Perforator Dissection Porcine Abdominal Model: A Novel Simulator to Improve Microsurgical Training

BACKGROUND

 Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as microsurgical training models, significant drawbacks limit their use. We recently developed a latex-perfused, nonliving, porcine abdomen perforator dissection simulation and described its anatomic similarity to the human deep inferior epigastric artery flap. The purpose was to assess the change in resident confidence in performing key operative steps of flap elevation and perforator dissection and obtain feedback on model realism and utility.

METHODS

 Seventeen plastic and reconstructive surgery resident physicians (postgraduate years 1-6) at a single institution participated in a perforator dissection session utilizing the simulation model. Each resident completed pre- and postactivity surveys to assess interval change in confidence in operating. The postactivity survey also asked residents to answer questions regarding their perception of the model's anatomic and surgical realism and utility in microsurgical training.

RESULTS

 Following a practice session using the latex-perfused, nonliving porcine abdomen, resident confidence was significantly increased in performing all key operative steps and the procedure overall (p = 0.001). All residents (n = 17, 100%) believed the model would improve "trainees' ability to perform perforator dissection in the operating room." Perforator, fascial, and pedicle anatomy were reported to be "Very" similar to human anatomy, with a median Likert score (MLS) of 4. Additionally, six out of the eight surgical steps were noted to be "Very" realistic, with only "Flap Design" and "Fascial Closure" found to be "Moderately" realistic with an MLS of 3.

CONCLUSION

 The latex-infused porcine abdominal model is a novel, realistic simulation for microsurgical trainee perforator dissection practice. This model offers a suitable substitute for perforator dissection practice, as its implementation within a microsurgery training course improves resident comfort and confidence.

Latex-Infused Porcine Abdominal Model: A Novel Microsurgery Simulator for Deep Inferior Epigastric Perforator Dissection

BACKGROUND

 Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as a microsurgical training model, there are significant drawbacks that limit their use, including cost, limited ability for repetition, and obstacles associated with animal care. Here we describe the creation of a novel perforator dissection model using latex augmented non-living porcine abdominal walls. We provide anatomic measurements that demonstrate valuable similarities and differences to human anatomy to maximize microsurgical trainee practice.

METHODS

 Six latex-infused porcine abdomens were dissected based on the deep cranial epigastric artery (DCEA). Dissection was centered over the abdominal wall mid-segment between the second and fourth nipple line. Dissection steps included exposure of lateral and medial row perforators, incision of anterior rectus sheath with perforator dissection, and dissection of DCEA pedicle. DCEA pedicle and perforator measurements were compared with deep inferior epigastric artery (DIEA) data in the literature.

RESULTS

 An average of seven perforators were consistently identified within each flap. Assembly of the model was performed quickly and allowed for two training sessions per specimen. Porcine abdominal walls demonstrate similar DCEA pedicle (2.6 ± 0.21 mm) and perforator (1.0 ± 0.18 mm) size compared with a human's DIEA (2.7 ± 0.27 mm, 1.1 ± 0.85 mm).

CONCLUSION

 The latex-infused porcine abdominal model is a novel, realistic simulation for perforator dissection practice for microsurgical trainees. Impact on resident comfort and confidence within a microsurgical training course is forthcoming.

Trigeminal or peripheral nerve stimulation improves functional outcomes of nerve recovery in a rodent forelimb gap repair model

BACKGROUND

The hypothesis of this study was that trigeminal nerve stimulation (TNS) or peripheral nerve stimulation (PNS) could improve functional outcomes of peripheral nerve injury in a rat forelimb model when compared to control rats not receiving electrical stimulation (ES). While PNS is known to improve outcomes after nerve surgery, the role of TNS has not been explored.

METHODS

Lewis rats were trained to perform a reach and grasp task before receiving a 2 mm gap repair of the ulnar and median nerves and randomized into four treatment groups: (1) sham injury, (2) nerve injury with sham ES, (3) nerve injury with PNS, and (4) nerve injury with TNS. Functional motor (median pull force and percent success in motor task) and sensory metrics (forelimb paw withdrawal thresholds) were collected both pre-injury and throughout rehabilitation. Nerves stained using Gomori's trichrome were assessed quantitatively and qualitatively.

