Cervicofacial Pediatric Tissue Expansion: Aesthetic Unit-Based Algorithm.

BACKGROUND: Tissue expansion is a powerful tool for reconstruction of pediatric soft-tissue pathologies, but complication rates for children have been reported as high as 40%. Infection and implant extrusion lead to premature removal and delays in reconstruction. Expanding the head and neck is uniquely challenging because the confluence of facial aesthetic units must be respected. These challenges have prompted the senior author's creation of an aesthetic-unit based algorithm. METHODS: A retrospective study of pediatric patients who underwent cervicofacial tissue expander placement by the senior author (R.J.R) was performed over a 17-year period. Predictor variables included age, sex, race, indication, number of expanders placed at each operation, serial expansion, expander type, expander size, home versus clinic inflation, and prophylactic antibiotics. Univariate and multivariate analyses were performed to identify risk factors for complications. RESULTS: An aesthetic-unit based reconstructive algorithm is proposed. Forty-eight pediatric patients had 111 cervicofacial tissue expanders placed. Twenty expanders were associated with complications (18%) for surgical site-infection (12.6%), extrusion (4.5%), and expander deflation (6.3%). Expanders placed for congenital nevi (p=0.042) and use of textured expander (p=0.027) were significantly associated with decreased complications. When controlling for covariates, serial expansion of the same site was associated with increased rates of readmission (p=0.027) after having just one prior expander. Iatrogenic ectropion occurred in 13.5% of the study population; expanders with at least one complication during tissue expansion were significantly associated with incidence of iatrogenic ectropion (p=0.026). CONCLUSION: By using an aesthetic-unit based algorithm, reconstructive outcomes can be optimized for pediatric cervicofacial tissue expansion.

Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study.

BACKGROUND: It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS: This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS: Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION: Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Lower Extremity Pediatric Tissue Expansion: A Single Surgeon's 16-Year Experience.

BACKGROUND: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population for lower extremity pathologies. Unfortunately, complication rates range from 19% to 40% in literature, including infection and implant extrusion, leading to delays in reconstruction. These challenges have prompted investigation toward categorizing risk factors for lower extremity tissue expander placement. METHODS: A retrospective study of pediatric patients who underwent lower extremity tissue expander placement by the senior author (R.J.R.) was performed over a 16-year period. Patient charts were reviewed to categorize baseline and operative characteristics. Primary outcome variables were surgical-site infection, expander extrusion, and expander deflation. Univariate and multivariate logistic regressions were performed ( α < 0.05). RESULTS: There were 59 tissue expanders in our cohort. The overall complication rate was 27.1% with a 77.2% successful reconstruction rate. Greater number of expanders placed during 1 operation is associated with 2.5 increased odds of having any complication and is associated with 0.4 decreased odds of having a successful reconstruction. Incisions made in scar tissue for expander placement appear to be associated with a greater than 7 times increased odds of readmission. CONCLUSIONS: Reconstruction of soft tissue pathologies using lower extremity tissue expanders in the pediatric population is an effective yet challenging technique. This study identified that the number of expanders inserted during 1 operation, incisions made over scar tissue, and expanders placed in the anterior thigh were correlated with having a negative impact on reconstructive outcomes. Extra care should be taken with patients who require multiple expanders during 1 operation and with choosing the location and incision of expander placement.

Expanding indications for urogenital transplantation: congenital and oncologic defects, and gender affirmation.

PURPOSE OF REVIEW: Penile transplantation has become an emerging option for patients with severe genital defects. Only transplantation restores anatomy, sexual, and reproductive function of the penis. However, penile transplantation comes with important technical, psychosocial, ethical, and surgical challenges that must be considered for successful implementation. Indications for penile transplantation have yet to be clearly elucidated. RECENT FINDINGS: Since 2006, only five penile transplants have been performed globally. Four of the five transplants have been performed following traumatic defects, and one was performed following a total penectomy from squamous cell carcinoma. Only two of the five penile transplants remain intact. However, long-term outcomes are encouraging with optimal surgical planning, patient selection, and immunologic compliance. Clinical implications and ethical considerations are discussed. SUMMARY: Penile transplantation is a novel solution for penile defects not amenable to traditional reconstructive approaches. With an evidence-based surgical technique, potential advantages include improved urinary function, sensation, and cosmesis. While patient selection is challenging, there is an ongoing effort to identify potential candidates. Indications are discussed in this article.

