Update on the Selection Criteria of Plastic Surgery Residents: A Survey of Program Directors and Associate Program Directors.

BACKGROUND: Plastic and reconstructive surgery (PRS) is recognized as a highly competitive specialty. Since the first assessment of resident selection criteria in 2007, PRS residency programs have adopted holistic review processes and adapted to changes such as a decline in medical schools participating in the Alpha Omega Alpha Honor Medical Society as well as the recent transition to pass/fail grading for the United States Medical Licensing Examination (USMLE) step 1 examination (Schultz et al. Plast Reconstr Surg Glob Open . 2020;8:e2892; Tadisina et al. Plast Reconstr Surg . 2017;139:330e-331e). This study was devised to evaluate current PRS residency criteria in light of these changes. METHODS: An anonymous, 12-item, electronic survey was generated and distributed using Alchemer. An email was sent to 171 program directors (PDs) and associate program directors (APDs) of PRS residency programs. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. Complete responses were collected and analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109). RESULTS: In total, 44 (25.7% response rate) of the 171 PDs and APDs completed the survey. Of the 16 programs (36.4%) with a USMLE cutoff score, 7 (43.8%) reported a range of 230 to 239 and 6 (37.5%) reported a range of 240 to 249. Without a score for step 1, the majority (48.8%) of respondents believe that step 2 scores will replace step 1 scores in terms of assessment criteria, and the content of recommendation letters was selected as the criterion with the greatest increase in weight (66.7%). In addition, 27.3% of programs require a step 2 score at the time of interview. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, maturity, and interview performance. CONCLUSIONS: Plastic and reconstructive surgery remains a highly competitive specialty for residency applicants. Our findings suggest that Alpha Omega Alpha membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters.

Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery.

BACKGROUND: Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. METHODS: We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). RESULTS: Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific. CONCLUSION: Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

The Pathogenesis and Treatment of the Stiff Finger.

"Stiff finger," defined as a finger with decreased range of motion in one or more joints, is commonly found after hand injury and is classified into flexion or extension deformities. Pathogenesis is due to dysfunction in one or more of the following anatomic components: (1) osseous and articular; (2) capsuloligamentous; (3) musculotendinous units; (4) soft tissue and fascia. Evaluation and treatment are based on accurate identification and correction of pathologic structures. The mainstay of treatment is directed hand therapy with exercises and splinting to mobilize stiff joints. Operative interventions are offered after gains from therapy have been exhausted.

Outcomes of arterial bypass preceding resection of retroperitoneal masses involving major vessels.

BACKGROUND: Current surgical management of retroperitoneal masses involving major vessels now includes complete en bloc resection with in situ venous, arterial, or combined reconstruction. No studies have investigated preresection arterial bypass for continuous lower extremity perfusion during definitive resection. Here, we characterize and compare the outcomes of surgery for retroperitoneal masses with major vascular involvement by a two-stage approach (femoral-femoral bypass preceding resection) and the traditional one-stage approach (consecutive resection and in situ vascular reconstruction). MATERIALS AND METHODS: We retrospectively reviewed patients who underwent resection of retroperitoneal masses and reconstruction of major arterial or venous structures from 2004 to 2016. Outcomes were compared with unpaired t-tests, chi-squared tests, and Kaplan-Meier analysis. RESULTS: Eight patients underwent a two-stage procedure, and seven underwent a one-stage procedure for retroperitoneal masses with vascular involvement. Mean (±SD) oncologic resection time (443 ± 215 versus 648 ± 128 min, P = 0.047) and postoperative ICU stay (0.9 ± 1.3 versus 4.4 ± 2.9 d, P = 0.018) were significantly shorter for the two-stage approach. CONCLUSIONS: To our knowledge, this is the first report of a two-stage approach for resection of retroperitoneal masses with major vessel involvement. Femoral-femoral arterial bypass before definitive resection could be a viable option for improving intraoperative vascular control and decreasing perioperative complications in these complex procedures.

Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment.

