The Montreal Plastic Surgery Residency Bootcamp: Structure and Utility.

Transitioning from medical school to surgical residency is a difficult endeavor. To facilitate this period, the University of Montreal's plastic surgery program developed and implemented an intensive 1-month bootcamp rotation. It is the only one of its kind and length amongst plastic surgery residency programs in North America. It includes didactic teachings in anatomy, cadaveric dissections, and surgical approaches for an array of procedures. Clinical and technical skills are reviewed with senior residents and attending surgeons. Research opportunities and case scenarios are also covered. An anonymous online 30-question survey was sent to all residents who participated in the bootcamp rotation between 2013 and 2020. Questions evaluated residents' knowledge of anatomy, basic surgical skills, common approaches, flap knowledge, and on-call case management, before and after the bootcamp. Seventeen plastic surgery residents responded to this questionnaire (81%). The majority confirmed that the bootcamp helped them prepare for residency, research, and on-calls, and also helped them expand their knowledge of anatomy and surgical skills. The residents responded positively to the bootcamp's structure and implementation. This study proposes that surgical programs could benefit from a bootcamp rotation at the beginning of their curriculum. The purpose is to facilitate the transition between medical school and postgraduate training, and to ensure a basic level of competence for all junior residents. Further prospective studies could demonstrate the bootcamp's impact in board certification rates and acceptance into fellowship training programs.

Kaposiform hemangioendothelioma with overlapping features of rapidly involuting congenital hemangioma and a delayed complication of necrotizing fasciitis.

We report the case of a male infant born at term with kaposiform hemangioendothelioma (KHE) of the right forearm and coagulopathy. Our case was unusual as it involuted leaving subcutaneous atrophy and prominent veins, which are more commonly observed in rapidly involuting congenital hemangioma. At 3 years of age, the child developed recurrent superficial thrombophlebitis localized to the area where the KHE had regressed. Subsequently, he developed necrotizing fasciitis and thrombotic veins in the same location and group A streptococcal septic shock.

Factors Influencing the Rate of Post-Mastectomy Breast Reconstruction in a Canadian Teaching Hospital.

BACKGROUND: Post-mastectomy breast reconstruction (PMBR) improves psychosocial well-being, quality of life, and body image. Reconstruction rates vary widely (up to 42% in the United States), but the few Canadian studies available report rates of 3.8% to 7.9%. We sought to evaluate the current state of breast reconstruction in 1 Canadian teaching hospital and factors determining patients' access to reconstruction. METHODS: We performed a retrospective chart review of all patients with breast cancer undergoing mastectomy alone or mastectomy and reconstruction at a Canadian hospital between 2010 and 2013. We calculated rates of breast reconstruction and compared patient characteristics between the 2 groups, and then performed a multiple logistic regression to determine factors increasing the odds of receiving breast reconstruction. RESULTS: A total of 152 patients underwent 154 total or modified radical mastectomies. We obtained a rate of PMBR of 21%, 14% immediate reconstruction, and 8% delayed. Statistical analysis showed that compared to patients with mastectomy alone, patients who received PMBR were significantly younger, with a larger percentage having bilateral mastectomies, non-invasive breast cancer, and residing further from the hospital. Patients less than 50 years old and those with bilateral mastectomies had significantly greater odds of having a reconstruction. CONCLUSIONS: Our Canadian tertiary care institution has a high volume of breast surgery and an active breast reconstruction team. However, the rate of immediate reconstruction remains low compared to similar centers in the United States. We recommend a united effort to increase awareness regarding PMBR and address common misconceptions hindering patients' access to breast reconstruction. LEVEL OF EVIDENCE: Epidemiologic study, Level III.

