Combining Allograft Adipose and Fascia Matrix as an Off-the-Shelf Scaffold for Adipose Tissue Engineering Stimulates Angiogenic Responses and Activates a Proregenerative Macrophage Profile in a Rodent Model.

OBJECTIVE: Bioscaffolds for treating soft tissue defects have limitations. As a bioscaffold, allograft adipose matrix (AAM) is a promising approach to treat soft tissue defects. Previously, we revealed that combining superficial adipose fascia matrix with AAM, components of the hypodermis layer of adipose tissue, improved volume retention, adipogenesis, and angiogenesis in rats 8 weeks after it was implanted compared with AAM alone. Here, we modified the fascia matrix and AAM preparation, examined the tissue over 18 weeks, and conducted a deeper molecular investigation. We hypothesized that the combined matrices created a better scaffold by triggering angiogenesis and proregenerative signals. METHODS: Human AAM and fascia matrix were implanted (4 [1 mL] implants/animal) into the dorsum of male Fischer rats (6-8 weeks old; ~140 g) randomly as follows: AAM, fascia, 75/25 (AAM/fascia), 50/50, and 50/50 + hyaluronic acid (HA; to improve extrudability) (n = 4/group/time point). After 72 hours, as well as 1, 3, 6, 9, 12, and 18 weeks, graft retention was assessed by a gas pycnometer. Adipogenesis (HE), angiogenesis (CD31), and macrophage infiltration (CD80 and CD163) were evaluated histologically at all time points. The adipose area and M1/M2 macrophage ratio were determined using ImageJ. RNA sequencing (RNA-seq) and bioinformatics were conducted to evaluate pathway enrichments. RESULTS: By 18 weeks, the adipose area was 2365% greater for 50/50 HA (281.6 ± 21.6) than AAM (11.4 ± 0.9) (P < 0.001). The M1/M2 macrophage ratio was significantly lower for 50/50 HA (0.8 ± 0.1) than AAM (0.9 ± 0.1) at 6 weeks (16%; P < 0.05). This inversely correlated with adipose area (r = -0.6; P > 0.05). The RNA-seq data revealed that upregulated adipogenesis, angiogenesis, and macrophage-induced tissue regeneration genes were temporally different between the groups. CONCLUSIONS: Combining the fascia matrix with AAM creates a bioscaffold with an improved retention volume that supports M2 macrophage-mediated angiogenesis and adipogenesis. This bioscaffold is worthy of further investigation.

Financial Models for an Academic Practice in Plastic Surgery.

In an attempt to investigate physician compensation in academic practice, financial reimbursement models of departments and/or divisions of plastic surgery within an academic university setting were evaluated. Method: Thirteen divisions or departments of plastic surgery were surveyed to obtain information regarding reimbursement models for plastic surgery. Results: Of the 13 plastic surgery groups surveyed, 11 were divisions within the department of surgery. The department chairs/chief and/or chief administrative officers were questioned regarding the following areas: (1) total compensation, 2) bonus and incentive compensation models, and (3) cosmetic and cash reimbursement. There were no regional differences that could be identified. As such, we grouped institutions into Western, Midwest, and Eastern regions. COVID-19 did not change any of the financial models that were established before the pandemic. Discussion: There is no ideal model for compensation, which varied among the institutions surveyed. All of these financial models were established before COVID-19 and did not significantly change with the pandemic. It appears that within this small sample size, compensation is based mainly on a $/wRVU model. Funding for research and educational teaching remains a challenge, which is not reimbursed well. Although faculty compensation may vary based on the institutions, the decision to enter and remain in academic practice includes a series of decisions. However, compensation is a significant factor, which should not be minimized.

Deconstructing Allograft Adipose and Fascia Matrix: Fascia Matrix Improves Angiogenesis, Volume Retention, and Adipogenesis in a Rodent Model.

