Update on Cold-Induced Injuries.

Cold-induced injuries are a major challenge for burn surgeons, leading to significant sequelae for the patients including amputations, long-term disability, and death. Rapid assessment and diagnosis are essential for optimal outcomes. Various therapies have emerged to improve outcomes. Topical, oral, and intravenous agents have shown to minimize the impact of cold-induced injuries. Thrombolytics have shown the greatest promise in improving tissue perfusion outcomes in cold-induced injuries. This article provides an update on the evidence-based assessment and management of cold-induced injuries, as well as reviews outcomes and future directions of this challenging pathology.

Evolution of the Coleman Technique.

SUMMARY: Fat grafting is one of the most revolutionary surgical techniques of our century, and it has changed the field of plastic surgery and regenerative medicine. Early reports of fat grafting date back to the late nineteenth century, but the results were unsatisfactory because of minimal graft retention. It was not until Sydney R. Coleman challenged the dogma and introduced a standardized approach to fat grafting after years of research and learning from experts across the world. The Coleman technique represents an evolutionary approach to fat grafting, with three main components: harvesting, refinement, and placement. The Coleman technique has been adopted and modified by surgeons around the world because it has allowed a reliable increase in fat graft survival through a standardized process. This article discusses the influencing factors and milestones that led to this world-known technique, in addition to Dr. Coleman's current practices, pearls, pitfalls, and lessons learned over the years. The knowledge of the true potential and usefulness of fat is in its infancy, with its regenerative potential becoming increasingly recognized. Current and future research will likely prove that autologous fat has many clinical applications beyond its well-known aesthetic and reconstructive benefits and extending beyond the regenerative realm.

Pediatric Plastic Surgery Operating Room Block-Time Utilization: A Casualty of Illness.

BACKGROUND: Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department. METHODS: The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated. RESULTS: Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as ''other,'' including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively). CONCLUSIONS: Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.

Outcomes of Furlow Double-Opposing Z-Plasty Palatoplasty for the Treatment of Symptomatic Overt and Occult Submucous Cleft Palate: A Comparison Study.

BACKGROUND: The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure. METHODS: This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score. RESULTS: A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score <7 without recommendation for secondary speech surgery) in 291 patients (82.1 percent). Apart from those requiring secondary surgery, there were no documented complications. Occult-type patients were 7.5 years old at palatoplasty with a speech score of 14.1; overt-type patients were 6.5 years old with a score of 15.7. Postoperative speech scores were similar for both groups. Secondary speech surgery patients had a higher preoperative score (16.9 versus 14.2). Age at time of palatoplasty and submucous cleft palate type were not predictive of the need for secondary surgery. Syndromic patients had higher preoperative and postoperative speech scores (15.6 and 7.5, respectively) than nonsyndromic patients (14.3 and 4.3) and needed secondary surgery more often (24.4 percent versus 9.2 percent). V-shaped velar vaulting on preoperative assessment was present in 92 percent of occult-type patients. CONCLUSIONS: Furlow palatoplasty is a safe and effective means of repairing submucous cleft palate. Patients with the occult type presented later with a lower Pittsburgh Weighted Speech Score. High preoperative speech score and syndromic status were associated with the need for secondary speech surgery. V-shaped velar vaulting is a reliable sign of occult submucous cleft palate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Characteristics and Academic Productivity Among Pediatric Plastic Surgeons in the United States.

BACKGROUND: The characteristics that predispose plastic surgeons to a career in pediatric plastic surgery remain unclear. Therefore, the aim of this study is to analyze the characteristics of current pediatric plastic surgeons and to determine their academic productivity. METHODS: Pediatric plastic surgeons were identified through an internet search of all academic children's hospitals affiliated with an Accreditation Council for Graduate Medical Education-accredited integrated or independent plastic surgery program. Demographics, training background, institutional and leadership positions, and academic productivity were determined. RESULTS: A total of 304 pediatric plastic surgeons were identified. The majority of pediatric plastic surgeons were white (n = 217, 71.8%) males (n = 235, 77.6%). Clinical fellowships were completed by 86.8% (n = 263) of the cohort, with craniofacial (n = 181, 59.7%) being the most common followed by hand (n = 54, 17.8%); 41.1% had clinical fellowship training at 10 institutions, with the top 3 most represented programs being University of Pennsylvania (n = 19, 6.2%), University of California-Los Angeles (n = 16, 5.3%), and Harvard University (n = 15, 4.9%); 25.7% (n = 78) held leadership positions within their institutions. A significant higher academic productivity was found among research fellowship-trained surgeons, chiefs of pediatric plastic surgery, fellowship directors, and members of departments of plastic surgery. Those who completed an independent residency had a significant higher H-index and number of citations. CONCLUSION: Pediatric plastic surgery is represented by surgeons of diverse training background. An elite cohort of programs has trained the most pediatric plastic surgeons. Lastly, high academic productivity was found to be correlated with certain demographic and leadership variables highlighting its impact on career advancement.

