Pulmonary Function After Pedicled Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction.

Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, have been shown to increase intra-abdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled TRAM flap breast reconstruction.A prospective clinical trial was conducted involving 22 women undergoing unilateral or bilateral pedicled TRAM flap breast reconstruction. Pulmonary function testing was conducted 1 week before the operation, 24 hours postoperatively, and 2 months postoperatively. The patients were stratified by age (<50 years vs ≥50 years), type of TRAM flap (unilateral vs bilateral), tobacco use (smoker vs nonsmoker), and body mass index. Changes were analyzed using 1-way repeated-measures analysis of variance and paired t tests. All comparisons used a 2-tailed test at the 0.05 level of significance.Other than residual volume, the 24-hour postoperative values were significantly lower than the preoperative values. The smokers had less change in functional residual capacity, total lung capacity, and forced vital capacity values than the nonsmokers at 24 hours postoperatively; however, they were noted to have decreased pulmonary function at baseline. The patients 50 years or older had significantly greater decline in functional residual capacity and residual volume compared with the younger cohort. No significant difference in pulmonary function testing values existed between those undergoing bilateral versus unilateral pedicled TRAM flap reconstruction. Pulmonary function tests returned to baseline at 2-month follow-up.Pulmonary function test values were significantly decreased at 24 hours after pedicled TRAM flap breast reconstruction.

International Programs in the Education of Residents: Benefits for the Resident and the Home Program.

There is a significant need for basic surgical care worldwide. In recent years, modest improvement in fulfilling this demand has been achieved through international medical mission trips from various organizations. These humanitarian endeavors and global health experiences have generated increasing interest in participating in international missions from surgical residents. However, many academic institutions currently do not have the infrastructure or desire to support surgical residents participating in medical missions. This paper aims to illustrate that careful, planned integration of medical mission trips into the residency curriculum will develop and enhance resident education and experience by fulfilling all six Accreditation Council for Graduate Medical Education (ACGME) core competencies and by benefitting the native program.

The Present Status of Global Mission Trips in Plastic Surgery Residency Programs.

OBJECTIVE: The present status of global mission trips of all of the academic Plastic Surgery programs was surveyed. We aimed to provide information and guidelines for other interested programs on creating a global health elective in compliance with American Board of Plastic Surgery (ABPS) and Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME/RRC) requirements. DESIGN: A free-response survey was sent to all of the Plastic Surgery Residency program directors inquiring about their present policy on international mission trips for residents and faculty. Questions included time spent in mission, cases performed, sponsoring organizations, and whether cases are being counted in their resident Plastic Surgery Operative Logs (PSOL). RESULTS: Thirty-one programs responded, with 23 programs presently sponsoring international mission trips. Thirteen programs support residents going on nonprogram-sponsored trips where the majority of these programs partner with outside organizations. Many programs do not count cases performed on mission trips as part of ACGME index case requirement. Application templates for international rotations to comply with ABPS and ACGME/RRC requirements were created to facilitate the participation of interested programs. CONCLUSIONS: Many Plastic Surgery Residency programs are sponsoring international mission trips for their residents; however, there is a lack of uniformity and administrative support in pursuing these humanitarian efforts. The creation of a dynamic centralized database will help interested programs and residents seek out the global health experience they desire and ensure standardization of the educational experience they obtain during these trips.

Traumatic palatal perforation after orotracheal intubation: a case report and a review of the literature.

In this report, we describe an unusual case of a traumatic palatal perforation caused by orotracheal intubation. The paucity of reports of palatal perforation resulting from intubation in the literature suggests that it is a rare occurrence. However, recognizing this potential complication and managing the airway appropriately may reduce patient morbidity.

A retrospective study comparing patient outcomes of wise pattern-inferior pedicle and vertical pattern-medial pedicle reduction mammoplasty.

This study compared patient outcomes of a single surgeon experience between those with inferior and medial pedicle breast reductions. A cohort of 84 patients was analyzed. In all, 49 inferior pedicle reductions and 35 medial pedicle reductions were performed. The average weight of tissue removed per breast was 639 g with the inferior pedicle technique and 450 g with the medial pedicle technique. Nipple transposition distance averaged 8.6 cm for the inferior pedicle group and 6.3 cm for the medial pedicle group. Scar revision surgery within 18 months was required in 5.7% of the medial pedicle group as compared with 0% in the inferior pedicle group. The overall complication rate was higher for the inferior pedicle group (28.6%) compared with the medial pedicle group (14.3%). In this study, medial pedicle reductions resulted in lower complication rates. The amount of tissue removed was less with medial pedicle reductions. Hypertrophic scarring was reduced in the medial pedicle reduction mammoplasty.

