Surgical Management of Hidradenitis Suppurativa: A Two-Center Retrospective Study.

BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory condition that presents a challenging reconstructive problem for plastic surgeons. METHODS: The authors performed a retrospective chart review of hidradenitis suppurativa patients managed with surgical excision between 2005 and 2020 at Brigham and Women's Hospital and Tulane University Medical Center. Operative cases associated with the same hospitalization were organized into treatment episodes and assessed for patient demographics, operative techniques, and outcomes. RESULTS: A total of 181 patients, 435 cases and 316 treatment episodes (Brigham and Women's Hospital, n = 269; Tulane University Medical Center, n = 47), were identified across two diverse institutions. Their respective series showed comparable patient demographics, and 94 percent of the combined episodes achieved wound closure and healing during the study period. Several techniques of closure were identified, including immediate closure and site-specific methods, such as an expedited staged closure using internal negative-pressure wound therapy as a temporary bridge, "recycled" skin grafting, and repurposing iodoform wicks as an adjunct wound healing therapy to immediate closure. CONCLUSIONS: This large multi-institutional retrospective chart review on the plastic surgical management of hidradenitis suppurativa demonstrates that surgery is an effective therapy for hidradenitis suppurativa and captures a diversity of site-specific techniques that may serve as a foundation for future prospective studies and evidence-based guidelines for the use of various techniques to optimize patients' surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Thoracic Aortic Graft Salvage after Sternal Wound Infection with Antibiotic Beads and Flap Coverage.

Infections involving thoracic aortic grafts are difficult to treat and have devastating consequences. The traditional approaches to surgical management include aggressive debridement with graft explantation and replacement. Despite treatment, the reported morbidity and mortality rates are high. The purpose of this study was to present our experience with an innovative approach to aortic graft salvage in the setting of sternal wound infection using antibiotic impregnated polymethylmethacrylate beads followed by definitive wound closure with flap coverage. A retrospective review identified patients with surgical wounds after aortic graft or cardiac valve placement over a 7-year period at a single institution. Patients were treated using an algorithm consisting of repeated surgical debridement and placement of antibiotic beads followed by flap coverage after suppression of the infection. A total of 20 patients were treated for surgical wounds, including 19 sternal and one thoracotomy wound. Culture positive surgical site infections were documented in 16 patients. One patient required a bead exchange before definitive closure. There were no in-hospital mortalities. All but two patients achieved successful infection suppression and wound closure with flap coverage. The use of antibiotic beads with serial debridement and flap closure may offer a valid option for aortic graft salvage in the setting of infected sternal wounds in the appropriate patient population. The proposed algorithm showed that patients may be successfully treated, and their infection suppressed without the need for graft removal. Mortality rates were lower from those previously reported in the literature.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Periprosthetic seroma occurrence after femoropopliteal bypass grafting: Surgical management after failure of non-surgical measures in relieving symptoms.

OBJECTIVE: Periprosthetic seroma is a rare complication of femoropopliteal bypass grafting. Periprosthetic seroma can be defined as the collection of non-infected serous fluid around a prosthetic arterial graft. There is a dearth of literature on how to manage periprosthetic seroma occurrence after femoropopliteal bypass especially in patients whose symptoms do not improve with typical conservative measures.Method/Results: This report highlights the case of a 70-year-old patient who had a femoropopliteal bypass using a 6 mm Propaten graft for peripheral arterial disease. The patient subsequently presented with leg edema. Leg ultrasound and computed tomography arteriogram showed a periprosthetic seroma with a patent graft. Patient was initially managed conservatively and semi-conservatively and ultimately with aggressive therapy utilizing exploration and surgical resection of the seroma capsule. CONCLUSION: Only surgical resection of the seroma capsule produced definitive resolution of the seroma and symptoms. Thigh exploration and surgical resection can be considered as part of the management modalities of periprosthetic seroma occurring after femoropopliteal bypass especially in patients who do not respond to typical conservative measures such as elevation, compression stockings, and diuretics.

