What Technique Results in the Lowest Rate of Velopharyngeal Insufficiency in Patients With Submucous Cleft Palate? A Systematic Review and Meta-Analysis

Objective: To determine which surgical technique offers the lowest rate of velopharyngeal insufficiency (VPI) without the need for further operative intervention, in pediatric patients with nonsyndromic submucous cleft palate (SMCP). Methods: This systematic review and meta-analysis included articles reporting on nonsyndromic pediatric patients treated surgically during childhood for SMCP, with data on postoperative speech outcomes and/or recommendations for secondary surgery. Main outcome measures included rates of unfavorable speech outcomes defined as persistent VPI requiring secondary surgery and speech outcome data. Results: 15 articles met our inclusion criteria, reporting on 383 children who underwent surgical treatment; 343 patients were included in studies reporting recommendations for secondary surgery. There was 1 randomized comparative trial, 4 comparative studies, and 10 single cohort studies. Eight articles used validated speech assessment tools. Our model showed the proportion of patients recommended for secondary surgery varied between techniques, ranging from 0.0% (CI 0.0, 1000) in pharyngeal flap to 17.8% (CI 8.9, 32.5) in straight line repair techniques, but there was no statistically significant difference between treatments (P = .33). Speech improvement ranged from 44.4% to 100%, with 9 studies recommending secondary surgery for some of their patient series. Conclusions: Although not of statistical significance, pharyngeal flap yields the lowest rate of reoperation as a primary technique for pediatric patients with nonsyndromic SMCP. Delayed repair age inherent to SMCP may render operations that rely on a functional levator muscle with less favorable outcomes. The absence of standardized surgical techniques, speech outcomes, speech therapy, and assessment make comparative analysis and recommendation difficult. We advocate for standardized speech assessment tools to improve future quantitative assessment of cleft surgery outcomes and a randomized controlled trial to better elucidate the preferred first-line technique.

Pediatric Hand Fracture Outcomes: How Often Do We Need to Operate?

Purpose: Pediatric hand fractures are frequent presentations to the emergency department. This study set out to evaluate the epidemiology, management, and outcomes, where care was imparted and by whom, and offer resource utilization suggestions regarding pediatric fractures presenting to a Canadian pediatric hospital. Methods: Records of patients from 0 to 18 years of age who presented to the British Columbia Children's Hospital Emergency Department between November 1, 2016, and January 31, 2021, with metacarpal or phalangeal fractures were analyzed. Results: A total of 524 hand fractures were identified in 499 patients. Over 60% of fractures occurred in boys. The number of fractures peaked at the age of 11 years for girls and 12 years for boys. Open fractures accounted for only 4.0% of all fractures. Approximately 40% of fractures were epiphyseal growth plate fractures, with Salter-Harris II fractures being the most common diagnosis overall. Management was primarily nonsurgical, with 75% of fractures managed with immobilization alone and 23% of fractures managed with bedside closed reduction and immobilization. Of the fractures requiring closed reduction, the majority were performed by the emergency physician with a success rate of 82%. Only 2.3% of all fractures required surgery. Conclusions: Hand fractures are common pediatric injuries and make up a large proportion of emergency room visits. The majority of fractures do not require formal surgery and are well managed with immobilization alone or closed reduction by an emergency room physician and immobilization. Nonsurgical treatment offers very encouraging outcomes. A certain percentage of these simple fractures would likely benefit from primary care management alone and not require specialist intervention.

Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations

OBJECTIVE

Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique.

RESULTS

Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation.

CONCLUSIONS

A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.

A Randomized Controlled Trial of Virtual Reality in Awake Minor Pediatric Plastic Surgery Procedures

BACKGROUND

Virtual reality has been used to alleviate pain and anxiety in a variety of medical procedures. The authors sought to explore the effects of virtual reality in common awake minor plastic surgery procedures where children may experience discomfort.