Trends in Academic "Ghost Publications" in Plastic Surgery Residency Applications: A 3-Year Study.

Plastic surgery is an attractive specialty to medical students. Residency training programs have the luxury of selecting their trainees from the "cream of the crop" from United States medical schools. Because of the steep competition for PGY-1 integrated program positions, the temptation exists for applicants to falsify parts of their applications, particularly those parts that are difficult to verify. METHODS: A retrospective analysis of the Integrated Plastic Surgery applications from the years (2010-2013) was done. Two reviewers manually and independently handsearched each of the articles in the databases (Medline, Scopus, Clinical trials, Google scholar) additionally, a specialized medical librarian corroborated. A ghost article was defined as the inability to find the listed applicant in the authorship list of the claimed article/abstract/chapter or the inability to find the submitted article. Misrepresentation was defined as a change in authorship order. Data were summarized and analyzed, generalized estimating equations model was used. SAS software, v9.4. RESULTS: All 392 applicants were included, 159 (2010-2011), 120 (2011-2012), and 119 (2012-2013). The number of manually reviewed records was 2,124. "Ghost" authorship was found in 234 articles out of 2,124 (11.02%). The overall rate of "Ghost" authorship in applicants to our program was found to be 34.4%, 135 applicants and misrepresentation in 5 cases (1.28%). CONCLUSIONS: Ghost publications are present in Plastic Surgery applications, its trend is similar through the years, "protective" factors are: first authorship and published peer reviewed abstract/article.

Blood Loss and Transfusion Rates in Microsurgical Head and Neck Reconstruction.

BACKGROUND: Free flap reconstruction cases of the head and neck are often complex, long and have a multitude of risks. One of the greatest risks is intraoperative blood loss and need for transfusion. The purpose of this study was to examine basic patient and procedure characteristics in head and neck free flap reconstruction pre- and postoperatively that may help to predict severity of blood loss. METHODS: A retrospective chart analysis of 67 free flap reconstructions for head and neck defects was performed. Patient characteristics, surgical variables, length of stay, and postoperative complications were reviewed and compared between the transfused and nontransfused patients. Characteristics between transfused and nontransfused patients were analyzed using two-tailed t tests and Fisher's exact tests. RESULTS: Of the 67 procedures, 19 reconstructions (28.4%) required a transfusion. Transfused patients were found to have a lower preoperative hemoglobin and elevated coagulation labs. The average length of stay was also statistically longer for transfused patients. There was no statistical difference in patient characteristics, length of surgery, type of free flap, or complication rate in the transfused versus nontransfused patients. CONCLUSIONS: Our study demonstrates that head and neck microsurgical resection and reconstruction presents patients with a transfusion risk of over 28%. We found that patients with a lower preoperative hemoglobin and abnormal coagulation levels are at a higher risk for receiving a transfusion. We also have demonstrated that patients who received a transfusion had a statistically significant longer length of stay.

Social problems in plastic surgery residents: a management perspective.

BACKGROUND: It is presumed that plastic surgery residents experience various social problems, just as do their peers in other specialty training programs and in the general public. These issues can occasionally disrupt the resident's personal training experience and sometimes the program as a whole. A survey was performed to assess the magnitude of the problem, and the issues revealed were assessed to assist the program director and the resident in reaching successful completion of the residency. METHODS: A survey was designed by the executive committee and staff of the American Council of Academic Plastic Surgeons and sent to all plastic surgery training programs in the United States. A response rate of 66 percent was achieved. The programs reported on the social issues occurring in their residents over the preceding 5 years. The results were presented at a business meeting of the Council. RESULTS: Thirty-seven percent of programs reported that at least one resident had left their program during the study period. Twenty percent reported that a resident had been asked to leave the program. The frequency of social problems resulting in disruption of the training program was tabulated in the following areas: divorce; pregnancy/parturition; financial, legal, or family issues; drug or alcohol abuse; illness/injury; and interpersonal conflicts. CONCLUSIONS: Plastic surgery residents experience social problems that can affect the timely completion of their training. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents' ultimate success, and adherence to institutional, legal, and accreditation body mandates.

