What to do with an incidental finding of a fused sagittal suture: a modified Delphi study.

OBJECTIVE: As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS: A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS: Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS: Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

A New Measure of Posterior Morphology in Sagittal Craniosynostosis: The Occipital Bullet Index.

INTRODUCTION: Sagittal craniosynostosis (SC) is associated with scaphocephaly, an elongated narrow head shape. Assessment of regional severity in the scaphocephalic head is limited by the use of serial computed tomographic (CT) imaging or complex computer programing. Three-dimensional measurements of cranial surface morphology provide a radiation-free alternative for assessing cranial shape. This study describes the creation of an occipital bulleting index (OBI), a novel tool using surface morphology to assess the regional severity in patients with SC. METHODS: Surface imaging from CT scans or 3D photographs of 360 individuals with SC and 221 normocephalic individuals were compared to identify differences in morphology. Cartesian grids were created on each individual's surface mesh using equidistant axial and sagittal planes. Area under the curve (AUC) analyses were performed to identify trends in regional morphology and create measures capturing population differences. RESULTS: The largest differences were located in the medial regions posteriorly. Using these population trends, a measure was created to maximize AUC. The OBI has an AUC of 0.72 with a sensitivity of 74% and a specificity of 61%. When the frontal bossing index is applied in tandem, the two have a sensitivity of 94.7% and a specificity of 93.1%. Correlation between the two scores in individuals with SC was found to be negligible with an intraclass correlation coefficient of 0.018. Severity was found to be independent of age under 24 months, sex, and imaging modality. CONCLUSIONS: This index creates a tool for differentiating control head shapes from those with SC and has the potential to allow for objective evaluation of the regional severity, outcomes of different surgical techniques, and tracking shape changes in individuals over time, without the need for radiation.

Prevalence of Prohibited Questions during Plastic Surgery Residency Interviews.

Despite rules set forth by the National Resident Matching Program and American Association of Medical Colleges (AAMC), prohibited questions during the residency interview process are well documented. This study describes the prevalence of these encounters by surveying residency applicants to integrated plastic and reconstructive surgery (PRS) programs for the 2022 match cycle. Methods: An anonymous 16-question REDCap survey was distributed to 2022 cycle applicants of a single PRS program. The applicants were queried about demographic information, interview experience, and questions deemed illegal by the AAMC/NRMP guidelines. Results: One hundred survey responses were attained for a 33.1% response rate. The majority of respondents were aged 26-30 (76%), women (53%), and white (53%); 33% received 15+ interviews for the application cycle. Seventy-eight percent of respondents reported being asked a prohibited question during at least one interview, with the most common "illegal" question categories being number/ranking of interviews (42%), marital status (33%), career balance (25%), and race/ethnicity (22%). Only 25.6% of applicants considered the subject matter inappropriate, whereas 42.3% were unsure. Although no applicant took action to report the potentially illegal scenarios, 30% said that their experiences influenced their rank list. Conclusions: Our survey study revealed that prohibited interview questions in PRS residency interviews are common. Permissible lines of questioning and discussion between programs and applicants during residency interviews have been defined by AAMC. Institutions should provide guidance and training to all participants. Applicants should be made aware of and empowered to utilize available anonymous reporting tools.

"Creation of the Scaphocephalic Index: Measurement of Global and Regional Severity in Scaphocephaly".

INTRODUCTION: The recently described frontal bossing index (FBI) and occipital bullet index (OBI) allow for quantification of scaphocephaly. A similar index examining biparietal narrowing has not been described. Addition of such an index measuring width would allow for direct evaluation of the primary growth restriction in sagittal craniosynostosis (SC) and the formation of an optimized global Width/Length measure. METHODS: CT scans and 3D photos were used to recreate scalp surface anatomy. Equidistant axial, sagittal, and coronal planes were overlaid creating a Cartesian grid. Points of intersection were analyzed for population trends in biparietal width. Using the most descriptive point coupled with the sellion's protrusion to control for head size, the vertex narrowing index (VNI) is formed. By combining this index with the FBI and OBI, the Scaphocephalic Index (SCI) is created as a tailored W/L measure. RESULTS: Using 221 control and 360 individuals with sagittal craniosynostosis, the greatest difference occurred superiorly and posteriorly at a point 70% of the head's height and 60% of the head's length. This point had an area under the curve (AUC) of 0.97 and sensitivity and specificity of 91.2% and 92.2% respectively. The SCI has an AUC of 0.9997, sensitivity and specificity >99%, and interrater reliability of 0.995. The correlation coefficients between the CT imaging and 3D photography was 0.96. CONCLUSION: The VNI, FBI, and OBI evaluate regional severity while the SCI is able to describe global morphology in patients with sagittal craniosynostosis. These allow for superior diagnosis, surgical planning, and outcome assessment, independent of radiation.

