Frontofacial Reconstruction Technique Modification With Preservation of Blood Supply to the Monobloc Segment.

ABSTRACT: Craniosynostosis syndromes, including Apert Syndrome, Pfeiffer Syndrome, and Crouzon Syndrome, share similar phenotypes, including bicoronal craniosynostosis, midface hypoplasia, hypertelorism, and exorbitism. The standard surgical treatment for these craniofacial abnormalities is monobloc osteotomy with distraction osteogenesis. Complications of this technique include the failure of osteogenesis or resorption of the frontal bone. The authors propose an alternative surgical technique with a frontal arch in continuity with the midface segment to ensure vascularization to anterior and posterior borders of distraction. A case report of an 8-year-old female patient with Apert Syndrome is reported using our technique. Our frontal arch monobloc distraction procedure preserves blood supply to a cranial component of the monobloc segment site that becomes the anterior portion of distraction rather than with the traditional devascularized frontal bone flap. This technique modification should improve osteogenesis outcomes by preventing resorption or failure of bone formation.

Serial Posterior Cranial Vault Distraction for the Treatment of Complex Craniosynostosis.

ABSTRACT: Posterior cranial vault distraction is an important modality in the management of craniosynostosis. This surgical technique increases intracranial volume and improves cranial aesthetics. A single procedure is often inadequate in patients with complex multisuture craniosynostosis, as some will go on to develop intracranial hypertension despite the operation. Considering the negative effects of intracranial hypertension, some patients may warrant 2 planned distractions to prevent this scenario from ever occurring. Three patients with complex multiple-suture synostosis and severe intracranial volume restriction (occipital frontal head circumferences [OFCs] <1st percentile) were treated with 2 planned serial posterior cranial vault distractions at the institution between 2013 and 2018. Demographics, intraoperative data, and postoperative distraction data were collected. The OFC was recorded pre- and postdistraction, at 3- and 6-month follow-up appointments. Patients had a corrected average age of 18 weeks at the time of their initial procedure. There was an average of 38 weeks between the end of consolidation and the time for their 2nd distraction procedure. There was an average age of 79 weeks at the time of the 2nd procedure. All patients had a substantial increase in OFC and improvement of the posterior calvarium shape. The average increase in OFC was 5.2 cm after first distraction and 4.3 cm after 2nd distraction. No postoperative complications were encountered. Planned serial posterior cranial vault distraction is a safe and effective strategy for increasing intracranial volume, improving aesthetic appearance, and preventing the consequences of intracranial hypertension in patients with multisuture craniosynostosis and severe intracranial volume restriction.

2011 ACGME Duty Hour Limits had No Association With Breast Reconstruction Complications.

BACKGROUND: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted further duty hour restrictions in response to concerns over long work hours and sleep deprivation in trainees and their effects on patient outcomes. The effect of duty hour restrictions on complications after breast reconstruction procedures has not been clarified. MATERIALS AND METHODS: A retrospective cross-sectional analysis was designed. The National Inpatient Sample database was queried in the 2 y before and 2 y after the 2011 duty hour changes. Patients undergoing breast reconstruction, the most common elective admission diagnosis for plastic surgery patients, were selected for analysis. Patient groups were separated by teaching hospitals (THs) and nonteaching hospitals and by pre- and post-ACGME change periods. Surgical complication rates, length of stay, and procedures were analyzed using complex survey-weighted univariate and multivariate logistic regression analysis, with additional sensitivity analysis applied. RESULTS: The number of procedures did not vary significantly in the period after duty hour restrictions in THs (n = 46,188, pre-ACGME versus n = 48,980, post-ACGME). Overall complication rates in teaching (9.54%, pre-ACGME versus 9.04%, post-ACGME; P = 0.561) and nonteaching hospitals (8.54%, pre-ACGME versus 7.70%, post-ACGME; P = 0.319) did not significantly change after the implementation of duty hour changes. On multivariate analysis, surgery performed in resident THs after duty hour changes was not associated with a significant change in overall (odds ratio [OR], 1.03; 95% confidence interval [95% CI], 0.77-1.37; P = 0.857) breast-specific complications (OR, 1.06; 95% CI, 0.77-1.46; P = 0.731) or general complications (OR, 1.11; 95% CI, 0.80-1.54; P = 0.541). CONCLUSIONS: Duty hour restrictions enacted in 2011 were not associated with postoperative complications after breast reconstruction.