BACKGROUND: Autologous fat grafting is commonly used for soft-tissue repair (approximately 90,000 cases per year in the United States), but outcomes are limited by volume loss (20% to 80%) over time. Human allograft adipose matrix (AAM) stimulates de novo adipogenesis in vivo, but retention requires optimization. The extracellular matrix derived from superficial fascia, interstitial within the adipose layer, is typically removed during AAM processing. Thus, fascia, which contains numerous important proteins, might cooperate with AAM to stimulate de novo adipogenesis, improving long-term retention compared to AAM alone. METHODS: Human AAM and fascia matrix proteins (back and upper leg regions) were identified by mass spectrometry and annotated by gene ontology. A three-dimensional in vitro angiogenesis assay was performed. Finally, AAM and/or fascia (1 mL) was implanted into 6- to 8-week-old male Fischer rats. After 8 weeks, the authors assessed graft retention by gas pycnometry and angiogenesis (CD31) and adipocyte counts (hematoxylin and eosin) histologically. RESULTS: Gene ontology annotation revealed an angiogenic enrichment pattern unique to the fascia, including lactadherin, collagen alpha-3(V) chain, and tenascin-C. In vitro, AAM stimulated 1.0 ± 0.17 angiogenic sprouts per bead. The addition of fascia matrix increased sprouting by 88% (2.0 ± 0.12; P < 0.001). A similar angiogenic response (CD31) was observed in vivo. Graft retention volume was 25% (0.25 ± 0.13) for AAM, significantly increasing to 60% (0.60 ± 0.14) for AAM/fascia ( P < 0.05). De novo adipogenesis was 12% (12.4 ± 7.4) for AAM, significantly increasing to 51% (51.2 ± 8.0) for AAM/fascia ( P < 0.001) by means of adipocyte quantification. CONCLUSIONS: Combining fascia matrix with AAM improves angiogenesis and adipogenesis compared to AAM alone in rats. These preliminary in vitro and pilot animal studies should be further validated before definitive clinical adoption. CLINICAL RELEVANCE STATEMENT: When producing an off-the-shelf adipose inducing product by adding a connective tissue fascial component (that is normally discarded) to the mix of adipose matrix, vasculogenesis is increased and, thus, adipogenesis and graft survival is improved. This is a significant advance in this line of product.

Asymptomatic Stroke After Hyaluronic Acid Filler Injection: Case Report and Literature Review.

Vascular compromise and blindness are reported but rare complications of facial soft tissue filler injections. Stroke is an even rarer complication resulting from intraarterial injection of fillers. We present a case of a patient suffering all 3 complications following hyaluronic acid filler injection: forehead skin vascular compromise, unilateral blindness, and ipsilateral subclinical strokes. Were it not for a stroke workup protocol, the incidental strokes may have otherwise gone undetected, suggesting the incidence of stroke from intraarterial injection may be higher than reported. Further, we review the literature and recommendations for prevention and management of threatened tissue ischemia and vision loss from facial filler injection.

Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis.

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.

Improving In Vitro Cartilage Generation by Co-Culturing Adipose-Derived Stem Cells and Chondrocytes on an Allograft Adipose Matrix Framework.

BACKGROUND: Microtia is an inherited condition that results in varying degrees of external ear deformities; the most extreme form is anotia. Effective surgical reconstruction techniques have been developed. However, these usually require multistage procedures and have other inherent disadvantages. Tissue engineering technologies offer new approaches in the field of external ear reconstruction. In this setting, chondrocytes are cultured in the laboratory with the aim of creating bioengineered cartilage matrices. However, cartilage engineering has many challenges, including difficulty in culturing sufficient chondrocytes. To overcome these hurdles, the authors propose a novel model of cartilage engineering that involves co-culturing chondrocytes and adipose-derived stem cells on an allograft adipose-derived extracellular matrix scaffold. METHODS: Auricular chondrocytes from porcine ear were characterized. Adipose-derived stem cells were isolated and expanded from human lipoaspirate. Then, the auricular chondrocytes were cultured on the allograft adipose matrix either alone or with the adipose-derived stem cells at different ratios and examined histologically. RESULTS: Cartilage induction was most prominent when the cells were co-cultured on the allograft adipose matrix at a ratio of 1:9 (auricular chondrocyte-to-adipose-derived stem cell ratio). Furthermore, because of the xenogeneic nature of the experiment, the authors were able to determine that the adipose-derived stem cells contributed to chondrogenesis by means of a paracrine stimulation of the chondrocytes. CONCLUSIONS: In this situation, adipose-derived stem cells provide sufficient support to induce the formation of cartilage when the number of auricular chondrocytes available is limited. This novel model of cartilage engineering provides a setting for using the patient's own chondrocytes and adipose tissue to create a customized ear framework that could be further used for surgical reconstruction.

Practical Strategies for Identifying and Managing Burnout in Plastic Surgeons.