Multicenter comparison of head shape outcomes for three minimally invasive strip craniectomy techniques for sagittal craniosynostosis.

OBJECTIVE: A literature gap exists comparing whole head shape outcome following correction of sagittal craniosynostosis. The objective of this multicenter study was to provide an analysis of long-term results following three different endoscopic strip craniectomy techniques for correction of sagittal craniosynostosis: 1) spring-assisted strip craniectomy, 2) wide-strip craniectomy with biparietal and bitemporal barrel-stave wedge osteotomies plus helmet orthosis, and 3) narrow-strip craniectomy plus orthosis without barrel staves. METHODS: Pre- and postoperative 3D stereophotogrammetric images were collected from patients who underwent craniosynostosis surgery. Procedures were divided among institutions as follows: spring-assisted strip craniectomies were performed at Atrium Health Wake Forest Baptist Hospital; narrow-strip craniectomies were performed at St. Louis Children's Hospital by one craniofacial surgeon; and wide-vertex craniectomies were performed at St. Louis Children's Hospital prior to 2010, and then continued at Children's Medical Center Dallas. Pre- and postoperative 3D whole-head composite images were generated for each procedure to visually represent outcomes at final follow-up and compared with age-matched normal controls. RESULTS: Patients in the spring-assisted strip craniectomy group showed normalization of frontal bossing and skull height compared with age-matched controls, whereas patients undergoing wide-strip craniectomy showed greater correction of occipital protrusion. Patients in the narrow-strip craniectomy cohort had intermediate results between these outcomes. Nested aggregate head shapes showed good correction of head shapes from all techniques. CONCLUSIONS: This large, retrospective, multicenter study illustrated whole head shape outcomes from three different craniectomy procedures. Although each procedure showed some differences in loci of primary correction, all three surgical methods demonstrated good correction of primary scaphocephalic deformity.

The Virtual Interview Experience: Advantages, Disadvantages, and Trends in Applicant Behavior.

Residency programs and applicants were forced to hold virtual interviews during the 2020-2021 application cycle. Inability to evaluate a program and/or applicant in person has intangible drawbacks. However, there are obvious advantages: cost, convenience, and comfort. Do the advantages outweigh the disadvantages? How have applicant behaviors changed to learn about programs in a virtual-only interview process? Methods: A survey was distributed to 302 applicants to a single plastic surgery residency program during the 2020 application cycle. Demographics, social media presence and utilization, and experience with the virtual application and interview process were analyzed. A 2018 survey from our institution was compared with a subset of questions for longitudinal analysis. Results: Seventy-six respondents (25.2%) completed the survey. Most applicants (88.2%) spent less than $1000 during the interview and application cycle. Over half (56.6%) did not receive letters of recommendation from outside their home program. A significant minority (27.6%) of applicants attended more than one interview in a single day. Compared to 2018, applicants in 2021 were significantly more likely to access alternative digital resources (forums/discussion boards, social media, and podcasts) when learning about programs. Average number of interviews remains in the range of pre-COVID studies, but the percentage of interviews attended increased. Conclusions: Applicants spent substantially less money on interviews and relied on alternative digital sources to learn about residency programs. This study objectively quantifies the advantages of virtual interviews. Disadvantages include inability to assess "fit" and lack of nonverbal communication.

Consumer Awareness and Comfort with Resident-run Cosmetic Clinics: A Crowdsourcing Study.

