The Left-handed Plastic Surgery Trainee: Perspectives and Recommendations.

Left-handed surgeons experience difficulty with tools designed for use in the right hand. The purpose of this study was to examine instrument laterality and to survey the experiences of left-handed plastic surgery trainees. METHODS: Count sheets for plastic surgery trays (reconstructive, microsurgery, rhinoplasty, craniofacial) were acquired from Tisch Hospital, NYU Langone Health. Instruments with right-handed laterality were tallied. A survey was also distributed to plastic surgery residents and fellows to determine hand preference for surgical tasks, and those who identified as left-handed described how handedness impacted their training. RESULTS: Right-handed laterality was seen in 15 (31.3%) of the 48 reconstructive instruments, 17 (22.7%) of the 75 rhinoplasty instruments, and 22 (31.0%) of the 71 craniofacial instruments. One-hundred percent of the 25 microsurgery instruments were ambidextrous. There were 97 survey responses. Trainees (17.5%) were identified as left-handed and were more likely than right-handed trainees to report operating with both hands equally or with the opposite hand (47.1% versus 1.3%; P < 0.001). Left-handed trainees were significantly more likely than right-handed trainees to use their nondominant hand with scissors (P < 0.001), electrocautery (P = 0.03), and needle drivers (P < 0.001) and when performing tissue dissection (P < 0.001) and microsurgery (P = 0.008). There was no difference in use of the nondominant hand between right and left-handed trainees for knot tying (P = 0.83) and in use of the scalpel (P = 0.41). CONCLUSIONS: Left-handed plastic surgery trainees frequently encounter instruments designed for the nondominant hand, with which they adaptively perform several surgical tasks. Mentoring may help trainees overcome the laterality-related challenges of residency.

Ulnar Nerve Compression due to Anconeus Epitrochlearis: A Case Report and Review of the Literature.

CASE: A 32-year-old right-handed surgeon presented with a history of intermittent pain at the right medial epicondyle, a mild Tinel's sign, and dysesthesia in the ulnar nerve distribution. Dynamic ultrasound demonstrated a hypertrophic anconeus epitrochlearis bilaterally, and chronic irritation of the ulnar nerve. Anterior release with myectomy of the accessory muscle was performed. No compressive symptoms were present at 1-year follow-up. CONCLUSIONS: The anconeus epitrochlearis is an often-underappreciated cause of ulnar nerve compression that can lead to significant functional impairment. Dynamic ultrasound is an excellent diagnostic modality, and anterior release with myectomy provides durable relief with minimal downtime.

Foundation-Based Cleft Care in Developing Countries.

BACKGROUND: Cleft deformities of the lip and palate affect nearly one in 500 to 700 births, and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused on developing countries. In this study, the authors evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. METHODS: A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, and their clinical, scientific, educational, and economic impact. RESULTS: A total of 244 articles were identified through the authors' search and reviewed. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, and international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care. CONCLUSIONS: Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care.

Three-Dimensional Analysis of Donor Masks for Facial Transplantation.

BACKGROUND: Face transplant teams have an ethical responsibility to restore the donor's likeness after allograft procurement. This has been achieved with masks constructed from facial impressions and three-dimensional printing. The authors compare the accuracy of conventional impression and three-dimensional printing technology. METHODS: For three subjects, a three-dimensionally-printed mask was created using advanced three-dimensional imaging and PolyJet technology. Three silicone masks were made using an impression technique; a mold requiring direct contact with each subject's face was reinforced by plaster bands and filled with silicone. Digital models of the face and both masks of each subject were acquired with Vectra H1 Imaging or Artec scanners. Each digital mask model was overlaid onto its corresponding digital face model using a seven-landmark coregistration; part comparison was performed. The absolute deviation between each digital mask and digital face model was compared with the Mann-Whitney U test. RESULTS: The absolute deviation (in millimeters) of each digitally printed mask model relative to the digital face model was significantly smaller than that of the digital silicone mask model (subject 1, 0.61 versus 1.29, p < 0.001; subject 2, 2.59 versus 2.87, p < 0.001; subject 3, 1.77 versus 4.20, p < 0.001). Mean cost and production times were $720 and 40.2 hours for three-dimensionally printed masks, and $735 and 11 hours for silicone masks. CONCLUSIONS: Surface analysis shows that three-dimensionally-printed masks offer greater surface accuracy than silicone masks. Greater donor resemblance without additional risk to the allograft may make three-dimensionally-printed masks the superior choice for face transplant teams. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction.