BACKGROUND: Physician burnout is a well-known problem and widespread issue in the field of medicine. Recently, more attention has been given to the significance of burnout among plastic surgeons. The cause of burnout is multifactorial, with emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment all playing a role. The objective of this article is to provide practical measures to help plastic surgeons in identifying the signs of burnout, thereby mitigating its consequences. METHODS: A literature review was performed to determine the comprehensive findings of previous research conducted on burnout among plastic surgeons. Particular interest was given to successful tactics used in managing work-related stress. Wellness strategies and resources from both academic and private medical settings were also obtained to further review methods for burnout management. RESULTS: There is a wide range of causes and risk factors for burnout among plastic surgeons. The majority of cases correlate with increased workload, loss of physician autonomy, and, in the context of trainees, lack of mentorship. Managing burnout can be supported by identification through survey tools. Establishing a wellness committee is also useful to develop institution-specific interventions. Equally as important, individuals must take steps to manage and minimize their burnout. CONCLUSIONS: This article provides practical strategies for institutions to identify and manage burnout among plastic surgeons. It is obvious that causes of burnout vary in different settings such as academic and community hospitals; therefore, it is critical for institutions to individualize their approach to burnout.

Etiology and Survival of Secondary Revascularizations after Hand and Digit Replantations.

Introduction Hand and digit replantations can be complicated by vascular insufficiency necessitating revision of the original replantation. To date, few studies have evaluated outcomes in secondary revascularizations following replantation. Therefore, the objective of this study was to evaluate the incidence, etiology, and survival rates following secondary revascularization after hand and digit replantations. Materials and Methods A literature search was performed on NCBI for studies documenting secondary revascularization procedures following hand and digit replant. Studies were evaluated for the etiology of vascular failure, frequency of secondary revascularization, and survival rates following intervention. Statistical analysis was conducted across the pooled dataset. Results A total of 16 studies including 1,192 amputations were analyzed. We found that 16.9% (201/1,192) of replants were complicated by vascular compromise. The frequency of vascular compromise was not statistically different between arterial and venous etiologies. The survival rate following secondary revascularization was 55.6%, with no significant difference between the arterial and venous groups. Secondary arterial revascularization was often treated with arterial revision (nine of nine studies) and/or with vein grafting (two of nine studies). Secondary revascularization for venous insufficiency resulted in different survival rates for nonsurgical modalities (58%) versus vein revision (37.5%) versus vein grafting (100%). Conclusion Survival rates following secondary revascularization are lower; however, they may be improved using vein grafts following venous insufficiency. These data can be used to better understand the etiology of replant failure and guide decision-making.

Impact of Immediate Surgical Reconstruction Following Wide Local Excision of Malignant Head and Neck Melanoma.

BACKGROUND: The role of surgical reconstruction following melanoma extirpation is well recognized. Although technical considerations depend on patient anatomy and surgeon preference, the optimal timing of reconstruction remains unclear. This study aims to evaluate clinical and oncologic outcomes in melanoma extirpation followed by immediate reconstruction. METHODS: We retrospectively identified patients who underwent immediate reconstruction following head and neck melanoma excision at our institution between January 2013 and December 2016. Demographic and clinical characteristics, operative variables, and outcome data were extracted. RESULTS: Overall, 197 patients (male 70.6%) underwent excision followed by immediate reconstruction. Of the 70 patients with a history of cutaneous malignancy, 46 (65.7%) had a prior melanoma and 26 (37.1%) had 2 or more types of skin cancers. Of the 202 lesions resected, 138 (68.3%) were invasive, whereas 64 (31.7%) were in situ. The most frequent anatomic location involved was the cheek (34.2%), followed by scalp (31.2%). Reconstruction technique varied, with 116 (57.4%) lesions repaired by adjacent tissue transfer, 24 (11.9%) by full-thickness skin graft, 23 (11.4%) by complex primary closure, 17 (8.4%) by split-thickness skin graft, and 22 (10.9%) by more than 1 technique. On postoperative pathologic assessment, 2 patients had positive margins and 5 experienced local recurrence (mean follow-up: 2.3 years). In an unadjusted bivariate analysis, history of melanoma (P = 0.015) was significantly associated with local recurrence. CONCLUSIONS: Reconstruction at time of excision is an oncologically safe approach for the management of patients with malignant melanoma. A prior history of melanoma may be associated with local recurrence.

Characteristics of Secondary Procedures following Digit and Hand Replantation.

Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.

The Molecular Pathogenesis of Dupuytren Disease: Review of the Literature and Suggested New Approaches to Treatment.