BACKGROUND: Resident cosmetic clinics (RCCs) are the training modality of choice among both residents and faculty and are a mainstay at most residency programs.1-4 Despite this, knowledge of RCCs among plastic surgery consumers remains untested. We hypothesize that the public would be aware of and receptive to RCCs. METHODS: Participants with prior cosmetic procedures or interest in future cosmetic procedures were recruited using Amazon Mechanical Turk and asked to complete a survey in September 2020. First, prior awareness of RCCs was assessed. After a brief description of RCCs, perceptions of safety and preferences for care were assessed. RESULTS: After screening for quality, 815 responses were included. Forty-five percent of consumers were aware of RCCs. Seventy-six percent of consumers believed that RCCs were just as safe as attending clinics and 65% were comfortable receiving care from fourth-year residents or higher. Belief in RCC safety was associated with 4.8 times higher odds of feeling comfortable receiving care at an RCC [95% confidence interval (3.3-7.1), P < 0.001]. When given a hypothetical choice between residents and attendings in two scenarios, 46% of consumers chose residents for abdominoplasty and 60% chose residents for Botox injections. Belief in RCC safety was associated with choosing a resident or being indifferent in both scenarios. CONCLUSIONS: Consumer preference regarding RCCs has largely been untested. This study shows that belief in RCC safety influences consumers' perceived comfort with receiving care at an RCC. This knowledge can help guide RCC practice and maximize learning opportunities for surgeons-in-training.

Long-Term Neurocognitive Outcomes of Spring-Assisted Surgery versus Cranial Vault Remodeling for Sagittal Synostosis.

BACKGROUND: A long-term neurocognitive comparison of patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling has not been performed. METHODS: Patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling were recruited from Wake Forest School of Medicine and Yale School of Medicine, respectively. Cognitive tests administered included an abbreviated intelligence quotient, academic achievement, and visuomotor integration. An analysis of covariance model compared cohorts controlling for demographic variables. RESULTS: Thirty-nine spring-assisted surgery and 36 cranial vault remodeling patients were included in the study. No significant differences between cohorts were found with respect to age at surgery, sex, race, birth weight, family income, or parental education. The cranial vault cohort had significantly older parental age (p < 0.001), and mean age at testing for the spring cohort was significantly higher (p = 0.001). After adjusting for covariates, the cranial vault cohort had significantly higher verbal intelligence quotient (116.5 versus 104.3; p = 0.0024), performance intelligence quotient (109.2 versus 101.5; p = 0.041), and full-scale intelligence quotient (114.3 versus 103.2; p = 0.0032). When included patients were limited to intelligence quotients from 80 to 120, the cranial vault cohort maintained higher verbal (108.0 versus 100.4; p = 0.036), performance (104.5 versus 97.7; p = 0.016), and full-scale (107.6 versus 101.5; p = 0.038) intelligence quotients. The cranial vault cohort had higher visuomotor integration scores than the surgery group (111.1 versus 98.1; p < 0.001). There were no significant differences in academic achievement. CONCLUSIONS: Sagittal synostosis patients who underwent cranial vault remodeling had higher intelligence quotient and visuomotor integration scores. There were no differences in academic achievement. Both cohorts had intelligence quotient scores at or above the normal range. Further studies are warranted to identify factors that may contribute to cognitive outcome differences. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Social media impact in the Match: A survey of current trends in the United States.

BACKGROUND: Applicants to integrated plastic and reconstructive surgery (PRS) residency in the United States spend exorbitant amounts of time and money throughout the interview process. Outside of first-hand experience through a visiting rotation, applicants utilize various resources in learning about a program. Today's applicants are "Millennials," the demographic cohort raised during the information age and proficient with digital technology. The authors evaluated whether programs have a presence on social media, and whether applicants are following these accounts. METHODS: An online survey was sent to applicants to a single integrated plastic surgery program evaluating basic demographics, social media utilization, and sources of information accessed throughout the residency application process. A manual search of popular social media platforms (Instagram, Facebook, and Twitter) was performed in October 2019. Accounts affiliated with integrated PRS programs were identified and analyzed. RESULTS: Eighty-four of 222 applicants (37.8%) completed the survey. Ninety-six percent of applicants were within the Millennial demographic. Ninety-six percent of applicants had some form of social media presence, with Facebook (90%) and Instagram (87%) being the most popular platforms. Seventy-three percent of applicants reported following a PRS residency social media account. As of October 2019, 59 integrated residency programs (73%) have active Instagram accounts. CONCLUSIONS: Applicants still rely on the program website when researching potential residencies, but social media is being rapidly adopted by programs. Program social media accounts should be used as a dynamic form of communication to better inform applicants of program strengths and weaknesses.