Are We Speaking the Same Language? A Systematic Review on the Use of Consistent Language in Reporting Fat Necrosis in Autologous Fat Grafting of the Breast.

BACKGROUND: Autologous fat grafting is a widely adopted approach to optimize outcomes in breast reconstruction and augmentation. Although fat necrosis is a well-known consequence of autologous fat grafting, it remains inconsistently defined in the literature. In late 2014, the Food and Drug Administration released a draft guidance to restrict future autologous fat grafting-a statement that was permissively modified in late 2017. In the context of evolving guidelines and autologous fat grafting outcome data, the language and descriptions of fat necrosis are inconsistent in the literature. METHODS: Five databases were queried for studies reporting fat necrosis following autologous fat grafting for breast reconstruction or augmentation from inception to August 11, 2022. Studies were temporally stratified according to released FDA guidelines: pre-2015, 2015-2017, and 2018-2022. RESULTS: Sixty-one articles met inclusion criteria. Prior to 2015, 6 of 21 studies (28.6%) offered clear definitions of fat necrosis. In contrast, the 2015-2017 period demonstrated an absence of clear fat necrosis definitions (0/13 studies, p = 0.03). Though the 2018-2022 period exhibited a rise in annual publications compared with the pre-2015 period (5.4 vs. 1.9, respectively, p = 0.04), this was not matched by a rise in clear fat necrosis reporting (14.8% studies, p = 0.45). Across all periods, only 16.4% of articles offered clear definitions, which exhibited wide heterogeneity. CONCLUSION: Despite the increasing popularity of autologous fat grafting, fat necrosis remains inconsistently defined and described, especially in the context of changing FDA guidelines. This limits the reliable interpretation and application of the current literature reporting fat necrosis outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care.

BACKGROUND: Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature. METHODS: A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics. RESULTS: Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency). CONCLUSIONS: Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.

Do Racial and Ethnic Disparities Exist in Management of Pediatric Mandible Fractures? A 30-Year Outcome Analysis.

BACKGROUND: Mandibular fractures are the most common of pediatric facial fractures. The effect of race on management/outcomes in these injuries has not been previously studied. Given the significant association between race and healthcare outcomes in many other pediatric conditions, an in-depth study of race as related to mandibular fractures in the pediatric patient population is warranted. METHODS: This was a 30-year retrospective, longitudinal study of pediatric patients who presented to a single institution with mandibular fractures. Patient data were compared between patients of different races and ethnicities. Demographic variables, injury characteristics, and treatment variables were analyzed to find predictors of surgical treatment and posttreatment complications. RESULTS: One hundred ninety-six patients met inclusion criteria, of whom 49.5% were White, 43.9% were Black, 0.0% were Asian, and 6.6% were classified as "other." Black and "other" patients were more likely than their White counterparts to be injured as pedestrians (P = 0.0005). Black patients were also more likely than White patients or "other" patients to be injured by assault than by sports-related injuries or animal-related accidents (P = 0.0004 and P = 0.0018, respectively). Race or ethnicity were not found to be a predictor of receiving surgical treatment (ORIF) or of posttreatment complications. The posttreatment rates for all the complications observed were comparable among all race and ethnic groups. Higher mandible injury severity score (odds ratio [OR], 1.25), condyle fracture (OR, 2.58), and symphysis fracture (OR, 3.20) were positively correlated with receiving ORIF as treatment. Mandible body fracture (OR, 0.36), parasymphyseal fracture (OR, 0.34), bilateral mandible fracture (OR, 0.48), and multiple mandibular fractures (OR, 0.34) were negatively correlated with receiving ORIF as treatment. Only high mandible injury severity score (OR, 1.10) was identified as an independent predictor of posttreatment complications. Lastly, Maryland's transition to an all-payer model in 2014 also had no impact on treatment modality; treatment of fractures among race and ethnicity were not significantly different pre- and post-2014. CONCLUSIONS: There is no difference in how patients are treated (surgically vs nonsurgically) and no difference in outcomes for patients based on race at our institution. This could be due to institutional ideology, services provided by a tertiary care center, or simply the more diverse patient population at baseline.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. DISCUSSION/CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model.

