Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

With high success rates of autologous breast reconstruction, the focus has shifted from flap survival to improved patient outcomes. Historically, a criticism of autologous breast reconstruction has been the length of hospital stay. Our institution has progressively shortened the length of stay after deep inferior epigastric artery perforator (DIEP) flap reconstruction and began discharging select patients on postoperative day 1 (POD1). The purpose of this study was to document our experience with POD1 discharges and to identify preoperative and intraoperative factors that may identify patients as candidates for earlier discharge. Methods: An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected. Results: Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1. Conclusions: POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.

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.

The Triangular Dart Flap: A Reconstructive Option for Soft Tissue Defects.

INTRODUCTION: Reconstruction of soft tissue defects after skin cancer excision remains a challenge. Options for reconstruction are numerous, including primary repair, local tissue rearrangement, and skin grafts, among others. In this series, the authors present a novel technique: The triangular dart flap. This is a single-stage tissue rearrangement that uses the redundant tissue of the dog-ear to aid in the closure of these wounds. METHODS: A retrospective review was conducted of all patients undergoing local tissue rearrangements by the senior author from 2009 to 2018. Factors were collected and analyzed, including age, size and cause of defect, comorbidities, smoking history, and postoperative complications. RESULTS: Twenty-four patients underwent reconstruction with a triangular dart flap for repair of malignant defects. Mean defect size was 7.3 cm2 (0.8-20 cm2), and mean repair size was 29.7 cm2 (6-80 cm2). Initial pathology included basal cell carcinoma (45.8%), melanoma in situ (29.2%), and squamous cell carcinoma (16.7%), among others. Location varied widely among face and extremities. Anesthesia was predominantly local only (79.1%). There were no major complications, and 5 (20.8%) minor complications. CONCLUSIONS: The triangular dart flap is a novel single-stage procedure, generally performed under local anesthesia only, for correction of Mohs defects. By using the redundant tissue of dog-ears to better approximate the wound edges, a tension-free primary closure can be achieved in sensitive areas, such as the nasal tip.

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.

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.

Initial Experience With Autologous Skin Cell Suspension for Treatment of Deep Partial-Thickness Facial Burns.

Facial burns present a challenge in burn care, as hypertrophic scarring and dyspigmentation can interfere with patients' personal identities, ocular and oral functional outcomes, and have long-term deleterious effects. The purpose of this study is to evaluate our initial experience with non-cultured, autologous skin cell suspension (ASCS) for the treatment of deep partial-thickness (DPT) facial burns. Patients were enrolled at a single burn center during a multicenter, prospective, single-arm, observational study involving the compassionate use of ASCS for the treatment of large total BSA (TBSA) burns. Treatment decisions concerning facial burns were made by the senior author. Facial burns were initially excised and treated with allograft. The timing of ASCS application was influenced by an individual's clinical status; however, all patients were treated within 30 days of injury. Outcomes included subjective cosmetic parameters and the number of reoperations within 3 months. Five patients (4 males, 1 female) were treated with ASCS for DPT facial burns. Age ranged from 2.1 to 40.7 years (mean 18.2 ± 17.3 years). Average follow-up was 231.2 ± 173.1 days (range 63-424 days). Two patients required reoperation for partial graft loss within 3 months in areas of full-thickness injury. There were no major complications and one superficial hematoma. Healing and cosmetic outcomes were equivalent to, and sometimes substantially better than, outcomes typical of split-thickness autografting. Non-cultured, ASCS was successfully used to treat DPT facial burns containing confluent dermis with remarkable cosmetic outcomes. Treatment of DPT burns with ASCS may be an alternative to current treatments, particularly in patients prone to dyspigmentation, scarring sequelae, and with limited donor sites.

The Sternum-Nipple Distance is Double the Nipple-Inframammary Fold Distance in Macromastia.