RESULTS

The sham ES group did not recover their pre-injury baseline functional outcomes. In contrast, the TNS and PNS groups fully recovered following injury, with no difference in functional outcomes between the pre-injury baseline and the final week of rehabilitation (P > 0.05, all). Histomorphology results demonstrated no quantitative difference, but qualitative differences in architecture were evident.

CONCLUSIONS

Electrical stimulation of the trigeminal nerve or the injured nerve improved the functional outcomes of nerve regeneration in rodents. Histomorphology results of nerves from the TNS group support the proposed central mechanisms. This is an important step in translating this therapy as an adjunct, non-invasive treatment for high, mixed nerve injuries in humans.

Evaluation of a Full-Time Microsurgeon Educator on Resident Training, Research Collaboration, and Grant Funding

BACKGROUND

 The value of a fully trained microsurgeon dedicated to a laboratory setting at an academic institution is largely unknown. Microsurgery training lacks a national standard despite its highly complicated nature. Our study aims to evaluate the impact of a single laboratory-dedicated microsurgeon on the microsurgical training of integrated plastic surgery residents and collaborative efforts in research.

METHOD

 We devised a three-faceted microsurgical training curriculum, including a collaborative multi-institutional microsurgery course, novel high-fidelity simulator models, and a dedicated microsurgeon. We cataloged grant funding achieved through support to other divisions' protocols. Time, in hours, spent on training and the number of anastomoses completed with the microsurgical educator in a laboratory setting over a 4-year period (2017-2021) were evaluated. Resident independence scores were collected from attending microsurgeons to quantify the translation of microsurgical training.

RESULTS

 Purchasing and maintenance costs of rats in our rodent facility decreased by $16,533.60 as 198 rats were replaced by our models. The residents who participated in our novel microsurgical training program were able to independently perform anastomoses in the OR by their postgraduate year 6. Additionally, the surgical support offered by our laboratory-dedicated microsurgeon led to a total of $24,171,921 in grant funding between 2017 and 2020.

CONCLUSION

 Hiring an expert microsurgical educator to train residents in a laboratory has proved promising in accelerating microsurgical mastery. Novel training modules, alternatives to animal models, save resources in housing and animal costs. The addition of a research-oriented-microsurgeon has improved collaborative efforts to advance a range of surgical fields.

Management of common conditions of the musician: a narrative review for plastic surgeons

Career-related injuries and disorders in professional musicians are prevalent across all their respective instruments and fields. They often endure long hours of intensive practice that demand high levels of precision, dexterity, and flexibility of their head, neck, hands, and upper extremities. Unlike the average patient, musicians are sensitive to even mild symptoms and deficits that can interfere with performance, which can potentially be career-threatening. Increasing attention to the care of musicians motivated performing arts medicine to tailor the practice to their individual and unique needs. Plastic surgeons are at the forefront of this practice; however, there are very limited reviews discussing plastic surgery management of the common injuries and disorders in musicians. This article reviews the most relevant literature of the past several decades regarding treatment modalities of the most common conditions endured by professional instrumentalists, with an emphasis on surgical considerations in the field of plastic surgery. A thorough literature search was performed for articles that encompass the interface between plastic surgery and musicians. We examined disorders of the head, ears, eyes, nose, throat, hands, and upper extremities including stress velopharyngeal incompetence, disruption of the embouchure, nerve entrapments, arthritis, traumatic injuries, focal dystonia, Linburg-Comstock syndrome, and overuse disorder. Overall, the goal of this review is to provide a summary of the existing and successful procedures performed to address prevalent musician conditions.

Rise Above the Competition: How Do Plastic Surgery Residency Applicants with NCAA Experience Fare in the Residency Match?

BACKGROUND

The integrated plastic surgery residency match continues to be highly competitive. Every year, some candidates are former NCAA athletes. While it is challenging to balance academic and athletic responsibilities, participation in NCAA sports may be predictive of continued success.

