrophic soft tissue defects, although high morbidity and mortality after these non-life-saving operations must be considered in patient selection.

Frontal Sinus Fractures.

The frontal bone serves a protective role, representing the transition between the facial skeleton and the cranium. Within its enclosure, the frontal sinus lies adjacent to many important intracranial structures, and injury to this region has severe complications if not properly managed. Historically, the goals of frontal sinus fracture management have been to best prevent intracranial complications with invasive procedures, but a recent shift favoring conservative management now aims to preserve the form and function of the frontal sinus and its outflow tract. With the advancement of endoscopic techniques and the development of new technologies, many alternatives to aggressive surgical management are available.

Differences in the Management of Pediatric Facial Trauma.

Craniofacial trauma is common in the pediatric population, with most cases limited to soft tissue and dentoalveolar injury. Although facial fractures are relatively rare in children compared with adults, they are often associated with severe injury and cause significant morbidity and disability. Initial evaluation of a child with facial trauma generally involves stabilizing the patient and identifying any severe concomitant injuries before diagnosing and managing facial injuries. The management of pediatric facial fractures is relatively more conservative than that of adults, and nonsurgical management is preferred when possible to prevent the disruption of future growth and development. Outcomes depend on the site of the injury, management plan, and subsequent growth, so children must be followed longitudinally for monitoring and the identification of any complications.