Resident Exposure and Involvement in Core Procedural Competencies within Pediatric Plastic Surgery.

Introduction: The implementation of competency-based residency training in plastic surgery is underway. Key competencies in plastic surgery have been previously identified, however, within the domain of pediatrics, data suggest limited exposure throughout training for Canadian graduates. This study aims to identify the exposure and involvement of residents in core pediatric cases. Methods: We performed a retrospective, multicenter review of plastic surgery resident case logs (T-Res, POWER, New Innovations) across 10 Canadian, English-speaking training programs between 2004 and 2014. Case logs were coded according to the 8 core pediatric competencies previously identified by a modified Delphi technique. Results: A total of 3061 of 59 405 cases (5.2%) logged by 55 graduating residents were core pediatric procedures with an average of 55.6 ± 23.0 cases logged per resident. The top 3 most commonly logged procedures were cleft lip repair, cleft palate repair, and setback otoplasty. The number of cases per program varied widely with the most at 731 and least at 85 logged cases. Roles across procedures have wide variation and residents are most commonly identified as the assistant rather than surgeon or co-surgeon. Conclusion: These findings highlight variability both within and across residency programs with a paucity of exposure and involvement in pediatric plastic surgery cases. This may present a conflict between current recommendations for residency-specific procedural competencies and true clinical exposure. Further curriculum development and simulation may be of benefit.

Introduction: La formation des résidents fondée sur les compétences est en voie d'être adoptée en chirurgie plastique. Les compétences clés sont d'ailleurs déjà établies, mais dans le domaine de la pédiatrie, les données indiquent que les diplômés canadiens y sont peu exposés pendant leur formation. La présente étude vise à déterminer l'exposition et la participation des résidents aux cas fondamentaux en pédiatrie. Méthodologie: Les chercheurs ont procédé à une analyse multicentrique rétrospective des registres de cas des résidents en chirurgie plastique (T-Res, POWER, New Innovations) de dix programmes de formation anglophones canadiens entre 2004 et 2014. Ils ont codé ces registres en fonction des huit compétences pédiatriques fondamentales préalablement déterminées par une technique Delphi modifiée. Résultats: Au total, 3 061 des 59 405 cas enregistrés (5,2 %) par 55 résidents de dernière année étaient des interventions pédiatriques fondamentales, et chaque résident a enregistré une moyenne de 55,6 ± 23,0 cas. Les trois interventions les plus enregistrées étaient la réparation de la fissure labiale, la réparation de la fissure palatine et l'otoplastie. Le nombre de cas enregistrés variait énormément d'un programme à l'autre, le plus élevé étant de 731 et le plus bas, de 85. Les rôles au cours des interventions étaient très variables, et les résidents étaient davantage qualifiés d'assistants que de chirurgiens ou de cochirurgiens. Conclusion: Ces observations font ressortir la variabilité des pratiques à la fois au sein des programmes de résidence et entre eux et démontrent le peu d'exposition et de participation des résidents aux cas de chirurgie plastique pédiatrique. Elles peuvent révéler un conflit entre les recommandations actuelles en matière de compétences interventionnelles des résidents et la véritable exposition clinique. Il pourrait être utile de voir à l'élaboration plus poussée du programme et des simulations.

Approach to nail trauma for primary care physicians.

OBJECTIVE: To provide an overview and approach to common nail bed injuries seen by primary care practitioners. SOURCES OF INFORMATION: An Ovid MEDLINE literature search was performed using search terms and studies were graded based on level of evidence. MAIN MESSAGE: Nail trauma is common in primary care practice and requires proper and prompt treatment to avoid lasting effects on finger function and cosmesis. When presented with a fingernail injury, primary care physicians should perform a thorough physical examination to determine extent of injury; take a history to rule out notable risk factors; perform a comprehensive neurovascular examination to assess pulp capillary refill, to do a 2-point discrimination, and to compare with an uninjured digit; and evaluate range of motion. Clinical evaluation may require local anesthesia and a tourniquet. Nail bed trauma can present in different ways and includes subungual hematomas, distal phalanx fractures, Seymour fractures, and-in more severe cases-fragmentation or avulsion of the nail bed. Treatment for subungual hematomas where the nail plate is intact does not require nail plate removal and nail bed exploration; however, exploration and repair are indicated for a nail plate injury, a proximal fracture involving the germinal matrix, and a distal phalanx fracture requiring stabilization. CONCLUSION: Fingertips are essential to normal hand function. Nail trauma is common and can be managed by primary care physicians. Shared decision making concerning management is based on the mechanism and extent of the injury and aims to prevent secondary deformities.

Approche à l'égard des traumatismes unguéaux pour les médecins de soins primaires.

