Feedback in Plastic and Reconstructive Surgery Education: Past, Present, and Future.

Education is to be provided efficiently and effectively according to guidelines in the United States by the Accreditation Council for Graduate Medical Education as core competencies and in Canada by the Royal College according to the CanMEDS framework. This article defines formative feedback, reviews the currently available validated feedback tools, and describes the future use of technology to enhance feedback in plastic surgery education.

Volar capsulodesis of the thumb metacarpophalangeal joint at the time of basal joint arthroplasty: a surgical technique using suture anchors.

PURPOSE: To document the long-term results of our volar metacarpophalangeal (MCP) joint capsulodesis technique that is completed concomitantly with basal joint arthroplasty and involves a suture anchor placement, short-term pinning, and a rigid hand therapy protocol. METHODS: We conducted a retrospective chart review to examine results over a 30-month period of our volar capsulodesis technique. Follow-up results were recorded 26 to 48 months after surgery. The treatment regimen included suture anchors, joint pinning for 6 weeks, and a strict hand therapy protocol. Indications for surgery were thumb MCP joint hyperextension deformity of at least 30° and radiographic evidence of stage 3 (or greater) basal joint arthritis. We examined preoperative and postoperative range of motion, pain, pinch strength, and complications. Average patient age was 63 years (range, 55-77 y). We treated 14 thumbs in 14 patients. RESULTS: After capsulodesis, average range of motion for the MCP joint of the thumb was 4° extension and 46° flexion. The last follow-up indicated no cases of hyperextension contracture. Complications included one superficial pin track infection (treated with oral antibiotics) and one patient's report of pain at the thumb MCP joint. CONCLUSIONS: When completed as described, thumb MCP joint capsulodesis performed concurrently with trapeziometacarpal arthroplasty can be a straightforward procedure that produces positive results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Etiology of breast masses after autologous breast reconstruction.

BACKGROUND: Determining the nature of a breast mass after autologous reconstruction can be difficult. METHODS: A retrospective review of all autologous breast reconstructions was performed over 10 years. All postoperative breast masses were identified. Tumor characteristics, adjuvant treatment, timing of the development of the mass, and correlation with radiology were reviewed. RESULTS: A total of 365 flaps were performed on 272 patients [253 deep inferior epigastric perforator (DIEP), 35 superficial inferior epigastric artery (SIEA), 22 muscle-sparing free transverse rectus abdominis myocutaneous (free MS-TRAM), 25 latissimus, and 30 pedicled TRAM]. Breast masses were identified in 66 breasts (18 %). The majority of these were from fat necrosis, occurring in 54 breasts (15 % overall; DIEP 13.4 %, SIEA 5.7 %, free MS-TRAM 15 %, latissimus 0 %, pedicled TRAM 47 %), first identified at a mean of 3 months. Recurrent carcinoma was diagnosed in 13 breasts (3.6 %). Factors associated with the postreconstruction mass representing recurrent carcinoma were later time period after reconstruction (mean 24 months), closer surgical margins, and lymphovascular invasion. Radiographic imaging accurately diagnosed recurrent carcinoma in 11 (92 %) of 12 patients in whom it was utilized and suggested a benign diagnosis in all 16 patients with fat necrosis in whom it was utilized. CONCLUSIONS: Breast masses frequently present after autologous reconstruction. Fat necrosis is the most common cause. Recurrent carcinoma can occur in the reconstructed breast and presents later. A higher index of suspicion for recurrence should accompany any mass in which prior lymphovascular invasion was present or if original margins were <1 cm. Radiographic imaging accurately identifies the cause of these masses.

Addition of an Oblique Interfragmentary Screw to T-plate Fixation Decreases Nonunion Rate in Trapeziometacarpal Arthrodesis.