A Dedicated Quarterly Research Meeting Increases Resident Research Productivity.

BACKGROUND: Research is a vital component of a plastic surgery residency. Residents participating in research are better able to critically evaluate literature, allowing them to stay current throughout their careers. Programs benefit from increased research by increasing their academic reputation and attracting stronger applicants. To discuss ongoing research projects, foster collaboration, and encourage resident involvement, a quarterly research meeting was implemented within our division. We report the effectiveness of a dedicated division-wide quarterly research meeting in increasing the academic productivity of plastic surgery residents. MATERIALS AND METHODS: Beginning in 2015, the Division of Plastic Surgery at our institution implemented a dedicated quarterly research meeting. Academic productivity was assessed by the number of publications in peer-reviewed journals, oral presentations at national meetings, and oral presentations at regional meetings. We examined the change in productivity before and after the implementation of the quarterly meeting. Unpaired t-test was used to compare temporal differences. A direct temporal comparison was made between the 3 y of data before the implementation of the quarterly meetings and the 2 y of data after implementation. RESULTS: In the 2 y after the implementation of the research meeting, residents published significantly more often with an average of 2 peer-reviewed journal articles published per year per resident compared with 0.47 peer-reviewed publications in the 3 y before implementation (2 versus 0.47 publications per resident per year, P = 0.009). Residents were also more likely to present at national (0 versus 0.75 presentations per resident per year, P = 0.028) and regional meetings (0 versus 1 presentations per resident per year, P = 0.001). CONCLUSIONS: Implementation of a formal quarterly research meeting significantly improves resident research productivity. Residents demonstrated more publications and oral presentations. These results suggest that a more formal quarterly discussion of division-wide research can improve resident research productivity.

Variables associated with length of stay in patients undergoing mastectomy and delayed-immediate breast reconstruction with tissue expander.

Delayed-immediate reconstruction with the placement of tissue expanders at the time of mastectomy is a common approach to breast reconstruction. The purpose of this study was to identify variables associated with increased LOS in patients that underwent bilateral or unilateral mastectomy with tissue expander placement. Bilateral procedure, a diagnosis of anxiety or depression, and age >55 years were independently associated with increased LOS. More recent year of surgery and Friday surgery were associated with decreased LOS.

Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database.

BACKGROUND: Lower extremity free flaps are a common way to treat both traumatic and oncologic lower extremity wounds. These patients often suffer postoperative complications. We sought to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify variables associated with postoperative complications. METHODS: Patients who had free flap procedure and a primary diagnosis code for lower extremity pathology were identified in the NSQIP database from 2006 to 2017. NSQIP includes data on preoperative, intraoperative, and postoperative variables, including information up to 30 postoperative days. Current procedural terminology (CPT) codes for free flaps and international classification of diseases (ICD) 9 and 10 codes for lower extremity pathology were used for our cohort. We examined overall and major complication rates. Major complications were defined as reoperation, readmission, organ space infection, or death. Univariate and multivariate analyses were used to identify associations with complications. RESULTS: Four hundred and eighty-three patients underwent lower extremity free flaps. Overall complication rate was 31.6% and major complication rate was 14.9%. Prolonged operative time (OR = 2.81, CI:1.76-4.48, p < .001), preoperative steroid use (OR = 3.04, CI:1.12-8.29, p = .030), and preoperative anemia (OR = 4.10, CI:2.00-8.41, p < .001) were independently associated with any complication. Diabetes (OR = 2.56, CI:1.24-5.29, p = .011) and prolonged operative time (OR = 3.75, CI:2.17-6.47, p < .001) were independently associated with major complications. CONCLUSIONS: In lower extremity flap reconstruction, associations with overall complications include prolonged operative time, steroid use, and anemia. Associations with major complications included diabetes and prolonged operative time. These associations can be used to guide interventions on patients identified to have greater risk of complications.

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures.