OBJECTIF: Présenter un aperçu et une approche concernant les lésions courantes au lit unguéal traitées par les professionnels des soins primaires. SOURCES DE L'INFORMATION: Une recherche documentaire a été effectuée dans Ovid MEDLINE, et les études ont été classées selon le niveau des données probantes. MESSAGE PRINCIPAL: Les traumatismes à l'ongle sont vus couramment dans la pratique des soins primaires; ils exigent un traitement sans retard pour éviter des effets persistants sur le fonctionnement et l'apparence du doigt. En présence d'une blessure à l'ongle d'un doigt, les médecins de soins primaires devraient effectuer un examen physique rigoureux pour déterminer l'étendue de la lésion; faire une anamnèse pour exclure des facteurs de risque manifestes; procéder à un examen neurovasculaire complet pour évaluer le temps de remplissage capillaire à la pulpe du doigt; faire une discrimination tactile en 2 points et comparer avec un doigt intact; et évaluer l'ampleur du mouvement. L'évaluation clinique peut nécessiter une anesthésie locale et un tourniquet. Les lésions au lit unguéal peuvent se présenter de diverses façons; ils comprennent des hématomes sous-unguéaux, des fractures à la phalange distale, des fractures de Seymour et, dans les cas plus graves, une fragmentation ou une avulsion du lit unguéal. Le traitement des hématomes unguéaux lorsque la lame ou tablette de l'ongle est intacte n'exige pas l'ablation de la lame ni l'exploration du lit unguéal; toutefois, une exploration et une réparation sont indiquées pour une lésion au lit unguéal, une fracture proximale impliquant la matrice germinale et une fracture à la phalange distale qui nécessite une stabilisation. CONCLUSION: Le bout des doigts est essentiel au fonctionnement normal de la main. Les traumatismes unguéaux sont fréquents et peuvent être pris en charge par les médecins de soins primaires. La prise de décision partagée concernant la prise en charge se fonde sur le mécanisme et l'ampleur de la blessure, et vise à prévenir des difformités secondaires.

A novel preclinical model of craniospinal irradiation in pediatric diffuse midline glioma demonstrates decreased metastatic disease.

Background: Diffuse midline glioma (DMG) is an aggressive pediatric central nervous system tumor with strong metastatic potential. As localized treatment of the primary tumor improves, metastatic disease is becoming a more important factor in treatment. We hypothesized that we could model craniospinal irradiation (CSI) through a DMG patient-derived xenograft (PDX) model and that CSI would limit metastatic tumor. Methods: We used a BT245 murine orthotopic DMG PDX model for this work. We developed a protocol and specialized platform to deliver craniospinal irradiation (CSI) (4 Gy x2 days) with a pontine boost (4 Gy x2 days) and compared metastatic disease by pathology, bioluminescence, and MRI to mice treated with focal radiation only (4 Gy x4 days) or no radiation. Results: Mice receiving CSI plus boost showed minimal spinal and brain leptomeningeal metastatic disease by bioluminescence, MRI, and pathology compared to mice receiving radiation to the pons only or no radiation. Conclusion: In a DMG PDX model, CSI+boost minimizes tumor dissemination compared to focal radiation. By expanding effective DMG treatment to the entire neuraxis, CSI has potential as a key component to combination, multimodality treatment for DMG designed to achieve long-term survival once novel therapies definitively demonstrate improved local control.

Something Stinks! Finding Ways to Manage Noxious Odours in the Operating Room and Other Clinical Settings A Randomized Controlled Trial.

Objectives: The hospital can be saturated with noxious smells. Anecdotally, medical staff apply products to surgical masks to lessen the impact of these smells. This study aimed to determine the odour-masking ability of 4 inexpensive and convenient products. Methods: A randomized, single-blinded crossover study was conducted in Vancouver, Canada. Participants, 19 to 30 years old, were invited to participate. Participants with active allergies, upper respiratory tract infection, alteration to sense of smell, or failure of olfactory screen were excluded from the study. An experimental odour was used in lieu of a noxious surgical odour. After smelling the experimental odour without barriers, participants were re-exposed to the odour using 5 surgical masks in randomized order. Each mask was lined with a test product (cherry lip balm, tincture of benzoin, Mastisol, mint toothpaste, and control [plain mask]). Participants rated the effectiveness of products at masking the experimental odour from 0 to 100 (0 = completely ineffective, 100 = completely effective). Participants also rated the pleasantness of the products, recorded if the products made them feel unwell, and identified their preferred product overall. Results: Eighty participants were included in the study (33 male, 47 female), averaging 24.2 years of age. Mean odour-masking effectiveness for cherry lip balm was 66.5 (±24.6), tincture of benzoin: 62.6 (±25.0), Mastisol: 61.3 (±23.9), mint toothpaste: 57.5 (±27.4), and control: 21.9 (±21.8). All products performed better than the control (P < .001), but there was no significant difference in performance between products. Cherry lip balm was the most preferred odour-masking product (29 participants), followed by mint toothpaste (22), Mastisol (14), tincture of benzoin (10), and control (5). Conclusions: All tested products demonstrated equivalent odour-masking abilities. If health care professionals choose to use an odour-masking product, they should consider their own olfactory preferences.

