A survey of current state of training of plastic surgery residents.

BACKGROUND: Plastic surgery training is undergoing major changes however there is paucity of data detailing the current state of training as perceived by plastic surgical trainees. Our aim was to determine the quality of training as perceived by the current trainee pool and their future plans. METHODS: A 25-item anonymous survey with three discrete sections (demographics, quality of training, and post-graduate career plans) was developed and distributed to plastic surgery residents during the academic year 2013. With the confidence interval of 95% and margin of error of 10%, our target response rate was 87 responders. RESULTS: We received a total of 114 respondents with all levels of Post Graduate Year in training represented. Upon comparison of residents with debt of <100,000 to residents with a debt of >250,000, those with higher debt were significantly less interested in fellowship training (p value 0.05) and were more likely to pursue private practice (p value <0.01). Disciplines within plastic surgery least offered as a separate rotation were microsurgery (45%) followed by aesthetic surgery (33%). 53.7% of the residents felt that they were least trained in aesthetic surgery followed by burn surgery 45.4%. Of note 56.4% intended to seek additional training after residency. Moreover residents with an average of 6.4 months of experience in an individual subspecialty were more likely to feel comfortable with that specialty. CONCLUSIONS: This survey highlights the areas and subspecialties that deserve attention as perceived by the current trainee pool.

Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas.

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas.

Nora's lesion: Case report and literature review of a bizarre parosteal osteochondromatous proliferation of a small finger.

A case of a left small finger tumour that was diagnosed on histopathological review as Nora's lesion (bizarre parosteal osteochondromatous proliferation) is reported. There have been fewer than 150 cases reported in the literature to date and its pathophysiology is yet to be defined. Due to its rare presentation, Nora's lesion can easily go unrecognized and therefore inappropriately managed.

The utility of deep soft-tissue cultures in diagnosing the causative agent of sternal osteomyelitis following median sternotomy.

BACKGROUND: The authors' goal was to determine whether the bacteria cultured from the mediastinal deep soft tissues matched those identified by the sternal bone cultures in cases of mediastinitis with clinically suspected sternal osteomyelitis, in hopes of eliminating the need for sternal bone biopsy. METHODS: The authors retrospectively reviewed the charts of 27 Detroit Medical Center patients who underwent median sternotomy and developed mediastinitis with clinical suspicion of osteomyelitis between 1996 and 2004. RESULTS: Although only 18 of 27 of the authors' patients had positive bone cultures, they demonstrate that in 94 percent (17 of 18) of these patients, the organisms cultured from the mediastinal deep soft-tissue cultures matched those cultured from the positive sternal bone cultures. CONCLUSIONS: With the results obtained from this study, the authors hope to promote a less-invasive means of investigating osteomyelitis in sternal wounds, to prevent the complications associated with obtaining a bone biopsy specimen in a contaminated soft-tissue setting. Instead, the authors suggest thoracic computed tomographic scanning as a noninvasive means of clinically demonstrating osteomyelitis of the sternum, and culture of the deep soft tissues of the mediastinum at the time of mediastinal debridement to determine the offending organism, if osteomyelitis is suggested by computed tomographic scan.

Fascial release of the pectoralis major: a technique used in pectoralis major muscle closure of the mediastinum in cases of mediastinitis.

BACKGROUND: The authors' goal was to demonstrate a technique of gaining added width from the right pectoralis major muscle flap through muscle fascia release, with the hope of attaining sturdier, tension-free dead space closure of the debrided mediastinum in cases of mediastinitis. METHODS: The authors measured the preincisional and postincisional widths of the right pectoralis major flap following release of the fascia in nine patients who underwent mediastinal reconstruction using pectoralis major muscle flaps from 2002 to 2004 at the Detroit Medical Center. RESULTS: The average width of the nine muscles was 16.3 +/- 1.7 cm before fascia release and 22.1 +/- 1.3 cm after release. The average increase in width was 5.8 +/- 1.3 cm, with a 95 percent confidence interval of 4.8 to 6.8 cm. A value of p < 0.0001 indicated that this increase in width was statistically significant. After fascial release, the width of the muscles increased by an average of 26.1 percent, with a 95 percent confidence interval of 21.6 to 30.6 percent. CONCLUSIONS: The authors present a new technique that can be used to gain additional width from the right pectoralis major muscle in cases of mediastinal reconstruction using the pectoralis major muscle flap. With the added 26 percent of width obtained from the right pectoralis major muscle with fascia release, the authors contend that a sturdier and tension-free closure of the mediastinal dead space can be obtained, further expanding the indications for use of the pectoralis major muscle flap as the sole closure modality in even the most complicated cases of mediastinitis.

Management of fulminant dissecting cellulitis of the scalp in the pediatric population: Case report and literature review.

A case of fulminant dissecting cellulitis of the scalp in a fifteen-year-old African American male is reported. The presentation was refractory to standard medical treatment such that treatment required radical subgaleal excision of the entire hair-bearing scalp. Reconstruction was in the form of split-thickness skin grafting at the level of the pericranium following several days of vacuum-assisted closure dressing to promote an acceptable wound bed for skin grafting and to ensure appropriate clearance of infection. Numerous nonsurgical modalities have been described for the treatment of dissecting cellulitis of the scalp, with surgical intervention reserved for patients refractory to medical treatment. The present paper reports a fulminant form of the disease in an atypical age of presentation, adolescence. The pathophysiology, etiology, natural history, complications and treatment options for dissecting cellulitis of the scalp are reviewed, and the authors suggest this method of treatment to be efficacious for severe presentations refractory to medical therapy.

Acute ligation of the radial and ulnar arteries: A case report and review of literature.

Isolated injury to the radial or ulnar artery results in no significant complications in patients who undergo repair or ligation of the injured artery. However, ligation of both infrabrachial vessels of the upper extremity is associated with limb loss from ischemia due to lack of collateral circulation. A rare case of acute ligation of both the radial and ulnar arteries in a drug abuser where collateral vessels preserved the circulation to the hand is reported.

Les blessures isolées de l'artère radiale ou de l'artère cubitale n'entraînent pas de complications importantes chez les patients qui subissent une réparation ou une ligature de l'artère lésée. Par contre, la ligature des deux vaisseaux sous-brachiaux du membre supérieur se solde par la perte de celui-ci en raison de l'ischémie causée par l'absence de circulation collatérale. Voici un cas rare de ligature des artères radiale et cubitale, réalisée en urgence chez un utilisateur de drogues chez qui la circulation sanguine dans la main a été assurée par les vaisseaux collatéraux.

Acute median nerve compression neuropathy from a foreign body in the forearm.

Acute compression of the median nerve in the forearm usually occurs from compartment syndrome. A case of acute compression neuropathy of the median nerve from a foreign body, where there was no evidence of compartment syndrome, is reported. The diagnosis was made from the patient's symptoms and radiographs. Early recognition and decompression of the forearm with removal of the foreign body led to full recovery.

D'ordinaire, la compression aiguë du nerf médian de l'avant-bras est causée par un syndrome de loge. Un cas de neuropathie de compression aiguë du nerf médian imputable à un corps étranger, sans trace de syndrome de loge, est décrit. Le diagnostic a été posé grâce aux symptômes du patient et à des radiographies. Un dépistage précoce et une décompression de l'avant-bras avec retrait du corps étranger ont permis un rétablissement total.