Background: T-plate fixation is a popular method for trapeziometacarpal arthrodesis in patients with osteoarthritis. Previous studies report an 8% to 18% rate of symptomatic nonunion and a 26% rate of radiographic nonunion. In this study, we present our surgical technique of trapeziometacarpal arthrodesis using the addition of an oblique interfragmentary screw to T-plate fixation on the rate of symptomatic and radiographic nonunion. Methods: A retrospective review of all trapeziometacarpal arthrodeses for osteoarthritis was completed by a single surgeon between 2010 and 2018. Preoperative demographics, pain, and Eaton classification were included. The technique was identical in all surgical cases, using a T-plate and oblique interfragmentary screw across the arthrodesis site from the metacarpal to the trapezium. Postoperative nonunion rate and time to clinical healing (absence of pain) and radiographic union were reviewed. Results: A total of 22 trapeziometacarpal arthrodeses were performed on 17 patients using the above technique. The average age was 53 years, 71% were women, and 53% involved the dominant hand. Mean preoperative Eaton classification was 2.74 (±0.73). Mean time to clinical healing was 34 days (±12 days), and mean time to radiographic union was 55 days (±23 days). Mean follow-up was 9 months, and no patients were found to have symptomatic or radiographic nonunion. Hardware removal was required bilaterally in 1 patient after complete healing. Conclusions: The addition of an oblique interfragmentary screw to T-plate fixation is a novel technique in trapeziometacarpal arthrodesis, resulting in no symptomatic or radiographic nonunion.

Prophylactic flap reconstruction of the knee prior to total knee arthroplasty in high-risk patients.

Insufficient soft-tissue coverage following total knee arthroplasty (TKA) may threaten prosthesis retention or compromise joint function. A retrospective review was conducted of all patients who underwent prophylactic flap reconstruction of the knee prior to TKA or salvage flap reconstruction over a 6-year period. Twenty-three patients underwent prophylactic flap reconstruction. Complications at the time of flap transfer were common (48%), however, all flaps survived. All 23 successfully completed subsequent TKA with no wound complications occurring at the time of TKA. Complications in the salvage group were also frequent (44%) and 3 required above knee amputation. Postoperative range of motion was significantly better in the prophylactic group, as well as when cutaneous flaps were chosen. Prophylactic flap reconstruction of the knee prior to TKA in high-risk patients is an excellent option in this small subset of patients, many of whom would not be offered TKA without addressing the compromised soft-tissue envelope first.

Three-dimensional Printing in Plastic Surgery: Current Applications, Future Directions, and Ethical Implications.

BACKGROUND: Three-dimensional printing (3DP) is a rapidly advancing tool that has revolutionized plastic surgery. With ongoing research and development of new technology, surgeons can use 3DP for surgical planning, medical education, biological implants, and more. This literature review aims to summarize the currently published literature on 3DP's impact on plastic surgery. METHODS: A literature review was performed using Pubmed and MEDLINE from 2016 to 2020 by 2 independent authors. Keywords used for literature search included 3-dimensional (3D), three-dimensional printing (3DP), printing, plastic, surgery, applications, prostheses, implants, medical education, bioprinting, and preoperative planning. All studies from the database queries were eligible for inclusion. Studies not in English, not pertaining to plastic surgery and 3DP, or focused on animal data were excluded. RESULTS: In total, 373 articles were identified. Sixteen articles satisfied all inclusion and exclusion criteria, and were further analyzed by the authors. Most studies were either retrospective cohort studies, case reports, or case series and with 1 study being prospective in design. CONCLUSIONS: 3DP has consistently shown to be useful in the field of plastic surgery with improvements on multiple aspects, including the delivery of safe, effective methods of treating patients while improving patient satisfaction. Although the current technology may limit the ability of true bioprinting, research has shown safe and effective ways to incorporate biological material into the 3D printed scaffolds or implants. With an overwhelmingly positive outlook on 3DP and potential for more applications with updated technology, 3DP shall remain as an effective tool for the field of plastic surgery.

Rethinking Global Health Education in Plastic Surgery Residency.

Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing.

Formative Feedback with In-Class Question Bank Utilization Improves Resident Satisfaction with General Surgery Didactics.

BACKGROUND: Formative feedback provides low-stakes opportunities for educational improvement. To enrich our basic science didactics, formative feedback measures were incorporated into our didactics using mobile devices. MATERIALS AND METHODS: Lecture changes included institutional paid access to a commercial question bank, a 5-item in-class pre-didactic quiz curated from the question bank and taken on the resident's mobile device, and group discussion of quiz topics. An anonymous survey was sent to participating residents. RESULTS: Overall response rate was 71% among residents. All reported that the new lecture format was a valuable addition to the basic science curriculum (100% Agree/Strongly Agree), and formative assessments provided valuable feedback about the progress of their learning (Strongly Agree = 42%, Agree =58%). All residents reported that in-class use of their mobile device for quizzes was convenient, with majority (84%) preferring it over paper printouts. Residents were more motivated to study before lecture (Strongly Agree = 42%, Agree =42%), with majority also reporting the new format helped identify weaknesses in their knowledgebase (Strongly Agree = 58%, Agree =33%). While majority of residents agreed that quizzes motivated them to study more after lecture, a large portion disagreed (42%). Majority of senior residents reported that the process of composing quizzes prior to lecture enriched their own learning (57%) and helped them find gaps in their knowledge (71%). CONCLUSION: Incorporating a commercial question bank within didactics gives general surgery residents formative feedback and encourages learning outside the classroom, leading to improved satisfaction with basic science didactics.

