Discrepancies in Gender Representation Between Integrated and Independent Plastic Surgery Programs.

PURPOSE: Despite increasing female representation in integrated plastic surgery training programs, independent programs have lower representation and slow improvement in female enrollment. Self-reported resident data were used to investigate trends of female representation in integrated and independent programs. METHODS: Data were collected from Accreditation Council of Graduate Medical Education resources of active residents' characteristics. Self-reported gender data were collected for integrated, independent, and general surgery programs from annual reports since 2009. χ2 analysis was conducted to compare female enrollment of integrated programs, independent programs, general surgery programs, and general surgery programs with matriculation-year adjustment. RESULTS: In 2008, 89 independent programs had nearly identical percentage of female enrollment with 30 integrated programs at 23.8% and 23.1%, respectively. Differences in representation between independent and integrated programs became significant in 2012, with independent programs demonstrating 25.1% female enrollment compared with 30.5% in integrated programs. This trend of higher female representation in integrated programs has persisted since 2012. To correct for preexisting disparity in general surgery programs, we compared female enrollment of independent programs with female enrollment of that class' general surgery matriculation-year 5 years earlier. In all examined years, general surgery still had proportionally higher female enrollment compared with independent programs, even with conservative 5-year matriculation adjustment. CONCLUSIONS: Dramatic differences in female enrollment were found between integrated and independent programs, with representation in integrated programs rising more quickly. Adjustments for previous rates of female enrollment in general surgery did not yield explanation for low independent program enrollment. Increasing female representation in independent training models will continue to create a more diverse workforce.

Molding Helmet Therapy for Deformational Brachycephaly.

BACKGROUND: Molding helmet therapy is used for the treatment of infants with deformational brachycephaly (DB). There is a lack of rigorous outcome measures of helmet therapy in patients with DB using 3-dimensional (3D) imaging, with most reports rely on either subjective or 2-dimensional analyses. Furthermore, the longitudinal assessment of head shape improvement over the course of helmet therapy has not been documented. Our goal was to assess the outcome of molding helmet therapy using 3D surface imaging, and to document the pace of improvement during treatment. METHODS: The head shape of 18 infants with DB who underwent orthotic molding helmet therapy was assessed. The 3D scans were obtained before treatment, during treatment, and at the end of treatment. First, we applied shape analysis techniques based on template deformation to obtain average (composite) heads of the 18 patients at the 3 time points of treatment (pretreatment, during, and posttreatment). In addition, we used 3D curvature analysis to quantify the degree of flatness at the same time points. RESULTS: Molding helmet therapy started at 6.7 ±â€Š0.9 months of age and lasted for 4.3 ±â€Š0.8 months. The overall difference in the occipital contour between pretreatment and end of treatment was 6.3 ±â€Š1.7 mm. Curvature analysis revealed that 15% of the back of the head had prehelmet marked flatness (mean curvature <5/m), which decreased to 9% at 2.5 months into treatment and 7% at the end of treatment. CONCLUSION: Over 65% of the head shape improvement occurred during the 2.5 months of molding helmet therapy.

Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement.

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.

Not Just Another Trigger Finger.

BACKGROUND: Open A1 pulley release for trigger finger has generally been considered a minor procedure with infrequent complications. Most reported complications are minor, including scar pain and tenderness, mild extension lag, and recurrence of triggering. Rates of major complications, such as bowstringing, neurovascular bundle injury, and infection requiring reoperation, are less than 1% to 4%. We aimed to describe the potentially devastating sequelae of these major complications and the subsequent consequences. METHODS: Three patients underwent open trigger finger release, which were all complicated by severe postoperative surgical site infection requiring multiple subsequent procedures. We review our initial management, subsequent reconstructive options, and outcomes with up to 19 years follow-up. RESULTS: All 3 adult patients who underwent open A1 pulley release for trigger finger developed a surgical site infection, leading to flexor tenosynovitis requiring urgent operative debridement and multiple subsequent procedures. Two patients were poorly controlled diabetics, and the third patient was otherwise healthy. Each patient ultimately developed distinct consequences from their postoperative course-finger stiffness and contracture, disabling bowstringing requiring the use of a pulley ring, and flexor tendon rupture requiring staged tendon reconstruction, respectively. All 3 patients at final follow-up had a permanent functional deficit. CONCLUSIONS: Major complications after trigger finger release are infrequent. However, if left untreated, particularly in diabetic patients, there can be disastrous consequences, resulting in permanent loss of function. This case series highlights the importance of accurate diagnosis of postoperative infections and expedient treatment thereafter.

