The Caregiver Burden of Helmet Therapy following Endoscopic Strip Craniectomy: A Phenomenological Qualitative Study.

INTRODUCTION: This cohort study aimed to elucidate the caregiver burden of helmet therapy (HT), following endoscopic strip craniectomy (ESC) to treat craniosynostosis, in an effort to inform clinicians and future caregivers navigating this therapeutic option. METHODS: Fourteen caregivers of children with positional plagiocephaly (6) and craniosynostosis treated by ESC (8) undergoing HT at a single center were recruited via convenience sampling. Using a phenomenological qualitative approach, semi-structured interviews were conducted to understand the experience of HT for caregivers. Data collection and analysis were iterative and conducted until thematic saturation was reached. RESULTS: Emerging themes revealed five domains of caregiver burden: emotional, cognitive, physical, psychosocial, and financial. No caregiver felt the therapy was too burdensome to complete. Caregivers of both groups also expressed positive aspects of HT related to support from the team, the noninvasive nature of treatment, and the outcomes of therapy. Furthermore, caregivers report overall satisfaction with the process, stating willingness to repeat the treatment with subsequent children if required. CONCLUSION: HT is associated with five major domains of caregiver burden; however, none of the caregivers regret choosing this treatment option, nor was the burden high enough to encourage treatment cessation. This study will inform future prospective analyses that will quantify real-time caregiver burden throughout HT.

Supraorbital minicraniotomy for open Ommaya reservoir placement in pediatric craniopharyngiomas: a case series and technical report.

OBJECTIVE: Craniopharyngiomas with a predominant cystic component are often seen in children and can be treated with an Ommaya reservoir for aspiration and/or intracystic therapy. In some cases, cannulation of the cyst can be challenging via a stereotactic or transventricular endoscopic approach due to its size and proximity to critical structures. In such cases, a novel placement technique for Ommaya reservoirs via a lateral supraorbital incision and supraorbital minicraniotomy has been used. METHODS: The authors conducted a retrospective chart review of all children undergoing supraorbital Ommaya reservoir insertion from January 1, 2000, to December 31, 2022, at the Hospital for Sick Children, Toronto. The technique involves a lateral supraorbital incision and a 3 × 4-cm supraorbital craniotomy, with identification and fenestration of the cyst under the microscope and insertion of the catheter. The authors assessed baseline characteristics and clinical parameters of surgical treatment and outcome. Descriptive statistics were conducted. A review of the literature was performed to identify other studies describing a similar placement technique. RESULTS: A total of 5 patients with cystic craniopharyngioma were included (3 male, 60%) with a mean age of 10.20 ± 5.72 years. The mean preoperative cyst size was 11.6 ± 3.7 cm3, and none of the patients suffered from hydrocephalus. All patients suffered from temporary postoperative diabetes insipidus, but no new permanent endocrine deficits were caused by the surgery. Cosmetic results were satisfactory. CONCLUSIONS: This is the first report of lateral supraorbital minicraniotomy for Ommaya reservoir placement. This is an effective and safe approach in patients with cystic craniopharyngiomas, which cause local mass effect but are not amenable to traditional Ommaya reservoir placement stereotactically or endoscopically.

Venous Anastomoses in Anterolateral Thigh Flaps for the Lower Extremity: Vessel Selection In Lieu of Obligatory Number.

BACKGROUND: Dual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer. METHODS: All free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors. RESULTS: Fifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m 2 was a predictor for both flap complication ( P = 0.025) and partial flap loss ( P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis. CONCLUSIONS: The number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity.

Endoscopic strip craniectomy with orthotic helmeting for safe improvement of head growth in children with Apert syndrome.

OBJECTIVE: Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome. METHODS: The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups. RESULTS: The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up. CONCLUSIONS: Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

Meningothelial Hamartoma of the Scalp in a Child With Gorlin Syndrome.

ABSTRACT: Meningothelial hamartoma of the scalp is a rare entity characterized by a mix of meningothelial tissue and various connective tissue elements. To the best of the authors' knowledge, there has only been one reported case of meningothelial hamartoma of the scalp in the setting of Gorlin syndrome in the literature. In this report, we describe the case of a 3-year-old boy with Gorlin syndrome who presented with a congenital scalp lesion. Histologic examination revealed scattered islands of meningothelial cells in a background of dense fibrous and vascular tissue, in keeping with meningothelial hamartoma of the scalp. The differential diagnoses of congenital scalp lesions and the association between Gorlin syndrome and meningothelial hamartoma of the scalp are discussed.

Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports.