Safety and efficacy of perforator flap breast reconstruction with combined intraabdominal procedures.

Genetic testing for BRCA mutations has led to greater needs for breast reconstruction and prophylactic gynecologic procedures. A retrospective review of all perforator flap breast reconstructions was performed over 5 years. A total of 316 flaps were performed on 232 patients. Nineteen patients had an intraabdominal procedure at the time of their breast reconstruction, including 8 unilateral and 11 bilateral reconstructions (22 flaps). The concomitant procedures incurred an additional mean operative time of 61 minutes. One arterial thrombosis occurred leading to a single flap failure (1/30, 3.3%). No significant differences were noted in complication rates between the combined group and those who did not have a simultaneous procedure (anastomotic complications 3.3% vs. 7.7%; failure rate 3.3% vs. 3.1%; abdominal wound 10.5% vs. 15%; fat necrosis 10% vs. 12.2%). The coordinated effort allowing simultaneous intraabdominal procedures and perforator flap breast reconstruction affords effective reconstruction for those requiring additional procedures without an increase in postoperative complication rates.

Recurrent synovial chondromatosis of the distal interphalangeal joint: case report.

A 59-year-old woman presented with recurrent synovial chondromatosis of the distal interphalangeal joint at the site of removal of what was thought to be a ganglion cyst in 2003 and the subsequent excision of a recurrent synovial chondromatosis in 2005. Although synovial chondromatosis is typically described as a benign, self-limiting process, recurrent disease and local erosion of the joint of this patient required wide excision with bone grafting and arthrodesis for definitive treatment.

Results of the Volar Approach in Proximal Interphalangeal Joint Arthroplasty.

BACKGROUND: Most hand surgeons use a dorsal approach for proximal interphalangeal (PIP) joint implant arthroplasty. However, a volar approach offers the advantage of no disturbance to the extensor mechanism, thus allowing early initiation of active range of motion. We examined our results in patients who underwent PIP joint arthroplasty via a volar approach. METHODS: Using a retrospective chart review, we evaluated the outcomes of patients undergoing PIP joint arthroplasty through a volar approach between 2001 and 2005 by 3 fellowship-trained hand surgeons at our institution. The indication for surgery was PIP joint pain with radiographic evidence of joint destruction. Variables included implant type, diagnosis, affected digit(s), preoperative and postoperative range of motion, and complications. Hand therapy was initiated on postoperative day 3 or 4. RESULTS: Over the 5 years, 25 PIP joints were replaced in 18 women and 2 men with the volar approach. Replacements consisted of 14 surface replacement prostheses, 9 pyrocarbon prostheses, and 2 silicone prostheses. The average age of patients at prosthesis implantation was 64 years (range, 39-75 years). Prostheses were placed in 1 index, 12 long, 7 ring, and 5 small digits. Average follow-up period was 33 months (range, 24-69 months). Preoperative diagnoses were osteoarthritis (14), rheumatoid arthritis (4), and posttraumatic arthritis (2). Preoperative total arc of motion averaged 42° (range, 0° extension to 80° flexion); postoperative total arc of motion averaged 56° (range, -10° extension to 90° flexion). Complications comprised 1 swan neck deformity, 1 deep infection, 1 dislocation (early), and 2 loose implants with flexion contractures. Seventeen patients had minimal or no pain at their last follow-up visit. CONCLUSIONS: PIP joint arthroplasty can be successfully implemented through a volar approach with various implant types and has outcomes similiar to the published results of the dorsal approach.

Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy.

