Initial Comparison of Resident and Attending Milestones Evaluations in Plastic Surgery.

BACKGROUND: Graduate medical education has recently undergone a major archetypal shift toward competency-based evaluations of residents' performance. The implementation of the Milestones program by the Accreditation Council for Graduate Medical Education (ACGME) is a core component of the shift, designed to ensure uniformity in measuring residency knowledge using a series of specialty-specific achievements. This study evaluates the correlation between residents' self-evaluations and program directors' assessments of their performance. METHODS: The study population comprised 12 plastic surgery residents, ranging from postgraduate year 1 to postgraduate year 6, enrolled in an integrated residency program at a single institution. RESULTS: Overall, average attending scores were lower than average resident scores at all levels except postgraduate year 6. Correlation between resident and attending evaluations ranged from 0.417 to 0.957, with the correlation of average scores of Patient Care (0.854) and Medical Knowledge (0.816) Milestones significantly higher than those of professional skillsets (0.581). "Patient care, facial esthetics" was the Milestone with the lowest average scores from both groups. Residents scored themselves notably higher than their attendings' evaluations in Practice-based Learning and Improvement categories (+0.958) and notably lower in Medical Knowledge categories such as "Cosmetic Surgery, Trunk and Lower Extremities" (-0.375) and "Non-trauma hand" (-0.208). The total possible number of participants in this study was 12. The actual number of participants was 12 (100%). CONCLUSIONS: The remarkable range of correlations suggests that expectations for performance standards may vary widely between residents and program directors. Understanding gaps between expectations and performance is vital to inform current and future residents as the restructuring of the accreditation process continues.

Improved Techniques and Future Advances in Plastic Surgery in Global Health.

BACKGROUND: Plastic surgery has a long-standing history of being deeply interconnected with global health. This paper reviews the current state of global health as it relates to plastic surgery and makes forecasts for the future. METHODS: This study reviews the most current literature on global plastic surgery, as well as offers insights based on our 2 senior authors' experiences. For our literature search, the MEDLINE database was queried using relevant keywords through both PubMed and OVID user interfaces. FINDINGS: Early exposure to global plastic surgery often leads to a lifelong involvement. Formal integration of global surgery into residencies is becoming more common. Models of care for global plastic surgery range from small to large groups, spanning the full spectrum of reconstructive plastic surgery. The best of these groups have longitudinal relationships with their operative sites to allow for continuous care. Logistics and funding are crucial for successful care. Technological advances will make long-distance care more facile in the future. CONCLUSIONS: Global plastic surgery is rewarding to both patient and physician. Plastic surgery has been and will continue to be committed to providing high-quality global health care.

Cleft and Craniofacial Coding in ICD-10.

OBJECTIVE: With the gradual replacement of the ICD-9 coding system by the newer ICD-10 system, there is a need to critically evaluate how the system improves-or fails to improve-the coding of specific cleft and craniofacial anomalies. The following review examines the new system and the key components for practitioners who treat patients with such anomalies. CONCLUSIONS: While seemingly beneficial in certain respects, the newer ICD-10 system remains far from ideal for cleft and craniofacial anomalies. With future iterations of the system, a more concerted effort to precisely code such anomalies is warranted, which will likely require input from key practitioners.

Cultural perspectives in facial allotransplantation.

Facial allotransplantation is a clinical reality, proposed to provide improved functional and aesthetic outcomes to conventional methods of facial reconstruction. Multidisciplinary efforts are needed in addressing not just the surgical and immunological issues but the psychological and sociological aspects as well. In view of this, an international survey was designed and conducted to demonstrate that attitudes toward facial allotransplantation are highly influenced by cultural background. Of all countries surveyed, France had the highest percentage of respondents willing to donate their faces (59%) and Iraq had the lowest (19%). A higher percentage of respondents were willing to accepting a face transplant (68%) than donate their face after death (41%). Countries with a dominant Western population show greater percentages of willingness to accept a face transplant, as they exhibit more positive variables, that is, (1) acceptance of plastic surgery for disfigurement and for cosmetic reasons and (2) awareness to the world's first face transplant. Countries with a dominant Western population also show greater percentages of willingness to donate their faces after death, as they exhibit more positive variables, that is, (1) positive attitude to organ donation by being an organ donor themselves, (2) acceptance of plastic surgery if disfigured, and (3) awareness to the world's first face transplant. Although religion was sometimes cited as a reason for not donating their faces, data analysis has shown religion not to be a strong associating factor to willingness to donate a face after death.

Complete calvarial agenesis in conjunction with a Tessier 1-13 facial cleft.

Amniotic band sequence (ABS) is a condition in which rupture of the amniotic sac leads to the development of a broad spectrum of fetal anomalies. A newborn male presented at term with multiple craniofacial and skeletal anomalies, including attachment of the placenta to the head, a paramedian facial cleft, and multiple skeletal anomalies. The patient has undergone several operations to date. The initial operation was performed to remove the attached placenta off the underlying dura, which was with a collagen matrix bound to a silicone membrane. The patient subsequently underwent split-thickness skin grafting with complete survival of the graft.

