Bilateral gluteal reconstruction with deep inferior epigastric perforator flaps and saphenofemoral arteriovenous loops.

The use of liquid silicone injections for soft tissue augmentation harbors numerous risks and is not approved by the FDA. Still, such injections are frequently performed by unlicensed providers, often in the gluteal region, and can lead to infection, soft-tissue breakdown, scarring, and disfigurement. The purpose of this case report was to demonstrate the use of immediate, abdominally based free flaps for reconstruction in a patient with bilateral total gluteal defects and limited inflow options in the setting of remote silicone injections. The patient is a 45-year-old female who developed chronically infected injected silicone in the bilateral buttocks leading to draining abscesses and soft tissue breakdown. The patient required radical debridement and excision of the bilateral buttocks to remove all foreign material. After intermediate skin grafting of the residual wounds, the patient then was deemed a candidate for bilateral free flap reconstruction of the buttocks. On exploration of the bilateral defects, both 20 cm × 10 cm in size, the gluteal vessels were non-usable, and preoperative CTA additionally had revealed no suitable posteriorly based perforators. Therefore, bilateral arteriovenous (AV) loops, measuring 30 cm in length, were then constructed utilizing the greater saphenous veins anastomosed to the femoral arteries which were then tunneled to the defect. The soft tissue defects were concurrently reconstructed with bilateral deep inferior epigastric perforator (DIEP) flaps measuring 16 cm × 12 cm. The postoperative course was complicated by small seromas in each groin requiring drain placement by interventional radiology on postoperative day 16. Otherwise, the patient's buttocks healed well, and functionally, the patient had regained the ability to sit and was satisfied with the aesthetic appearance of the reconstruction as of last follow-up at 10 months. Abdominally based free flap reconstruction with AV loops, in this case, provided for successful reconstruction of otherwise challenging soft-tissue defects with limited inflow options.

Crowdsourcing the Impact of Illustration in Cleft Surgery Education.

OBJECTIVE: This study aimed to (1) assess layperson preferences for how surgical information is presented; (2) evaluate how the format of visual information relates to layperson comfort with undergoing surgery, perceptions of surgeon character traits, and beliefs about artistic skill impacting plastic surgery practice; and (3) identify sociodemographic characteristics associated with these outcomes. DESIGN: A survey was developed in which one of five standardized sets of information depicting a unilateral cleft lip repair was presented as (1) text alone, (2) quick sketches, (3) simple drawings, (4) detailed illustrations, or (5) photographs. SETTING: Online crowdsourcing platform. PARTICIPANTS: Raters aged 18 years and older from the United States. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): After viewing the surgical information, participants answered three sets of Likert scale questions. Ratings were averaged to produce three composite scores assessing (1) comfort with undergoing surgery (2) perceptions of surgeon character traits, and (3) beliefs about plastic surgery and artistry. RESULTS: Four hundred seventy-nine participants were included. Surgeon character traits score was highest among participants who viewed detailed illustrations at 4.46 ± 0.59, followed by photographs at 4.43 ± 0.54, text alone at 4.28 ± 0.59, simple drawings at 4.17 ± 0.67, and quick sketches at 4.17 ± 0.71 (p = 0.0014). Participants who viewed detailed illustrations rated surgical comfort score and plastic surgery and artistry score highest, although differences did not achieve statistical significance. CONCLUSIONS: Viewing detailed cleft lip repair illustrations was significantly associated with positive perceptions of surgeon character traits. Our data help to contextualize methods of communication and education valued by the public when seeking cleft care.

A Retrospective and Prospective Cohort Study Comparing Pediatric Patients With Cleft Lip and Palate From the United States and Guatemala.