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n = 389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Introduction: Les fractures du radius distal sont des blessures courantes de la main et du poignet qui exigent souvent une réadaptation intensive. Les chercheurs ont voulu déterminer les facteurs de risque associés au congé dans un établissement de soins post-aigus après la réparation d'une fracture du radius distal. Méthodologie: Les chercheurs ont fouillé la base de données 2011-2016 des NSQIP pour extraire tous les codes CPT (terminologie procédurale actuelle) qui correspondaient aux réparations des fractures ouvertes du radius distal. Les patients atteints d'autres blessures traumatiques ont été exclus. Les chercheurs ont colligé les caractéristiques démographiques des patients, leurs maladies sous-jacentes, les facteurs périopératoires, les données de laboratoire et l'information chirurgicale. Le résultat primaire consistait à déterminer la destination du congé postopératoire, soit le domicile ou l'établissement de soins postaigus, et à établir quels facteurs permettent de prédire un congé dans un établissement de soins postaigus. Les résultats secondaires incluaient des réadmissions non planifiées, la reprise de l'opération et les complications. Résultats: Entre 2011 et 2016, un total de 12 001 patients ont subi la réparation d'une fracture ouverte du radius distal et reçu de l'information complète lors de leur congé. De ce nombre, 3,24% (n = 389) ont obtenu leur congé dans des établissements de réadaptation. L'analyse multivariée a établi que les facteurs suivants étaient associés à un congé dans un établissement de soins postaigus : un âge de 65 ans ou plus, la race blanche, l'insuffisance pondérale, la prise de stéroïdes après l'opération, une classification d'ASA supérieure à 2, l'admission à partir d'un centre de soins de longue durée ou le fait d'être déjà hospitalisé, l'anémie, la chirurgie bilatérale, une classification des plaies autres que propre et des complications avant le congé. Conclusion: La présente étude a déterminé que certains facteurs associés au congé dans un établissement de soins postaigus après une réparation du radius distal peuvent contribuer à des conseils appropriés aux patients et à un triage de l'hôpital vers le domicile plutôt que vers un autre établissement.

Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty.

SUMMARY: As volume and understanding of genital gender affirming surgery (gGAS) has grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and non-binary individuals. Given the diverse spectrum of individuals seeking phalloplasty, we emphasize the importance of patient driven decision-making, beginning with the initial consultation. Phalloplasty surgery is not a one-size-fits-all surgery, but instead should be viewed from an individually-customized approach. This article discusses the technical details for vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty (SOP). The technique involves degloving the clitoral shaft, with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris, and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and re-suspends the labia minora anteriorly, improving final aesthetics and striving to meet patient genital goals.

Associations of discharge destination and length of stay in lower extremity free flap reconstruction.

Patients with lower extremity defects requiring free flap reconstruction often have difficult postoperative courses with prolonged length of stay and need for transfer to a post-acute care facility. The primary aim of this study was to determine associations of preoperative and perioperative variables with length of stay and discharge destination in patients undergoing lower extremity free flap reconstruction. The secondary aim was to determine associations of various complications with their discharge destination. The 2011- 2017 NSQIP database was queried for CPT codes for free flap procedures and ICD-9/ICD-10 codes for lower extremities. Univariate and multivariate analyses were used to determine associations of preoperative and perioperative variables with length of stay and discharge destination in patients undergoing lower extremity free flap reconstruction and associations of complications with their discharge destination. A total of 420 patients were identified who underwent lower extremity reconstruction in 2011-2017. Of 79.8% were discharged home and 21.2% were discharged to destinations other than home. On multivariate analysis, female gender, age > 55, ASA class > 2 and dependent functional status were found to have independent associations with discharge to post-acute care facilities. ASA classification greater than 2, active smoking, and discharge to a post-acute care facility all were independently associated with prolonged length of stay. Increased length of stay and discharge to post-acute care facility are closely associated. Understanding variables that influence length of stay and need for discharge to post-acute care facilities can help identify patients that may be triaged through appropriate interventions and expectation management.

Local delivery of FK506 to a nerve allograft is comparable to systemic delivery at suppressing allogeneic graft rejection.