Comparison of 2 Sagittal Craniosynostosis Repair Techniques: Spring-Assisted Surgery Versus Endoscope-Assisted Craniectomy With Helmet Molding Therapy.

INTRODUCTION: This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. METHODS: Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. RESULTS: The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. CONCLUSIONS: Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.

Academics in the Pandemic: Early Impact of COVID-19 on Plastic Surgery Training Programs.

The COVID-19 global pandemic has impacted plastic surgery training in the United States, requiring unprecedented measures to prepare for potential surges in critically ill patients. This study investigates how plastic surgery programs responded to this crisis, as well as how successful these changes were, through a survey of program directors and of residents at academic training programs in the United States. METHODS: Two separate anonymous online surveys were conducted via REDCap between April 16 and June 4, 2020. The first survey was distributed to program directors, and the second was distributed to plastic surgery residents. Resident responses were then subdivided for an analysis between geographic regions. RESULTS: Of the 59 program director responses (43.7%), the majority of programs implemented a platoon approach for resident coverage. A minority did the same for attending coverage. In total, 92% transitioned to virtual didactics only. Plastic surgery residents covered alternative services at 25% of responding institutions, and an additional 68% had a plan in place for responding to personnel shortages. Overall, residents were satisfied with their program's response in a variety of categories. When subdivided based on geographic region, respondents in the Northeast and Northwest were less satisfied with resident wellness, personal and loved ones' safety, and program communication. CONCLUSIONS: With the possibility of a "second wave," successful methods of academic programs adapting to the pandemic should be communicated to reduce the future impact. Increased frequency of communications between program directors and residents can improve mental health and wellness of the resident population.

Spring-Assisted Strip Craniectomy Versus Cranial Vault Remodeling: Long-Term Psychological, Behavioral, and Executive Function Outcomes.

BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ±â€Š10.27) compared to the SAS cohort (54.64 ±â€Š10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.

Provision and Utilization of Team- and Community-Based Operative Care for Patients With Cleft Lip/Palate in North Carolina.

OBJECTIVE: To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]-approved multidisciplinary teams or from community providers). DESIGN: Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015. SETTING/PATIENTS AND MAIN OUTCOME MEASURES: Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as "Team" versus "Community," and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care. RESULTS: Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance. CONCLUSIONS: American Cleft Palate Craniofacial Association -approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.

Outcomes of Endoscopic Versus Open Spring Assisted Surgery for Sagittal Craniosynostosis.

Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (n = 51) and minimally-invasive (n = 50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65 minutes, compared to 53 minutes (P < 0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31 minutes versus 29 minutes (P = 0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.

Long-Term Outcomes of Spring-Assisted Surgery for Sagittal Craniosynostosis.

BACKGROUND: Spring-assisted surgery is an accepted alternative to cranial vault remodeling for treatment of sagittal craniosynostosis. The long-term safety and efficacy profiles of spring-assisted surgery have not been established. METHODS: This study is a retrospective examination of all patients treated with spring-assisted surgery (n = 175) or cranial vault remodeling (n = 50) for sagittal craniosynostosis at the authors' institution from 2003 to 2017. Data collected included demographic and operative parameters, preoperative and postoperative Cephalic Indices, and complications. Whitaker grades were assigned blindly by a craniofacial surgeon not involved in patients' care. RESULTS: The mean age at surgery was significantly lower for the spring-assisted surgery group compared with the cranial vault remodeling group (4.6 months versus 22.2 months; p < 0.001). Even when combining spring placement with spring removal operations, total surgical time (71.1 minutes versus 173.5 minutes), blood loss (25.0 ml versus 111.2 ml), and hospital stays (41.5 hours versus 90.0 hours) were significantly lower for the spring-assisted surgery cohort versus the cranial vault remodeling group (p < 0.001 for all). There were no differences in infection, reoperation rate, or headaches between the groups. The percentage improvement in Cephalic Index was not significantly different at 1 (p = 0.13), 2 (p = 0.99), and 6 (p = 0.86) years postoperatively. At 12 years postoperatively, the spring-assisted surgery group had persistently improved Cephalic Index (75.7 preoperatively versus 70.7 preoperatively). Those undergoing spring-assisted surgery had significantly better Whitaker scores, indicating less need for revision surgery, compared with the cranial vault remodeling group (p = 0.006). CONCLUSION: Compared with the authors' cranial vault remodeling technique, spring-assisted surgery requires less operating room time and is associated with less blood loss, but it has equivalent long-term Cephalic Indices and subjectively better shape outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Obstructive Sleep Apnea Secondary to Pharyngeal Narrowing From Horizontal Donor Site Closure During Posterior Pharyngeal Flap Surgery.