International importance of robust breast device registries.

BACKGROUND: Breast implants are high-risk devices that have been at the epicenter of much debate and controversy. In light of the Poly Implant Prothèse crisis, data registries among 11 national societies around the world are cooperatively calling for the urgent need to establish robust national clinical quality registries based on international best practice within a framework of international collaboration. METHODS: A survey was conducted on the historic and current status of national breast device registries. Eleven countries participated in the study, illustrating different data collection systems and registries around the world. Data collection was designed to illustrate the capabilities of current national registries, with particular focus on capture rate and outcome reporting mechanisms. RESULTS: A study of national breast implant registries revealed that less than half of the participating countries had operational registries and that none of these had adequately high data capture to enable reliable outcome analysis. The study revealed that the two most common problems that discouraged participation are the complexity of data sets and the opt-in consent model. CONCLUSIONS: Recent implant crises have highlighted the need for robust registries. This article argues the importance of securing at least 90 percent data capture, which is achievable through the opt-out consent model. Since adopting this model, the Australian Breast Device Registry has increased data capture from 4 percent to over 97 percent. Simultaneously, it is important to foster international collaboration from the outset to avoid duplication of efforts and enable the development of effective international early warning systems.

Evaluation of abdominal wall strength after TRAM flap surgery.

Evaluation of abdominal wall function after transverse rectus abdominis musculocutaneous (TRAM) flap surgery has been mostly subjective. The purpose of this study was to measure abdominal wall strength objectively and to compare the results with the patient's performance of daily activities. Abdominal wall strength was objectively measured with the B200 IsoStation machine preoperatively and 1 year after TRAM flap breast reconstruction. These data were compared with the results of a questionnaire evaluating the patient's performance of daily activities. The results of this testing in 21 patients demonstrated the following: (1) a decrease in abdominal wall strength after bilateral pedicled TRAM flap surgery, which was significant in trunk flexion (34.2 +/- 16.9 ft-lbs to 20.6 +/- 15.2 ft-lbs); (2) compensation by other truncal musculature, with an increase in the strength of trunk rotation (18.8 +/- 13.5 ft-lbs to 28.6 +/- 17.7 ft-lbs) seen after unilateral pedicled TRAM flap surgery; (3) minimal interference with the patient's daily activities; and (4) no effect of mesh on strength. A relationship was demonstrated between the degree of loss of strength in trunk flexion and the patient's difficulty in performing certain activities. The patients who had the greatest loss in trunk flexion following the use of both pedicles also had the most difficulty in performing some daily activities. The patients were satisfied with their reconstructive procedure, with an average score of 8.3 (on a scale of 1 to 10), and reported an improvement in the appearance of their abdomen, with an average increase of 5.1 to 6.8 (on a scale of 1 to 10).

Academic plastic surgery: faculty recruitment and retention.

BACKGROUND: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. METHODS: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. RESULTS: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. CONCLUSIONS: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

Core measures: implications for plastic surgery.

BACKGROUND: Perioperative complications are a major source of morbidity, mortality, and expenditures in health care. Many of these complications are preventable with simple, cost-effective measures when implemented in a standardized manner. Surgical specialties are increasing efforts to implement standardized and easily monitored measures to reduce perioperative complications. METHODS: The recommendations provided by the U.S. Department of Health and Human Services and published by the Joint Commission on Accreditation of Healthcare Organizations were summarized as they pertain to plastic surgery. A review of recent plastic surgery literature was pursued to evaluate these recommendations as they pertain to the specialty. RESULTS: Measures exist to reduce the incidence of perioperative infection, venous thromboembolism, and mortality associated with cardiac events. These measures include type and timing of prophylactic antibiotics, maintenance of perioperative normothermia, appropriate hair removal, early discontinuation of urinary catheters, appropriate venous thromboembolism prophylaxis, and use of preoperative beta-blockers. CONCLUSIONS: As national quality measures are implemented across an increasing number of specialties, the expansions will likely affect plastic surgery. These measures are evidence based and validated across a diverse group of surgical specialties, resulting in improved measured outcomes. Plastic surgeons would benefit by actively providing leadership as these and similar measures are implemented.