BACKGROUND: Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition. RESULTS: A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods. CONCLUSION: The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.

Micro/nanobubbles: Improving Pancreatic Islet Cell Survival for Transplantation.

PURPOSE: The preservation of transplantable tissue is directly tied to and limited by the ischemia time. Micro/nanobubbles (MNBs) are miniature gaseous voids that allow for the oxygenation of tissue given their high oxygen-carrying capacity. One of the current limitations of islet cell transplantation for type 1 diabetes is poor islet survival, caused by hypoxia, after harvesting the cells from pancreata. As such, the purpose of this study was to elucidate whether MNBs, when added to standard culture medium, improve islet cell survival postharvest. MATERIALS AND METHODS: Islet cells were harvested from Sprague-Dawley rat pancreas tissue via a standard collagenase digestion and gradient purification. To create the MNB solution, a shear-based generation system was used to produce both air- and oxygen-filled MNBs in standard Connaught Medical Research Laboratories (CMRL) medium. Four groups, consisting of 500 islet equivalents, were cultured with either the standard CMRL medium, macrobubble-CMRL, MNB (air)-CMRL, or MNB (O2)-CMRL, and they were incubated at 37°C. Each treatment solution was replenished 24 hours postincubation, and after 48 hours of culture, dithizone staining was used to determine the islet cell counts, and the viability was assessed using Calcein AM/propidium iodide staining. RESULTS: Islet cells that were preserved in macrobubble-CMRL, MNB (air)-CMRL, and MNB (O2)-CMRL conditions showed an increased survival compared with those cultured with standard CMRL. The islet cells cultured in the MNB (air)-CMRL condition demonstrated the greatest cell survival compared with all other groups, including the pure oxygen-carrying MNBs. None of the MNB treatments significantly altered the viability of the islet cells compared to the control condition. CONCLUSIONS: The addition of MNBs to culture medium offers an innovative approach for the oxygenation of transplantable tissue, such as islet cells. This study demonstrated that MNBs filled with air provided the most optimal addition to the islet cell culture medium for improving islet cell survival amongst the treatment groups we tested. Given these findings, we hypothesize that MNBs may also improve the oxygenation and survival of a variety of other tissues, including fat grafts from lipoaspirate, chronic wounds, and solid organs.

Adipose-derived stem cell extracellular vesicles: A systematic review✰.

INTRODUCTION: Extracellular vesicles (EVs) are cell-secreted packages that deliver cargo to target cells to effect functional and phenotypic changes. They are secreted by many different cell types, including adipose-derived stem cells (ADSCs), which are a promising field of study in regenerative medicine. Our aim was to perform a systematic review of the literature to summarize the scientific work that has been conducted on ADSC EVs to date. METHODS: The Pubmed database was queried with keywords (and variations of) "adipose derived stem cell," "stromal vascular fraction," and "extracellular vesicles." We excluded review papers, then manually screened articles based on title and abstract. Full-text articles were assessed for eligibility to include in final review. RESULTS: While an extensive body of research exists on EVs, a much smaller proportion of that is original research on ADSC EVs. Of 44 manuscripts that met our database search criteria, 21 articles were selected for our systematic review. CONCLUSION: ADSC EVs were found to exert effects on angiogenesis, cell survival and apoptosis, inflammation, tissue regeneration, and reduction of disease pathology. Further studies examine characteristics of ADSC EVs. Future work should aim to further detail the safety profiles of ADSC EVs given their potential for cell-based therapies. The body of research studies characterizing ADSC EVs continues to expand, and much work remains to be done before human pilot studies can be considered. To our knowledge, we offer the first systematic review summarizing the research on ADSC EVs and their determined roles to date.

The New Frontier: A Review of Augmented Reality and Virtual Reality in Plastic Surgery.

Mixed reality, a blending of the physical and digital worlds, can enhance the surgical experience, leading to greater precision, efficiency, and improved outcomes. Various studies across different disciplines have reported encouraging results using mixed reality technologies, such as augmented and virtual reality. To provide a better understanding of the applications and limitations of this technology in plastic surgery, we performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The initial query of the National Center for Biotechnology Information database yielded 2544 results, and only 46 articles met our inclusion criteria. The majority of studies were in the field of craniofacial surgery, and uses of mixed reality included preoperative planning, intraoperative guides, and education of surgical trainees. A deeper understanding of mixed reality technologies may promote its integration and also help inspire new and creative applications in healthcare.