HISTORIQUE: La reconstruction mammaire postmastectomie (RMPM) améliore le bien-être psychosocial, la qualité de vie et l'image corporelle. Le taux de reconstructions varie considérablement (jusqu'à 42 % aux États-Unis), mais les quelques études canadiennes signalent un taux de 3,8 % à 7,9 %. Les auteurs ont cherché à évaluer la situation relative aux reconstructions mammaires dans un hôpital universitaire canadien et les facteurs déterminant l'accès à la reconstruction. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers de toutes les patientes atteintes d'un cancer du sein qui avaient subi une simple mastectomie ou une mastectomie suivie d'une reconstruction dans un hôpital canadien entre 2010 et 2013. Ils ont calculé le taux de reconstructions mammaires et comparé les caractéristiques des patientes des deux groupes, puis ont procédé à une régression logistique multiple pour déterminer les facteurs qui accroissaient la probabilité de reconstruction mammaire. RÉSULTATS: Au total, 152 patients ont subi 154 mastectomies radicales totales ou modifiées. Les chercheurs ont obtenu un taux de RMPM de 21 %, soit 14 % de reconstructions immédiates et 8 % de reconstructions tardives. L'analyse statistique a révélé que, par rapport aux patientes qui avaient subi une simple mastectomie, celles qui avaient reçu une RMPM étaient considérablement plus jeunes, et un plus fort pourcentage avait subi une mastectomie bilatérale, était atteint d'un cancer du sein non invasif et habitait loin de l'hôpital. Les patientes de moins de 50 ans et celles qui avaient subi une mastectomie bilatérale couraient une plus grande chance de subir une reconstruction. CONCLUSIONS: Notre établissement de soins tertiaires canadien effectue un fort volume de chirurgies du sein et dispose d'une équipe de reconstruction mammaire active. Cependant, le taux de reconstructions immédiates demeure faible par rapport à celui de centres similaires aux États-Unis. Nous recommandons d'adopter un front uni pour mieux faire connaître la RMPM et calmer les erreurs courantes qui empêchent les patients d'avoir accès à la reconstruction mammaire. Qualité des preuves : Étude épidémiologique, niveau III.

Occlusal Relations in Patients With Scaphocephaly.

Scaphocephaly results from a premature fusion of the sagittal suture. Usually, cranial vault corrective surgery is performed during the first year of life. There is currently no scientific data regarding occlusion of scaphocephalic patients, or the potential effect of craniovault surgery on the occlusion. The aims were to describe occlusion in scaphocephalic patients and compare with a general pediatric population, and to compare the difference in occlusion of surgically versus unoperated treated scaphocephalic subgroup. A total of 91 scaphocephalic patients (71 boys aged between 2 and 11 y) seen at the Craniofacial Clinic of CHU Ste-Justine's formed the experimental group. All patients received an orthodontic assessment. Among them, 44 underwent craniovault surgery, whereas 47 remained unoperated. Thirty-eight (33 boys; 17 operated) had lateral cephalometric radiographies, some of them also had cephalometric growth follow-ups. Clinical values for dental classification and overjet indicate an increased prevalence of class II malocclusions in scaphocephalic patients. However, interestingly enough, cephalometric values indicative of skeletal class II malocclusions (ie, N-A perp HP, N-B perp HP, N-Pog perp HP, Wits, N-A-Pog) remained within normal limits. Some cephalometric values present statistically significant differences between operated and unoperated patients (ANS-PNS t2, P = 0.025; /1-FH t2, P = 0.028), but these are individual variations not related to scaphocephaly. Maxillary width of scaphocephalic children remains within normal limits. Scaphocephalic patients clinically presented more class II malocclusions compared with normal children. Radiographic values remain, however, within normal limits for both anteroposterior and transverse dimensions. Corrective craniovault surgery did not affect occlusion in these patients.

Therapy of ulcerated hemangiomas.