A 5-year review of ethics complaints to the American Society of Plastic Surgeons.

BACKGROUND: The Code of Ethics of the American Society of Plastic Surgeons (ASPS) exists to encourage and enforce ethical behavior among its members. Complaints against individual members may be filed by patients or their representatives, members of the Society, or other members of the public. METHODS: Data from a total of 677 complaints from 2004 to 2008 were reviewed by the author. These complaints were categorized with regard to geographic area, type of complaint, and the outcome of the investigation of the complaint, including disciplinary actions. The system of managing these complaints within the Society is discussed. RESULTS: States with the most complaints filed included California, Florida, Texas, Illinois, and New York, with all others having a minimal number. The most common complaint was filed regarding unethical advertising, followed by unprofessional conduct and participation in a contest. Differences in frequency of complaints were statistically significant (Fisher's exact test, p < 0.001). Fifty-four cases were heard by the Judicial Council, with 31 receiving discipline, primarily the less severe types of censure. The total number of complaints per year seems to be trending downward. CONCLUSIONS: Ethical complaints (filed mostly by ASPS members) vary in frequency according to geographic area and the type of complaint. A downward trend was noted in the total number of complaints over the years 2004 to 2008, although this was not statistically significant. Given the basic purposes of the development of a code of ethics and its subsequent enforcement, the ethical construct within the ASPS seems to serve the specialty well.

Incidence of breast hematoma after placement of breast prostheses.

BACKGROUND: Prosthetic breast implants are frequently used by plastic surgeons for reconstructive and aesthetic procedures. One known complication of the procedure is postoperative breast hematoma. However, the incidence and risk factors of this problem are not fully characterized. METHODS: A retrospective analysis was performed of a prospectively collected patient medical record database based on procedure codes to identify breast hematomas and possible risk factors over a 12-year period from November of 1996 to October of 2008. RESULTS: One thousand nine hundred thirty-six operations were performed on 3474 breasts with prosthetic implants used. Average patient follow-up was 48.9 months, with 32 hematomas identified following 32 operations. The latest hematoma identified was 21 months after the procedure. Hematomas were identified on average 37 days after the operation. CONCLUSIONS: In the authors' experience, postoperative breast hematomas after prosthetic implant placement occur in 0.92 percent of breast prostheses placed. No individual surgical approach is associated with the occurrence of breast hematomas. Hematomas are not statistically associated with any measured patient or surgically defined characteristic. Specifically, no statistical significance was shown for larger implant size, reoperation, operative indication, type of surgery, or implant type as an independent risk factor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Optimizing revenue at a cosmetic surgery centre.

BACKGROUND: The demand for cosmetic surgery and services has diminished with recent fluctuations in the economy. To stay ahead, surgeons must appreciate and attend to the fiscal challenges of private practice. A key component of practice economics is knowledge of the common methods of payment. OBJECTIVE: To review methods of payment in a five-surgeon group practice in central Texas, USA. METHODS: A retrospective chart review of the financial records of a cosmetic surgery centre in Texas was conducted. Data were collected for the five-year period from 2003 to 2008, and included the method of payment, the item purchased (product, service or surgery) and the dollar amount. RESULTS: More than 11,000 transactions were reviewed. The most common method of payment used for products and services was credit card, followed by check and cash. For procedures, the most common form of payment was personal check, followed by credit card and financing. Of the credit card purchases for both products and procedures, an overwhelming majority of patients (more than 75%) used either Visa (Visa Inc, USA) or MasterCard (MasterCard Worldwide, USA). If the amount of the individual transaction surpassed US$1,000, the most common method of payment transitioned from credit card to personal check. CONCLUSIONS: In an effort to maximize revenue, surgeons should consider limiting the credit cards accepted by the practice and encourage payment through personal check.

Plastic surgery leadership in an institution: a primer.

Leadership can be defined as not only the position of a leader, but the ability to function as one. This brief review of leadership is focused on what is involved in leading a plastic surgery unit in an institution. Characteristics of a good leader, identified by those who are being led, are discussed. In addition to that, the character of the individual leading is also reviewed, because it is such a critical ingredient in a person's capacity to lead others. Leadership characteristics can be learned and opportunities for growth in this area are discussed. The result of good leadership of a plastic surgery unit will indubitably result in the enhancement of the plastic surgery unit in an institution and plastic surgery as a specialty.