Indocyanine Green Angiography Precise Marking for Indeterminate Burn Excision: A Prospective, Multi-centered, Double-blinded Study.

BACKGROUND: During burn excision, the clinical judgment whether to excise or not excise the area with indeterminate burn depth is difficult. Indocyanine green angiography (ICGA) has been reported to provide high accuracy in diagnosing indeterminate burns. This study aims to evaluate the complete wound closures in both short-term and long-term outcomes after using ICGA precise marking to guide indeterminate burn excision. METHODS: This was a prospective, multi-centered, double-blinded, experimental study. The participants were admitted to the hospital with indeterminate burn wounds. ICGA precise marking was performed. The deep second-degree burn was painted, excised, and subsequently covered with skin grafts and measured on day 5. The superficial burns were measured on day 21. All wounds were followed-up at two months. RESULTS: Thirty indeterminate burn sites were included in this study. Using ICGA precise marking, the overall rate of short-term complete wound closure, which combined superficial and deep burns, was found to be as high as 96.7% (29/30). The long-term complete wound closures at two months confirmed the short-term result and yielded 100.0% of complete wound closure. The complete wound closures between the short-term and long-term measurements were not significantly different (P > 0.999). CONCLUSIONS: Using ICGA precise marking to guide indeterminate burn excision resulted in an excellent rate of complete wound closure and an insignificant difference between short-term and long-term wound outcomes. ICGA is a competent method to aid decision-making in burn surgery of the indeterminate area.

An Inconvenient Truth of Clinical Assessment and Indocyanine Green Angiography Precise Marking for Indeterminate Burn Excision.

The clinical assessment of indeterminate burn wounds has relatively poor accuracy. Indocyanine green angiography (ICGA) has high accuracy and can be used to mark wounds precisely so as to guide burn excision. This study aimed to assess the differences between ICGA and clinical assessment marking and compare the marking result with the long-term wound outcome. METHODS: This was a prospective, multicentered, triple-blinded, experimental study. Indeterminate burn wounds were clinically assessed, and the area to be excised was firstly marked by the attending surgeon. ICGA marking was then performed by a second surgeon. Measurement of the marked area was conducted by a third surgeon. Three surgeons were each blinded to the others' processes. The wounds were followed up to assess complete wound closures on day 21. RESULTS: There were 20 burn sites included in the study. There was a significant difference in the marked areas between clinical assessment and ICGA (mean, 57.3 ± 44.1%; P = 0.001). The maximum difference found was as high as 160.9%. The correction rate of ICGA marking to complete wound closure on day 21 was 95.0%. Over 90% of the decreased areas of excision-which were assessed by ICGA to be superficial burns but evaluated by clinical assessment to be deep burns-were completely healed on day 21. CONCLUSIONS: ICGA contributes to a significant difference versus clinical assessment in the marking for excision of indeterminate burns and strongly associates with long-term wound outcomes. The burn wounds can be assessed precisely to reduce unnecessary excision and prevent inadequate excision.

Plastic Surgery Across Continents: A Comparison of Residency Training in Subsaharan Africa and the United States.

ABSTRACT: There is a demonstrated need for access to plastic surgical care in low- and middle-income countries worldwide. Recently, there is increasing interest in promoting transcontinental partnerships between academic institutions to improve training opportunities for local surgeons while increasing access to care for patients. Before such programs can be established, it is crucial for US-based surgeons and educators to understand the existing training models in different countries. The aim of this study is to identify the current plastic surgery training model in the College of Surgeons of East, Central, and Southern Africa (COSECSA) group of African nations and compare this to training in the United States. The curricula of 2 accrediting bodies of plastic surgery, COSECSA and the Accreditation Council for Graduate Medical Education of the United States, were compared. Similarities included the length of dedicated plastic surgery training, curriculum content, and final evaluation structure. Differences include training pathways, assessment methodology, and regulation regarding specific competencies, program requirements, and resident benefits. These findings establish a baseline understanding of how plastic surgical training is organized, delivered, and evaluated in Africa, highlight opportunities for educational initiatives, and serve as a foundation for future efforts to develop collaborative partnerships in these communities. Future research will include a survey sent to program directors and plastic surgery attendings in the COSECSA regions to gather additional information.

What Influences a Plastic Surgery Resident to Pursue an Academic Career?

BACKGROUND: A previous study demonstrated that independent model plastic surgery residents are less likely to pursue a career in academic surgery than those graduating from other surgical fellowships. This study was designed to evaluate whether a significant curriculum change emphasizing academic plastic surgery skills would be significant in influencing a plastic surgery resident's decision to pursue a career in academic plastic surgery. METHODS: A survey was sent to 30 consecutive graduates of a university plastic surgery residency program. This program had transitioned from a clinically focused independent residency-training model to an integrated model with a new and structured academic emphasis. Respondents who graduated after this transition ("ACADEMIC" n = 19) were compared with those who graduated before ("CLINICAL" n = 9). Results were analyzed using Fisher's exact test and Wilcoxon rank sum test. RESULTS: There were a total of 28 respondents (response rate = 93%). A higher percentage of the ACADEMIC group, in contrast to the CLINICAL group reported that they spent time during residency performing clinical research (84% versus 33%, P = 0.013), and that they are currently conducting clinical research in their practices (79% versus 0%, P < 0.001). These graduates were also more likely to have engaged their mentor both regarding professional issues (61% versus 0%, P = 0.016), and as a role model when choosing a career plan (72% versus 17%, P = 0.050). Finally, a higher percentage of the ACADEMIC exposed group entered an academic practice after training (44% versus 0%, P = 0.026). CONCLUSION: In a single plastic surgery residency program, the transition to strong academic mentorship with a structured academic educational program focus correlated with an increase in academic careers among program graduates. A proactive academically oriented educational and mentoring environment may help attract residents to careers in academic surgery.