OBJECTIVES

This study aimed to evaluate the impact of participation in collegiate athletics on applicant anticipated rank and academic success.

METHODS

All applications received from 2017 to 2020 at a single institution were reviewed for participation in NCAA athletics (Division I-III). Our primary outcome of interest was applicant anticipated rank by letter of reference writers. Applications were also examined for demographic information, membership in AOA, number of research publications, and USMLE board certification examination scores.

RESULTS

After reviewing 885 applications, 61 applicants (6.89%) were former NCAA athletes. Former NCAA involvement was associated with the highest effect on anticipated ranking (- 0.22, p=0.001). Former NCAA involvement demonstrated the highest odds of receiving an anticipated ranking in the top 5 (OR 1.83, p=0.025). We found no significant difference in research productivity between the two groups, including first authorships or USMLE Step 1 board certification exam scores. A significant difference was seen in race distribution, with forty-five (80.4%) of athlete applicants identifying as Caucasian, while 430 (56.5%) of non-athletes identified as Caucasian (p=0.012).

CONCLUSION

Former athletes applying to become integrated plastic surgery residents overcome the challenges of balancing athletic and academic pursuits with a higher anticipated rank in the integrated plastic surgery match while having comparable academic achievement. Former collegiate athletes have demonstrated greater success in and after residency. Former NCAA participation demonstrated the highest odds of receiving a top-5 rank. Former NCAA applicants showed no difference in academic productivity LEVEL OF EVIDENCE V: Case series study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Database Tracking in Gender-Affirming Surgery: Are Patients Falling Through the Cracks?

BACKGROUND

This study sought to examine risk factors for venous thromboembolism in transfeminine vaginoplasty. Secondarily, the authors outline reasons why patients are not adequately classified for research purposes despite using relevant queried codes.

METHODS

Transgender patients undergoing vaginoplasty were identified with diagnostic and procedure-specific codes using a national surgical database from 2010 through 2019.

RESULTS

There were 457 transgender vaginoplasties performed, with 24 wound dehiscences, 17 unplanned reoperations, and 12 surgical site infections. With zero cases of venous thromboembolism, risk factor analysis was deferred.

CONCLUSIONS

Heterogeneity in coding practices for gender-affirming surgery led to an uncharacteristically small cohort of transfeminine vaginoplasty patients captured in the database. Current diagnostic and procedure-specific codes are nonspecific and unbundled, hindering accurate assessment of the incidence of standard surgical complications.

Surgical and demographic predictors of free flap salvage after takeback: A systematic review

BACKGROUND

Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage.

METHODS

A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis.

RESULTS

The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure.

CONCLUSIONS

Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.

Efficacy of bone stimulators in large-animal models and humans may be limited by weak electric fields reaching fracture

Noninvasive electronic bone growth stimulators (EBGSs) have been in clinical use for decades. However, systematic reviews show inconsistent and limited clinical efficacy. Further, noninvasive EBGS studies in small animals, where the stimulation electrode is closer to the fracture site, have shown promising efficacy, which has not translated to large animals or humans. We propose that this is due to the weaker electric fields reaching the fracture site when scaling from small animals to large animals and humans. To address this gap, we measured the electric field strength reaching the bone during noninvasive EBGS therapy in human and sheep cadaver legs and in finite element method (FEM) models of human and sheep legs. During application of 1100 V/m with an external EBGS, only 21 V/m reached the fracture site in humans. Substantially weaker electric fields reached the fracture site during the later stages of healing and at increased bone depths. To augment the electric field strength reaching the fracture site during noninvasive EBGS therapy, we introduced the Injectrode, an injectable electrode that spans the distance between the bone and subcutaneous tissue. Our study lays the groundwork to improve the efficacy of noninvasive EBGSs by increasing the electric field strength reaching the fracture site.

Diversity Drives Innovation: The Impact of Female-Driven Publications

BACKGROUND

Gender disparities are pervasive in academic plastic surgery. Previous research demonstrates articles authored by women receive fewer citations than those written by men, suggesting the presence of implicit gender bias.