The posterior pharyngeal flap is frequently the surgical intervention of choice for the correction of velopharyngeal insufficiency. Our patient initially presented for a superiorly based, posterior pharyngeal flap to correct for velopharyngeal insufficiency. However, the postoperative recovery was complicated by severe obstructive sleep apnea, which warranted division and subsequent takedown of the flap. Despite flap takedown, our patient's obstructive sleep apnea persisted. The patient's clinical course suggests that donor site closure, and not the actual pharyngeal flap, caused the persistent obstructive sleep apnea.

Outcomes Analysis of Chief Cosmetic Clinic Over 13 Years.

BACKGROUND: Adequate resident training in aesthetic surgery has become increasingly important with rising demand. Chief resident aesthetic clinics allow hands on experience with an appropriate amount of autonomy. The purpose of this study was to compare resident cosmetic clinic outcomes to those reported in the literature. Furthermore, we sought to assess how effective these clinics can be in preparing residents in performing common aesthetic surgery procedures. METHOD: A retrospective chart review of 326 patients and 714 aesthetic procedures in our chief cosmetic clinic over a 13-year period was performed, and complication and revision rates were recorded. In addition, an electronic survey was sent to 26 prior chief residents regarding their experience and impressions of the chief resident aesthetic clinic. RESULT: A total of 713 procedures were performed on 326 patients. Patient ages ranged from 5 to 75 years old (mean, 40.8 years old) with a mean follow-up of 76.2 days. On average, there were 56 procedures performed per year. Of the 714 total procedures performed, there were 136 minor procedures and 578 major procedures. Of the 136 minor procedures, there were no complications and there was 1 revision of a cosmetic injection. Of the 578 major procedures, the overall complication rate was 6.1% and the revision rate was 12.8%. Complication and revision rates for each individual surgery were further analyzed and compared with the literature. The complication rates for these procedures fell within the reference ranges reported. In regards to the chief resident survey, there was a 77% response rate. All respondents reported that the chief resident clinic positively affected their residency education and future practice. Ninety percent of respondents felt "very comfortable" performing facelifts, body contouring, and aesthetic breast surgery. No respondents completed a subsequent cosmetic fellowship, and 60% stated that their positive experience in chief clinic contributed to their decision not to pursue a cosmetic fellowship. CONCLUSIONS: Chief resident clinics can provide results with acceptable complication and revision rates that fall within the acceptable ranges in the literature. In addition, it provides a valuable experience that leaves residents with high comfort levels in performing key procedures in aesthetic surgery.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices.

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.

Long-Term Outcomes of Pediatric Cranial Reconstruction Using Resorbable Plating Systems for the Treatment of Craniosynostosis.

BACKGROUND: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. METHODS: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. RESULTS: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. CONCLUSIONS: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.

A Systematic Approach to Predicting Spring Force for Sagittal Craniosynostosis Surgery.

Spring-assisted surgery (SAS) can effectively treat scaphocephaly by reshaping crania with the appropriate spring force. However, it is difficult to accurately estimate spring force without considering biomechanical properties of tissues. This study presents and validates a reliable system to accurately predict the spring force for sagittal craniosynostosis surgery. The authors randomly chose 23 patients who underwent SAS and had been followed for at least 2 years. An elastic model was designed to characterize the biomechanical behavior of calvarial bone tissue for each individual. After simulating the contact force on accurate position of the skull strip with the springs, the finite element method was applied to calculating the stress of each tissue node based on the elastic model. A support vector regression approach was then used to model the relationships between biomechanical properties generated from spring force, bone thickness, and the change of cephalic index after surgery. Therefore, for a new patient, the optimal spring force can be predicted based on the learned model with virtual spring simulation and dynamic programming approach prior to SAS. Leave-one-out cross-validation was implemented to assess the accuracy of our prediction. As a result, the mean prediction accuracy of this model was 93.35%, demonstrating the great potential of this model as a useful adjunct for preoperative planning tool.