The objective of this study was to determine if locally delivered FK506 could prevent allogeneic nerve graft rejection long enough to allow axon regeneration to pass through the nerve graft. An 8mm mouse sciatic nerve gap injury repaired with a nerve allograft was used to assess the effectiveness of local FK506 immunosuppressive therapy. FK506-loaded poly(lactide-co-caprolactone) nerve conduits were used to provide sustained local FK506 delivery to nerve allografts. Continuous and temporary systemic FK506 therapy to nerve allografts, and autograft repair were used as control groups. Serial assessment of inflammatory cell and CD4+ cell infiltration into the nerve graft tissue was performed to characterize the immune response over time. Nerve regeneration and functional recovery was serially assessed by nerve histomorphometry, gastrocnemius muscle mass recovery, and the ladder rung skilled locomotion assay. At the end of the study, week 16, all the groups had similar levels of inflammatory cell infiltration. The local FK506 and continuous systemic FK506 groups had similar levels of CD4+ cell infiltration, however, it was significantly greater than the autograft control. In terms of nerve histmorphometry, the local FK506 and continunous systemic FK506 groups had similar amounts of myelinated axons, although they were significantly lower than the autograft and temporary systemic FK506 group. The autograft had significantly greater muscle mass recovery than all the other groups. In the ladder rung assay, the autograft, local FK506, and continuous systemic FK506 had similar levels of skilled locomotion performance, whereas the temporary systemic FK506 group had significanty better performance than all the other groups. The results of this study suggest that local delivery of FK506 can provide comparable immunosuppression and nerve regeneration outcomes as systemically delivered FK506.

Surgical Management of Pachyonychia Congenita in a 3-Year-Old.

Pachyonychia congenita is a rare genetic disorder characterized by hypertrophic nail plates, hyperkeratotic nail beds, and thickened hyponychium of the fingers and toes, impairing manual dexterity and resulting in poor aesthetics. The current body of literature describes various treatment modalities, but no singular approach has been defined as the gold standard. In this case, the authors employed different surgical techniques for treating pachyonychia congenita to evaluate the most effective approach. A 3-year-old boy presented with hypertrophic nail growth involving all digits of both hands and feet. Three surgical procedures were performed on the patient's fingers and toes using germinal matrix excision (GME) alone, GME plus partial sterile matrix excision (pSME), or GME plus complete sterile matrix excision (cSME). The digits treated with GME + cSME exhibited no recurrence of nail growth. Those treated with GME alone exhibited recurrence of hypertrophic nail growth, although their growth slowed. Excision of GME + cSME prevented recurrence of hypertrophic nails, while GME alone or with pSME led to slower-growing hypertrophic nails. Complete excision of the germinal and sterile matrices with skin graft closure may be a definitive treatment for pachyonychia congenita, but further studies are needed to validate these findings.

Preferences for and barriers to gender affirming surgeries in transgender and non-binary individuals.

Background: The transgender/non-binary community continues to be an underserved population in medicine, and our understanding of their interests, disinterests, and barriers to transition-related healthcare is quite limited, especially among the diverse gender identities within the transgender/non-binary umbrella. Aim: To determine the interests, disinterests and barriers to gender affirming surgeries for transgender men, transgender women and non-binary individuals of any birth-assigned sex. Methods: An anonymous, online survey using REDcap was applied across all 50 states and advertised through social media, healthcare organization websites and flyers. The responses of individuals greater than 18 years of age who identified as transgender or non-binary were analyzed. Results: Compared to the 2015 US Transgender Survey, interest in gender affirming surgeries was higher across all gender identities surveyed and for all procedures, by an average of 38%. Interest overall in gender affirming procedures varied greatly among gender identity groups as well as with age differences. Barriers were found to be a mixture of lack of resources for recovery, financial, and a fear of complications. Discussion: Our results highlight that a desire for these procedures is unique for each individual and should never be assumed for transgender/non-binary patients. In order to better aid this underserved population, the medical community must further work to mitigate the barriers to gender affirming procedures by decreasing cost, investigating ways to increase access to resources for recovery, and improving outcomes for each of the gender affirming surgeries.

Smartphone Use for Patient Photography by Plastic Surgery Trainees.