METHODS

A randomized controlled trial compared virtual reality to standard-of-care distraction among children aged 6 to 16 years undergoing awake minor plastic surgery procedures at a quaternary children's hospital. Primary outcome was change in Faces Pain Scale-Revised pain score, and secondary outcomes included change in Venham Situational Anxiety Scale score, procedure duration, administration of local anesthetic, and pain/anxiety management satisfaction.

RESULTS

Mean pain and anxiety scores were similar in both groups (p = 0.60 and p = 0.18, respectively), and procedure duration was shorter with virtual reality (22 minutes versus 29 minutes; p = 0.002). Duration remained shorter in a linear regression model accounting for procedure type (p = 0.01). Similar proportions of children received additional local anesthetic after the initial dose (virtual reality, n = 6; standard of care, n = 9; p = 0.19) and median pain management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.41). Median anxiety management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.05). Younger children reported more "fun" than older children with virtual reality (p = 0.02). Surgeons reported interest "using virtual reality again" in 83 percent of cases.

CONCLUSIONS

The use of virtual reality for awake pediatric plastic surgery reduced procedure time but not pain or anxiety compared to standard of care in children aged 6 to 16 years. Virtual reality was safe and well-liked and should be considered as an additional tool. Increased efficiency may allow more cases to be performed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Through-and-Through Dissection of the Soft Palate for Pharyngeal Flap Inset: A "Good-Fast-Cheap" Technique for Any Etiology of Velopharyngeal Incompetence

OBJECTIVE

To determine the efficacy and resource utilization of through-and-through dissection of the soft palate for pharyngeal flap inset for velopharyngeal incompetence (VPI) of any indication.

DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

Thirty patients were included. Inclusion criteria were diagnosis of severe VPI based on perceptual speech assessment, confirmed by nasoendoscopy or videofluoroscopy; VPI managed surgically with modified pharyngeal flap with through-and-through dissection of the soft palate; and minimum 6 months follow-up. Patients with 22q11.2 deletion syndrome were excluded.

INTERVENTION

Modified pharyngeal flap with through-and-through dissection of the soft palate.

MAIN OUTCOME MEASURE(S)

Velopharyngeal competence and speech assessed using the Speech-Language Pathologist 3 scale.

RESULTS

The median preoperative speech score was 11 of 13 (range, 7 to 13), which improved significantly to a median postoperative score of 1 of 13 (range 0-7; P < .001). Velopharyngeal competence was restored in 25 (83%) patients, borderline competence in 3 (10%), and VPI persisted in 2 (7%) patients. Complications included 1 palatal fistula that required elective revision and 1 mild obstructive sleep apnea that did not require flap takedown. Median skin-to-skin operative time was 73.5 minutes, and median length of stay (LOS) was 50.3 hours.

CONCLUSIONS

This technique allows direct visualization of flap placement and largely restores velopharyngeal competence irrespective of VPI etiology, with low complication rates. Short operative time and LOS extend the value proposition, making this technique not only efficacious but also a resource-efficient option for surgical management of severe VPI.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis

Background:

Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids.

Methods:

We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality.

Results:

A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found.

Conclusions:

Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

The Presence of Ghost Publications Among Canadian Plastic Surgery Residency Applicants: How Honest Are Canadians?

Background:

Physicians with history of unprofessional behaviour during their medical training are shown to be 3 times more likely to have board disciplinary action later in their career. One realm in which unprofessional behaviour takes place is the phenomenon of unverifiable publications or “ghost publications.” To that end, this study aims to assess the rate of ghost publications among a recent cohort of Canadian Plastic Surgery residency applicants to determine if this phenomenon is geographic in nature.

Methods:

The current study was a retrospective, cross-sectional observational study; a review of all residency applications submitted to a single Canadian Plastic Surgery residency program from 2015 to 2018 was performed and all their listed publications were verified for accuracy. The review was conducted by a third party librarian and a research coordinator blinded to the authors identifying information. “Ghost publication” was defined as any publication listed as “published,” “accepted,” or “in-press” that did not exist in the literature.