Surgical Education Module Improves Operative Proficiency in Endoscopic Carpal Tunnel Release: A Blinded Randomized Controlled Trial of Trainees.

OBJECTIVE: The purpose of this study is to evaluate whether an interactive endoscopic carpal tunnel release (ECTR) surgical education module can improve knowledge of surgical indications and improve procedural competency. DESIGN: An ECTR education module was developed and trainees at various level of training were enrolled and randomized to surgical module and nonmodule (control) groups. Subjects were instructed that they would be the primary surgeon performing an ECTR. A written assessment was administered before and after module completion or independent case preparation to test comprehension of the procedure. The senior author evaluated each subject's intraoperative performance using a 5-point scoring system. Statistical analysis was performed using chi-square and paired t-tests. SETTING: This study took place at a tertiary care hospital at the University of Wisconsin. RESULTS: In all, 30 subjects were tested (15 surgical module and 15 nonmodule). There were no differences in prepreparation test scores between groups. Postpreparation test scores following use of the module were significantly higher compared to the nonmodule group. The average operation performance scores for the surgical module group and nonmodule group were 96% and 82%, respectively. The surgical module group performed significantly better on all operative steps except for dressing application. Surgical module subjects without prior ECTR experience (n = 7) had operative scores that were significantly higher than those for nonmodule subjects without previous ECTR experience (n = 8) (95% vs. 75%). There was no difference in operative scores between surgical module subjects with no prior experience (n = 7) and nonmodule subjects who had performed at least 1 prior case (n = 7) (95% vs. 89%). CONCLUSIONS: The use of an ECTR surgical education module demonstrates a significant benefit in ECTR-naïve subjects. When compared to subjects with previous ECTR experience, ECTR-naïve subjects trained using the surgical module demonstrate better familiarity with the equipment and equivalent performance of the procedure.

The Current State of Global Surgery Training in Plastic Surgery Residency.

BACKGROUND: The current state of global surgery training in U.S. plastic surgery residency programs remains largely undefined. METHODS: An electronic survey was distributed to Accreditation Council for Graduate Medical Education-certified plastic surgery residency programs. Programs with global health curricula were queried regarding classification, collaboration details, regions visited, conditions/procedures encountered, costs, accreditation, and personal sentiment. Residencies without global health curricula were asked to select barriers. RESULTS: Sixty-four of 81 residency programs returned questionnaires (response rate, 79 percent). Twenty-six programs (41 percent) reported including a formal global health curriculum; 38 did not (59 percent). When asked to classify this curriculum, most selected clinical care experience [n = 24 (92 percent)], followed by educational experience [n = 19 (73 percent)]. Personal reference was the most common means of establishing the international collaboration [n = 19 (73 percent)]. The most commonly encountered conditions were cleft lip-cleft palate [n = 26 (100 percent)], thermal injury [n = 17 (65 percent)], and posttraumatic reconstruction [n = 15 (57 percent)]. Dominant funding sources were primarily nonprofit organizations [n = 14 (53 percent)]. Although the majority of programs had not applied for residency review committee accreditation [n = 23 (88 percent)], many considered applying [n = 16 (62 percent)]. Overall, 96 percent of programs (n = 25) supported global health training in residency, choosing exposure to different health systems [n = 22 (88 percent)] and surgical education [n = 17 (68 percent)] as reasons. Programs not offering a global health experience most commonly reported lack of residency review committee/plastic surgery operative log recognition of cases performed abroad [n = 27 (71 percent)], funding for trip expenses [n = 25 (66 percent)], and salary support [n = 24 (63 percent)] as barriers. CONCLUSIONS: Residencies incorporating global health training describe the experience positively. Funding and case accreditation are the major obstacles to implementing these curricula.

Aggressive Digital Papillary Adenocarcinoma: Case Report of a Positive Sentinel Lymph Node and Discussion of Utility of Sentinel Lymph Node Biopsy.

Aggressive digital papillary adenocarcinoma (ADPA) is an uncommon eccrine sweat gland tumor of the distal extremities that is associated with a high rate of local recurrence and distant metastasis. Current opinion suggests that sentinel lymph node evaluation should be done for high-risk tumors where lymph node spread is a concern. Despite documented spread to regional lymph nodes, information on sentinel lymph node status in ADPA is reported infrequently, with only 1 documented case of positive findings. We report on a case of ADPA of the right long finger where sentinel lymph node biopsy was done and positive for metastases in the axilla, resulting in a subsequent completion lymphadenectomy. To determine the benefit of sentinel lymph node biopsy in ADPA, there is a need for more cases of sentinel lymph node evaluation along with data on local recurrence and distant metastasis in those with positive and negative findings.

Gouty flexor tenosynovitis of the digits: report of three cases.

Gouty tenosynovitis in the hand is a rare entity. To date the limited cases described have involved predominantly extensor tendons in the fingers and flexor tendons in the palm or wrist. Flexor tendon involvement is less common and has been reported only twice to our knowledge distal to the palm. We report 3 cases of extra-articular gout presenting as tophaceous involvement of flexor tendons in the fingers. All cases were treated surgically. These cases are presented to heighten awareness of this rare entity and to provide a setting for a discussion of management.