Central venous catheters (CVCs) are invaluable devices in large animal research as they facilitate a wide range of medical applications, including blood monitoring and reliable intravenous fluid and drug administration. Specifically, the tunneled multi-lumen Hickman catheter (HC) is commonly used in swine models due to its lower extrication and complication rates. Despite fewer complications relative to other CVCs, HC-related morbidity presents a significant challenge, as it can significantly delay or otherwise negatively impact ongoing studies. The proper insertion and maintenance of HCs is paramount in preventing these complications, but there is no consensus on best practices. The purpose of this protocol is to comprehensively describe an approach for the insertion and maintenance of a tunneled HC in swine that mitigates HC-related complications and morbidity. The use of these techniques in >100 swine has resulted in complication-free patent lines up to 8 months and no catheter-related mortality or infection of the ventral surgical site. This protocol offers a method to optimize the lifespan of the HC and guidance for approaching issues during use.

Optimizing Prepectoral Implant Placement and Concomitant Fat Grafting After Tissue Expansion.

BACKGROUND: Prepectoral implant-based breast reconstruction is often supplemented by autologous fat grafting to optimize aesthetic outcomes. This usually entails several rounds of modest fat transfer to minimize risk of necrosis; however, the limits of fat grafting at expander exchange are not known. METHODS: A single-institution retrospective review from July 2016 to February 2022 was performed of all patients who underwent (1) mastectomy, (2) prepectoral tissue expander placement, (3) expander exchange for implant, and (4) at least one round of autologous fat transfer. Student t test and χ 2 test were used. RESULTS: A total of 82 breasts underwent a single round of fat grafting during implant placement (group 1); 75 breasts underwent fat grafting that occurred in multiple rounds and/or in delay to implant placement (group 2). Group 1 received more fat at the time of implant placement (100 mL; interquartile range, 55-140 mL; P < 0.001) and underwent fewer planned operative procedures compared with group 2 (1.0 vs 2.2, P < 0.001). Total fat volume in group 2 did not significantly exceed that of group 1 until after 3 rounds of fat transfer (128.5 mL; interquartile range, 90-130 mL; P < 0.01). There was no difference in the rate of fat necrosis between groups after the first round (15.9% vs 9.3%, P = 0.2) and final round (15.9% vs 12.0%, P = 0.5) of fat grafting. Complication rates were similar between groups (3.7% vs 8.0%, P = 0.2). CONCLUSIONS: A 2-stage approach of prepectoral tissue expander placement with single round of larger volume fat transfer at expander exchange reduces overall number of operative procedures without increased risks.

Mentorship is Critical: An Analysis of the 2022 Plastic Surgery Match.

BACKGROUND: As the second cycle impacted by COVID-19, the 2022 Plastic and Reconstructive Surgery (PRS) Match maintained virtual interviews while offering a modest lift of subinternship restrictions. The residency application process continues to evolve, with changes such as pass/fail United States Medical Licensing Examination Step 1 reporting prompting programs to reconsider metrics of applicant success. It is critical to address the impact of board scores, mentorship, and resource availability on a diverse applicant population in the PRS Match. METHODS: A survey was electronically administered to students applying to a single institutional PRS residency program. The survey inquired about demographics, application statistics, mentorship experience, and match outcomes. Logistic regressions were modeled to assess for odds of matching into plastic surgery. RESULTS: In total, 151 responses were analyzed, a 49.7% response rate. Most participants were female (52.3%), White (68.9%), and not Hispanic/Latino (84.8%). The largest percentage of respondents had a faculty mentor only from their home institution (55.0%) and a resident mentor from only their home institution (32.3%). Participants with a faculty mentor from both a home and outside institution had 7.4 times the odds of matching into PRS ( P = 0.02) than students with no faculty mentorship. Students with dual-institution resident mentorship had 18.5 times higher the odds of matching compared with students with no resident mentorship ( P < 0.001). CONCLUSIONS: Subjective metrics, rather than objective scores, had the most influence on successfully matching into plastic surgery. As the PRS Match continues to become increasingly competitive, it behooves programs to provide equitable access to resources such as mentorship.

The Impact of Socioeconomic Factors on the 2022 Plastic Surgery Match.