A Global Evaluation of Surgical Techniques and Results of Unilateral Cleft Lip Repairs.

BACKGROUND: Variations in the clinical presentation of the unilateral cleft lip resulted in numerous surgical repair techniques used around the world. No universally accepted method exists to evaluate aesthetic surgical results. The purpose of this study is to use the Hubli lip grading system, developed by Smile Train, to evaluate the aesthetic results of unilateral cleft lip repairs based on the surgical technique used. METHODS: A retrospective review was conducted of unilateral cleft lip repair operations performed by Smile Train surgeons throughout Africa, Americas, Asia Pacific, and Europe and Middle East between 2014 and 2018. Using the Hubli lip grading criteria, factoring in cleft severity, acceptable outcomes were identified and compared with the surgical technique used. RESULTS: Eight thousand forty-one unilateral cleft lip repairs were reviewed. The majority utilized the rotational advancement technique (n = 5541, 68.9%) with a statistically significant percentage of acceptable outcomes (92.1%), followed by an acceptance rate of 91.9% with variations of the z-plasty technique, 90.5% with the straight-line repair and its variations, and 88.4% using "other" techniques (P < 0.05). The rotational advancement had the highest acceptable outcomes for complete cleft lips (94.7%, P < 0.0001), associated alveolar clefting (94.2%, P < 0.05), and concomitant clefting of the hard and/or soft palate (94.3%, P < 0.05). CONCLUSION: Regardless of surgical technique used, Smile Train surgeons maintain high rates of successful surgical outcomes. Results of our study will help complement and support existing medical infrastructure and training systems Smile Train employs for surgeons working with comprehensive cleft care teams around the world.

Ambulatory Access: Improving Scheduling Increases Patient Satisfaction and Revenue.

BACKGROUND: Even before seeing a physician, patients must first gain access to the hospital system. At large hospitals with high patient volumes, access to specialty care can pose a particular challenge. This study examines the effects of specific initiatives to increase clinic capacity, appointment use, and ease of scheduling on both patient satisfaction and hospital revenue. METHODS: In 2017, a task force at a large, multidisciplinary pediatric hospital instituted a number of initiatives to increase patient access to ambulatory specialty clinics. Clinic sessions were standardized to a 4-hour template, and unscheduled, "held" appointment slots were required to be made available ("flipped") 72 hours before the appointment. A patient-centered electronic scheduling platform was also implemented. Patient satisfaction was assessed using Press Ganey scores. Revenue estimates were calculated for increases in "new" and "return" patient appointments. RESULTS: Total new appointment slots increased by over 44 percent, with over 53,000 appointments added annually. The number of held appointment slots declined by 93 percent. A total of 17,996 annual appointments were added in surgical subspecialties, and an additional 14,756 more surgical appointments were completed. Over 2000 appointments were scheduled by means of the online patient portal. Press Ganey "ease-of-scheduling" scores increased from 57 percent to 72 percent over the intervention period. Hospitalwide, these initiatives generated an estimated $8.3 million in revenue opportunity. CONCLUSION: Standardizing clinic sessions and optimizing clinic availability generates new appointment opportunities, improves patient experience, and increases hospital revenue.

Quantifying Free Fibula Flap Growth After Pediatric Mandibular Reconstruction.

INTRODUCTION: The free fibula flap (FFF) is a preferred option for adult mandibular reconstruction. Due to skeletal immaturity, its routine use in pediatric patients remains in question. Inconsistencies regarding the ability of the FFF to grow in concordance with the patients' natural growth currently exist in the literature. The purpose of this report is to quantify mandibular growth in a young patient undergoing partial hemi-mandibular reconstruction with a FFF utilizing advanced three-dimensional software. METHODS: A 2-year old underwent left hemi-mandibular reconstruction with a FFF following resection of a desmoid tumor. The condyle was preserved. Using 3D software, changes in mandibular growth and morphology were evaluated based on preoperative (2.1 years old) and postoperative (2.5 years and 5.2 years old) computed tomography imaging. RESULTS: Mandibular growth occurred throughout the mandible in both postoperative evaluations. Greatest growth was seen in the ramus height. Fibula growth was also seen when comparing measurements to the virtual surgical planning guide. A novel parts comparison analysis revealed the greatest growth potential occurred at the condyle. CONCLUSION: Providing an objective evaluation using 3D software, we have demonstrated growth throughout the reconstructed mandible, with greatest growth occurring at the preserved condyle. Despite scientific limitations of our study, the potential for mandibular growth appears to remain after FFF reconstruction, offering successful functional and cosmetic outcomes.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes.