Results:

A total of 196 applications of 186 applicants were submitted over the span of 4 years. A total of 362 publications listed as peer-reviewed articles, belonging to 114 applications were extracted and reviewed. Among the 362 publications listed as peer-reviewed articles, 2 could not be found in the literature (0.55%). Additionally, 42 citations were found with 48 minor differences than what was cited.

Conclusions:

The rate of ghost publications among recent applicants to a Plastic Surgery residency program is low (less than 1%). Future studies should investigate methods to further improve and instill the value of professionalism in our future plastic surgery trainees.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

Background

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

Methods

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

Results

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

Conclusions

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Image guided sclerotherapy for the treatment of venous malformations

Background

Percutaneous sclerotherapy is the preferred method of treatment for VMs (venous malformations). However, treatment protocols vary, and research on the most effective sclerosant is conflicting. Additionally, there is limited knowledge on the effect of sclerosant volume on treatment outcome. This study aims to determine the outcomes and complications of image-guided sclerotherapy for VMs with respect to sclerosant and sclerosant volume. Towards this, a 10-year retrospective chart review was conducted of patients with VMs treated with sclerotherapy at the Vascular Anomalies Clinic at British Columbia Children’s Hospital.

Results

Thirty-four patients with VMs were treated of which 15 had a successful outcome, 13 had a failed outcome, and 6 had additional planned treatments after the study time period. Lesions on the head and neck or classified as type I or II had the highest success rates. Combination therapy with both ethanol and 3% STS (sodium tetradecyl sulphate), and ethanol alone had a higher success rate (64% and 60%) compared to 3% STS (11%). Major complications were most associated with 3% STS (17%) followed by ethanol (9%), and no major complications were found with combination. No relationship between the volume of sclerosant per lesion volume and outcome was found.

Conclusions

Combination and ethanol were the most effective sclerosants in terms of highest success rates and lowest complication rates, and sclerosant volume per lesion volume had no effect on outcomes. Future work should aim at studying larger sample sizes to account for the multiple factors that may influence the choice of sclerosant and treatment outcomes.

Early Placement of Ventilation Tubes in Infants with Cleft Lip and Palate: A Systematic Review

Objective

Studies have shown that the majority of cleft lip and palate (CLP) children have middle ear fluid present at the time of lip repair (3-4 months). Despite hearing loss, the majority of children do not undergo ventilation tube treatment if required until the time of palate repair (9-12 months). We aimed to examine the effectiveness and potential complications of early ventilation tube placement prior to palatoplasty in infants with cleft lip and palate.

Data Sources

Medline (1946-2015), Embase (1980-2015), and EBM Reviews (Cochrane Central Register of Controlled).

Review Methods

Data sources were searched for publications that described the results of early ventilation tube placement in children with CLP prior to cleft palate repair. Two independent reviewers appraised the selected studies.

Results

Of 226 studies identified, 6 studies met the inclusion criteria. Early ventilation tube insertion in CLP gave similar speech and audiology outcomes to non-CLP children undergoing ventilation tube insertion and better outcomes than those children with CLP having later ventilation tube insertion at or after the time of palate closure. The main reported side effect was otorrhea, being higher for children with CLP having early ventilation tube insertion (67% vs 33%), with a reduction in otorrhea with increasing age. Larger studies with longer-term outcome reporting are required to fully address the study objectives.

Conclusion

Published data are limited but appear to support early insertion of ventilation tubes in children with CLP to restore middle ear function and maximize audiologic and speech outcomes.

How Well Are We Doing at Teaching Critical Appraisal Skills to Our Residents? A Needs Assessment of Plastic Surgery Journal Club

Objective

To perform a needs assessment of journal club in plastic surgery residency programs. Specifically, this study focused on potential gaps in journal club associated with teaching and assessing critical appraisal of the literature, an important component of medical education and practice.