BACKGROUND: In 2022, the plastic and reconstructive surgery (PRS) match faced unprecedented system-wide transitions that have redefined conventional measures of applicant success. This challenges the equitable assessment of student competitiveness and diversity in the field. METHODS: A survey of demography, application content, and 2022 match outcomes was distributed to applicants to a single PRS residency program. Comparative statistics and regression models were performed to assess the predictive value of factors in match success and quality. RESULTS: A total of 151 respondents (response rate 49.7%) were analyzed. Although step 1 and step 2 CK scores were significantly higher among matched applicants, neither examination predicted match success. Most respondents (52.3%) were women, although gender was also not significantly associated with match success. Underrepresented in medicine applicants made up 19.2% of responses and 16.7% of matches, and the plurality of respondents (22.5%) were raised with a household income ≥$300,000. Both Black race and household income ≤$100,000 were associated with lower odds of scoring above a 240 on either step 1 or step 2 CK (Black: OR, 0.03 and 0.06; P < 0.05 and P < 0.001; income: OR, 0.07-0.47 and 0.1 to 0.8, among income subgroups), receiving interview offers (OR, -9.4; P < 0.05; OR, -11.0 to -5.4), and matching into PRS (OR, 0.2; P < 0.05; OR, 0.2 to 0.5), compared with White and high-income applicants, respectively. CONCLUSIONS: Systemic inequities in the match process disadvantage underrepresented in medicine candidates and those from lower household incomes. As the residency match continues to evolve, programs must understand and mitigate the impacts of bias in various application components.

Lessons learned from the first 15 years of penile transplantation and updates to the Baltimore Criteria.

Since 2006, five penis transplants have been performed worldwide. Mixed outcomes have been reported, and two of the five penile transplants have required explantation. However, the long-term outcomes have been encouraging when compliance is implemented, whether standard induction and triple therapy maintenance, or single therapy maintenance. Follow-up monitoring of transplant recipients has enabled a synthesis of technical considerations for surgical success and has shown stable leukocyte counts and renal function after a donor bone-marrow-based immunomodulatory regimen followed by tacrolimus monotherapy as long as 3 years post-transplant, as well as continuous nerve regeneration of penile allografts 3 years post-transplant. Areas of uncertainty include the ethics of donor-recipient colour mismatch, surveillance for sexually transmitted infections and how to optimize patient compliance. Questions also remain with respect to the long-term immunological sequelae of penile tissue, functional outcomes, psychosocial implications and patient selection. Patient counselling should be modified to mention the possibility of long-term improvement in nerve regeneration and sufficient renal function with single-therapy maintenance, and to build a longitudinal dialogue and partnership between the patient and the multidisciplinary care team regarding the risks of sexually transmitted infection instead of surveillance.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

USMLE Step 1 Pass/Fail is Here: Are Plastic Surgery Applicants Really Better Off?

OBJECTIVE: As of January 26, 2022, the United States Medical Licensing Examination(USMLE) Step 1 score reporting will be changed from a numeric scoring system to pass/fail. Although the new scoring policy is expected to benefit medical students, there is concern that it will also amplify preexisting disadvantages and worsen disparities for students applying in the already-competitive plastic surgery match. Whether the reporting change will tangibly benefit applicants to plastic surgery has yet to be elucidated. DESIGN: A cross-sectional survey was distributed to medical students and graduates via social media platforms. Data were analyzed using Student t test and Chi-squared statistic, with an alpha level set at 0.05. SETTING: Data collection and analysis was performed at Johns Hopkins University School of Medicine. PARTICIPANTS: This study included a sample of 120 American Medical Trainees (AMTs) and International Medical Trainees (IMTs) who are interested in plastic surgery. RESULTS: The plurality of respondents were against the new Step 1 score reporting (AMT: 40.7%; IMT: 44.3%), but differences existed between AMTs when compared to IMTs, especially regarding opinions about the reporting change on stress levels and competitiveness of highly competitive specialties. Regardless of training status, respondents felt that the pass/fail scoring system would increase their likelihood to engage with more research, dual apply, prioritize studying for Step 2 CK, and consider a dedicated research year. CONCLUSIONS: While a pass/fail reporting system for Step 1 may alleviate some stress for medical trainees, other issues arise that may perpetuate disparities and bias against students with little resources in the field of plastic surgery. Residency programs should offer anticipatory guidance regarding prioritization of aspects of application to ease this psychosocial and financial pressure, as well as help students reorganize their constrained time.