Objectifs: L'hôpital peut être saturé d'odeurs nauséabondes. On rapporte que le personnel médical applique des produits sur leurs masques chirurgicaux pour atténuer l'impact de ces odeurs. Cette étude visait à déterminer l'efficacité de quatre produits masqueurs d'odeurs, et ce de façon pratique et peu couteuse. Méthodes: Une étude croisée a simple insu et a répartition aléatoire a été menée à Vancouver, Canada. Des participants âgés de 19 à 30 ans, ont été invités à participer. Les participants souffrant d'allergies actives, d'une infection des voies respiratoires supérieures, d'une altération olfactive, ou aillant échoué la procédure de sélection ont été exclus de l'étude. Une odeur expérimentale a été utilisée au lieu d'une odeur nauséabonde chirurgicale. Après avoir senti l'odeur expérimentale, les participants ont été réexposés à la même odeur à cinq reprises. A chaque reprise, le participant était muni d'un de 5 masques tapissé d'un agent masquant d'odeur (baume à lèvres aux cerises, teinture de benzoïne, mastisol, dentifrice à la menthe, et contrôle [masque standard]). L'ordre des masques a été déterminé de façon aléatoire. Les participants ont noté sur une échelle de 0 à 100 l'efficacité des produits à masquer l'odeur (0: complètement inefficace, 100: complètement efficace). Les participants ont également évalué la qualité plaisante des agents, si ceux-ci les rendaient nauséeux, et ont ensuite identifié leur produit préféré parmi l'ensemble. Résultats: Quatre-vingts participants ont été inclus dans l'étude (33 hommes, 47 femmes), âgés en moyenne de 24,2 ans. L'efficacité des produits à masquer l'odeur expérimentale étaient d'une moyenne de 66,5 (+24,6) pour le baume à lèvres aux cerises ; 62,6 (+25,0) pour la teinture de benzoine ; 61,3 (+23,9) le mastisol ; 57,5 (+27,4) pour le dentifrice à la menthe, et 21,9 (+21,8) le contrôle. Tous les agents testés ont reçu une note supérieure au contrôle (P < .001). Par-contre, il n'y avait pas de différence significative entre les agents. Le baume à lèvres aux cerises était le produit préféré (29 participants), suivi du dentifrice à la menthe (22), du mastisol (14), de la teinture de benzoine (10), et finalement du contrôle (5). Conclusions: Tous les produits testés ont démontré une efficacité similaire, celle-ci supérieure comparée au contrôle. Si les professionnels de la santé souhaitent d'utiliser un produit qui masque les odeurs, ils devraient tenir compte de leurs propres préférences.

Novel RAF Fusions in Pediatric Low-Grade Gliomas Demonstrate MAPK Pathway Activation.

Brain tumors are the most common solid tumor in children, and low-grade gliomas (LGGs) are the most common childhood brain tumor. Here, we report on 3 patients with LGG harboring previously unreported or rarely reported RAF fusions: FYCO1-RAF1, CTTNBP2-BRAF, and SLC44A1-BRAF. We hypothesized that these tumors would show molecular similarity to the canonical KIAA1549-BRAF fusion that is the most widely seen alteration in pilocytic astrocytoma (PA), the most common pediatric LGG variant, and that this similarity would include mitogen-activated protein kinase (MAPK) pathway activation. To test our hypothesis, we utilized immunofluorescent imaging and RNA-sequencing in normal brain, KIAA1549-BRAF-harboring tumors, and our 3 tumors with novel fusions. We performed immunofluorescent staining of ERK and phosphorylated ERK (p-ERK), identifying increased p-ERK expression in KIAA1549-BRAF fused PA and the novel fusion samples, indicative of MAPK pathway activation. Geneset enrichment analysis further confirmed upregulated downstream MAPK activation. These results suggest that MAPK activation is the oncogenic mechanism in noncanonical RAF fusion-driven LGG. Similarity in the oncogenic mechanism suggests that LGGs with noncanonical RAF fusions are likely to respond to MEK inhibitors.

Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training.

