Evaluating the Impact of Resident Participation and the July Effect on Outcomes in Autologous Breast Reconstruction.

OBJECTIVE: Although resident involvement in surgical procedures is critical for training, it may be associated with increased morbidity, particularly early in the academic year-a concept dubbed the "July effect." Assessments of such phenomena within the field of plastic surgery have been both limited and inconclusive. We sought to investigate the impact of resident participation and academic quarter on outcomes for autologous breast reconstruction. METHODS: All autologous breast reconstruction cases after mastectomy were gathered from the 2005-2012 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were constructed to investigate the association between resident involvement and the first academic quarter (Q1 = July-September) with 30-day morbidity (odds ratios [ORs] with 95% confidence intervals). Medical and surgical complications, median operation time, and length of stay (LOS) were also compared. RESULTS: Overall, 2527 cases were identified. Cases with residents (n = 1467) were not associated with increased 30-day morbidity (OR, 1.20; 0.95-1.52) when compared with those without (n = 1060), although complications including transfusion (OR, 2.08; 1.39-3.13) and return to the operating room (OR, 1.46; 1.11-1.93) were more frequently observed in resident cases. Operation time and LOS were greater in cases with resident involvement.In cases with residents, there was decreased morbidity in Q1 (n = 343) when compared with later quarters (n = 1124; OR, 0.67; 0.48-0.92). Specifically, transfusion (OR, 0.52; 0.29-0.95), return to operating room (OR, 0.64; 0.41-0.98), and surgical site infection (OR, 0.37; 0.18-0.75) occurred less often during Q1. No differences in median operation time or LOS were observed within this subgroup. CONCLUSIONS: Our study reveals that resident involvement in autologous breast reconstruction is not associated with increased morbidity and offers no evidence for a July effect. Notably, our results suggest that resident cases performed earlier in the academic year, when surgical attendings may offer more surveillance and oversight, is associated with decreased morbidity.

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Cadaveric Porcine Model for Teaching and Practicing Conjunctival Autograft Creation.

PURPOSE: Conjunctival autografting is a technically difficult step of pterygium surgery, and novice surgeons have limited opportunities to develop and practice their surgical skills. The porcine eye model closely approximates the human eye in tissue consistency when preparing conjunctival and limbal-conjunctival grafts. This study assessed the efficacy of a cadaveric porcine model in teaching and improving a novice's skills of conjunctival autograft creation. METHODS: A novice was taught to prepare 5 × 5 mm conjunctival grafts and created 58 grafts on fresh porcine eyes. The conjunctival graft thickness was measured using standard histological techniques. RESULTS: Between grafts 1-10 and grafts 49-58, there was a statistically significant difference in both thickness (P < 0.0001; mean thickness, 133 ± 27 and 87 ± 23 µm, respectively) and time of creation (P = 0.037; median time, 191 and 126 seconds, respectively). CONCLUSIONS: The cadaveric porcine model may be a useful method for teaching this important technique to novice surgeons.

State-of-the-art autogenous ear reconstruction in cases of microtia.

Ear reconstruction is considered to be a challenging form of surgery. In cases of microtia, surgeons must reconstruct complex missing contours, which necessitates the use of a support and skin remnants to cover this support. Although the use of synthetic material has been proposed in order to avoid harvesting and carving cartilage, the best long-term choice for reconstructing an ear is autologous rib cartilage. This procedure requires good understanding of the 3-dimensional architecture of the ear and learning the step-by-step construction of a harmonious framework (which with practice will become the most straightforward part of the procedure). Surgery, usually performed at the age of 9 or 10 years, is planned in 2 stages. In the first stage, the framework is placed under a skin pocket. Six months later, the sulcus is created using an additional cartilage graft for projection and a skin-grafted galeal fascial flap. In order to shorten the learning curve, a detailed carving process is described here, as well as a tool to enable training before surgery. Remnants of the microtic ear can have many different shapes; therefore, a comprehensive approach to skin management is proposed, providing a simple surgical classification for all types of microtia. Furthermore, some refinements of the cartilage framework and the construction of the retroauricular sulcus have improved results. Whenever possible, successful reconstruction of a microtic ear with autologous rib cartilage, as opposed to synthetic materials, is by far the best option.

Incorporating hair replacement into your practice.

The author defines the essential management skills that are unique to building a successful hair restoration surgery team and contrasts these skills with those needed to manage a general cosmetic surgery practice. Strategies for hair technician selection, training, supervision, and management are discussed, emphasizing the management skill areas that are different from those of general medical office or cosmetic surgery practices. Attention is given to the components of a contemporary hair restoration surgery operating suite: size, specialized equipment and tools, and essential support systems.