BACKGROUND: When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes. METHODS: Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement. RESULTS: Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair. CONCLUSIONS: This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.

The History and Mission of Smile Train, a Global Cleft Charity.

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.

Kenny-Caffey Syndrome Type 2: A Unique Presentation and Craniofacial Analysis.

Kenny-Caffey Syndrome Type 2 (KCS2) is a rare genetic disorder characterized by short stature, skeletal dysplasia, primary hypoparathyroidism, and delayed closure of the anterior fontanelle. Patients with KCS2 typically require multidisciplinary management due to numerous craniofacial and skeletal anomalies. Craniosynostosis, however, has not yet been identified in a patient with KCS2 to the best of our knowledge. We present the first case of craniosynostosis in the setting of KCS2 and provide a comprehensive analysis of the associated craniofacial findings to date. The authors will describe the craniofacial features specific to our patient and review the characteristic morphological features in a manner relevant to early recognition and focused evaluation.

Quantification of Mandibular Morphology in Pierre Robin Sequence to Optimize Mandibular Distraction Osteogenesis.

BACKGROUND: Mandibular distraction osteogenesis (MDO) is the primary surgical intervention to treat airway obstruction in Pierre Robin sequence (PRS). Current morphologic studies of PRS mandibles do not translate into providing airway management decisions. We compare mandibles of infants with nonsyndromic PRS to controls characterizing morphological variances relevant to distraction. We also examine how morphologic measurements and airway grades correlate with airway management. METHODS: Patients with PRS under 2 months old were age and sex matched to controls. Demographic and perioperative data, and Cormack-Lehane airway grades were recorded. Computed tomography scans were used to generate mandibular models. Bilateral condylions, gonions, and the menton were identified. Linear and angular measurements were made. Wilcoxon rank sum and 2-sample t tests were performed. RESULTS: Twenty-four patients with PRS and 24 controls were included. Seventeen patients with PRS required MDO. PRS patients had shorter ramus heights (16.7 vs 17.3 mm; P = .346) and mandibular body lengths (35.3 vs 39.3 mm; P < .001), more acute gonial angles (125.3° vs 131.3°; P < .001), and more obtuse intergonial angles (94.2° vs 80.4°; P < .001) compared to controls. No significant differences were found among patients requiring MDO versus conservative management nor among distracted patients with high versus low airway grades. CONCLUSION: Our study examines the largest and youngest PRS population to date regarding management of early airway obstruction with MDO. Our findings indicate that univector mandibular body distraction allows for normalization in nonsyndromic patients with PRS, and airway obstruction management decisions should remain clinical.

Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

BACKGROUND: Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. METHODS: A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. RESULTS: The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. CONCLUSIONS: Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

The Effects of Session Standardization and Template Optimization on Improving Access to High-Demand Pediatric Subspecialty Care.

A major focus of US health care systems is ensuring timely patient access to subspecialty care. This article describes the experiences of a large children's hospital after implementation of clinic session standardization and template optimization. Outpatient specialty clinic sessions were standardized to 4-hour periods, and all unfilled complex appointment slots were made available for any appointment type within 72 hours of the clinic date. Three high-demand outpatient clinical services achieved increased aggregate potential and completed outpatient appointments over a 2-year period. These improvements were mostly due to an increase in providers and were not always coupled to shorter patient lag times.

Facial Gunshot Wounds.