Methods

This is a qualitative study that utilized an online survey tool to collect information about the characteristics of journal club in plastic surgery residency programs in both Canada and the United States. Both program directors and residents were surveyed.

Results

When presented with a range of objectives, both program director and resident responses identified that teaching critical appraisal skills was often the main goal of journal club in their program (67.1%). Most trainees perceived that journal club was at least somewhat effective in improving their critical appraisal skills. Despite this perception, many residents felt that they had minimal to no experience in critical appraisal of the literature upon entry into their respective residency programs (46.2%), and only 29.2% indicated that they received formal instruction regarding critical appraisal. Three-quarters of residents indicated that there was no tool provided to aid them in their analysis of the literature. Finally, most residents also responded that they were not assessed objectively with regard to their performance.

Conclusions

Although residents in our study perceive journal club to at least somewhat improve their critical appraisal skills, evidence in the literature has been controversial. It cannot be assumed that residents are learning the skills they need by simply attending and reading the articles associated with journal club. Future study should focus on the best way to meet these objectives.

Spontaneously Resolved Macrocystic Lymphatic Malformations: Predictive Variables and Outcomes

INTRODUCTION

Lymphatic malformations are benign, low-flow vascular malformations that typically present at or near birth. Due to morbidity associated with operative treatment, nonoperative treatment with injection of sclerosant has become the mainstay of therapy. Over the past 15 years, several patients at our centre with macrocystic (>2 cm cyst size) lymphatic malformations have seen their lesions resolve spontaneously while awaiting treatment. In this study, we review features of these patients that may contribute to spontaneous resolution.

METHOD

A retrospective chart review was conducted from our Vascular Anomalies Clinic database (1999-2014) of all macrocystic lymphatic malformations; characteristics of patients with spontaneous resolution were reviewed.

RESULTS

Of 61 patients with macrocystic lymphatic malformations, 7 cases (11.5%; 4 females, 3 males) resolved spontaneously. Median age at malformation appearance was 2 years (range: 0-6.5 years), with median age at resolution of 4 years (range: 10 months-7 years). Median time from appearance to resolution was 24 months (range: 3-43 months), with a median follow-up time of 4 years (range: 1-15 years). All but 1 case was associated with local or upper respiratory tract infection antecedent to resolution. Six of the 7 lesions were located in the neck.

CONCLUSION

Among the cases reviewed, there was a common theme of upper respiratory tract or local infection antecedent to spontaneous lesion resolution. Compared to the literature, our proportion of malformations presenting after birth and the proportion of malformations presenting in the neck region were higher than those of other series. Although side effects associated with treatment are generally mild and/or rare, risks related to sclerotherapy and the accompanying requirement for general anesthesia in pediatric populations nevertheless exist. As the median time from lesion appearance to resolution was 24 months, it may be reasonable to observe these malformations for up to 24 months before proceeding with treatment if the lesion does not impair function and disfigurement is not considerable, particularly if the lesion presents after birth and/or is located in the neck region.

Airway Management in Pierre Robin Sequence: The Vancouver Classification

BACKGROUND

Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and respiratory distress. There is no standard clinical classification used in the management of neonatal airway in patients with PRS. The goal of our study was to review the presentation and management of patients with PRS and formulate a clinical grading system and treatment algorithm.

METHODS

A 10-year retrospective review of all neonates diagnosed with PRS was performed after obtaining institutional ethics approval. Patients were identified using our cleft lip and palate program database. Inclusion criteria were 2 of the following 3 clinical features-glossoptosis, retrognathia, or airway obstruction. We collected demographic data, clinical information (coexisting airway morbidity, maxillary-mandibular discrepancy, type of intervention used, complications, and outcomes (feeding, length of stay, and airway status) during the first year of life.