Pediatric Orthognathic Surgery: A NSQIP-P Comparison of Peri-Operative Factors and Outcome Differences Between Cleft and Noncleft Patients.

OBJECTIVE: The present study aimed to investigate the risk factors, complication profiles, and clinical outcomes of cleft and noncleft patients undergoing single jaw (mandibular or LeFort 1) and bimaxillary (BSSO + LeFort 1). DESIGN: Retrospective Cross-sectional Study Setting: National Surgical Quality Improvement Program database 2018-2019. PATIENTS: Pediatric patients. INTERVENTIONS: Outcomes for mandibular, LeFort 1, and bimaxillary osteotomy were retrospectively evaluated for cleft and noncleft patients. MAIN OUTCOME MEASURES: Multivariate logistic regression was used to determine the odds of complications and length of stay for cleft and noncleft patients undergoing single jaw and double jaw surgery. RESULTS: 669 pediatric patient underwent orthognathic surgery in the study period; the majority received LF1 only (n = 385; 58.3%), followed by mandible only (n = 179; 27.1%), and bimaxillary (n = 105; 15.9%%). Cleft differences were present in 56% of LFI patients, 32% of mandibular patients, and 22% of bimaxillary patients. After multivariate adjustment, ASA class III was associated with nearly 400% increased odds of any complication including readmission and reoperation (OR = 5.99; CI [[1.54-23.32]], p < 0.01, and 65% increased LOS (ß-coefficient = 1.65, CI [1.37-1.99], p < 0.01). Presence of cleft was not significantly associated with odds of any complication (p = 0.69) nor increased LOS (p = 0.46) in this population. CONCLUSION: Complications remained low between surgery types among cleft and noncleft patients. The most significant risk factor in pediatric orthognathic surgery was not the presence of cleft but rather increased ASA class. Though common in patients seeking orthognathic surgery, cleft differences did not cause additional risk after adjustment for other variables.

A 10-Year Review of Surgical Outcomes at the Johns Hopkins and University of Maryland Resident Aesthetic Clinic.

Background: In 2014, the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) increased minimum aesthetic surgery requirements. Consequently, the resident aesthetic clinic (RAC) has become an ever more important modality for training plastic surgery residents. Objectives: To analyze demographics and long-term surgical outcomes of aesthetic procedures performed at the Johns Hopkins and University of Maryland (JH/UM) RAC. A secondary objective was to evaluate the JH/UM RAC outcomes against those of peer RACs as well as board-certified plastic surgeons. Methods: We performed a retrospective chart review of all patients who underwent aesthetic procedures at the JH/UM RAC between 2011 and 2020. Clinical characteristics, minor complication rates, major complication rates, and revision rates from the JH/UM RAC were compared against 2 peer RACs. We compared the incidence of major complications between the JH/UM RAC and a cohort of patients from the CosmetAssure (Birmingham, AL) database. Pearson's chi-square test was used to compare complication rates between patient populations, with a significance set at 0.05. Results: Four hundred ninety-five procedures were performed on 285 patients. The major complications rate was 1.0% (n = 5). Peer RACs had total major complication rates of 0.2% and 1.7% (P = .07 and P = .47, respectively). CosmetAssure patients matched to JH/UM RAC patients were found to have comparable total major complications rates of 1.8% vs 0.6% (P = .06), respectively. At JH/UM, the minor complication rate was 13.9%, while the revision rate was 5.9%. Conclusions: The JH/UM RAC provides residents the education and training necessary to produce surgical outcomes comparable to peer RACs as well as board-certified plastic surgeons.

Management of Minor Suture Craniosynostosis.

Although most reported cases of minor suture involvement include multiple sutures, isolated suture involvement has been reported. Morphologic differences such as scaphocephaly and anterior plagiocephaly have been reported. Management should involve proper identification and multidisciplinary treatment. Surgical treatment should involve the expansion of the cranial vault as well as the correction of the deformity.

Radiographic imaging modalities for perinatal brachial plexus palsy: a systematic review.

PURPOSE: Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. METHODS: A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. RESULTS: Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. CONCLUSION: This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.