Craniomaxillofacial gunshot injuries, resulting from assault, suicide attempts, and accidental trauma, represent a major public health dilemma in the United States. Due to the extent of injury and resulting osseous and soft tissue loss, facial gunshot wounds pose a unique challenge to the reconstructive surgeon. Initial management should use advanced trauma life support principles with the goal of patient stabilization. Acute operative management should center around wound decontamination, debridement, and temporary closure. Historically, definitive surgical management focused on delayed reconstruction secondary to high rates of wound infections, necrosis, and ischemia. With improvements in imaging modalities, the advent of virtual surgical planning, and the popularization of microvascular free flaps, contemporary methods have shifted toward earlier more definitive reconstruction. Autologous free tissue transfer has resulted in a decrease in hospital stay and the number of overall surgeries. Importantly, due to the variability in injury pattern and complexity in reconstruction, a systematic approach toward intervention is needed to mitigate complications and optimize overall functional and aesthetic outcomes.

Best Study Strategy for the NBME Clinical Science Surgery Exam.

INTRODUCTION: Providing medical students with effective study strategies is paramount in fostering their success on the NBME Clinical Science Surgery exam. As of yet, there has not been a comprehensive inquiry into a study strategy for this exam. We aim to identify if the following are associated with higher NBME raw exam scores: (1) the use of popular study materials, (2) the number of study materials used, and (3) the amount of time spent studying throughout the clerkship. METHODS: Over the period of 1 academic year, third-year medical students at our institution were administered a survey during their surgical clerkship inquiring about study materials used and hours spent studying per week. The data were then matched to students' raw NBME scores and then depersonalized. A total of 82 of 193 (42%) students responded with an overall average raw score of 76.74 on the NBME Clinical Science Surgery exam. By comparing our data to the NBME national average of 70 with a standard deviation of 8, a z test was used to compare the population mean to our sample means. RESULTS: When investigating resources used, the combination of using an online question bank and a high yield review book yielded a high z score (6.23) and using 4 resources yielded the highest z score (6.28). Regarding study hours, the highest z scores were seen when students studied for 6 to 10 hours per week during the first half of the clerkship, and 11 to 15 hours per week during the second half of the clerkship (5.76 and 6.02, respectively). CONCLUSIONS: In conclusion, higher NBME Clinical Science Surgery exam scores were correlated with the use of multiple and varied types of resources and increasing study time closer to the exam date. The resources and methods utilized by students achieving the highest exam scores can be recommended by surgical educators and employed by other medical students to foster academic success.

A Systematic Review of Resident Aesthetic Clinic Outcomes.

BACKGROUND: Providing residents with comprehensive training in aesthetic surgery has proven challenging. Resident aesthetic clinics propose an educational value to trainees while providing successful patient outcomes. OBJECTIVES: This study systematically reviewed the available literature regarding resident aesthetic clinic outcomes to determine the efficacy of the clinic in resident training, surgical results, and patient satisfaction. METHODS: An electronic database search was performed to identify literature reporting on resident aesthetic clinics. Studies were excluded if the resident clinic was not aesthetic in nature, if only nonsurgical aesthetic procedures were performed, and if clinic outcomes were not evaluated. Study quality was assessed using the Newcastle Ottawa Scale for nonrandomized studies. RESULTS: Ten of 148 identified studies met inclusion criteria; 2 utilized a survey, 3 were retrospective cohort studies, and 5 were retrospective cohort studies also utilizing a survey. Clinic schedules, surgical case volume, and surgical procedures performed all varied. One study received a Newcastle Ottawa Scale score of 7 of a possible 9 stars, 2 studies received 5 stars, 5 studies received 4 stars, and 2 could not be assessed using the scoring system. Six studies analyzed surgical results as a primary outcome, reporting acceptable complication and revision rates. Four studies evaluated patient opinions of the clinics and reported overall high satisfaction rates. CONCLUSIONS: This systematic review suggests that resident aesthetic clinics enhance resident education while providing safe and successful surgical results to patients.