BACKGROUND: Cutaneous ulceration is the most common complication of infantile hemangiomas (IHs) seen in a pediatric dermatology practice. OBJECTIVE: The most effective treatments in our experience are compared to those in the current literature. METHODS: The study was a retrospective chart review of therapy of 169 ulcerated IHs at a tertiary care pediatric hospital and a literature review. RESULTS: Combination therapy was the rule. Local wound care was required in all, pain management in 72%, pulsed dye laser in 42%, infection control in 38%, diminution of the hemangioma through systemic therapy in 36%, and suppression of bleeding in 2%. LIMITATIONS: A retrospective review compared to a case-control study has inherent bias. In addition, our cases were all at a tertiary referral center. CONCLUSION: All ulcerated IHs benefit from local barrier creams or dressings. Pulsed dye laser, antibiotics, topical morphine 0.1% in hydrogel, topical becaplermin, and, most importantly, systemic therapy (especially propranolol) to reduce the hemangioma may be useful.

Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers.

BACKGROUND/OBJECTIVE: Few options, apart from the buttock area, are available for autologous breast reconstruction in thin teenagers. The aim of the present study was to objectively evaluate and compare donor-site morbidity of the inferior gluteal artery perforator (IGAP) flap with that of the previously described inferior gluteal musculocutaneous flap. METHOD: A retrospective review of all IGAP flaps for breast reconstruction performed in teenagers between June 2006 and April 2011 at the Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, was performed. Patients were invited to undergo a specific physical evaluation and complete a questionnaire on aesthetic and functional outcomes. RESULTS: Thirteen records and 11 photographic charts were reviewed. Lateral buttock flattening was noticeable in nine of 11 cases. Three patients experienced some degree of inferior displacement of the gluteal crease. All six patients available for the appointment presented with a zone of dysesthesia or hypoesthesia in the territory of the operated buttock and/or posterior thigh. No motor impairment was found. The questionnaire, completed by eight patients, revealed that six were satisfied or very satisfied with the surgery. Appearance of the operated buttock was rated 3.4 on a scale from 1 to 5 (5 = normal) compared with the normal side. CONCLUSIONS: The IGAP flap remains a suitable option for breast reconstruction in slim teenagers. Similar to the myocutaneous flap, the major donor-site morbidity of the IGAP flap remains sensory impairment involving the posterior femoral cutaneous nerve. There is, however, less visible lateral depression when it is harvested as a perforator flap.

HISTORIQUE ET OBJECTIF: Il existe peu de foyers de prélèvement, à part la région des fesses, pour effectuer une reconstruction mammaire autologue chez des adolescentes minces. La présente étude visait à évaluer et à comparer objectivement la morbidité au foyer de prélèvement du lambeau de l'artère perforante du grand fessier inférieur (APFI) à celle décrite antérieurement au foyer de prélèvement du lambeau musculocutané du grand fessier inférieur. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse rétrospective de tous les lambeaux de l'APFI en vue d'une reconstruction mammaire chez des adolescentes entre juin 2006 et avril 2011 au Centre hospitalier universitaire Sainte-Justine de Montréal, au Québec. Les patientes étaient invitées à subir une évaluation physique précise et à remplir un questionnaire sur les issues esthétiques et fonctionnelles. RÉSULTATS: Les chercheurs ont analysé 13 dossiers médicaux et 11 dossiers photographiques. Ils ont remarqué un aplatissement de la partie latérale de la fesse dans neuf des 11 cas. Trois patientes ont subi un certain degré de déplacement inférieur du pli fessier. Les six patientes disponibles pour le rendezvous présentaient une zone de dysesthésie ou d'hypoesthésie dans le territoire de la fesse opérée ou de la cuisse postérieure. Aucune n'avait d'atteinte motrice. Le questionnaire, qu'avaient rempli huit patientes, a révélé que six d'entre elles étaient satisfaites ou très satisfaites de l'opération. L'apparence de la fesse opérée a obtenu une note de 3,4 sur une échelle de 1 à 5 (5=normal) par rapport au côté normal. CONCLUSIONS: Le lambeau de l'APFI demeure une possibilité acceptable pour procéder à une reconstruction mammaire chez des adolescentes minces. À l'instar du lambeau myocutané, la principale morbidité au foyer de prélèvement du lambeau de l'APFI est une atteinte sensorielle touchant le nerf cutané fémoral postérieur. La dépression latérale est toutefois moins visible lorsqu'on fait le prélèvement sous forme de lambeau de l'artère perforante.