BACKGROUND: The reliability of deep inferior epigastric artery perforator (DIEP) flap reconstruction following abdominal liposuction is controversial. The authors' early cases were technically successful; however, they experienced high partial flap loss and fat necrosis rates. The authors sought to compare DIEP flap outcomes in the setting of prior liposuction after the use of intraoperative indocyanine green angiography compared to when flaps were assessed on clinical grounds alone. METHODS: A retrospective review of a consecutive series of DIEP flaps following liposuction at a single institution was performed, comparing those evaluated on clinical grounds alone and those in which indocyanine green angiography was used intraoperatively. Outcomes measured included anastomotic complications, total flap loss, partial flap loss, fat necrosis, and postoperative abdominal wounds. RESULTS: Thirteen DIEP flaps following prior liposuction were performed on 11 patients from July of 2003 through January of 2014. All patients had preoperative imaging with duplex ultrasound or computed tomographic angiography to analyze perforator suitability before surgical exploration. Seven flaps were evaluated intraoperatively on clinical grounds alone. Six flaps were assessed and modified based on indocyanine green angiography. All flaps were successful; however, partial flap loss and fat necrosis rates dropped from 71.4 percent to 0 percent when indocyanine green angiography was used intraoperatively (p = 0.02). CONCLUSIONS: Indocyanine green angiography is an excellent vascular imaging modality for intraoperative use to assess flap perfusion, and improves outcomes in DIEP flaps when harvested after prior abdominal suction lipectomy.

Wide local excision and split-thickness skin graft for circumferential Paget's disease of the anus.

BACKGROUND: Our aim was to evaluate the results of wide local excision followed by split-thickness skin graft for circumferential perianal Paget's disease. METHODS: Between 1995 and 1999, 5 patients with perianal Paget's disease underwent wide local excision of the disease. The circumferential involvement was documented by preoperative mapping. Standard orthograde bowel cleansing and oral antibiotics were given the day prior to surgery. The wound was allowed to granulate and confirmation of negative margins was obtained on permanent sections taken from the excised specimens. On postoperative day 4, split-thickness skin grafts harvested from the lateral thigh were applied (surface using area ranging from 100 cm(2) to 240 cm(2)). The grafts were secured in place with a 3-0 Vicryl suture and covered with a pressure dressing. After 4 days of bedrest, the dressing was taken down under anesthesia (day 8). RESULTS: Graft survival was 100% in 3 patients, 80% in 1 patient, and 70% in another. Postoperatively, clinical follow-up was conducted at 3-month intervals. In 2 patients, anal stenosis developed after the operation and resolved by gentle self-dilation. At a mean follow-up of 42 months (range 21 to 78), adequate cosmetic and functional results were obtained. Recurrence of Paget's disease has occurred in 1 patient (at 21 months) and an invasive anal gland carcinoma was found in 1 patient (at 48 months). CONCLUSIONS: Wide local excision and circumferential split-thickness skin grafting achieves adequate cosmetic and functional results without the need for diverting colostomy. However, there is a considerable recurrence rate after surgery, which warrants very close follow-up to rule out recurrent disease or underlying adenocarcinoma.

Minimally invasive options in Dupuytren's contracture: aponeurotomy, enzymes, stretching, and fat grafting.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Perform needle aponeurotomy, fat grafting, Digit Widget insertion, and collagenase injection for Dupuytren's cords. (2) Describe how cords can be stretched without surgery. (3) Explain to patients the risks and benefits of these new alternatives of treatments. SUMMARY: Surgery for Dupuytren's contracture used to be the only alternative of treatment. The past 5 years have seen the widespread adoption of minimally invasive treatments in the form of needle aponeurotomy and collagenase injection to disrupt the cords and restore range of motion. Even newer and perhaps as effective treatments such as fat grafting and mechanical stretching with the Digit Widget may also end up being important tools of treatment. The reader will be introduced to all of these modalities with text, illustration, and videos.

Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction.

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.

Reconstruction of the burned hand.

This article summarizes the initial management of acute burn injuries to the hand, in addition to treatment and reconstructive options. The goal of treatment for a burn injury to the hand is primarily a functional hand. This is best achieved by appropriate early treatment, the right selection from a wide range of possible reconstructive procedures, and focused occupational hand therapy.

Preliminary soft-tissue distraction versus checkrein ligament release after fasciectomy in the treatment of dupuytren proximal interphalangeal joint contractures.