A Systematic Review on Airbag-Induced Burns.

Airbags significantly reduce fatalities and injuries in automobile crashes, but they have been found to be associated with burns. Specifically, airbags can cause burns through thermal or chemical mechanisms and commonly affect the arms, hands, face, and eyes. While most airbag-induced burns are minor, some may cause unfavorable outcomes. Our study aimed to systematically review airbag-induced burns to assess etiology, type, and treatment of these injuries. A systematic review of case reports pertaining to airbag-induced cutaneous and ocular burns was conducted. Data reviewed included type/location of burns, severity of burn, total number of patients, treatment, complications, and outcome after treatment. We identified 21 case reports that met our inclusion criteria with a total of 24 patients reported in the studies. Of the studies identified, 38% were chemical burns and 25% were thermal burns. Most commonly the upper extremities were burned in 42% of cases, followed by eyes (25%) and face (21%). Most burns identified were superficial partial thickness (58%). Treatment outcomes were good for cutaneous burns, with 95% healing without complication. However, ocular injuries lead to permanent impaired eye function in 71% of cases. In our systematic review, we highlighted the common risk factors, prognosis, and treatment for thermal, chemical, and ocular burns. Airbag-induced burns have a relatively good prognosis but must be recognized and treated immediately to reduce the risk of serious sequelae.

Influence of Residency Training on Research Productivity and Plastic Surgery Career.

BACKGROUND: The impact of residency training on academic productivity and a career in academic plastic surgery remains uncertain. Previous literature has explored the influence of training institutions on academic careers in surgery. The aims of the study were to assess research productivity during plastic surgery residency training and to illustrate how differences in training programs impact resident research productivity. METHODS: Academic plastic surgery faculty that graduated in the past 10 years were identified through an Internet search of all Accreditation Council for Graduate Medical Education-accredited residency and fellowship training programs. Research productivity was compared based on h-index, number, and quality of peer-reviewed articles published during residency. RESULTS: Three hundred seventy-five academic plastic surgeons were identified and produced 2487 publications during residency. The 10 most productive training institutions were Johns Hopkins, Georgetown, University of Michigan, Stanford, University of California Los Angeles, Northwestern, Harvard, New York University, University of Pennsylvania, and Baylor. Academic productivity was higher among integrated residents (integrated = 8.68 publications, independent = 5.49 publications, P < 0.0001). The number of publications positively correlated to faculty size (r = 0.167, P = 0.0013), National Institute of Health (NIH) funding (r = 0.249, P < 0.0001), residency graduation year (r = 0.211, P < 0.0001), and negatively correlated with Doximity ranking (r = -0.294, P < 0.0001). H-index was positively correlated with number of publications (r = 0.622, P < 0.0001), faculty size (r = 0.295, P < 0.0001), and NIH funding (r = 0.256, P < 0.0001) and negatively correlated with Doximity ranking (r = -0.405, P < 0.0001) and residency graduation year (r = -0.163, P < 0.0001). CONCLUSIONS: Our study has found that there is an elite cohort of programs that are the most productive research institutions. Resident research productivity is higher among integrated residents, recent graduates, and programs that are larger in size, with a higher Doximity ranking and NIH funding. This study can guide medical students and future applicants who are interested in a career in academic plastic surgery in the selection of programs that match their career aspirations.

The Relationship of Residency and Fellowship Sites to Academic Faculty and Leadership Positions.