Measuring quality of life in cleft lip and palate patients: currently available patient-reported outcomes measures.

BACKGROUND: Patient-reported outcomes in cleft lip and palate treatment are critical for patient care. Traditional surgical outcomes focused on objective measures, such as photographs, anatomic measurements, morbidity, and mortality. Although these remain important, they leave many questions unanswered. Surveys that include aesthetics, speech, functionality, self-image, and quality of life provide more thorough outcomes assessment. It is vital that reliable, valid, and comprehensive questionnaires are available to craniofacial surgeons. METHODS: The authors performed a literature review to identify questionnaires validated in cleft lip and palate patients. Qualifying instruments were assessed for adherence to guidelines for development and validation by the scientific advisory committee and for content. RESULTS: The authors identified 44 measures used in cleft lip and palate studies. After 15 ad hoc questionnaires, eight generic instruments, 11 psychiatric instruments, and one non-English language questionnaire were excluded, nine measures remained. Of these, four were never validated in the cleft population. Analysis revealed one craniofacial-specific measure (Youth Quality of Life-Facial Differences), two voice-related measures (Patient Voice-Related Quality of Life and Cleft Audit Protocol for Speech-Augmented), and two oral health-related measures (Child Oral Health Impact Profile and Child Oral Health Quality of Life). The Youth Quality of Life-Facial Differences, Child Oral Health Impact Profile, and Child Oral Health Quality of Life questionnaires were sufficiently validated. None was created specifically for clefts, resulting in content limitations. CONCLUSIONS: There is a lack of comprehensive, valid, and reliable questionnaires for cleft lip and palate surgery. For thorough assessment of satisfaction, further research to develop and validate cleft lip and palate surgery-specific instruments is needed.

Principles and practice of disaster relief: lessons from Haiti.

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.

Vomer bone graft to augment the deficient cleft maxilla.

Patients with clefts of the lip and palate commonly develop maxillary hypoplasia. In addition to orthognathic surgery, augmentation of the anterior maxilla may be necessary in these patients to restore symmetry to the nasomaxillary complex. Bone graft may be obtained from numerous sites. All require a separate incision at the donor site and may result in additional morbidity.The authors describe a 16-year-old with a complete right unilateral cleft of the lip and palate who underwent maxillary advancement at the Le Fort I level. Pronounced sagittal deficiency of the maxilla necessitated osseous augmentation. The patient's deformity resulted in deviation of the superior vomer bone. This bone was of adequate quality to be used as an onlay graft for the maxilla. This is the first report documenting the use of vomer as a bone graft for maxillary augmentation.

Leadership trends in plastic surgery.

BACKGROUND: The authors examined the recent trends in the composition, appointment, and turnover of chairpersons in academic plastic surgery. METHODS: A survey regarding the characteristics of the current and former department chairpersons in plastic surgery was mailed to the 89 existing academic plastic surgery programs. The survey focused on the age, gender, subspecialty, interim tenure, and overall tenure of the two groups. RESULTS: An initial response was received from 60 chairpersons. The majority of current chairpersons are male (81 of 89, 91 percent), which is slightly lower than the group of immediate past chairs, of whom 98 percent (87 of 89) were male. From the questionnaires, it was noted that for both the current and former groups of chairpersons, the 40- to 50-year age range was the most frequent age group at which an individual was appointed to that position. Approximately one-third (35.7 percent) of the current group consider themselves "general plastic surgeons." This differs from their predecessors, of whom 56.0 percent reported the same designation. An increase in the promotion of existing faculty to chairpersons was also noted. As compared with 44.2 percent of the previous group, 69.5 percent of the current chairpersons were promoted from within the department. CONCLUSIONS: The population of academic chairpersons in plastic surgery is changing. Today, more chairpersons appear to be younger and specialty trained. Examining the history of academic leadership and identifying trends in any field of medicine can only help to better prepare the specialty for the future.

A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care.

Due to the complex, and often tenuous nature of microsurgical tissue transfer, postoperative monitoring of free tissue flaps plays a vital role in the management of such patients. Some of the more challenging reconstructive problems occur in patients with lower extremity trauma, yet to date, no preferred protocol exists for the postoperative care of lower extremity free flaps. The present study sought to evaluate and assess current preferences in monitoring following lower extremity free tissue transfer. Members of the American Society of Plastic Surgeons (ASPS) were surveyed with regard to their choice for postoperative monitoring and return to dependent positioning ("dangling"). The results demonstrate that there is some agreement among surgeons regarding the optimal means for postoperative monitoring. Most rely on clinical observation in addition to conventional Doppler probe for an average of 4.8 days. Most surgeons follow their own flaps in addition to relying on the residents and nursing staff. The study also notes a wide variety in the times and frequencies at which dangling of the extremity was commenced. Most respondents initiate dangling within 2 weeks of surgery and begin with only 1 to 5 minutes per session.

Dabska tumor arising in lymphangioma circumscriptum.