BACKGROUND: The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes. METHODS: Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed. RESULTS: The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025). CONCLUSIONS: Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Anesthesia duration as a marker for surgical complications in office-based plastic surgery.

BACKGROUND: Office-based plastic surgery has continued to rise in the past 2 decades with the increased demand for cosmetic surgery. Although several large studies have shown the safety of office-based surgery, current regulations place some restrictions on ambulatory office-based surgical facilities. To provide further evidence-based literature on the safety of office-based plastic surgery, we examine surgical complication rates as a function of anesthesia duration. METHODS: This is a retrospective review of 2595 patients who underwent office-based plastic surgery procedures between October 2000 and January 2005. All patients received general anesthesia for a broad range of cosmetic surgeries. The primary measured outcome was minor and major surgical complications. Complication rates were examined as a function of anesthesia duration of less than or greater than 4 hours. The follow-up period was 30 days. Statistical analysis was completed using SPSS v.19. RESULTS: Most of the patients were female with an average age of 41 years. An increase in the occurrence of minor surgical complications such as postoperative nausea and vomiting (2.8% vs 5.7%, P=0.0175) and urinary retention (0.7% vs 7.6%, P<0.0001) was noted in the greater than 4-hour anesthesia duration group. Overall, there were 66 (2.5%) patients that required reoperation because of surgical complications with no statistical difference between the 2 groups (P=0.098). The only major morbidities were 1 pulmonary embolism (<4 hours) and 1 deep vein thrombosis (>4 hours). Five (0.19%) patients were admitted to the hospital during the follow-up period for surgical and/or medical management (3 hematomas, 1 deep vein thrombosis, and 1 pulmonary embolism). There were no cases of reintubation, major cardiac complications, or death in this series. CONCLUSIONS: Duration of general anesthesia in office-based plastic surgery does not seem to be an indicator of major morbidity and mortality. Although minor complications such as postoperative nausea and vomiting and urinary retention were higher in patients with anesthesia greater than 4 hours, there was no significant increase in major complications. Change in surgical venue would not likely alter the outcome of the increase in minor complications. Therefore, anesthesia duration should not be used as a guideline for safety of office-based plastic surgery.

Mirror-image trigger thumb in dichorionic identical twins.

The congenital vs acquired etiology of pediatric trigger thumb is the subject of considerable debate. Existing case reports of bilateral presentation in identical twins and first-degree familial association support the congenital hypothesis. However, prospective studies have yet to report a neonate presenting with this anomaly at birth. This article describes the first known set of dichorionic, monozygotic identical twins with unilateral trigger thumbs, affecting contralateral (mirror-image) hands and with asynchronous age at presentation (11 months and 18 months, respectively).Pediatric trigger thumb is caused by a mismatch between the flexor pollicis longus tendon and its A1 synovial pulley. Four sets of twins have been previously reported in the literature with trigger thumb. Of these, 3 sets were monozygotic twins who had bilaterally affected thumbs. Together with the absence of trauma, a congenital etiology was suggested. The fact that pediatric trigger thumb is generally seen several months after birth was felt to be due to infants holding their thumbs clutched in their palms until 6 months. However, no confirmed cases of trigger thumb have been diagnosed at birth in several large prospective studies of newborns.In the current case, the asynchronous presentation of unilateral trigger thumbs in identical twins does not support a solely congenital cause. Furthermore, the mirror-image presentation contradicts current embryological understanding of the temporal course of twinning and the determination of laterality. Thus, a multifactorial etiology is supported with both a genetic and acquired component affecting the development of this condition.

Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.

BACKGROUND: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment. METHODS: The authors conducted a prospective clinical trial of tissue expander-implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis. RESULTS: Fifty-one tissue expander-implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity. CONCLUSIONS: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Factors associated with poor healing and recurrence of venous ulceration.