International plastic surgery missions: a framework for resident education using the CanMEDS competencies.

Residency education has shifted over the past decade in an attempt to graduate well-rounded physicians. There is a recognition that a physician's abilities must extend beyond medical knowledge. The Royal College of Physicians and Surgeons of Canada introduced the CanMEDS physician competency framework in 2005. The framework provides 7 areas of competencies that are aimed at providing improved patient care. These competencies are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Teaching and evaluating many of these competencies is often challenging for residency training programs. We believe that international surgical missions provide a prime opportunity to teach and evaluate all CanMEDS' roles.Plastic surgery is a field with many different organizations involved in international surgery. Many plastic surgery training programs offer opportunities for residents to become involved in these international surgical missions. Through these trips, residents gain surgical experience, see a variety and volume of clinical cases, and have the opportunity to travel to a foreign country and experience different cultures. We believe that international plastic surgery surgical missions also provide an exceptional micro environment for the teaching of CanMEDS roles. Using examples from residents' personal experiences on international plastic surgery missions to China, Mali, and Cambodia, we describe the benefits of these missions in transferring the CanMEDS competencies to resident training.

Propranolol in the treatment of problematic infantile hemangioma: review of 35 consecutive patients from a vascular anomalies clinic.

BACKGROUND: Propranolol, a nonselective ß-blocker, has been reported as efficient for controlling the growth of complicated infantile hemangiomas (IHs). No uniformly accepted protocol exists regarding the administration of oral propranolol for IH. OBJECTIVE: We sought to share our experience using propranolol for problematic IH and to evaluate the efficacy of this treatment modality. METHODS: A retrospective chart review analysis was performed for 35 consecutive children treated with propranolol as an oral solution on an outpatient basis in our dermatology/vascular anomalies clinic. A protocol was established with the help of our pediatric cardiologists, including pretreatment electrocardiography and echocardiography. Medical photographs taken after 2 months of treatment were rated by two independent evaluators. RESULTS: We treated 31 girls and 4 boys with a median age of 3.5 months. Rapid improvement was reported in the first days of treatment in 34 patients. Mean improvement after 2 months was 61.5%. No serious adverse effects were reported. CONCLUSION: Propranolol was effective in controlling the proliferative phase of problematic IH. It was well tolerated in our study. Outpatient treatment is possible if parents follow strict guidelines. Propranolol should be a first-line treatment for problematic IH in carefully selected patients.

Propranolol in the treatment of problematic infantile hemangioma: review of 35 consecutive patients from a vascular anomalies clinic.

BACKGROUND: Propranolol, a nonselective ß-blocker, has been reported as efficient for controlling the growth of complicated infantile hemangiomas (IHs). No uniformly accepted protocol exists regarding the administration of oral propranolol for IH. OBJECTIVE: We sought to share our experience using propranolol for problematic IH and to evaluate the efficacy of this treatment modality. METHODS: A retrospective chart review analysis was performed for 35 consecutive children treated with propranolol as an oral solution on an outpatient basis in our dermatology/vascular anomalies clinic. A protocol was established with the help of our pediatric cardiologists, including pretreatment electrocardiography and echocardiography. Medical photographs taken after 2 months of treatment were rated by two independent evaluators. RESULTS: We treated 31 girls and 4 boys with a median age of 3.5 months. Rapid improvement was reported in the first days of treatment in 34 patients. Mean improvement after 2 months was 61.5%. No serious adverse effects were reported. CONCLUSION: Propranolol was effective in controlling the proliferative phase of problematic IH. It was well tolerated in our study. Outpatient treatment is possible if parents follow strict guidelines. Propranolol should be a first-line treatment for problematic IH in carefully selected patients.