North American residency programs are transitioning to competency-based medical education (CBME) to standardize training programs, and to ensure competency of residents upon graduation. At the centre of assessment in CBME are specific surgical procedures, or procedural competencies, that trainees must be able to perform. A study previously defined 31 procedural competencies for aesthetic surgery. In this transition period, understanding current educational trends in resident exposure to these aesthetic procedures is necessary. The aim of this study was to characterize aesthetic procedures performed by Canadian plastic surgery residents during training, as well as to describe resident performance confidence levels and degree of resident involvement during those procedures. Case logs were retrieved from all 10 English-language plastic surgery programs. All aesthetic procedures were identified, and coded according to previously defined core procedural competencies (CPCs) in the aesthetic domain of plastic surgery. Data extracted from each log included the procedure, training program, resident academic year, resident procedural role, and personal competence. From July 2004 to June 2014, 6113 aesthetic procedures were logged by 55 graduating residents. Breast augmentation, mastopexy, and abdominoplasty were the most commonly performed CPCs, and residents report high levels of competence and surgical role in these procedures. Facial procedures, in particular rhinoplasty, as well as nonsurgical CPCs are associated with low exposure and personal competence levels. Canadian plastic surgery residents are exposed to most of the core aesthetic procedural competencies, but the range of procedures performed is variable. With the implementation of CBME, consideration should be given to supplementation where gaps may exist in aesthetic case exposure.

Resident Behaviours to Prioritize According to Canadian Plastic Surgeons.

INTRODUCTION: Many articles have been published outlining the resident selection process for plastic surgery training programs. However, which qualities Canadian plastic surgeons value most in their current residents remains unclear. A national survey study was conducted to identify which attributes surgeons associate with the highest resident performance and which behaviours trainees should prioritize during their training. METHODS: A literature review was performed to identify studies that documented attributes valued in plastic surgery applicants and characteristics of high-performing surgical residents. These qualities were extracted to construct a survey consisting of both ranking and open-ended questions. After an iterative review process, the survey was disseminated nationally to consultants and trainees of Canadian plastic surgery training programs. RESULTS: Survey responses were obtained from 120 invitees and a weighted rank was calculated for each evaluated attribute. The terms integrity, professional, and work ethic were viewed as the most important attributes prized by surgeons. Dishonesty, lack of dependability, and unprofessionalism were viewed as the most concerning behaviours. Additionally, disinterest and arrogance were identified by the open-ended questions as behaviours surgeons would like to see less frequently in their trainees. When compared to surgeons, trainees undervalued the importance of knowledge and the impact of unprofessional behaviour. CONCLUSIONS: With the multiple roles that a resident must fulfill, understanding which attributes are of the most importance will help focus self-directed learning and development within residency programs. Ultimately, instilling the importance of integrity and professionalism is most highly valued by members of the Canadian plastic surgery community.

Preclinical and clinical investigation of intratumoral chemotherapy pharmacokinetics in DIPG using gemcitabine.

BACKGROUND: Hundreds of systemic chemotherapy trials in diffuse intrinsic pontine glioma (DIPG) have not improved survival, potentially due to lack of intratumoral penetration, which has not previously been assessed in humans. METHODS: We used gemcitabine as a model agent to assess DIPG intratumoral pharmacokinetics (PK) using mass spectrometry. RESULTS: In a phase 0 clinical trial of i.v. gemcitabine prior to biopsy in children newly diagnosed with DIPG by MRI, mean concentration in 4 biopsy cores in patient 1 (H3K27M diffuse midline glioma) was 7.65 µM. These compare favorably to levels for patient 2 (mean 3.85 µM, found to have an H3K27-wildtype low-grade glioma on histology), and from a similar study in adult glioblastoma (adjusted mean 3.48 µM). In orthotopic patient-derived xenograft (PDX) models of DIPG and H3K27M-wildtype pediatric glioblastoma, gemcitabine levels and clearance were similar in tumor, pons, and cortex and did not depend on H3K27 mutation status or tumor location. Normalized gemcitabine levels were similar in patient 1 and the DIPG PDX. CONCLUSIONS: These findings, while limited to one agent, provide preliminary evidence for the hypotheses that lack of intratumoral penetration is not why systemic chemotherapy has failed in DIPG, and orthotopic PDX models can adequately model intratumoral PK in human DIPG.

Canadian Plastic Surgery Resident Operative Experience in Hand Surgery.