OBJECTIVES

The aim of this study was to describe current citation trends in plastic surgery literature and assess gender bias. The expectation was that women would be cited less frequently than their male peers.

METHODS

Articles published between 2017 and 2019 were collected from 8 representative plastic surgery journals stratified by impact factor. Names of primary and senior authors of the 50 most cited articles per year per journal were collected and author gender was determined via online database and internet search. The median numbers of citations by primary and senior author gender were compared by Kruskal-Wallis test.

RESULTS

Among 1167 articles, women wrote 27.3% as primary author and 18% as senior author. Women-authored articles were cited as often as those authored by men (P > 0.05) across all journal tiers. Articles with a female primary and male senior author had significantly more citations than articles with a male primary author (P = 0.038).

CONCLUSIONS

No implicit gender bias was identified in citation trends, a finding unique to plastic surgery. Women primary authors are cited more often than male primary authors despite women comprising a small fraction of authorship overall. Additionally, variegated authorship pairings outperformed homogeneous ones. Therefore, increasing gender diversity within plastic surgery academia remains critical.

To Decline or Accept: A Guide for Determining the Legitimacy of Academic Conference Invitations

IMPORTANCE

After the rise of predatory journals characterized by false claims of legitimacy and a pay-to-publish model, similar "predatory conferences" have become increasingly common. The email inbox of an academic physician can be filled with daily announcements encouraging conference attendance, abstract submission, and often panel or keynote speaker invitations. It therefore becomes important for the plastic surgeon to be able to discern whether these invitations are from "predatory" conferences or legitimate career advancement opportunities, especially early in practice.

OBJECTIVE

To aid the invited physician in determining the legitimacy of a conference, we aimed to characterize objective features of conferences for which email invitations have been received and use this information to build a decision-making guide.

DESIGN

We analyzed all conference invitations received by the email of one academic plastic surgeon in a 4-month period. These conferences were organized into 3 groups based on affiliation with known professional societies. The following information was collected if available: affiliation with a professional society, type of invitation, conference location, conference format (in-person, virtual, or hybrid), conference title, conference fees, conference organizer, associated journals or publishers, abstract journal submission, grammar, headshots, time to abstract review, and acceptance.

RESULTS

There were 56 unique conference invitations. These were categorized into 15 affiliated conferences, 28 unaffiliated conferences, and 17 conferences of undetermined affiliation. Unaffiliated conferences were more likely to solicit speaker invitations ( P < 0.001), claim to be "international" ( P = 0.001), send emails with grammatical errors ( P < 0.001), use unprofessional headshots on the conference Web site ( P < 0.001), and have reduced virtual conference fees ( P = 0.0032) as compared with conferences affiliated with known professional societies. When comparing the attendance and presenter fees of in-person venues, there was no significant difference between affiliated and unaffiliated conferences ( P = 0.973, P = 0.604). Affiliated conferences were more likely to take place in the United States ( P = 0.014).

CONCLUSIONS AND RELEVANCE

We present a method to quickly assess the legitimacy of an academic meeting by way of a few important questions. Based on our findings, emails soliciting conference speakers, claims of international presence, grammatical errors, unprofessional headshots, and reduced virtual conference fees are all characteristics that should raise red flags.

Electrical Stimulation of Acute Fractures: A Narrative Review of Stimulation Protocols and Device Specifications

Orthopedic fractures have a significant impact on patients in the form of economic loss and functional impairment. Beyond the standard methods of reduction and fixation, one adjunct that has been explored since the late 1970s is electrical stimulation. Despite robust evidence for efficacy in the preclinical arena, human trials have mixed results, and this technology is not widely accepted. The purpose of this review is to examine the body of literature supporting electrical stimulation for the purpose of fracture healing in humans with an emphasis on device specifications and stimulation protocols and delineate a minimum reporting checklist for future studies of this type. We have isolated 12 studies that pertain to the administration of electrical stimulation for the purpose of augmenting fracture healing in humans. Of these, one was a direct current electrical stimulation study. Six studies utilized pulsed electromagnetic field therapy and five used capacitive coupling. When examining these studies, the device specifications were heterogenous and often incomplete in what they reported, which rendered studies unrepeatable. The stimulation protocols also varied greatly study to study. To demonstrate efficacy of electrical stimulation for fractures, the authors recommend isolating a fracture type that is prone to nonunion to maximize the electrical stimulation effect, a homogenous study population so as to not dilute the effect of electrical stimulation, and increasing scientific rigor in the form of pre-registration, blinding, and sham controls. Finally, we introduce the critical components of minimum device specification reporting for repeatability of studies of this type.