We describe a case of Dabska tumor (DT) occurring within a large congenital lymphangioma circumscriptum on the thigh of a 14-year-old female. Diagnostic biopsy showed numerous intravascular papillary projections lined by atypical endothelial cells within the anastomosing vascular channels of a lymphangioma circumscriptum. DT is regarded as a vascular tumor of intermediate malignant potential, most probably of lymphatic origin. Although it has been described in pre-existing lymphangiomas, to the best of our knowledge this is the first case to be described in a pre-existing lymphangioma circumscriptum. During a follow-up of 9 years, the lymphangioma circumscriptum has recurred, but there has been no evidence of DT recurrence or metastasis.

A survey of microvascular protocols for lower-extremity free tissue transfer I: perioperative anticoagulation.

Reconstruction of the lower extremity using free tissue transfer is performed throughout the country by numerous surgical teams. However, no established protocol exists for the use of anticoagulation in the perioperative period. The present study sought to analyze trends in current protocols regarding perioperative anticoagulation for lower-extremity free flap reconstruction. Members of the American Society of Plastic Surgeons were surveyed with regard to their preferences for perioperative anticoagulation in conjunction with lower-extremity free tissue transfer. The results demonstrated tremendous variability in both the agents used and therapeutic periods employed. They highlighted the absence of 1 or more common anticoagulation protocols and tried to establish common trends in the use of such agents.

Mandibular distraction for amniotic band syndrome in the neonate.

Prior reports have advocated the use of distraction osteogenesis (DO) in the management of neonates with mandibular hypoplasia to avoid early tracheostomy and its associated morbidity. Our center recently reported on the successful use of DO in a neonate with muscular dystrophy, a condition which affects the bone as well as the adjacent skeletal muscle. Herein, we describe the use of neonatal DO for mandibular hypoplasia in the setting of amniotic band sequence (ABS). The child had significant soft tissue contracture in the region of the cheek, associated with bilateral transverse facial clefts. This report highlights the successful utilization of DO for the treatment of mandibular hypoplasia and airway compromise in a patient with ABS.

Congenital midline cervical cleft.

Congenital midline cervical cleft (CMCC) is a rare disorder of the ventral neck that is clinically evident at birth and must be differentiated from the more common thyroglossal duct cyst. The case of CMCC presented here was associated with chromosomes 13/14 de novo Robertsonian translocations as well as midline deformities including a sacral tuft and a minor tongue-tie. The case is presented as well as discussion of histopathology, embryology, and surgical treatment.

Effect of VEGF on tail artery interpositional loop (TAIL) flap: a rodent model for flap prefabrication.

The authors introduce an experimental model of flap prefabrication, the tail artery interpositional loop (TAIL) flap. In this model, an arterial segment from a rat tail is used to create an arteriovenous (A-V) fistula. This fistula is positioned beneath the abdominal skin flap to vascularize the overlying tissue, and a barrier of Silastic sheeting is placed below the fistula to prevent vascular ingrowth from the underlying bed. The efficacy of this new model was tested by investigating the effect of a single topical application of recombinant human VEGF (165). Treatment and control groups each contained 20 animals. In the control group, mean survival skin areas at 1, 2, 3, and 4 weeks were 12.5 percent, 27 percent, 35 percent, and 50 percent, respectively. In the VEGF (165)-treated group, survival rates were 14.8 percent, 37 percent, 48 percent, and 74.3 percent, respectively. Statistically significant differences were noted between the two groups at the 2-week ( p = 0.047), 3-week ( p = 0.048), and 4-week ( p = 0.023) time intervals. The authors conclude that the TAIL flap is a novel and useful animal model to study flap prefabrication.

Rat epigastric flow-through flap as a modulated arteriovenous fistula: model for the radial artery flow-through flap in distal arterial bypass.

The authors describe a rat flap model that is useful for flow studies. It is an epigastric flow-through flap that mimics the clinical use of a radial artery flow-through (RAFT) flap that has been used as an adjunct to a distal lower extremity arterial bypass graft to improve patency when there is potential high outflow resistance. The hypotheses were that this RAFT flap serves two purposes: 1) it allows additional blood flow through the skin flap and drainage via the vena comitans to increase the blood flow through the bypass graft and help to maintain bypass graft patency; and 2) it acts as a modulating arteriovenous fistula in which the additional flow through the vena comitans of the flow-through flap fluctuates with distal arterial outflow resistance. The rat epigastric flow-through flap model was designed to test these hypotheses. High outflow resistance was induced by sequentially ligating the outflow vessels of the rat femoral artery. Using this model, an increase in blood flow to the skin via the epigastric artery of the flow-through flap was demonstrated as outflow obstruction increased. Then, the patency rates of the flow-through flap bypass were compared to an interpositional arterial graft. The flow-through flap maintained patency while the arterial interposition bypass thrombosed, with near total outflow obstruction induced by serial ligation of the outflow vessels (75 percent patent anastomoses at 1 week for flow-through flap vs. 0 percent for the arterial graft). This flow study demonstrates the inherent ability of the flow-through flap to divert blood flow through the skin capillaries when there is high arterial outflow resistance. The authors believe that a flow-through flap such as the RAFT flap can be an important adjunct to the traditional distal arterial bypass in a subset of patients with high outflow resistance in the recipient artery.