PURPOSE: Core procedural competencies (CPCs) in hand surgery have been previously described. However, it is unknown whether plastic surgery residents receive sufficient operative experience with these procedures. This study aimed to determine whether Canadian plastic surgery residents are receiving adequate exposure to CPCs in hand surgery during residency training. METHODS: Hand surgery case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014 were reviewed from 3 databases. For each CPC in hand surgery, perceived resident role and self-competence scores were collected and analyzed. Core procedural competencies encompass core essential procedural competencies (CEPCs) and nonessential procedural competencies. RESULTS: There were 55 graduating plastic surgery residents included in the study. A total of 14,909 procedures were logged for 42 CPCs, with an average of 271 procedures/resident. When grouped by subdomain within hand surgery, procedures with the most exposure were related to traumatic finger injuries (29%) and neuropathies (22%). The least common procedures were related to flap reconstructions (0.3%) and muscle release (0.1%). Many residents reported receiving no operative experience (range, 2% to 100%) or between 1 and 10 cases of CEPCs (range, 7% to 50%). Most graduating residents (58% to 72%) did not feel competent independently performing 60% of the most common procedures. There were weak to moderate correlations between role and self-competence, and between postgraduate year and self-competence. CONCLUSIONS: Currently, many plastic surgery residents graduate from training programs with little to no exposure for over half of the CEPCs in hand surgery. CLINICAL RELEVANCE: Given the great diversity in hand surgery CPCs, it is difficult for residents to gain adequate operative experience during their residency in all of the CPCs.

Variable Experience in Microsurgery and Flap-Based Procedures Among Canadian Plastic Surgery Residents.

TITLE: Variable experience in microsurgery and flap-based procedures among Canadian plastic surgery residents. OBJECTIVE: Plastic surgery residencies are transitioning toward a competency-based education model. It is not known whether trainees can realistically achieve proficiency in microsurgical techniques during their training. This study aims to define the operative experience in the core microsurgical flap procedures among Canadian plastic surgery residents. DESIGN: Microsurgical core procedural competencies (CPCs) have been described. A retrospective review was conducted, evaluating case logs recorded by graduating plastic surgery residents at 10 Canadian English-speaking training programs between 2004 and 2014. Perceived role and competence scores were also collected and analyzed. SETTING: University of Toronto, Toronto, ON, Canada; University of British Columbia, Vancouver, BC, Canada. RESULTS: Among 27 microsurgical CPCs, 2082 procedures were logged and each resident performed an average of 37.9 (±21.7) procedures. Anterolateral thigh flaps, radial forearm-based flaps, and digit replants were the most common; however, 10.9% to 14.5% of residents did not have any operative experience with these flaps. Most residents reported zero operative experience with many of the CPCs (10.9%-100%). Co-Surgeon (50%) and First Assistant (30%) were the most common roles. None of the graduating residents reported feeling competent enough to independently perform 50% of the microsurgery CPCs. There was no difference in perceived roles when programs with ≥5 residents were compared against programs with fewer trainees. There were weak to moderate correlations between role and self-perceived competence, and between Post Graduate Year and self-perceived competence. CONCLUSIONS: There is wide variation in resident operative experience in microsurgical CPCs. Many residents graduate with little to no experience in many of the core procedures. Identifying areas of deficiency may help guide curriculum development in the new competency-based education model.

Correction: BPTF regulates growth of adult and pediatric high-grade glioma through the MYC pathway.

The original version of this Article omitted the following from the Acknowledgements: This work was supported by the Luke's Army Pediatric Cancer Research Fund St. Baldrick's Scholar Award. This has now been corrected in both the PDF and HTML versions of the Article.

BPTF regulates growth of adult and pediatric high-grade glioma through the MYC pathway.

High-grade gliomas (HGG) afflict both children and adults and respond poorly to current therapies. Epigenetic regulators have a role in gliomagenesis, but a broad, functional investigation of the impact and role of specific epigenetic targets has not been undertaken. Using a two-step, in vitro/in vivo epigenomic shRNA inhibition screen, we determine the chromatin remodeler BPTF to be a key regulator of adult HGG growth. We then demonstrate that BPTF knockdown decreases HGG growth in multiple pediatric HGG models as well. BPTF appears to regulate tumor growth through cell self-renewal maintenance, and BPTF knockdown leads these glial tumors toward more neuronal characteristics. BPTF's impact on growth is mediated through positive effects on expression of MYC and MYC pathway targets. HDAC inhibitors synergize with BPTF knockdown against HGG growth. BPTF inhibition is a promising strategy to combat HGG through epigenetic regulation of the MYC oncogenic pathway.

Burn Care and Surgical Exposure amongst Canadian Plastic Surgery Residents: Recommendations for Transitioning to a Competency-Based Medical Education Model.

With the ongoing implementation of a competency-based medical education (CMBE) model for residency programs in North America, emphasis on the duration of training has been refocused onto ability and competence. This study aims to determine the exposure of burn-related core procedural competencies (CPCs) in Canadian Plastic Surgery Residents in order to enhance curricular development and help define its goals. A retrospective review of burn-related resident case logs encompassing all 10 English-speaking plastic surgery residency programs from 2004 to 2014 was performed, including analysis of personal competence scores and resident role by Postgraduate Year (PGY)-year. Case logs of a total of 55 graduating plastic surgery residents were included in the study. Overall, 4033 procedures in burn and burn-related care were logged, accounting for 6.8% of all procedures logged. On average, each resident logged 73 burn procedures, 99% of which were CPCs. The most frequently performed procedure was harvest and application of autograft, allograft, or xenograft, while emergent procedures such as escharotomy and compartment release were performed on average less than one time per resident. Personal competence scores as well as role of the resident (surgical responsibility) increased as PGY-year progressed during residency. Canadian plastic surgery residency programs provide adequate exposure to the majority of the scope of burn care and surgery. However, infrequently encountered but critical procedures such as escharotomy and fasciotomy may require supplementation through dedicated educational opportunities. CMBE should identify these gaps in learning through facilitation of resident competency evaluation. With consideration for the amount of exposure to burn-related CPCs as identified, plastic surgery residency programs can work toward achieving competency in all aspects of burn care and surgery prior to the completion of residency.