RESULTS

Sixty-three patients met our inclusion criteria. Of these, 55 (87%) had cleft palate and 17 (27%) were syndromic. Forty-eight (76%) patients were managed by prone positioning. Of the 15 surgically managed patients, the initial procedure was floor of mouth release in 7, mandibular distraction osteogenesis (MDO) in 4, and tongue-lip adhesion in 4. Five patients with coexisting airway morbidity needed a second surgery; 2 had MDO and 3 tracheostomies (one patient was later decannulated). Seven (47%) of the surgically managed patients required a gastrostomy tube.

CONCLUSION

At present, there is no consensus on neonatal airway management in infants with PRS. From our review of 63 patients with PRS, we hereby propose a simple 4-point classification system and treatment algorithm, based on clinical features.

Do plastic surgery division heads and program directors have the necessary tools to provide effective leadership?

Background

Effective leadership is imperative in a changing health care landscape driven by increasing expectations in a setting of rising fiscal pressures. Because evidence suggests that leadership abilities are not simply innate but, rather, effective leadership can be learned, it is prudent for plastic surgeons to evaluate the training and challenges of their leaders because there may be opportunities for further growth and support.

Objective

To investigate the practice profiles, education/training, responsibilities and challenges of leaders within academic plastic surgery.

Methods

Following research ethics board approval, an anonymous online survey was sent to division heads and program directors from all university-affiliated plastic surgery divisions in Canada. Survey themes included demographics, education/training, job responsibilities and challenges.

Results

A response rate of 74% was achieved. The majority of respondents were male (94%), promoted to their current position at a mean age of 48 years, did not have a leadership-focused degree (88%), directly manage 30 people (14 staff, 16 faculty) and were not provided with a job description (65%). Respondents worked an average of 65 h per week, of which 18% was devoted to their leadership role, 59% clinically and the remainder on teaching and research. A discrepancy existed between time spent on their leadership role (18%) and related compensation (10%). Time management (47%) and managing conflict (24%) were described as the greatest leadership challenges by respondents.

Conclusions

Several gaps were identified among leaders in plastic surgery including predominance of male sex, limitations in formal leadership training and requisite skill set, as well as compensation and human resources management (emotional intelligence). Leadership and managerial skills are key core competencies, not only for trainees, but certainly for those in a position of leadership. The present study provides evidence that academic departments, universities and medical centres may benefit by re-evaluating how they train, promote and support their leaders in plastic surgery.

Pediatric flexor tendon injuries: A 10-year outcome analysis

BACKGROUND

Primary flexor tendon repair was first introduced in the 1960s. Since then, major advances in the understanding of flexor tendon anatomy and biology have led to improved outcomes following repair. Relative to the adult population, sparse knowledge exists as to which operative and postoperative treatments are most successful in children. This is due, in part, to the rarity of pediatric tendon lacerations compared with the adult population, but also related to challenges when working with smaller anatomy and the decreased compliance in children with respect to rehabilitation protocols. Published reports indicate that the incidence of 'good' flexor tendon repair outcomes is as low as 53%.

OBJECTIVE

To determine the injury pattern and demographics of pediatric flexor tendon injuries involving zones I, II and III over the past decade, and to report results and identify treatment paradigms that are associated with optimal outcomes.

METHODS

A retrospective chart review of all flexor tendon injuries involving zones I, II and III between April 2001 and December 2010 was performed. Parameters reviewed included demographics, injury mechanism, repair technique, outcomes and complications.

RESULTS

A total of 47 patients with a median age of eight years experienced 100 tendon injuries. The most common cause of injury was glass (n=22), with the most common digit injured being the small finger (n=30). Tendon injuries included the following: flexor digitorum superficialis (n=46); flexor digitorum profundus (n=45), flexor pollicis longus (n=8); and adductor pollicis longus (n=1). Zone III had the highest number of injuries (n=47), followed by zone II (n=39). Ninety tendons were repaired using polyester suture, the most common size being 4-0. The modified Kessler technique was used in the majority of cases (n=62). Only 22 tendons underwent an epitendinous repair. Splint immobilization was used in 30 patients and a full cast in 17. The median duration of immobilization was four weeks. Forty-two patients underwent postoperative hand therapy. Using the American Society for Surgery of the Hand Total Active Motion (TAM) score, 40 of 47 patients experienced 100% recovery with no functional limitations. Two patients had a score <100%, not necessitating further surgery. A second operation was required for five patients. All patients in this group demonstrated 100% TAM at one year.