Orofacial clefts (OFC) remain among the most prevalent congenital abnormalities worldwide. In the United States in 2010 to 2014, 16.2 of 10,000 live births are born with OFC compared with 23.6 of 10,000 in Alta Verapaz, Guatemala in 2012. Demographics and cleft severity scores were retrospectively gathered from 514 patients with isolated OFC at the Children's Hospital of Philadelphia scheduled for surgery from 2012 to 2019 and from 115 patients seen during surgical mission trips to Guatemala City from 2017 to 2020. Risk factors were also gathered prospectively from Guatemalan families. The Guatemalan cohort had a significantly lower prevalence of cleft palate only compared with the US cohort, which may be a result of greater cleft severity in the population or poor screening and subsequent increased mortality of untreated cleft palate. Of those with lip involvement, Guatemalan patients were significantly more likely to have complete cleft lip, associated cleft palate, and right-sided and bilateral clefts, demonstrating an increased severity of Guatemalan cleft phenotype. Primary palate and lip repair for the Guatemalan cohort occurred at a significantly older age than that of the US cohort, placing Guatemalan patients at increased risk for long-term complications such as communication difficulties. Potential OFC risk factors identified in the Guatemalan cohort included maternal cooking-fire and agricultural chemical exposure, poor prenatal vitamin intake, poverty, and risk factors related to primarily corn-based diets. OFC patients who primarily rely on surgical missions for cleft care would likely benefit from more comprehensive screening and investigation into risk factors for more severe OFC phenotypes.

Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission.

OBJECTIVE: To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention. DESIGN: Prospective study with all participants receiving an educational intervention. SETTING: Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020. PARTICIPANTS: A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery. INTERVENTION: Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points. MAIN OUTCOME MEASURE: Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up. RESULTS: Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based. CONCLUSIONS: In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

Does Dedicated Research Time During Residency Predict Resident Academic Productivity and a Future Academic Career?

OBJECTIVE: Dedicated research time is a component of certain plastic surgery programs, and yet, there is limited research examining its impact on academic productivity and career outcomes. This study aimed to assess the effect of dedicated research time on the academic productivity of residents and the likelihood of pursuing an academic career. METHODS: We conducted a cross-sectional study that examined bibliometric indices of integrated plastic surgery residency graduates from 2010 to 2020. Academic productivity was determined by the number of peer-reviewed publications and h-index 1 year after residency graduation. Results were analyzed using descriptive statistics, χ2 test, t test, and logistic regression. RESULTS: Data on plastic surgery residency graduates were analyzed (N = 490 from 46 programs). The mean numbers of publications and h-index per research track graduate were 26.1 and 8.23, respectively. The mean numbers of publications and h-index per nonresearch track graduate were 15.9 and 5.97, respectively. After controlling for the University of Alabama research ranking through multilinear regression analysis, we found that pursuing dedicated research time was an independent predictor of increased h-index and publication output, although it did not predict an increased likelihood of pursuing an academic career. CONCLUSIONS: Participating in dedicated research during residency increases academic productivity, irrespective of the residency program's research rank. Given this finding, offering research years can help support the mission of fostering academic opportunities within plastic surgery.

Risk Factors for Occipital Step-Off Deformities in Posterior Vault Distraction Osteogenesis.

PURPOSE: The goal of this study was to investigate patient specific factors and surgical techniques that affect occipital step-off deformity in children undergoing posterior vault distraction osteogenesis (PVDO). METHODS: Patients who underwent PVDO were retrospectively reviewed and included if a high resolution three-dimensional computed tomography scan was available 1-year post-distractor removal. Two craniofacial surgeons were blinded to individual subjects and presented with 3 still images of three-dimensional bone reconstructions and asked to rate the degree of step off: none, mild, moderate, or severe. The data were analyzed with multinomial logistic regressions and other appropriate statistics. RESULTS: Forty-one patients met inclusion criteria. All patients had multisuture or bicoronal craniosynostosis. Multinomial logistic regression identified age at PVDO (Cox and Snell = 0.487, P < 0.001) as a predisposing factor and one potentially protective factor, height of osteotomy (Cox and Snell = 0.394, P = 0.004) in univariate models. Post-hoc pairwise Mann-Whitney U test revealed there was decreased step-off rating when comparing osteotomy below torcula (median 0, [IQR 0, 3]) and above torcula (median 3 [IQR 1, 4]; P = 0.036) as well as a decreased step-off when below inion (median 0 [IQR 0, 1]; P = 0.001) was compared to above the torcula. CONCLUSIONS: Older age at PVDO predict increased risk of developing an occipital step-off deformity after PVDO, while design of the occipital osteotomy below the inion is protective. Barrel staves with greenstick outfracture did not lower the risk of occipital step-off in this sample, the reasons for which are unclear.