Subperiosteal release of the floor of the mouth to correct airway obstruction in pierre robin sequence: review of 31 cases.

OBJECTIVE: The purpose of this study was to evaluate subperiosteal release of the floor of the mouth (SRFM) musculature to correct neonatal airway obstruction in children with Pierre Robin sequence and to compare this procedure with other surgical options available. METHODS: A retrospective chart review of patients who underwent a SRFM for neonatal severe airway obstruction unresponsive to conservative management was performed. Preoperative and postoperative oxygenation parameters, sleep studies, feeding difficulties, and long-term evolution were documented. RESULTS: Thirty-one consecutive patients between 1995 and 2009, 19 boys and 12 girls, had an SRFM procedure to alleviate severe neonatal airway obstruction. Eight children were syndromic, 15 had associated malformations, and eight had an isolated Pierre Robin sequence. The airway obstruction was corrected with SRFM alone in 26 children (84%), three patients remained dependent on nasopharyngeal airway, and two required subsequent mandibular osteogenic distraction procedures following the SRFM to manage persistent obstruction. No patient required a tracheostomy. The average age at SRFM was 33 days, and the patients were kept intubated for an average of 6 days postoperatively. Average hospital stay after the surgery was 45 days, and 10 patients went home with gavage feeding. CONCLUSIONS: The SRFM is effective for the treatment of severe airway obstruction in patients with Pierre Robin sequence. The procedure is simple and has fewer complications and secondary procedures than other surgical options for correction of the airway obstruction.

Palmoplantar keratoderma and skin grafting: postsurgical long-term follow-up of two cases with Olmsted syndrome.

Olmsted syndrome is a rare congenital mutilating palmoplantar keratoderma associated with periorificial keratotic plaques. Treatment options include topical keratolytics, systemic retinoids, and debulking procedures. Full-thickness excision of hyperkeratotic plaques followed by skin grafting has been reported in the medical literature, although long-term results have not been evaluated. We present two cases of Olmsted syndrome with severe palmoplantar keratoderma treated with excision and skin grafting, along with long-term clinical results 11 years (patient 1) and 6 years (patient 2) following the initial surgery.

Donor-site morbidity of the inferior gluteal musculocutaneous flap for breast reconstruction in teenagers.

The purpose of this study is to objectively evaluate donor-site morbidity of the inferior gluteal musculocutaneous flap in teenagers. All cases of breast reconstruction performed between 1996 and 2005 using an inferior gluteal flap were reviewed. Flap size, weight, and pedicle origin were noted. Donor-site morbidity was assessed for scarring, contour deformity, muscle function, and sensation. The charts of 15 patients were reviewed, and 6 patients were available for further investigation. The average flap size and weight were 17 cm x 7 cm and 430 g, respectively. All patients had a well-concealed scar with minimal buttock asymmetry. Sensory assessment showed some degree of hypoesthesia in the territory of the posterior femoral cutaneous nerve in all patients. There was no functional loss. Donor-site morbidity of the inferior gluteal musculocutaneous flap is largely related to posterior thigh hypoesthesia despite preservation of the posterior femoral cutaneous nerve.

Prenatal diagnosis of cloverleaf skull: watch the hands!

Pfeiffer syndrome is an extremely rare autosomal-dominant condition whose prenatal diagnosis has only been reported 6 times, mainly on the basis of a fetal cloverleaf skull deformity. Three types have been described, each with a different prognosis. This case report stresses the need to thoroughly analyze the fetus and particularly the fetal hands in case of prenatal observation of a cloverleaf skull. The discovery of characteristic hand abnormalities allowed the early prenatal detection of type 2 Pfeiffer syndrome in our patient.