Tissue Expansion for Severe Foot and Ankle Deformities: A 16-Year Review.

BACKGROUND: Tissue expansion in the lower extremity is controversial, with studies reporting complication rates as high as 83%. Few studies have looked at tissue expansion prior to orthopaedic correction of severe foot and ankle deformities, and those available are restricted to clubfoot in the pediatric population. Here, we report the largest case series on the use of tissue expanders for the reconstruction of severe foot and ankle deformity and the only report in adults. METHODS: This is a retrospective chart review of the senior author's practice over a 16-year study period. All patients over 18 years of age who underwent tissue expansion prior to definitive orthopaedic correction of a severe foot and ankle deformity were included. Patient demographics, etiology of deformity, rate of expansion, and complications were recorded. Major complications were defined as those which required surgical intervention. Data were analyzed using descriptive statistics. RESULTS: Nineteen cases were performed on 16 patients. Our overall complication rate was 31.6% (6/19), with major complications occurring in 21.1% (4/19) of cases, and minor complications occurring in 10.5% (2/19) of cases. Despite this, 94.7% (18/19) of cases went on to receive definitive orthopaedic correction after tissue expansion. No demographic parameters were associated with occurrence of complications. CONCLUSIONS: This represents the largest report on lower extremity tissue expansion for severe foot and ankle deformity correction. While we observed complications in 31.6% of patients, 94.7% of cases went on to receive definitive orthopaedic correction with successful primary closure.

HISTORIQUE: L'expansion tissulaire des membres inférieurs est controversée, car des études font état d'un taux de complications atteignant les 83 %. Peu d'études ont porté sur l'expansion tissulaire avant la correction orthopédique de graves déformations du pied et de la cheville, et celles qui existent se limitent au pied bot dans la population pédiatrique. Les auteurs rendent compte de la plus grande série de cas sur l'utilisation d'expandeurs tissulaires en vue de la reconstruction de graves déformations du pied et de la cheville, la seule à être menée chez des adultes. MÉTHODOLOGIE: La présente étude rétrospective traite des dossiers de l'auteur principal sur une période de 16 ans. Tous les patients de plus de 18 ans qui ont subi une expansion tissulaire avant la correction orthopédique définitive d'une grave déformation du pied et de la cheville en ont fait partie. Les chercheurs ont consigné la démographie des patients, l'étiologie des déformations, le taux d'expansion et les complications. Ils ont défini les complications majeures comme celles qui exigent une intervention chirurgicale. Ils ont analysé les données à l'aide de statistiques descriptives. RÉSULTATS: Les chercheurs ont relevé 19 cas chez 16 patients. Le taux de complications global s'élevait à 31,6 % (six cas sur 19). Des complications majeures se sont produites dans 21,1 % des cas (quatre sur 19) et des complications, mineures, dans 10,5 % des cas (deux sur 19). Malgré tout, 94,7 % des cas (18 sur 19) ont subi une correction orthopédique définitive après l'expansion tissulaire. Aucun paramètre démographique ne laissait présager les complications. CONCLUSIONS: La présente étude est le rapport le plus vaste des expansions tissulaires pour corriger de graves déformations du pied et de la cheville. Les auteurs ont observé des complications chez 31,6 % des patients, mais 94,7 % des cas ont profité d'une correction orthopédique définitive et d'une fermeture primaire réussie.

Toward the Assessment of Core Procedural Competencies among Canadian Plastic Surgery Residents.