Surgical Fellowships Demonstrate Variable Improvement in Gender Representation Despite Greater Female Enrollment in General Surgery Residencies.

OBJECTIVE: Despite increasing female representation in General Surgery (GS) residency training programs, proportional improvement of female enrollment in surgical fellowships has yet to be quantified. We aimed to assess if female enrollment in surgical fellowships has improved at an equivalent rate in 7 different surgical fellowship options after GS. DESIGN AND SETTING: Data were collected from Accreditation Council for Graduate Medical Education (ACGME) resources which disclosed active resident and fellow characteristics. Gender identification was self-reported by residents to ACGME. Gender data collected for GS programs and surgical fellowships including Surgical Critical Care, Colon, and Rectal Surgery, Pediatric Surgery, Plastic Surgery, Surgical Oncology, Thoracic Surgery, and Vascular Surgery from annual reports. Pearson Chi-squared analysis was conducted between GS residencies and fellowship programs in their corresponding years using Stata15 software. RESULTS: In all years examined, fellowships in Vascular, Thoracic, and Plastic Surgery had significantly lower female enrollment in proportion to the number of female GS residents (p = <0.02). In all years examined, Surgical Oncology, Pediatric, Colon and Rectal, and Surgical Critical Care had female enrollment that was, at minimum, proportional to female enrollment in GS residency, indicating equitable gender representation. Surgical Oncology (2016), Pediatric (2020) and Surgical Critical Care (2016) fellowships each had 1 year where female enrollment was significantly higher than General Surgery. CONCLUSIONS: The enrollment of female surgeons in Plastic, Vascular, and Thoracic Surgery fellowships has not improved proportionally despite an increase in female GS residents. These results suggest the possibility of persistent factors that deter female enrollment in Vascular, Thoracic and Plastic Surgery fellowships that are not present to the same degree in fields with equitable fellowship female enrollment. Female representation in surgical fellowships is vital to improving gender diversity in all disciplines of surgery, particularly academic surgery.

Assessing the quality and reliability of patient information regarding aesthetic fat grafting on YouTube.

PURPOSE: Patients increasingly consult social media regarding aesthetic surgery. Given the popularity of fat transfer operations, this study assesses the quality and reliability of patient information available on YouTube regarding aesthetic fat grafting. METHODS: The terms "fat grafting" and "fat transfer" were searched on YouTube with respect to the terms "face", "breast", "buttock", and "Brazilian butt lift". Filtered by view count, the top 20 unique, English language, aesthetic surgery-related videos for each search combination were reviewed by three independent reviewers for demographic and descriptive characteristics. Videos were rated for information reliability and quality using the modified DISCERN (MD) tool (1 = low, 5 = high) and global quality scale (GQS) (1 = poor, 5 = excellent). RESULTS: Out of 80 total videos, 76% were authored by physicians and 24% by laypersons. The overall mean MD score was 1.5 and the mean GQS was 2.6. Videos authored by physicians outscored those by non-medical authors (MD: 1.6 vs. 1.3; GQS 2.7 vs. 2.2). Board-certified plastic surgeon videos (N = 30) scored higher on both the MD (1.7 vs 1.3) and GQS (3.1 vs 2.2) than those of non-medical authors. On the contrary, videos by laypersons and non-plastic surgeons had 40% more views, twice as many "likes" and nearly double as many subscribers. CONCLUSION: The overall quality of information presented in aesthetic fat grafting procedures videos on YouTube is low and from unreliable sources. Surgeons should educate patients regarding potentially inaccurate information, and professional societies should disseminate high-quality media.