BACKGROUND: Reduction mammaplasty is one of the most commonly performed plastic surgery operations. For a majority of techniques, the most common long-term complication is pseudoptosis. It has previously been proposed that upper breast suspensory ligaments (SL) are weaker than lower breast SL. We tested this hypothesis through anthropometry of the proxies for upper and lower SL strength: the sternal notch-nipple (SN-N) distance and the nipple-inframammary fold (N-IMF) distance, respectively. METHODS: An institutional review board-approved retrospective review of patients undergoing reduction mammoplasty in an academic faculty practice between 2008 and 2015 was conducted. Patient demographics included age, race, and body mass index (BMI); patient comorbidities included smoking status, diabetes, and hypertension. Breast anthropometric measurements included SN-N and N-IMF. Sternal notch-nipple was used as the primary metric of the upper SL strength, whereas N-IMF was used as the primary metric of the lower SL strength. Intraoperative details included reduction technique and resection mass. Postoperative complications were recorded, including nipple areola complex necrosis and hematoma. Linear regression analysis was performed with the primary endpoint of the relationship between SN-N and N-IMF distance in macromastia. RESULTS: Data from 208 patients, totaling 400 individual breast measurements, were collected. The mean SN-N length was 35.1 cm, mean N-IMF length was 16.0 cm, and mean resection weight was 1094 g. Linear regression found that N-IMF distance could be predicted as 45% of the SN-N distance (N-IMF = 0.454 * SN-N). This was a strong relationship, demonstrated by univariate analysis of SN-N and N-IMF (R, 0.624; P < 0.001). A Wise pattern was used in 89.9% of cases; an inferior pedicle was used in 83.7% of cases. Nipple areola complex necrosis occurred in 15 breasts (3.75%). Sternal notch-nipple (R, 0.127; P = 0.011) and N-IMF (R, 0.119; P = 0.017) were both predictive of nipple areola complex necrosis (Table 4). CONCLUSIONS: In our series, the N-IMF distance increased 0.45 cm for every 1 cm increase in the SN-N distance. This relationship strengthens our primary hypothesis that the lower pole ligaments stretch at a significantly slower rate than the upper pole ligaments. Taking this into consideration, we suggest that surgeons seeking to minimize pseudoptosis rates should favor techniques that minimally disrupt the lower SL.

A member of the Phosphate transporter 1 (Pht1) family from the arsenic-hyperaccumulating fern Pteris vittata is a high-affinity arsenate transporter.

Pteris vittata exhibits enhanced arsenic uptake, but the corresponding mechanisms are not well known. The prevalent form of arsenic in most soils is arsenate, which is a phosphate analog and a substrate for Phosphate transporter 1 (Pht1) transporters. Herein we identify and characterize three P. vittata Pht1 transporters. Pteris vittata Pht1 cDNAs were isolated and characterized via heterologous expression in Saccharomyces cerevisiae (yeast) and Nicotiana benthamiana leaves. Expression of the PvPht1 loci in P. vittata gametophytes was also examined in response to phosphate deficiency and arsenate exposure. Expression of each of the PvPht1 cDNAs complemented the phosphate uptake defect of a yeast mutant. Compared with yeast cells expressing Arabidopsis thaliana Pht1;5, cells expressing PvPht1;3 were more sensitive to arsenate, and accumulated more arsenic. Uptake assays with yeast cells and radiolabeled (32)P revealed that PvPht1;3 and AtPht1;5 have similar affinities for phosphate, but the affinity of PvPht1;3 for arsenate is much greater. In P. vittata gametophytes, PvPht1;3 transcript levels increased in response to phosphate (Pi) deficiency and arsenate exposure. PvPht1;3 is induced by Pi deficiency and arsenate, and encodes a phosphate transporter that has a high affinity for arsenate. PvPht1;3 probably contributes to the enhanced arsenate uptake capacity and affinity exhibited by P. vittata.

Metatarsal reconstruction with a fibular osteocutaneous flap: a novel approach utilizing virtual surgical planning.

SUMMARY: Craniofacial reconstruction remains the main application for virtual surgical planning (VSP). We present a case in which this technology was applied to reconstruct a bony defect of the first metatarsal bone from a gunshot injury. VSP was used to facilitate a 1-stage reconstruction with a fibular osteocutaneous flap. A template of the reconstructed bone was designed based on the virtual mirror-image, noninjured bone. Prefabricated cutting guides facilitated precise shaping of the vascularized bone accounting for location of perforators. Successful reconstruction of the metatarsal bone was achieved with excellent functional outcomes. We believe that VSP can be a valuable tool in reconstruction of metatarsal bones by facilitating precise intraoperative shaping and anatomic orientation of the vascularized flap and reducing flap ischemia and operative time.