BACKGROUND: Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS: The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS: Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Predictors of Adverse Outcomes in the Management of Mandibular Fractures.

BACKGROUND: Mandibular fractures are the most common isolated facial fractures in the United States. Various risk factors have been associated with increased rates of postoperative complications. However, national outcome reports are limited and data are conflicting. Using a national multi-institutional database, the authors sought to analyze 30-day outcomes after mandibular fracture repair and determine risk factors for complications, readmission, and reoperation. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement database was performed to identify patients undergoing surgical treatment of mandibular fractures between 2010 and 2015 using current procedural terminology codes. Primary outcomes included: wound complications, overall complications, as well as readmission and reoperation rates. Multivariate regression analysis was performed to adjust for confounders. RESULTS: A total of 953 patients were eligible for analysis. Mean patient age was 34.5 years, 84% were males, and 50% were active smokers. Wound complications, overall complications, 30-day reoperation, and readmission occurred in 4.0%, 7.9%, 2.2%, and 33% of patients, respectively. Age was a significant risk factor for 30-day readmission (odds ratio [OR] = 1.06, P = 0.01), reoperation (OR = 1.05, P = 0.01), and overall complications (OR = 1.03, P = 0.02) on multivariate analysis, and smoking was a significant risk factor for 30-day reoperation (OR = 4.86, P = 0.03). CONCLUSION: The analysis identified age as an independent risk factor for readmission, reoperation, and overall complications. Smokers were also nearly 5 times as likely to undergo additional surgery. This is particularly important given that over half of patients were active smokers, highlighting the importance of perioperative patient education and smoking cessation within this population.

From "Coordinated" to "Integrated" Residency Training: Evaluating Changes and the Current State of Plastic Surgery Programs.

BACKGROUND: Since the inception of the integrated model, educational leaders have predicted its ongoing evolution, as the optimal plastic surgery curriculum remains a source of debate. With the now complete elimination of the "coordinated" pathway, the total number of integrated programs has arguably reached a plateau. Accordingly, this study examines the current state of training in integrated residencies and reevaluates the variability in the first 3 years of training observed previously. METHODS: Program information was obtained for all 68 integrated plastic surgery programs, and rotation schedules were available for 59. Plastic, general, and subspecialty surgery exposures were quantified and compared. Inclusion of rotations "strongly suggested" by the Residency Review Committee was also examined. RESULTS: Plastic surgery exposure ranged from 3.5 to 25 months (mean, 13.9 ± 5.4 months). General surgery ranged from 5 to 22.5 months (mean, 12.8 ± 4.7 months). Subspecialty rotations ranged from 0 to 8 months (mean, 3.6 ± 1.8 months). There was no difference in mean plastic surgery exposure between programs based within departments versus divisions (15.4 months versus 13.3 months; p = 0.184). There remained significant variability in the inclusion of 18 non-plastic surgery rotations, including the "strongly suggested" rotations. CONCLUSIONS: Plastic surgery exposure remains highly variable with a greater than 7-fold difference between programs. This suggests that programs are still sorting out the ideal curriculum. However, there is an overall trend toward earlier and increased plastic surgery exposure, which now exceeds the average time spent on general surgery rotations.

Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database.

BACKGROUND: Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS: We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (ß = .62; P < .001). CONCLUSIONS: Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy.

BACKGROUND: Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated. METHODS: The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders. RESULTS: Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications. CONCLUSION: Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Bimaxillary Orthognathic Surgery Is Associated With an Increased Risk of Early Complications.