Patients' Perceptions of Importance for Self-Administered Correct Site Surgery Checklist: A Multisite Study.

PURPOSE: The purpose of this study was to describe and validate the association between patient's self-administered correct site checklist and perceptions of importance for safe surgery. DESIGN: A multisite nonexperimental, quantitative, descriptive study. METHODS: A convenience sample of 173 adult patients from four different geographical multisite hospitals was included in the study. Inclusion criteria were age 18 to 75 years old, scheduled for surgery/procedure with laterality and ability to follow instructions. After IRB approval, investigators explained the purpose of the study, process and obtained consent from willing participants. Participants with clinical or behavioral limitations were excluded from the study. Participants completed a 24 item survey before and during surgery using a four-point Likert scale from one (not important) to four (extremely important). Descriptive data was analyzed using means, standard deviations, and percentage. All data was summarized and analyzed with STATA 12. FINDINGS: Most of the participants perceived the importance of the survey checklist items positively implying that the active engagement is an important role for safe surgery. However, a few participants reported some of the items as not important/somewhat important: "It is on my left or right side" (6.9%); "surgery on my: (state your limb) and (right or left site) (1.9-3%); "check electronic access or copy of imaging with correct name and site" (14.9%); "state your name and birthday" (4%), "check correct ID bracelet information" (2.9%) and "believe in having an active role in preventing error" (2.3%). Some participants responded, "My surgeon knows it or surgery has been scheduled".  Findings indicated that even though the importance of correct site surgery is critical for patient's surgery, a few patients reported it as noncritical and relied on healthcare team for their safety. CONCLUSIONS: This study validated the importance of the patients' perceived roles in promoting safe, correct site surgery and by engaging patients in mitigating correct site surgical errors. Therefore, inclusion of patients as an integral part of the healthcare team is necessary through education and encouragement to speak out.

Learner Drawing and Sculpting in Surgical Education: A Systematic Review.

BACKGROUND: Historically, surgery was developed through the visual work of artist-scientists, yet visual art in modern surgical education is rare. The aim of this review is to evaluate the existing literature of learner creation of visual art as an educational tool in surgery and to discuss its potential in augmenting surgical learning. METHOD: A systematic review of surgical educational interventions involving learner drawing, painting, and sculpting was conducted in 2020. RESULTS: Our search yielded 388 unique articles, and 12 met inclusion criteria. Seven articles described drawing and sculpting courses designed to develop judgement or aesthetic sense, and five described initiatives to teach or assess surgical anatomy or knowledge. Common goals included the measurement and observation of live models to enhance judgement of proportions, understanding of three-dimensional (3D) anatomical structure, hand-eye coordination, and communicative drawing ability for patient education and medical documentation. Notable outcomes included improved retention of anatomy, correlation of drawing and image labeling with in-service exam scores, and correlation of procedural drawing with ability to perform the same procedure in a simulation. CONCLUSIONS: Our review suggests that all surgical disciplines could benefit from artistic training through improved visual communication and deeper understanding of 3D anatomy. Such benefits can be translated into Accreditation Council for Graduate Medical Education (ACGME) Core Competencies to guide surgical residency programming. We propose that visual art serves as an educational tool to improve perceptual skill and anatomical understanding in the modern surgeon; however more research is needed to clarify the best modality for incorporation.

Facial Hair Transplantation for Transgender Patients: A Literature Review and Guidelines for Practice.

BACKGROUND: Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients. OBJECTIVES: This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients. METHODS: A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction. RESULTS: We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations. CONCLUSIONS: Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density.

Perianesthesia Nurses Pain Management Practices: Findings and Recommendations From a National Descriptive Study of Members of the American Society of Perianesthesia Nurses.