INTRODUCTION: Hypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications. METHODS: A literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars. RESULTS: We identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS. CONCLUSION: We found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases "complicated SIRS" and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation. APPLICABILITY OF RESEARCH TO PRACTICE: We urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.

The Impact of Social Media on Plastic Surgery Residency Applicants.

BACKGROUND: Plastic surgeons have been early adopters of social media, and the efficacy and ethics of this practice have been studied. In addition, plastic and reconstructive surgery (PRS) training programs have begun using social media to connect with the public, including prospective PRS applicants. The ability of social media to attract prospective residency applicants is unknown. This study aims to examine the influence of social media on prospective residency applicants and their perception of a plastic surgery program. METHODS: In the academic years 2018 and 2019, we conducted an anonymous, voluntary survey among applicants applying to both the integrated and independent Harvard PRS residency programs. The survey collected data regarding demographics, social media usage, online information gathering, and PRS programs' social media influence on applicants' perception/rank position of programs. RESULTS: One hundred nine surveys were completed (23%). Ninety-seven percent of respondents reported searching online for information about residency programs. Twenty percent of respondents noted that a residency program's social media platform "influenced their perception of a program or intended rank position of a program" and 72% of those respondents indicated a positive effect on their perception of a program and its rank list position. At least 15% of respondents were concerned that engaging with a program's social media account would attract attention to their own social media accounts. CONCLUSIONS: Applicants routinely rely on online resources to gather information regarding prospective residency programs. Fear of attracting attention to their own personal social media pages may limit applicants' engagement with PRS programs on social media. However, residency programs can still utilize social media to deliver important messages, especially as social media usage continues to grow.

Nasal Tip Delamination: A Technique for Nasal Tip Projection and Control in Rhinoplasty.

BACKGROUND: Control of tip projection and rotation is critical to a successful rhinoplasty. Suture techniques that change the relationship of the medial crura to the caudal septum can effectively manage tip position, but may be technically challenging or require specialized sutures. The authors present a technique ("tip delamination") that allows symmetrical exposure of the medial crura and caudal septum for accurate placement of projection control sutures using commonly available suture materials. METHODS: We describe a novel technique to completely expose (or delaminate) the medial crura of the lower lateral cartilages to allow for 360-degree access to and manipulation of these critical structures. We present a case series of 3 patients. RESULTS: Exemplary cases with 1 intraoperative video will be reviewed to demonstrate how tip delamination allows for more precise control of the medial crura and nasal tip. CONCLUSIONS: Nasal tip delamination is a simple technique for manipulating the medial crura and nasal tip in rhinoplasty procedures. Nasal tip delamination adds minimal time and morbidity to the procedure and offers significant control for the surgeon, with beneficial outcomes for the patient.

The Scale-Up of the Global Surgical Workforce: Can Estimates be Achieved by 2030?

BACKGROUND: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown. METHODS: A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts. RESULTS: To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico's previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India's previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030. CONCLUSION: With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.

Short Runs for a Long Slide: Principalization in Complex Facial Restoration after Acid Attack Burn Injury.

Burn injuries are responsible for a significant portion of surgically treatable morbidity throughout the world and particularly in underdeveloped and developing countries. Intentional flame, chemical, and contact burns are unfortunately a common mechanism of injury. It is estimated that intentional chemical burns are responsible for between 2 and 20% of burn injuries seen at burn centers in lower income countries. Women are commonly targeted and the perpetrators are often known to the victims. The combination of a high disease prevalence, limited surgical and anesthetic resources, a vulnerable patient population, and largely disfiguring, nonlethal injuries present unique challenges for the reconstructive surgeon who may not encounter such cases regularly. In this article, we present a case of a 16-year-old female who sustained severe, full-thickness burns to the face including eyelids, neck, abdomen, and upper extremities after an intentional acid attack. She began her treatment course with us approximately 1 year after the injury. The deformities of her oral and periorbital regions presented particularly difficult reconstructive problems, including impending visual loss. Using plastic surgical principalization, we provided our patient adequate restoration of facial form and function through numbers of interventions using fundamental and state-of-the-art techniques.

Volar Resurfacing of the Thumb with a Superficial Circumflex Iliac Artery Perforator Flap after Hydrofluoric Acid Burn.