BACKGROUND: Plastic surgery residency training programs are working toward integrating competency-based education into program curriculum and training, a key component of which involves establishing core procedural competencies. This study aims to determine the exposure of graduating Canadian plastic surgery residents to established core procedural competencies. METHODS: A retrospective review of case log procedure data using three databases (T-Res, POWER, and New Innovations) from graduating residents at all 10 Canadian English-speaking plastic surgery training programs between 2004 and 2014 was completed. Case logs were coded according to 177 core procedural competencies identified as "core" by the Delphi method among an expert panel of Canadian plastic surgeons. RESULTS: A total of 59,405 procedures were logged by 55 graduating residents across Canada between 2004 and 2014 (average, 1080 ± 352 procedures per resident). Of 13 plastic surgery domains, 44 percent of all procedures were within either hand, upper extremity, and peripheral nerve (28.3 percent) or nonaesthetic breast (16.1 percent). The most frequently performed core procedural competencies (average case logs per resident) included breast reduction (65.3 ± 33.9); open carpal tunnel release (46.7 ± 34.2); breast reconstruction, implant-based (39.6 ± 20.5); and wound management (35.7 ± 28.6). Sixty-two of 177 procedures were logged on average less than once in 5 years of residency, including escharotomy, temporal parietal fascia flap, Guyon canal release, and soft-tissue fillers. CONCLUSION: This study identifies areas of exposure and underexposure to plastic surgery core procedural competencies, and can help focus surgical education on areas of greater need for surgical skills training and acquisition.

Consensus of Leaders in Plastic Surgery: Identifying Procedural Competencies for Canadian Plastic Surgery Residency Training Using a Modified Delphi Technique.

BACKGROUND: Transitioning to competency-based surgical training will require consensus regarding the scope of plastic surgery and expectations of operative ability for graduating residents. Identifying surgical procedures experts deemed most important in preparing graduates for independent practice (i.e., "core" procedures), and those that are less important or deemed more appropriate for fellowship training (i.e., "noncore" procedures), will focus instructional and assessment efforts. METHODS: Canadian plastic surgery program directors, the Canadian Society of Plastic Surgeons Executive Committee, and peer-nominated experts participated in an online, multiround, modified Delphi consensus exercise. Over three rounds, panelists were asked to sort 288 procedural competencies into five predetermined categories within core and noncore procedures, reflecting increasing expectations of ability. Eighty percent agreement was chosen to indicate consensus. RESULTS: Two hundred eighty-eight procedures spanning 13 domains were identified. Invitations were sent to 49 experts; 37 responded (75.5 percent), and 31 participated (83.8 percent of respondents). Procedures reaching 80 percent consensus increased from 101 (35 percent) during round 1, to 159 (55 percent) in round 2, and to 199 (69 percent) in round 3. The domain "burns" had the highest rate of agreement, whereas "lower extremity" had the lowest agreement. Final consensus categories included 154 core, essential; 23 core, nonessential; three noncore, experience; and 19 noncore, fellowship. CONCLUSIONS: This study provides clarity regarding which procedures plastic surgery experts deem most important for preparing graduates for independent practice. The list represents a snapshot of expert opinion regarding the current training environment. As our specialty grows and changes, this information will need to be periodically revisited.

Perioperative and Long-Term Smoking Behaviors in Cosmetic Surgery Patients.

BACKGROUND: Many plastic surgeons advocate smoking cessation before patients undergo cosmetic surgery with extensive soft-tissue dissection. Smoking cessation rates after cosmetic surgery are unknown. The preoperative consultation may be an opportunity to promote long-term smoking cessation. METHODS: This is a retrospective, cross-sectional cohort study. All patients over an 8-year study period who smoked before their preoperative consultation; who quit 2 weeks before surgery; and who subsequently underwent rhytidectomy, abdominoplasty, or mastopexy were included. Patients were asked to complete a Web-based survey at long-term follow-up. RESULTS: Eighty-five smokers were included, and 47 patients completed the survey, for a response rate of 55.3 percent. Average follow-up was 63.3 months. Five respondents were social smokers and thus excluded. Of the 42 daily smokers, 17 patients (40.5 percent) were no longer smoking cigarettes on a daily basis at long-term follow-up. Of these 17 patients, 10 (23.8 percent) had not smoked since their operation. A total of 24 patients (57.1 percent) had reduced their cigarette consumption by any amount, and 70.8 percent (17 of 24) of these patients agreed that discussing adverse surgical outcomes related to smoking influenced their ability to quit/reduce. Twenty-one of 42 patients (50.0 percent) admitted that they were not compliant with the preoperative smoking cessation instructions. CONCLUSIONS: This is the first report to investigate long-term smoking cessation from a cosmetic surgery practice. The authors have shown a positive association between smoking cessation and cosmetic surgery. Requesting a period of cessation before cosmetic surgery may promote long-lasting smoking cessation.

A Review of 101 Consecutive Subcutaneous Mastectomies and Male Chest Contouring Using the Concentric Circular and Free Nipple Graft Techniques in Female-to-Male Transgender Patients.