BACKGROUND: After completion of training, a physician's training institution has a lasting and meaningful impact on career trajectory. Training program influence on first job placement and academic promotions remain uncertain in academic plastic surgery. The aim of this study was to determine the impact of training and internal bias in academic plastic surgery employment and promotion. METHODS: Academic plastic surgery faculty were identified through an internet search of all Accreditation Council for Graduate Medical Education-accredited residency training programs. Faculty demographics, training background, employment, and leadership status were gathered. The analysis examined the impact of internal recruitment bias on first job employment, the impact of training history on institutional leadership promotion (chair/chief, residency director, or fellowship director), and the impact of alumni effect on academic employment. RESULTS: A significant proportion of recent graduates (38.6%) are practicing at the same institution as where they received residency or fellowship training. Of the 229 institutional leaders, 31.5% of chairs/chiefs, 39.6% of residency directors, and 37.5% of fellowship directors were internal hires. Overall, 34% of plastic surgery faculty in the United States share a common training program with at least 1 colleague. The top 5 programs that have the most faculty who trained at their hiring institution are Harvard (30 faculty), University of Southern California (15 faculty), University of California Los Angeles (12 faculty), University of Michigan (12 faculty), and Albert Einstein (12 faculty). Overall, 54% of plastic surgery departments employ 2 or more faculty who share a common external training program. The top 5 programs that have the most faculty who share an external training program are (1) Methodist Houston, 8 faculty who trained at Baylor; (2) Hofstra, 7 faculty who trained at New York University; (3) Stanford, 6 faculty who trained at University of California, Los Angeles; (4) Wisconsin, 5 faculty who trained at University of Pittsburgh Medical Center; and (5) University of Southern California, 4 faculty who trained at New York University. CONCLUSIONS: The study highlights that an internal bias exists in the recruitment for first jobs and leadership promotions. However, a clear bias of internal hiring exists at several institutions. In addition, an alumni effect was identified, where some programs have a bias of hiring faculty who trained at the same external institution.

Neutrophil Extracellular Traps Drive Mitochondrial Homeostasis in Tumors to Augment Growth.

Neutrophil infiltration and neutrophil extracellular traps (NET) in solid cancers are associated with poorer prognosis, but the mechanisms are incompletely understood. We hypothesized that NETs enhance mitochondrial function in tumor cells, providing extra energy for accelerated growth. Metastatic colorectal cancer tissue showed increased intratumoral NETs and supranormal preoperative serum MPO-DNA, a NET marker. Higher MPO-DNA correlated with shorter survival. In mice, subcutaneous tumor implants and hepatic metastases grew slowly in PAD4-KO mice, genetically incapable of NETosis. In parallel experiments, human cancer cell lines grew slower in nu/nu mice treated with DNAse, which disassembles NETs. PAD4-KO tumors manifested decreased proliferation, increased apoptosis, and increased evidence of oxidative stress. PAD4-KO tumors had decreased mitochondrial density, mitochondrial DNA, a lesser degree of ATP production, along with significantly decreased mitochondrial biogenesis proteins PGC1α, TFAM, and NRF-1. In vitro, cancer cells treated with NETs upregulated mitochondrial biogenesis-associated genes, increased mitochondrial density, increased ATP production, enhanced the percentage of cancer cells with reduced mitochondrial membrane potential, and increased the oxygen consumption rate. Furthermore, NETs increased cancer cells' expression of fission and fusion-associated proteins, DRP-1 and MFN-2, and mitophagy-linked proteins, PINK1 and Parkin. All of which were decreased in PAD4-KO tumors. Mechanistically, neutrophil elastase released from NETs activated TLR4 on cancer cells, leading to PGC1α upregulation, increased mitochondrial biogenesis, and accelerated growth. Taken together, NETs can directly alter the metabolic programming of cancer cells to increase tumor growth. NETs represent a promising therapeutic target to halt cancer progression. SIGNIFICANCE: Neutrophils through the release of NETs facilitate the growth of stressed cancer cells by altering their bioenergetics, the inhibition of which induces cell death.

Delayed Hypersensitivity Reaction after Nipple Tattooing: A Novel Case Report.

We present a patient who underwent bilateral 3-dimensional (3D) nipple tattooing for nipple areolar reconstruction after implant-based breast reconstruction for breast cancer. Several weeks after nipple tattooing, the patient developed a delayed hypersensitivity reaction around both of her tattooed nipple areolar complexes. This is the first case reported in the literature of a hypersensitivity reaction from 3D nipple tattooing.