Medical photography has become essential to patient care, trainee education, and research in highly visual specialties such as plastic surgery. As smartphone technology advances, plastic surgeons and trainees are using their personal smartphones to take medical photographs prompting ethical and legal concerns about patient consent and privacy. This study aims to determine the prevalence of personal smartphone use for patient photography among plastic surgery trainees, evaluate encryption practices, and establish understanding of current guidelines. Through a survey of 71 plastic surgery trainees throughout the United States, we show that 99% use their personal cell phone to take medical photographs while only 65% use HIPAA-compliant photo storage applications, and only 49% are aware of standard guidelines. This highlights that personal smartphone use among plastic surgery trainees is ubiquitous and there is a need for additional education and access to HIPAA-compliant photo storage applications.

Current Practices in the Pathologic Assessment of Breast Tissue in Transmasculine Chest Surgery.

BACKGROUND: No guidelines exist regarding management of breast tissue for transmasculine and gender-nonconforming individuals. This study aims to investigate the experiences and practices regarding perioperative breast cancer risk management among the American Society of Plastic Surgeons members performing chest masculinization surgery. METHODS: An anonymous, online, 19-question survey was sent to 2517 U.S.-based American Society of Plastic Surgeons members in October of 2019. RESULTS: A total of 69 responses were analyzed. High-volume surgeons were more likely from academic centers (OR, 4.88; 95 percent CI, 1.67 to 15.22; p = 0.005). Age older than 40 years [ n = 59 (85.5 percent)] and family history of breast cancer in first-degree relatives [ n = 47 (68.1 percent)] or family with a diagnosis before age 40 [ n = 49 (71.0 percent)] were the most common indications for preoperative imaging. Nineteen of the respondents (27.5 percent) routinely excise all macroscopic breast tissue, with 21 (30.4 percent) routinely leaving breast tissue. Fifty-one respondents (73.9 percent) routinely send specimens for pathologic analysis. There was no significant correlation between surgical volume or type of practice and odds of sending specimens for pathologic analysis. High patient costs and patient reluctance [ n = 27 (39.1 percent) and n = 24 (35.3 percent), respectively] were the most often cited barriers for sending specimens for pathologic analysis. Six respondents (8.7 percent) have found malignant or premalignant lesions in masculinizing breast specimens. CONCLUSIONS: Large variation was found among surgeons' perioperative management of chest masculinizing surgery patients regarding preoperative cancer screening, pathologic assessment of resected tissue, and postoperative cancer surveillance. Standardization of care and further studies are needed to document risk, incidence, and prevalence of breast cancer in the transmasculine population before and after surgery.

Thirty-Day Outcomes following Upper Extremity Flap Reconstruction.

Introduction Flap reconstructions of upper extremity defects are challenging procedures. It is important to understand the surgical outcomes of upper extremity flap reconstruction, as well as associations between preoperative/perioperative variables and complications. Materials and Methods The National Surgical Quality Improvement Program (NSQIP) database was queried for patients from 2005 to 2016 who underwent flap reconstruction of an upper extremity defect. Patient and perioperative variables were collected for identified patients and assessed for associations with rates of any complication and major complications. Results On multivariate analysis, American Society of Anesthesiologists (ASA) classification >2, bleeding disorder, preoperative steroid use, free flap reconstruction, wound classification other than clean, and nonplastic surgeon specialty were independently associated with any complications. Bleeding disorder, ASA classification >2, male gender, wound classification other than clean, and preoperative anemia were independently associated with major complications. Free flap reconstruction was associated with increased length of stay, operative time, any complications, transfusions, and unplanned reoperations. Conclusion There is an association between complications in patients undergoing upper extremity free flap reconstruction and ASA classification >2, preoperative anemia, preoperative steroid use, bleeding disorders, and contaminated wounds. Male patients may require more thorough counseling in activity restriction following reconstruction. Free flaps for upper extremity reconstruction will require increased planning to reduce the chance of complications.

Patient-reported opioid use for tissue expander-based breast reconstruction.

INTRODUCTION: There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use. METHODS: Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use. RESULTS: A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026). CONCLUSIONS: These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.

Hand and Wrist Injuries Among Collegiate Athletes: The Role of Sex and Competition on Injury Rates and Severity.