INTRODUCTION: Orthognathic surgery plays an important role in restoring aesthetic facial contour, correcting dental malocclusion, and the surgical treatment of obstructive sleep apnea. However, the rate of complications following bimaxillary as compared with single-jaw orthognathic surgery remains unclear. The authors therefore sought to evaluate complication rates following bimaxillary as compared with single-jaw orthognathic surgery MATERIALS AND METHODS:: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify comparison groups. Preoperative characteristics and postoperative outcomes were compared between groups. The listed procedures have different operating times and characteristics with longer time expected in the bimaxillary osteotomies group. Regression analyses were performed to control for potential confounders. RESULTS: The 3 groups of interest included patients who underwent mandibular osteotomies (n = 126), LeFort I osteotomy (n = 194), and bimaxillary osteotomies (n = 190). These procedures have different operating times, with a longer time expected with bimaxillary osteotomies. Patients undergoing bimaxillary osteotomies had significantly higher rates of early wound complications, overall complications, longer mean operative time, and mean hospital length of stay. Performing bimaxillary osteotomies in the outpatient setting was an independent risk factor for wound complications (OR = 12.58; 95% CI: 1.66-95.20; P = 0.01), while an ASA class of 3 or more was an independent risk factor for overall complications (OR = 3.61; 95% CI: 1.02-12.75; P = 0.04) and longer hospital length of stay (ß = 4.96; 95% CI: 2.64 - 7.29; P < 0.001). CONCLUSIONS: Surgery in the outpatient setting as well as patient American Society of Anesthesiology physical status class 3 or higher were independent factors for postoperative adverse events in patients undergoing bimaxillary surgery. Our findings highlight the importance of addressing modifiable risk factors preoperatively and the need for closer postoperative monitoring in this patient population for optimal outcomes.

Combined Primary Cleft Lip and Palate Repair: Is It Safe?

BACKGROUND: Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS: A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (ß = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (ß = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION: Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

Obesity and Lower Extremity Reconstruction: Evaluating Body Mass Index as an Independent Risk Factor for Early Complications.

BACKGROUND: The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed to identify patients undergoing local- or free-flap reconstruction of the lower extremity between 2010 and 2015. Preoperative variables and outcomes were compared between obese (body mass index ≥ 30) and nonobese patients. Chi-square analysis and Fisher's exact test were used for categorical variables and t-tests for continuous variables. Multivariate regression was performed to control for confounders. RESULTS: Univariate analysis of medical and surgical outcomes revealed that obese patients undergoing local flaps of the lower extremity required a significantly longer operative time (187.7 ± 123.2 vs. 166.2 ± 111.7 minutes; p = 0.003) and had significantly higher rates of superficial surgical site infection (SSI; 7.2% vs. 4.5%; p = 0.04). On univariate analysis, there were no significant differences in any postoperative outcomes between obese and nonobese patients undergoing microvascular free flaps of the lower extremity.On multivariate regression analysis, obesity was not an independent risk factor for superficial SSI (odds ratio = 1.01, p = 0.98) or increased operative time (ß = 16.01, p = 0.14) for local flaps of the lower extremity. CONCLUSION: Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.

Otologic considerations in a full face transplant recipient.

Facial transplantation provides a functional and aesthetic solution to severe facial disfigurement previously unresolved by conventional reconstruction. Few facial allografts have been ear containing; hence, there is limited knowledge of the postoperative otologic considerations. We describe the case of a 44-year-old man who underwent transplantation of the total face, eyelids, ears, scalp, and skeletal subunits in 2015 after an extensive thermal injury. We detail the patient's transition from osseointegrated prosthetic ears to an ear-containing facial allograft, and describe the unique surgical approach and challenges encountered. Subsequent bilateral revision meatoplasties were performed, which provided relief from stenosis of the external auditory meatus. Laryngoscope, 129:2008-2011, 2019.

Free Ulnar Forearm Flap: Design, Elevation, and Utility in Microvascular Nasal Lining Reconstruction.

Reconstruction of the nasal lining has traditionally been performed using the folded radial forearm free flap, given its reliable blood supply, pliability, and familiarity to surgeons with respect to its harvest. More recently, the free ulnar forearm flap has been proposed as an alternative reconstructive option for the nasal lining, with safe and reliable outcomes, and improved donor-site morbidity compared with its radial counterpart. In this article, the authors provide educational video footage with accompanying text description of the senior author's (E.D.R) approach to design and elevation of the free ulnar forearm flap for the purpose of reconstructing a composite nasal defect. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Appraisal of the Free Ulnar Flap Versatility in Craniofacial Soft-tissue Reconstruction.

