Technical Strategies for Harvest of the Subtotal Pedicled Fillet of Thigh Flap for Reconstruction of External Hemipelvectomy and Hemicorporectomy Defects.

External hemipelvectomy and hemicorporectomy have been described in the literature for a variety of indications. A commonly used reconstructive technique is the pedicled anterior subtotal fillet of thigh flap. However, there are few descriptions regarding the technical pearls of harvest and inset of this flap. Here, we describe our step-by-step technique, as performed in three patients. The flap is pedicled on the common femoral artery and extends longitudinally to the knee to achieve the length required to extend past the midline and resurface sacral pressure ulcers, which are commonly found in patients who undergo this procedure for refractory pelvic osteomyelitis. Additionally, we describe a potential salvage option with late division of the popliteal artery to preserve the option for free tissue transfer of a subtotal fillet of lower leg flap.

Airway Obstruction Risk in Unique Infant Cleft Phenotype: PSIO Protocol Modification Recommendations.

Patients presenting with a unique unilateral cleft phenotype may be at risk of nasal airway obstruction which can be exacerbated by presurgical infant orthopedic (PSIO) appliance therapy and lip taping. Four patients presented to the UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center with a cleft phenotype characterized by: An anteriorly projected greater alveolar segment and medial collapse of the lesser segment posteriorly, leading to cleft alar base displacement posteromedial to the anteriorly projected greater segment. Resultant bilateral nasal airway obstruction: cleft ala drape over the leading edge of the greater segment's alveolus (cleft side obstruction) and caudal septum displacement secondary to attachments to the orbicularis oris from the noncleft side (noncleft side obstruction). The patient described presented at 3 months old from an outside institution, where PSIO therapy was undertaken. A second opinion was sought due to concern of significant difficulty in breathing and feeding with the PSIO oral plate. Lip-nose adhesion (LNA) was elected and airway obstruction was immediately relieved after this intervention. Lip-nose adhesion releases the tethered cleft side alar base from the pyriform rim of the posteromedially collapsed lesser segment and unites the superior lip and nostril sill-relieving the cleft side nostril obstruction. During the LNA, the caudal septum is surgically released from the anterior nasal spine and is uprighted, relieving the obstructed noncleft nostril. In this cleft anatomy, the treatment alternatives of modification to the PSIO appliance or LNA should be carefully considered in consultation with the surgeon, PSIO provider, and the infant's caretakers.

A Qualitative Survey Study of United States Burn Units: Pathways to a Career in Burn Surgery.

With current changes in training requirements, it is important to understand the venues in the United States for a general surgery (GS) and plastic surgery (PS) resident interested in pursuing a burn surgery career. The study aims to evaluate the pathways to a career in burn surgery and the current state of leadership. A cross-sectional study was conducted between August and September 2017. A 12-question survey was sent to all burn unit directors in the United States, asking about their background, who manages various aspects of burn care and the hiring requirements. Responses were received from 55 burn unit directors (47% response rate). Burn units are lead most commonly by physicians who received GS training (69%), but the majority either did not undergo fellowship training (31%) or completed a burn surgery fellowship (29%). While surgical care (GS = 51%, PS = 42%) and wound care (GS = 51%, PS = 42%) were predominantly managed by GS- or PS-trained burn teams, management of other aspects of burn care varied depending on the institution, demonstrating that a shift in burn care management. The desired hiring characteristics, including GS (67%) or PS residency (44%) and a burn surgery (55%), trauma surgery (15%), or critical care (44%) fellowship. Directors' training significantly influenced their preferences for hiring requirements. While leadership in burn surgery is dominated by GS-trained physicians, the surgical and wound care responsibilities are shared among PS and GS. Although one third of current directors did not undergo fellowship training, aspiring surgeons are advised to obtain a burn surgery and/or critical care fellowship.