PURPOSE: The purpose of this study was to identify current individual practice of perianesthesia nurses regarding assessment and documentation of pain. DESIGN: Descriptive cross-sectional design using vignette technique. METHODS: Vignettes with questions available via electronic survey offered to attendees of the 2017 American Society of PeriAnesthesia Nurses National Conference. FINDINGS: Total of 1,680 perianesthesia nurses participated; 41.4% reported assessment of pain compared with 36.7% who reported documentation of pain assessment. The numeric (0 to 10) pain intensity score was the most commonly used assessment method. Only 16.4% assessed for and documented pain location, 14.4% assessed for and documented quality of pain. CONCLUSIONS: Pain assessment should include intensity, location, quality, and functional impact. The gap between nurses' practices in assessment and documention of pain may be related to system barriers. Embedding evidence-based best practice within electronic health records may improve both. Prior literature, as well as our findings, indicate these trends (missed documentation and assessment) are more global than only perianesthesia nursing.

Empowering Nurses: Creation of a Peer-Reviewed Journal as a Catalyst for Innovative Nursing Research and Enhancing Evidence-Based Nursing Practice.

An internal peer-reviewed journal was created to promote high-quality nursing practice, improve patient outcomes, and inspire nurses at an academic medical center. The goal of the journal was to increase nurses' utilization of evidence-based practice (EBP). The publication provides a platform that facilitates the dissemination of nursing research and supports the implementation of EBP across the organization.

Delphi Study: ASPAN Adult Patient Pain and Comfort Practices.

PURPOSE: The American Society of PeriAnesthesia Nurses (ASPAN) is responsible for establishing evidence-based standards to guide perianesthesia nursing practice. The ASPAN model for evidence-based practice acknowledges the potential for the Delphi technique to identify priorities for perianesthesia research. The purpose of this Delphi study was to generate a consensus on pain and comfort among a panel of experts. DESIGN: ASPAN convened a panel of experts to provide recommendations based on seven categories, this led to the development of a questionnaire to build consensus. METHODS: Survey conducted among panel of experts to obtain consensus. Two survey rounds were completed. FINDINGS: A consensus was obtained reaching a 70% benchmark for an acceptance. CONCLUSIONS: The results found a consensus on topics required for education and competency among perianesthesia nurses including transfer and discharge criteria related to pain and comfort, resources for perianesthesia nurses, policy guidelines, and the management of the special needs of perianesthesia patients.

Burnout and Resiliency in Perianesthesia Nurses: Findings and Recommendations From a National Study of Members of the American Society of PeriAnesthesia Nurses.

PURPOSE: Describe prevalence of burnout in perianesthesia nurses, explore risks, mitigating factors. DESIGN: Cross-sectional descriptive. METHODS: Survey containing Maslach Burnout Inventory, Short Form-12, and Social Support and Personal Coping was emailed to American Society of PeriAnesthesia Nurses. Regression analysis examined relationships between burnout and health, social support, personal coping, substance use, and demographics. FINDINGS: Of 2,837 respondents, 18% were currently and 35% were formerly burned out, with lower incidence in those >40 years. Currently burned out nurses had worse health and also perceived a lack of advancement opportunities and organizational investment in the individual. Lower burnout was associated with regular participation in physical (P < .001), creative (P = .004), or mindfulness hobbies (P < .001) and ease in discussing work problems with spouse or partner (P = .001). CONCLUSIONS: Despite burnout nurses' empathy for their patients is maintained. Interests outside of work, personal and work support, healthy work environment, and regular physical activities can improve burnout.

Preventing Opioid-Induced Respiratory Depression in the Hospitalized Patient With Obstructive Sleep Apnea.

PURPOSE: To enhance the role of nursing interventions in the management of perioperative opioid-induced respiratory depression (OIRD) in patients with obstructive sleep apnea (OSA). DESIGN: Narrative review of the literature. METHODS: Literature reviewed with emphasis on recommendations by professional and accrediting organizations. FINDINGS: Postsurgical OIRD increases hospital stay (55%), cost of care (47%), 30-day readmission (36%), and inpatient mortality (3.4 fold). OSA increases the risk of OIRD and may result in legal claims averaging $2.5 million per legal claim. CONCLUSIONS: Nursing interventions are essential to improving outcome and reduce cost in the management of postsurgical OIRD in OSA patients.