The unique anatomical characteristics of the forearm region make it especially popular as a free flap donor site for craniofacial soft-tissue reconstruction. The free ulnar forearm flap is less hirsute and allows for better concealment of donor site scar as compared with its radial counterpart. Despite these factors, the free radial forearm flap remains more popular among reconstructive surgeons. Through the presented case series, we hope to emphasize the versatile nature of the free ulnar forearm flap in addressing various craniofacial soft-tissue defects. Following institutional review board approval, a retrospective review of the senior authors' clinical experience performing microvascular free ulnar forearm flap reconstruction of craniofacial soft-tissue defects was performed. A total of 10 patients were identified through our review. Soft-tissue defect locations included lower eyelid (n = 2), tongue and floor of mouth (n = 2), lower lip (n = 2), palatopharyngeal area (n = 1), nose (n = 1), and palate (n = 1). Trauma was the most common defect etiology (n = 5), followed by malignancy (n = 4), and iatrogenic injury in 1 case. All patients demonstrated good aesthetic and functional outcomes related to vision, speech, and oral intake at follow-up when applicable. The free ulnar forearm flap is a versatile reconstructive option that can be used to address a wide spectrum of craniofacial soft-tissue defects and offers numerous advantages over its radial counterpart.

Single-Stage Primary Cleft Lip and Palate Repair: A Review of the Literature.

BACKGROUND: Single-stage cleft lip and palate repair is a debated surgical approach. While some studies have described favorable outcomes, concerns include the effect on craniomaxillofacial growth and increased risk of complications. To this date, there has not been a comprehensive appraisal of available data following combined cleft lip and palate repair. METHODS: An extensive literature review was performed to identify all relevant articles. The level of evidence of these articles was graded according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence Scale. RESULTS: A total of 22 relevant articles were identified, all of which were retrospective in nature. Patient age at the time of surgery ranged from 1 month to 10 years, the longest duration of follow-up was 18 years, and the largest study included 106 patients. Review of the literature shows that overall surgical outcomes following combined cleft lip and palate repair are encouraging. An increased rate of postoperative fistulas with associated speech abnormalities in some studies is noteworthy. Importantly, there is no evidence to suggest an impact on craniomaxillofacial growth, and psychosocial outcomes and parental satisfaction seem to be improved with single-stage surgery as compared with the staged approach. CONCLUSIONS: Our review shows overall favorable outcomes associated with combined cleft lip and palate repair. The limited follow-up time or nature of evaluated outcomes in some studies may underrepresent the true rate of adverse events, and highlights the need for additional long-term studies with standardized follow-up. To our knowledge, our review is the first to evaluate existing data regarding outcomes following combined cleft lip and palate repair.

Outpatient versus Inpatient Primary Cleft Lip and Palate Surgery: Analysis of Early Complications.

BACKGROUND: Fiscal constraints are driving shorter hospital lengths of stay. Outpatient primary cleft lip surgery has been shown to be safe, but outpatient primary cleft palate surgery remains controversial. This study evaluates outcomes following outpatient versus inpatient primary cleft lip and palate surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing primary cleft lip and palate surgery between 2012 and 2015. Patient clinical factors and 30-day complications were compared for outpatient versus inpatient primary cleft lip and palate surgery. Univariate and multivariate analyses were performed. RESULTS: Three thousand one hundred forty-two patients were included in the primary cleft lip surgery group and 4191 in the primary cleft palate surgery group. Patients in the cleft lip surgery group with structural pulmonary abnormalities had a significantly longer hospital length of stay (ß, 4.94; p = 0.001). Patients undergoing outpatient surgery had a significantly higher risk of superficial (OR, 1.99; p = 0.01) and deep wound dehiscence (OR, 2.22; p = 0.01), and were at a significantly lower risk of reoperation (OR, 0.36; p = 0.04) and readmission (OR, 0.52; p = 0.02). CONCLUSIONS: Outpatient primary cleft lip surgery is safe and has a complication profile similar to that of inpatient surgery. Outpatient primary cleft palate surgery is common practice in many U.S. hospitals and has a significantly higher rate of wound complications, and lower rates of reoperation and readmission. In properly selected patients, outpatient palatoplasty can be performed safely. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.