CONCLUSION

Pediatric flexor tendon injuries remain rare and usually involve the dominant hand holding or manipulating an object. An excellent outcome was found in 95.9% of patients assessed by TAM scores. Repair technique was chosen according to the size of tendon involved. Patients not treated with hand therapy and not immobilized in a cast were often too young to participate in rehabilitation. Based on the results, immobilization of young children for four weeks is safe and does not worsen functional outcomes. Of the patients requiring a second procedure, no predictive variables for poorer outcomes were found on analysis of age, outcome, cause, location, repair technique, rehabilitation protocol or zone of injury.

Inpatient silver sulphadiazine versus outpatient nanocrystalline silver models of care for pediatric scald burns: A value analysis

BACKGROUND/OBJECTIVE

Scalds represent the most frequent pediatric burn injury. Inpatient nonsurgical wound management of small or medium-size burns (<20% total body surface area) represents a significant proportion of the cost of care, with nanocrystalline silver (NCS) and silver sulphadiazine (SSD) among the most commonly used dressings. Although several articles have described healing outcomes using these dressings, there are few concurrent economic analyses. To analyze overall health care value (outcomes/cost) in burns not requiring surgery, the authors compared management of scald burns with NCS versus SSD from both a quality perspective and using bottom-up microcosting to determine which dressing option optimizes health care value.

METHODS

A value analysis was performed. Published studies investigating NCS and/or SSD in the treatment of pediatric burns over the past 25 years were analyzed. Healing time, hospital duration and frequency of dressings were chosen as quality metrics. A bottom-up microcosting analysis was performed to estimate costs associated with the two dressing options.

RESULTS

Over the 25-year period, 356 studies investigated the use of SSD in burns, while 55 studies evaluated the use of NCS. Mean age and burn size were equivalent. Mean time to healing was 14.9 days for NCS and 17.2 days for SSD. The mean duration of hospital stay was 14.9 days for SSD and 5.9 days for NCS. Dressings were performed twice per week for NCS, and once or twice per day for SSD. The mean total cost per patient to the health care system was estimated to be $61,140 for SSD and $17,220 for NCS.

CONCLUSION

Published outcomes of healing time are equivalent or slightly better using NCS over SSD for pediatric scalds. The financial model illustrated a potential significant cost saving with NCS, primarily as a result of an outpatient model of care. Overall health care value is optimized using NCS for pediatric scalds.

Management of pediatric penile keloid

Keloids are abnormal scar tissue growths that extend beyond the original area of injury, occasionally occurring post-surgery. Risk factors for keloids include skin trauma, infection, prolonged wound healing and individuals of certain ethnicities. Keloid formation on the penis, however, is a rare occurrence even among circumcised males, and can produce both aesthetic and functional complications. We document the tenth patient in the literature, to our knowledge, to present with a keloid of the penis.

Reconstructive or cosmetic plastic surgery? Factors influencing the type of practice established by Canadian plastic surgeons

BACKGROUND

Some argue that the specialty of plastic surgery is facing a changing identity. Challenged by factors such as increasing competition in the cosmetic marketplace and decreasing reimbursement for reconstructive procedures, many American plastic surgeons have increasingly adopted cosmetic-focused practices. The present study investigated the currently unknown practice profiles of Canadian plastic surgeons to determine the reconstructive-cosmetic mix, as well as factors that influence practice type to determine whether a similar pattern exists in Canada.