BACKGROUND: Plastic surgeons are often approached for wound management and closure of chronic venous ulcers that fail to heal despite multimodal management. The authors present a retrospective analysis of a large series of venous ulcers to determine factors predicting nonhealing and recurrence. METHODS: Consecutive patients with chronic venous ulcers (≥ 2-cm diameter) were examined for the presence of superficial, perforating, or deep venous disease, including reflux and/or obstruction. Treatment included compression, venous ligation, stripping, thermal ablation, sclerotherapy, and local wound care. Ulcers refractory to 6 months of treatment were defined as nonhealing ulcers. Data were analyzed for differences in baseline patient and ulcer characteristics and clinical course of nonhealing ulcers. Data were compared using Wilcoxon rank sum, chi-square, and Fisher's exact tests using Sigma Stat and SPSS, with α set at p < 0.05. RESULTS: The authors identified 153 ulcers in 127 patients. Factors associated with ulcer nonhealing included advanced age, increased body mass index, history of deep venous thrombosis, noncompliance with compression therapy, and large ulcer area. One hundred thirty-one of the ulcers (85.6 percent) healed within 6 months and 147 (96 percent) of the ulcers ultimately healed without the need for operative plastic surgical intervention. CONCLUSIONS: A thorough understanding of risks and expected clinical course is required for assessment of the nonhealing venous ulcer. The authors recommend identification and correction of underlying venous abnormality and a minimum of at least 6 months of compression and local wound care followed by reassessment of venous function before operative plastic surgical intervention should be considered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Current practice among plastic surgeons of antibiotic prophylaxis and closed-suction drains in breast reconstruction: experience, evidence, and implications for postoperative care.

BACKGROUND: Despite their widespread use, there are no evidence-based guidelines on the management of closed-suction drains or antibiotics in postmastectomy breast reconstruction. The purpose of this study was to assess consensus and variation in postoperative care among plastic surgeons. METHODS: The authors designed and administered a self-reported, anonymous survey to 4669 American Society of Plastic Surgeons and Canadian Society of Plastic Surgeons members in October 2009. RESULTS: A total of 650 completed surveys were available for analysis. A majority (>81%) of respondents reported using closed-suction drains in breast reconstruction. Most surgeons (>93%) used a volume criteria for drain removal, most commonly when drain output was ≤30 mL over 24 hours (>86%). Preoperative antibiotic use was nearly universal (98%), usually consisting of intravenous cefazolin (97%). Postoperative care demonstrated less uniformity with outpatient antibiotics administered by 72% of respondents. Surgeons were divided on when to discontinue outpatient antibiotics: 46% preferred concomitant discontinuation with drains, whereas 52% preferred a specific postoperative day. No clear consensus was observed for the number (1 or 2) or type (Jackson-Pratt or Blake) of drains used. Respondents were further divided on the restriction of postoperative showering with drains and the use of acellular dermal matrix. CONCLUSIONS: These results demonstrate a consensus for drain use, drain removal, and preoperative antibiotic administration. There was no consensus for number or type of drain used, postoperative antibiotic use, shower restrictions, and use of acellular dermal matrix. Our results further emphasize the need for evidence-based postoperative-care guidelines specific to breast reconstruction.

The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast reconstruction.

Tissue expander/implant breast reconstructions by 5 surgeons at a single institution from 2005 to 2008 were retrospectively identified and divided into 2 cohorts: use of acellular dermal matrix (ADM, n = 75) versus standard submuscular placement (n = 52). The ADM group had a statistically significant higher rate of infection (28.9% vs. 12.0%, P = 0.022), reoperation (25.0% vs. 8.0%, P = 0.011), expander explantation (19.2% vs. 5.3%, P = 0.020), and overall complications (46.2% vs. 22.7%, P = 0.007). When stratifying by breast size, a higher complication rate was not observed with the use of ADM in breasts less than 600 g, whereas ADM use in breasts larger than 600 g was associated with a statistically significant higher rate of infection when controlling for the occurrence of skin necrosis. The ADM cohort had a significantly higher mean initial tissue expander fill volume (256 mL vs. 74 mL, P < 0.001) and a significantly higher mean initial tissue expander fill ratio (49% vs. 17%, P < 0.001). Further work is needed to define the ideal patient population for ADM use in tissue expander/implant breast reconstruction.