A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists.

BACKGROUND: Burnout affects all medical specialists, and concern about it has become common in today's health care environment. The gold standard of burnout measurement in health care professionals is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures emotional exhaustion, depersonalization (DP), and personal accomplishment. Besides affecting work quality, burnout is thought to affect health problems, mental health issues, and substance use negatively, although confirmatory data are lacking. This study evaluates some of these effects. METHODS: In 2011, the American Society of Anesthesiologists and the journal Anesthesiology cosponsored a webinar on burnout. As part of the webinar experience, we included access to a survey using MBI-HSS, 12-item Short Form Health Survey (SF-12), Social Support and Personal Coping (SSPC-14) survey, and substance use questions. Results were summarized using sample statistics, including mean, standard deviation, count, proportion, and 95% confidence intervals. Adjusted linear regression methods examined associations between burnout and substance use, SF-12, SSPC-14, and respondent demographics. RESULTS: Two hundred twenty-one respondents began the survey, and 170 (76.9%) completed all questions. There were 266 registrants total (31 registrants for the live webinar and 235 for the archive event), yielding an 83% response rate. Among respondents providing job titles, 206 (98.6%) were physicians and 2 (0.96%) were registered nurses. The frequency of high-risk responses ranged from 26% to 59% across the 3 MBI-HSS categories, but only about 15% had unfavorable scores in all 3. Mean mental composite score of the SF-12 was 1 standard deviation below normative values and was significantly associated with all MBI-HSS components. With SSPC-14, respondents scored better in work satisfaction and professional support than in personal support and workload. Males scored worse on DP and personal accomplishment and, relative to attending physicians, residents scored worse on DP. There was no significant association between MBI-HSS and substance use. CONCLUSIONS: Many anesthesiologists exhibit some high-risk burnout characteristics, and these are associated with lower mental health scores. Personal and professional support were associated with less emotional exhaustion, but overall burnout scores were associated with work satisfaction and professional support. Respondents were generally economically satisfied but also felt less in control at work and that their job kept them from friends and family. The association between burnout and substance use may not be as strong as previously believed. Additional work, perhaps with other survey instruments, is needed to confirm our results.

Survival and Growth of Orientia tsutsugamushi in Conventional Hemocultures.

Orientia tsutsugamushi, which requires specialized facilities for culture, is a substantial cause of disease in Asia. We demonstrate that O. tsutsugamushi numbers increased for up to 5 days in conventional hemocultures. Performing such a culture step before molecular testing could increase the sensitivity of O. tsutsugamushi molecular diagnosis.

Advanced Practice Providers' Perceptions of Patient Workload: Results of a Multi-Institutional Survey.

OBJECTIVE: This study examines data collected from a survey of advanced practice providers' (APPs') perceptions of reasonable versus actual APP-to-patient ratios and other factors that affect workload burden in both inpatient and outpatient clinical settings. BACKGROUND: Advanced practice providers provide accessible, cost-effective, and quality care in a growing number of specialty practices across multiple patient care settings. They are caring for higher volumes of patients and assuming more responsibilities while continuing to navigate highly complex healthcare systems. Limited evidence or benchmark data exist that would assist in determining optimal workload and staffing models that include APPs. METHODS: A group of advanced practice leaders developed and distributed a 43-question survey of workload factors to a highly diverse APP workforce. RESULTS: There were 1466 APPs across 37 areas of practice who responded to the survey distributed in 14 separate organizations. The perceived reasonable workload was lower than the actual workload for 22 specialty practice areas. The analysis included years of experience as an APP, work hours, on-call commitment, nonclinical responsibilities, and time spent in documentation, direct patient care, and performing procedures. CONCLUSIONS: There is a consensus among APPs, within their practice area, about what constitutes a reasonable patient assignment, despite the variability in APP experience, organizational culture, processes, and patient acuity.