METHODS

An anonymous online survey regarding practice profiles was distributed to all 352 Canadian plastic surgeons with e-mail accounts registered with the Canadian Society of Plastic Surgeons and/or the Canadian Society for Aesthetic Plastic Surgery.

RESULTS

The survey response rate was 34% (120 responses), of which 75% of respondents currently had a reconstructive practice and 25% had a cosmetic practice. Reconstructive surgeons had more educational debt following their training, spent more time on emergency call, academics and teaching and, when deciding which type of practice to establish, were more influenced by academic opportunities and less influenced by financial and nonfinancial metrics. Similarities between the groups included hours worked per week and academic achievements.

CONCLUSIONS

The field of reconstructive plastic surgery appears to be thriving in Canada. While a transition from reconstructive to cosmetic practice is common, compared with their American colleagues, a greater proportion of Canadian plastic surgeons maintain reconstructive practices. Differences between reconstructive and cosmetic plastic surgeons are discussed.

What is the ultimate fate of presented abstracts? The conversion rates of presentations to publications over a five-year period from three North American plastic surgery meetings

BACKGROUND

Advancements in clinical decision-making are influenced by presentations made at scientific conferences or publications in journals with extensive readership. However, many ideas shared at annual conferences fail to be published, and most surgeons attend these meetings only sporadically.

OBJECTIVE

To quantify the conversion rates of meeting presentations to publications in North American plastic surgery.

METHODS

MEDLINE (OvidSP) and PubMed databases were cross-referenced with abstracts accepted for podium presentation at the Canadian Society of Plastic Surgeons, American Society of Plastic Surgeons, and American Association of Plastic Surgeons annual meetings from 2003 to 2007. Parameters reviewed included publication rate, time to publication, subspecialty, trial type, publication journal and journal impact factor.

RESULTS

Over the five-year study period, 45.00% of the 888 presentations were published in peer-reviewed journals. The mean time to publication was 22 months (range 1.00 to 85.90 months). In total, 57.00% of the 400 publications appeared in Plastic and Reconstructive Surgery; 47.20% of publications were case series study design. The majority of publications were of the reconstruction subspecialty (31.00%). Abstracts from the American Society of Plastic Surgeons had the highest conversion rate (57.70%). Publications based on abstracts presented at the American Association of Plastic Surgeons had the highest mean journal impact factor (2.33). The Canadian Society of Plastic Surgeons had the highest total number of publications (n=161).

CONCLUSIONS

From the three North American annual general meetings reviewed, there was a modest conversion rate of mainly reconstructive case series published predominantly in a single journal, Plastic and Reconstructive Surgery. Several years often pass from the genesis of a research hypothesis to final publication, and because the majority of presentations fail to be published, presentations should be observed with a critical eye given the more stringent peer review process and time required for final publication. In an effort to improve conversion rates, departments and faculty members must foster a culture that prioritizes publication.

Ambulatory cleft lip surgery: A value analysis

BACKGROUND

Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost.

OBJECTIVES

To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced.

METHODS

A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair.

RESULTS

On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada.

CONCLUSIONS

The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.

Treatment of congenital epulis (granular cell tumour) with excision and gingivoperiosteoplasty

Congenital epulis, or granular cell tumour, is a rare, benign intraoral tumour present on the mucosa of the alveolar ridge, with the potential to interfere with respiration and feeding. Treatment involves surgical excision, and recurrences are rare. The management of the alveolar deficiency associated with this tumour has not previously been addressed. In the present report, a patient with a typical epulis, treated surgically with excision and extrapolation of Millard's gingivoperiosteoplasty technique to reconstruct the associated alveolar defect with restoration of alveolar ridge continuity, is presented. The differential diagnosis and complications of this tumour are discussed.