Management Modalities and Outcomes Following Acute Scaphoid Fractures in Children: A Quantitative Review and Meta-Analysis.

BACKGROUND: Early evaluation and appropriate management of pediatric scaphoid fractures are necessary to avoid complications. To date, current management of pediatric fractures varies among providers. The objective of this study was to compare clinical outcomes following different treatment modalities. METHODS: A PubMed literature search identified studies involving acute scaphoid fractures in children. Studies were evaluated for treatment provided and their respective effects on union rate, wrist range of motion, and wrist pain. Data were pooled across studies, and quantitative statistical analysis was conducted to compare outcomes. RESULTS: Seventeen studies representing 812 acute pediatric scaphoid fractures were included in the current analysis. We found 93.5% of scaphoid fractures were treated with cast immobilization vs 6.5% treated surgically as 13 of 17 authors treated all fractures with immobilization vs 4 of 17 studies who offered surgical intervention. We found pediatric scaphoid fractures had excellent bone union rates (96.2%) with no difference between the cast immobilization and surgery groups ( P value NS). Long- and short-arm thumb spica immobilization protocols were commonly employed; however, we found no difference in the rates of union ( P value NS). At follow-up, 99.0% of patients treated nonoperatively had normal wrist range of motion and 96.8% were pain free. CONCLUSIONS: Pediatric scaphoid fractures have excellent outcomes. Nonoperative treatment results in a high rate of union with few posttreatment wrist symptoms. Nonsurgical treatment represents an adequate treatment modality in a majority of acute pediatric scaphoid fractures, wherein the role for surgery needs to be better defined.

Predictors of Patient Satisfaction in Hand and Upper Extremity Clinics.

Introduction Patient satisfaction is an important clinical marker for hand/upper extremity patients. Few studies have investigated the predictors of patient satisfaction in the clinic setting. Our objective was to analyze patient satisfaction surveys to explore factors that influence patient satisfaction. Materials and Methods We conducted a retrospective analysis assessing patient satisfaction in the hand/upper extremity clinics at our university medical center between 2012 and 2018. Patient satisfaction was assessed via Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Patient demographics, satisfaction scores, and clinic experience questionnaire responses were evaluated. Statistical analysis was conducted to identify significant trends. Results Between 2012 and 2018, 102 surveys were completed. Scores ranged from 5 to 10 with an average provider rating of 9.56. We found six factors significantly influenced patient satisfaction: adequate time was spent with the provider, provider showed respect, patient was seen by provider within 15 minutes of appointment time, provider listened sufficiently, patient received understandable medical instructions, and understandable medical explanations ( p < 0.05). Conclusion Achieving patient satisfaction is an important clinical marker in hand/upper extremity clinics. Patient satisfaction has defined predictors wherein various clinical factors can influence patient satisfaction and willingness to refer their provider to other patients.

Microsurgery Training Resource Variation among US Integrated Plastic Surgery Residency Programs.

BACKGROUND: Given emerging focus on competency-based surgical training and work-hour limitations, surgical skills laboratories play an increasingly important role in resident education. This study was designed to investigate educational opportunities in microsurgery across integrated residency programs. METHODS: Senior residents (PGY 4-6) at integrated plastic surgery programs were surveyed during the 2016 to 2017 academic year to determine each program's access to: training microscopes and anastomosis models, video-based skills assessment, pre-requisite skills exams, flap courses, or a formal microsurgical training curriculum. Programs were stratified based on large size (>18 residents) and presence of microsurgery fellows. Chi-squared analysis was performed with p < 0.05 to assess statistical significance. RESULTS: Survey responses were collected from 32 of 60 eligible programs (53% response rate). Sixty-nine percent provide access to one to two training microscopes, 25% provide three or more, and 6% provide none. Sixty-nine percent of programs train anastomosis with nonliving prosthetics, 66% with living biologics, and 50% with nonliving biologics. Large program size or having microsurgical fellows was not associated with increased access to training microscopes or specific anastomosis models. Programs without microsurgery fellows reported more often that a formal microsurgery curriculum would be helpful (90 vs. 58% of programs with fellows, p = 0.0003). Respondents who indicated that creating a formal curriculum would not be helpful elaborated that their program already has a formal curriculum or a high volume of microsurgery cases. CONCLUSION: This study demonstrates the current variation in microsurgery training at integrated plastic surgery residency programs. A formal microsurgical training curriculum is commonly viewed as being helpful, particularly at programs without microsurgery fellows.