Electronic Bone Growth Stimulators for Augmentation of Osteogenesis in In Vitro and In Vivo Models: A Narrative Review of Electrical Stimulation Mechanisms and Device Specifications

Since the piezoelectric quality of bone was discovered in 1957, scientists have applied exogenous electrical stimulation for the purpose of healing. Despite the efforts made over the past 60 years, electronic bone growth stimulators are not in common clinical use. Reasons for this include high cost and lack of faith in the efficacy of bone growth stimulators on behalf of clinicians. The purpose of this narrative review is to examine the preclinical body of literature supporting electrical stimulation and its effect on bone properties and elucidate gaps in clinical translation with an emphasis on device specifications and mechanisms of action. When examining these studies, trends become apparent. In vitro and small animal studies are successful in inducing osteogenesis with all electrical stimulation modalities: direct current, pulsed electromagnetic field, and capacitive coupling. However, large animal studies are largely unsuccessful with the non-invasive modalities. This may be due to issues of scale and thickness of tissue planes with varying levels of resistivity, not present in small animal models. Additionally, it is difficult to draw conclusions from studies due to the varying units of stimulation strength and stimulation protocols and incomplete device specification reporting. To better understand the disconnect between the large and small animal model, the authors recommend increasing scientific rigor for these studies and reporting a novel minimum set of parameters depending on the stimulation modality.

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

BACKGROUND

There is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one's perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age.

OBJECTIVES

The authors hypothesized that covering the lower third of the face with a mask will make a person appear younger.

METHODS

One hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients' age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis.

RESULTS

Masked patients on average appeared 6.17% younger (mean difference = 3.16 years, P < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, P = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age (P = 0.0617) and patients BMI > 35 (P = 0.5084).

CONCLUSIONS

The mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.

Pyoderma gangrenosum demographics, treatments, and outcomes: an analysis of 2,273 cases

OBJECTIVE

Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis. This condition has clinical features analogous to infectious processes and must be quickly diagnosed to be properly treated. The purpose of this study was to characterise relevant clinical features associated with pyoderma gangrenosum based on a large inpatient cohort.

METHOD

The National Inpatient Sample (US) was used to identify patients with the diagnosis of pyoderma gangrenosum using ICD-9 diagnosis code 686.01, during the years 2008-2010. Data was collected on demographics, associated diagnoses, treatments and outcomes. Data analysis was performed using SAS 9.3 software.

RESULTS

A total of 2,273 adult patients were identified with pyoderma gangrenosum. Mean age was 56 years; 66.4% were female; 71.1% were Caucasian. Pyoderma gangrenosum was the primary diagnosis in 22.6% of patients, followed by cellulitis (9.4%), inflammatory bowel disease (IBD) (6.9%), wound/ulcer (5.4%), sepsis (4.7%), and postoperative infection/complication (2.7%). The most common procedures performed were wound debridement (5.3%), skin biopsy (5.1%), esophagogastroduodenoscopy (2%), large bowel biopsy (1.9%), and incision and drainage (1.1%). A total of 74 patients (3.2%) died during hospitalisation.

CONCLUSION

Pyoderma gangrenosum is a serious skin condition, frequently associated with systemic disease, and often confused with other skin pathergies. Pyoderma gangrenosum should be considered when evaluating patients with ulcers, wounds, and post-operative complications. A high index of suspicion is necessary for early and accurate diagnosis and prompt treatment.