Assessing the Quality and Reliability of Patient Information Regarding First-Aid for Acute Burns on YouTube.

Given ever increasing ease of access to technology, the majority of adults first turn to the internet for medical advice. The world wide web is filled with user-generated content within multiple social media platforms that lack a governing body to validate the information's accuracy and reliability. The authors performed a qualitative review of first-aid burn resources available on YouTube using two validated scales: Modified Discern and Global Quality Scale. A search was conducted using the term "burn treatment" on September 18, 2019. Of 120 reviewed videos, 59 met their inclusion criteria. 36% (n = 21) of the speakers had formal medical training, with only 12% (n = 7) identified as burn care professionals. The mean views originating from nonmedical speakers (162,675) were more than eight times that originating from burn centers (14,975). The quality of the videos was compared by video source, speaker, and specialty. Burn centers had the highest Modified Discern and Global Quality Scale scores, 2.91 and 2.86, respectively (P < .05). Additionally, the authors were able to demonstrate that there was a statistically significant higher quality of videos when the speaker was a burn care professional or had formal medical training. Unfortunately, their review demonstrated that videos originating from hospital systems and burn centers made up a minority of the online media content. These results illustrate an opportunity for improvement by way of increased content creation to bolster the online presence of the burn community and provide patients with more accurate information.

Foot Salvage with Selective Arterialization of Pedal Venosomes.

BACKGROUND: Lower extremity salvage using microvascular flaps can be considered in high-functioning patients, but indications for salvage are often restricted by distal microvascular disease that may threaten the foot as a whole. Selective arterialization of specific pedal venosomes is a novel potential solution to this problem. METHODS: A 48-year-old man with a chronic left plantar forefoot wound, osteomyelitis of the second and third metatarsal heads, and critical limb ischemia was evaluated for foot salvage. Despite a patent popliteal to posterior tibial bypass graft, residual ischemia was present in the first and second toes due to severe microvascular disease. This wound was reconstructed with a free partial medial rectus abdominis flow-through flap based on the medial branch of the deep inferior epigastric artery. The lateral branch was used as a flow-through vessel to arterialize the dorsal veins of the first webspace. RESULTS: Arterialization of the first webspace veins resulted in an immediate intraoperative improvement of the color of the first and second toes, along with creation of an arterial Doppler signal. The flap effectively covered the wound. The patient went on to heal completely and return to unrestricted ambulation. Transcutaneous oxygen measurement values of the dorsal foot improved from 35.8 mm Hg preoperatively to 48.3 mm Hg postoperatively. CONCLUSIONS: In patients with focal areas of critical ischemia, selective arterialization of the venous system may be an effective method of preventing tissue loss and improving wound healing. A flow-through flap can be used to accomplish this in tandem with wound reconstruction.

Comparison of an unsupervised machine learning algorithm and surgeon diagnosis in the clinical differentiation of metopic craniosynostosis and benign metopic ridge.

Metopic suture closure can manifest as a benign metopic ridge (BMR), a variant of normal, to "true" metopic craniosynostosis (MCS), which is associated with severe trigonocephaly. Currently, there is no gold standard for how much associated orbitofrontal dysmorphology should trigger surgical intervention. In our study, we used three-dimensional (3D) curvature analysis to separate the phenotypes along the spectrum, and to compare surgeons' thresholds for operation. Three-dimensional curvature analyses on 43 subject patients revealed that the mean curvature of mid-forehead vertical ridge was higher for patients who underwent operation than those who did not undergo operation by 1.3 m-1 (p < 0.0001). In addition, these patients had more retruded supraorbital areas by -16.1 m-1 (p < 0.0001). K-means clustering classified patients into two different severity groups, and with the exception of 2 patients, the algorithm's classification of deformity completely agreed with the surgeons' decisions to offer either conservative or operative therapy (i.e. 96% agreement). The described methods are effective in classifying severity of deformity and in our experience closely approximate surgeon therapeutic decision making. These methods offer the possibility to consistently determine when surgical intervention may be beneficial and to avoid unnecessary surgeries on children with benign metopic ridge and associated minimal orbitofrontal deformity.