BACKGROUND: Many techniques exist for subcutaneous mastectomy in female-to-male transgender patients. The authors review outcomes for two techniques and present an algorithm to aid surgeons in technique selection. METHODS: One hundred one consecutive female-to-male transgender patients undergoing subcutaneous mastectomy using the concentric circular or free nipple graft technique were retrospectively reviewed. An algorithm for procedure selection was created using classification and regression tree analysis. Aesthetic results (nipple-areola complex, scar, and chest contour) were also independently reviewed. RESULTS: Two hundred two subcutaneous mastectomies were performed (concentric circular, 92 breasts; free nipple graft, 110 breasts). The overall complication rate was 21.3 percent, with 6.4 percent requiring operative intervention (free nipple graft, 1 percent; concentric circular, 13 percent; p < 0.001). The overall revision rate was 23.8 percent (free nipple graft, 12.7 percent; concentric circular, 37.0 percent; p < 0.001). In the concentric circular group, there were 3.3 times the odds of total complications (p = 0.03) and 4.0 times the odds of revision surgery (p < 0.001). Mean aesthetic scores for the concentric circular technique were superior to free nipple graft for scar (3.39 versus 2.62; p < 0.001) and contour (3.82 versus 3.34; p < 0.001). CONCLUSIONS: In patients who meet selection criteria, the concentric circular technique is preferred because of fewer scars, improved aesthetic contour, and potential for retained nipple sensation. These patients must be counseled regarding the higher rate of complications and revisions. It was determined that smokers and those with a nipple-to-inframammary fold distance greater than 7 cm or nipple-to-inframammary fold distance less than 7 cm and a body mass index greater than 27 kg/m should undergo the free nipple graft technique because of the increased risk of complications with the concentric circular technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

How Well Are We Doing at Teaching Critical Appraisal Skills to Our Residents? A Needs Assessment of Plastic Surgery Journal Club.

OBJECTIVE: To perform a needs assessment of journal club in plastic surgery residency programs. Specifically, this study focused on potential gaps in journal club associated with teaching and assessing critical appraisal of the literature, an important component of medical education and practice. METHODS: This is a qualitative study that utilized an online survey tool to collect information about the characteristics of journal club in plastic surgery residency programs in both Canada and the United States. Both program directors and residents were surveyed. RESULTS: When presented with a range of objectives, both program director and resident responses identified that teaching critical appraisal skills was often the main goal of journal club in their program (67.1%). Most trainees perceived that journal club was at least somewhat effective in improving their critical appraisal skills. Despite this perception, many residents felt that they had minimal to no experience in critical appraisal of the literature upon entry into their respective residency programs (46.2%), and only 29.2% indicated that they received formal instruction regarding critical appraisal. Three-quarters of residents indicated that there was no tool provided to aid them in their analysis of the literature. Finally, most residents also responded that they were not assessed objectively with regard to their performance. CONCLUSIONS: Although residents in our study perceive journal club to at least somewhat improve their critical appraisal skills, evidence in the literature has been controversial. It cannot be assumed that residents are learning the skills they need by simply attending and reading the articles associated with journal club. Future study should focus on the best way to meet these objectives.

OBJECTIF: Effectuer une évaluation des besoins des clubs de lecture dans les programmes de résidence en chirurgie plastique. La présente étude portait plus précisément sur les lacunes potentielles des clubs de lecture pour l'enseignement et l'évaluation critique des publications, un élément important de l'enseignement et de la pratique de la médecine. MÉTHODOLOGIE: La présente étude qualitative a fait appel à un sondage en ligne pour colliger de l'information sur les caractéristiques des clubs de lecture dans les programmes de résidence en chirurgie plastique, à la fois au Canada et aux États-Unis. Tant les directeurs de programme que les étudiants ont été sondés. RÉSULTATS: Lorsqu'on leur présentait une série d'objectifs, les directeurs de programme et les résidents répondaient que, souvent, les clubs de lecture étaient d'abord destinés à enseigner des compétences en évaluation critique (67,1 %). La plupart des étudiants trouvaient que les clubs de lecture étaient au moins quelque peu efficaces pour améliorer leurs compétences en évaluation critique. Malgré cette perception, de nombreux résidents trouvaient qu'ils avaient une expérience minimale, sinon inexistante, de l'évaluation critique des publications à leur arrivée en résidence (46,2 %), et seulement 29,2 % indiquaient avoir reçu une formation formelle en évaluation critique. Les trois quarts des résidents précisaient qu'aucun outil ne leur était fourni pour les aider à analyser les publications. Enfin, la plupart ajoutaient que leur performance n'avait pas fait l'objet d'une évaluation objective. CONCLUSIONS: Même si les résidents à l'étude trouvaient que les clubs de lecture amélioraient au moins quelque peu leurs compétences en évaluation clinique, les preuves tirées des publications sont controversées. Il est impossible de présumer que les résidents acquièrent les compétences dont ils ont besoin simplement en assistant aux clubs de lecture et en lisant les articles exigés. De prochaines études devront porter sur le meilleur moyen de respecter ces objectifs.