BACKGROUND: There is a high incidence of hand and wrist injuries in athletes participating in collegiate sports, but there is little information published characterizing them. PURPOSE: To characterize hand and wrist injuries in collegiate athletes using a large national database. STUDY DESIGN: Descriptive epidemiology study. METHODS: This retrospective cross-sectional analysis was designed using data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program database to identify hand and wrist injuries (exclusive of any radial or ulnar fractures) in male and female collegiate athletes participating in NCAA Division I, II, and III sports from 2004 to 2015. Descriptive analyses were performed on stratified data to examine the associations between these injuries and sport, event type, and sex. RESULTS: Men's ice hockey (8.25 per 10,000 athlete-exposures [AEs]) and women's ice hockey (8.21 per 10,000 AEs) had the highest rate of hand and wrist injuries in all exposures. In every sport except women's gymnastics (P = .107), injuries were more commonly sustained during competition rather than during practice. Ligamentous injury to the phalynx was the most commonly sustained injury overall (1.416 per 10,000 AEs), and a metacarpal fracture was the most commonly sustained hand or wrist fracture (0.507 per 10,000 AEs). Injuries sustained during men's wrestling (14.08 days) and women's gymnastics (10.39 days) incurred the most time lost from sport. Surgery for hand and wrist injuries was most commonly required for men's football (0.413 per 10,000 AEs) and women's field hockey (0.404 per 10,000 AEs). CONCLUSION: Hand and wrist injuries were common among collegiate athletes. Male athletes experienced injuries with more frequency and severity. Injuries occurred more commonly during competition. While the majority of injuries were minor and did not require surgery, certain sports conferred a much higher risk of significant injuries requiring a surgical intervention.

The confidence gap: Findings for women in plastic surgery.

BACKGROUND: In a surgical field, where surgeons are, "sometimes wrong, but never in doubt," lack of confidence can have detrimental effects on career advancement. In other fields there is evidence that a gap exists between women and men in the amount of confidence they display, and that confidence is a proxy for success. METHODS: This study used the General Self Efficacy Scale and Rosenberg Self-Esteem Scale confidence surveys to assess self confidence amongst female trainees and attending plastic surgeons, to search for baseline characteristics associated with higher confidence scores. RESULTS: Of the 73 participants, protective factors associated with increased female plastic surgeon confidence include age, parity, more advanced academic status, and mentorship. CONCLUSIONS: In order to matriculate into a surgical training program, there must be a measure of confidence and resiliency, but further work needs to be done to identify and address gender gaps in training and early academic careers.

A Comparison of Common Plastic Surgery Operations Using the NSQIP and TOPS Databases.

Both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the American Society of Plastic Surgeons Tracking Operations and Outcomes for Plastic Surgeons (TOPS) databases track 30-day outcomes. METHODS: Using the 2008-2016 TOPS and NSQIP databases, we compared patient characteristics and postoperative outcomes for 5 common plastic surgery procedures. A weighted TOPS population was used to mirror the NSQIP population in clinical and demographic characteristics to compare postoperative outcomes. RESULTS: We identified 154,181 cases. Compared with NSQIP patients, TOPS patients were more likely to be younger (47.9 versus 50.0 years), have American Society of Anesthesiologists class I-II (92.1% versus 74.6%), be outpatient (66.0% versus 49.3%), and be smokers (18.7% versus 11.7%). TOPS had extensive missing data: body mass index (40.6%), American Society of Anesthesiologists class (34.9%), diabetes (39.3%), and smoking status (37.2%). NSQIP was missing <1% of all shared categories except race (15.6%). The entire TOPS cohort versus only TOPS patients without missing data had higher rates of dehiscence (5.1% versus 3.5%) and infection (2.1% versus 1.7%). TOPS versus NSQIP patients had higher dehiscence rates (5.1% versus 1.0%) but lower rates of return to the operating room (3.1% versus 6.6%), infection (2.1% versus 3.0%), and medical complications (0.3% versus 2.2%). Nonweighted and weighted TOPS cohorts had similar 30-day outcomes. CONCLUSIONS: NSQIP and TOPS populations are different in characteristics and outcomes, likely due to differences in collection methodology and the types physicians using the databases. The strengths of each dataset can be used together for research and quality improvement.

Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention.

BACKGROUND: Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient's perspective. METHODS: The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors' patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors' migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors' patients experienced before and after surgical migraine therapy. RESULTS: Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms. CONCLUSION: This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors' patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.