Nora's lesion: Case report and literature review of a bizarre parosteal osteochondromatous proliferation of a small finger

A case of a left small finger tumour that was diagnosed on histopathological review as Nora's lesion (bizarre parosteal osteochondromatous proliferation) is reported. There have been fewer than 150 cases reported in the literature to date and its pathophysiology is yet to be defined. Due to its rare presentation, Nora's lesion can easily go unrecognized and therefore inappropriately managed.

Management of fulminant dissecting cellulitis of the scalp in the pediatric population: Case report and literature review

A case of fulminant dissecting cellulitis of the scalp in a fifteen-year-old African American male is reported. The presentation was refractory to standard medical treatment such that treatment required radical subgaleal excision of the entire hair-bearing scalp. Reconstruction was in the form of split-thickness skin grafting at the level of the pericranium following several days of vacuum-assisted closure dressing to promote an acceptable wound bed for skin grafting and to ensure appropriate clearance of infection. Numerous nonsurgical modalities have been described for the treatment of dissecting cellulitis of the scalp, with surgical intervention reserved for patients refractory to medical treatment. The present paper reports a fulminant form of the disease in an atypical age of presentation, adolescence. The pathophysiology, etiology, natural history, complications and treatment options for dissecting cellulitis of the scalp are reviewed, and the authors suggest this method of treatment to be efficacious for severe presentations refractory to medical therapy.

Management of Pelvic Heterotopic Ossification Post-Myocutaneous Flap Reconstruction of a Sacral Pressure Ulcer

Heterotopic ossification (HO) is a process whereby lamellar bone forms in the soft tissues surrounding a joint. The most common type of HO is traumatic myositis ossificans, which develops following traumatic injuries, burns or arthroplasty. A variety of other forms of HO also exist, such as those associated with central nervous system injury and systemic forms that can manifest at other joints simultaneously. Clinically, patients can present with decreased range of motion, pressure ulcers, nerve compression, swelling, pain or asymptomatically. Symptomatic patients are most commonly treated with surgical debridement of the affected heterotopic deposits.

Spinal dysraphism (SD) is a term describing a wide range of congenital malformations of the neural tube, ranging from spina bifida occulta to the more severe form, myelomeningocele. The cause of SD is multifactorial and has been associated with chromosomal disorders, teratogenic exposure and folate deficiency. Many patients with SD experience neuropathy below the affected neurological level, making them particularly susceptible to pressure ulcers. If these ulcers are severe and do not respond to conservative therapy, they often require surgical debridement and flap reconstruction – a clinical scenario that rarely results in HO.

The present article describes a case involving a patient with pelvic HO following myocutaneous flap reconstruction of a pressure ulcer. The patient was successfully treated with oral bisphosphonate and aggressive physiotherapy.

Management of pelvic heterotopic ossification post-myocutaneous flap reconstruction of a sacral pressure ulcer

Heterotopic ossification (HO) is a process whereby lamellar bone forms in the soft tissues surrounding a joint. The most common type of HO is traumatic myositis ossificans, which develops following traumatic injuries, burns or arthroplasty. A variety of other forms of HO also exist, such as those associated with central nervous system injury and systemic forms that can manifest at other joints simultaneously. Clinically, patients can present with decreased range of motion, pressure ulcers, nerve compression, swelling, pain or asymptomatically. Symptomatic patients are most commonly treated with surgical debridement of the affected heterotopic deposits.Spinal dysraphism (SD) is a term describing a wide range of congenital malformations of the neural tube, ranging from spina bifida occulta to the more severe form, myelomeningocele. The cause of SD is multifactorial and has been associated with chromosomal disorders, teratogenic exposure and folate deficiency. Many patients with SD experience neuropathy below the affected neurological level, making them particularly susceptible to pressure ulcers. If these ulcers are severe and do not respond to conservative therapy, they often require surgical debridement and flap reconstruction - a clinical scenario that rarely results in HO.The present article describes a case involving a patient with pelvic HO following myocutaneous flap reconstruction of a pressure ulcer. The patient was successfully treated with oral bisphosphonate and aggressive physiotherapy.