A right-hand-dominant 55-year-old male automotive mechanic presented 24 hours following a hydrofluoric acid burn to the volar left thumb. Despite the severity of soft tissue injury, the neurovascular bundles were intact. Although a free toe-pulp flap is often described to cover volar digit defects, the resultant 6- × 4-cm full-thickness injury of the thumb was too large to be adequately covered by a toe-pulp flap or other commonly used local flaps from the ipsilateral hand. The authors used a superficial circumflex iliac artery perforator (SCIP) flap to reconstruct the volar surface of the thumb from the tip to the metacarpophalangeal joint. They used an arterial anastomosis with the princeps pollicis artery so that the anastomosis was well outside the zone of injury. The patient recovered from the procedure without event and was discharged home on postoperative day 5. At his 2-week postoperative visit, protective sensation with diminished light touch was intact. The authors conclude that the SCIP flap is a technically challenging but versatile, thin flap with minimal donor site morbidity that can be used to resurface the volar aspect of the thumb. The SCIP flap is a valuable resource for the hand surgeon confronted with larger soft tissue defects of the hand.

Global surgical, obstetric, and anesthetic task shifting: A systematic literature review.

BACKGROUND: Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature. METHODS: We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups. RESULTS: We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data. CONCLUSION: Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Surgical Non-governmental Organizations: Global Surgery's Unknown Nonprofit Sector.

BACKGROUND: Charitable organizations may play a significant role in the delivery of surgical care in low- and middle-income countries (LMICs). However, in order to quantify their collective contribution, to account for the care they provide in national surgical plans, and to maximize coordination between organizations, a comprehensive database of these groups is required. We aimed to create such a database using web-available data. METHODS: We searched for organizations that meet the United Nations Rule of Law definition of non-governmental organizations and provide surgery in LMICs. We termed these surgical non-governmental organizations (s-NGOs). We screened multiple sources including a listing of disaster relief organizations, medical volunteerism databases, charity commissions, and the results of a literature search. We performed a secondary review of each eligible organization's website to verify inclusion criteria and extracted data. RESULTS: We found 403 s-NGOs providing surgery in all 139 LMICs, with most (61 %) incorporating surgery into a broader spectrum of health services. Over 80 % of s-NGOs had an office in the USA, the UK, Canada, India, or Australia, and they most commonly provided surgery in India (87 s-NGOs), Haiti (71), Kenya (60), and Ethiopia (55). The most common specialties provided were general surgery (184), obstetrics and gynecology (140), and plastic surgery (116). CONCLUSIONS: This new catalog includes the largest number of s-NGOs to date, but this is likely to be incomplete. This list will be made publicly available to promote collaboration between s-NGOs, national health systems, and global health policymakers.

Global Surgery 2030: a roadmap for high income country actors.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries.

BACKGROUND: The Lancet Commission on Global Surgery calls for universal access to safe, affordable, and timely surgical care. Two requisite components of timely access are (1) the ability to reach a surgical provider in a given timeframe, and (2) the ability to receive appropriately prompt care from that provider. We chose a threshold of 2 h in view of its relevance in time-to-death in post-partum haemorrhage. Here, we use geospatial mapping to enumerate the percentage of a nation's population living within 2 h of a surgeon and the surgeon-to-population ratio for each provider. METHODS: Geospatial mapping was used to identify the population living within a 2-h driving distance (access zone) of a health-care facility staffed by a surgeon. Surgeon locations were extracted from Ministries of Health, professional society databases, and published literature for countries which had available data. Data were reviewed by individuals knowledgeable of in-country distribution. Spatial distribution of providers was mapped with Google Maps engine. Access zones were constructed around every provider through estimation of driving times in Google Maps. The number of people living within zones was estimated with the Socioeconomic Data and Applications Center Population Estimation Service. Surgeon-to-population ratios were constructed for every individual access zone and averaged to report a single ratio. FINDINGS: Results (% country's population living within an access zone; average surgeon:population ratio within all access zones) are reported for nine countries with available data: Somaliland (16·9%; 1:118 306), Botswana (31·0%; 1:64 635), Ethiopia (39·6%; 1:229 696), Rwanda (41·3%; 1:158 484), Namibia (43·4%; 1:69 385), Zimbabwe (54%; 1:148 292), Mongolia (55·5%; 1:10 500), Sierra Leone (70·3%; 1:106 742), and Pakistan (84·4%, 1:139 299). Surgeon-to-population ratios vary substantially even within countries; in Sierra Leone, urban access zones have a ratio of 1:45 058 and rural access zones have a ratio of 1:467 929. INTERPRETATION: Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness. Living outside of an access zone makes timely access to surgical care highly unlikely, and in view of low surgeon-to-population ratios and poor prehospital transport, even living within a 2-h access zone might not confer 2-h access. Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery. FUNDING: None.