BACKGROUND: Checkrein ligament release for treatment of proximal interphalangeal joint Dupuytren contractures does not address the shortened arteries or deficient skin. The Digit Widget uses soft-tissue distraction to overcome these issues. This study compares checkrein ligament release after fasciectomy versus preliminary soft-tissue distraction, followed by operative release, for treatment of proximal interphalangeal joint Dupuytren contractures. METHODS: The authors compared operative and postoperative characteristics of patients treated with either fasciectomy plus checkrein ligament release or Digit Widget distraction between 2001 and 2008. Seventeen patients (20 digits) underwent ligament release (mean contracture, 55.9 degrees); six of these 20 were reoperations. Thirteen patients (17 digits) underwent distraction (mean contracture, 67.6 degrees); 10 of 17 were reoperations. RESULTS: The 20 digits treated with fasciectomy plus ligament release had an average extension improvement of 31.4 degrees (range, -4 to 70 degrees). Digits treated with distraction had an average extension improvement of 53.4 degrees (range, 30 to 75 degrees) (p<0.001 versus ligament release). Three digits treated with distraction improved to full proximal interphalangeal extension. Initial contractures of 60 degrees or less treated by ligament release (n=12) or distraction (n=7) improved by means of 28.8 degrees and 47.7 degrees, respectively (p=0.048). Contractures greater than 60 degrees treated by ligament release (n=8) or distraction (n=10) improved by means of 35.3 degrees and 57.3 degrees, respectively (p=0.02). CONCLUSION: Soft-tissue distraction followed by operative release showed greater correction than Dupuytren fasciectomy plus checkrein ligament release. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effects of carpal tunnel syndrome on adaptation of multi-digit forces to object weight for whole-hand manipulation.

The delicate tuning of digit forces to object properties can be disrupted by a number of neurological and musculoskeletal diseases. One such condition is Carpal Tunnel Syndrome (CTS), a compression neuropathy of the median nerve that causes sensory and motor deficits in a subset of digits in the hand. Whereas the effects of CTS on median nerve physiology are well understood, the extent to which it affects whole-hand manipulation remains to be addressed. CTS affects only the lateral three and a half digits, which raises the question of how the central nervous system integrates sensory feedback from affected and unaffected digits to plan and execute whole-hand object manipulation. We addressed this question by asking CTS patients and healthy controls to grasp, lift, and hold a grip device (445, 545, or 745 g) for several consecutive trials. We found that CTS patients were able to successfully adapt grip force to object weight. However, multi-digit force coordination in patients was characterized by lower discrimination of force modulation to lighter object weights, higher across-trial digit force variability, the consistent use of excessively large digit forces across consecutive trials, and a lower ability to minimize net moments on the object. Importantly, the mechanical requirement of attaining equilibrium of forces and torques caused CTS patients to exert excessive forces at both CTS-affected digits and digits with intact sensorimotor capabilities. These findings suggest that CTS-induced deficits in tactile sensitivity interfere with the formation of accurate sensorimotor memories of previous manipulations. Consequently, CTS patients use compensatory strategies to maximize grasp stability at the expense of exerting consistently larger multi-digit forces than controls. These behavioral deficits might be particularly detrimental for tasks that require fine regulation of fingertip forces for manipulating light or fragile objects.

Pyoderma gangrenosum complicating bilateral total knee arthroplasty.

Pyoderma gangrenosum is an ulcerative, necrotic dermatosis of unknown etiology. It is frequently associated with inflammatory, hematologic, or neoplastic disease. Clinical and physical evaluation can imitate postoperative wound infections. This article reports a case of pyoderma gangrenosum in a patient who underwent bilateral total knee arthroplasty. Her postoperative course was complicated by wound dehiscence and ulceration in both knees. Her condition deteriorated despite debridements and antibiotic therapy. Deep intraoperative cultures were all negative. Once the diagnosis of pyoderma gangrenosum was established and once appropriate treatment with steroids was initiated, her condition improved. The diagnosis of pyoderma gangrenosum should be considered in patients with wound deterioration who remain culture-negative and fail to respond to debridement and antibiotic treatment. This case report highlights the presentation of pyoderma gangrenosum and its ability to be misdiagnosed as infection. A delay in treatment may result in unnecessary surgery that will further exacerbate this inflammatory condition.

Superficialization of deep arteriovenous access procedures in obese patients using suction-assisted lipectomy: A novel approach.

Successful dialysis access necessitates superficial arteriovenous fistula (AVF) placement to facilitate identification of anatomical landmarks for safe cannulation. Suction-assisted lipectomy (SAL) may be an alternative to traditional surgical AVF revision procedures for placing fistulas more superficially. Three patients with an average body mass index of 45.2 kg/m(2), with inaccessible AVFs due to obesity, underwent ultrasound-guided SAL of their upper extremities. Successful cannulation was achieved within two weeks. A clinically insignificant hematoma and arm swelling occurred in one patient. SAL provides a safe and effective alternative for salvaging deep AVFs for dialysis access in the upper extremities of obese patients.