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Coronavirus disease 2019 (COVID-19) pandemic has had far reaching impacts on all aspects of the healthcare system, including plastic surgery training. Due to reduction in the number of elective surgery cases and need for social distancing, plastic surgery education has shifted from the operating room to the virtual learning environment. Although these changes have been qualitatively described, the authors present a quantitative analysis of plastic surgery training changes due to the COVID-19 pandemic. Our study has identified residents' greatest impediments and inquired about suggestions for further improvements. Our goal is to help residency programs through the COVID-19 pandemic era and contribute to future guidelines when residency education encounters additional unexpected changes.An institutional review board approved anonymous survey using Qualtrics was forwarded on April 23, 2020 to US plastic surgery program directors to be distributed to plastic surgery residents and fellows. Questions centered on the impact of COVID-19 on residents' well-being, education and career plans results were collected for data analysis. Residents were given the option to be in a raffle to win a $50 amazon gift card. Completion of the survey was both anonymous and voluntary.A total of 69 trainees responded (52 integrated residents and 17 independent fellows) from 18 states. Fifty-one percent were male and 49% were female. Fifty-six percent of trainees plan to complete a fellowship program after graduation, 31% will join private practice. Nine percent of trainees reported changes in their postgraduation plans due to the pandemic, 67% were senior trainees. Of those whose goals were affected by COVID-19 pandemic, 56% opted to pursue additional fellowship training. They described reduced operative exposure and cancelations of elective surgeries (50%), the limited availability of private practice jobs (37.5%), and financial reasons (12.5%) for their decision. Twelve percent reported being concerned about not meeting the necessary requirements to finish their residency and graduate on time. Seventy-six percent of trainees expressed concerns about the health and safety of themselves, family and loved ones. Forty-nine percent of trainees reported increased levels of stress since the onset of the pandemic. Ninety-seven percent of trainees reported having reduction in their operative time during the COVID-19 pandemic. They utilized their nonoperative time for online education modules (84%), educational readings (82%), and research (80%). Plastic surgery trainees learned about national webinars through emails from professional society (83%), co-resident/fellow (77%), program director emails (74%), and social media (22%). Webinars attended were mostly through virtual platform modalities, among which Zoom and Webex were the most preferred. Less interactions with colleagues and faculty was the biggest barrier to adopting virtual conferences. Despite this, 72% agreed that having grand rounds, didactics and journal clubs online increased attendance. Additionally, 88% of respondents expressed interests in attending professional society sponsored virtual grand rounds in the future.Results from our survey demonstrated that the overwhelming majority of plastic surgery residents have had reductions in operative times and widespread curriculum changes during the COVID-19 pandemic. These recent changes have increased residents' stress levels and adversity affected their future career plans. Additionally, COVID-19 has heralded an increase in virtual conferences and learning modules. Plastic surgery trainees expressed a preference for virtual educational platforms and interest in continuing virtual didactics in the future. This may irreversibly change the landscape of future plastic surgery training.

Within the United States, the number of players participating in baseball increased by nearly 21% to 15.9 million between 2014 and 2019. Additionally, batting helmets with face-masks are encouraged yet optional in youth baseball as well as college baseball and softball. in light of inconsistencies in safety equipment enforcement and usage, this study aims to perform a comparative analysis of the number and frequency of baseball and softball-related craniofacial injuries (CFis).Data regarding baseball and softball-related injuries were gathered from the National Electronic Injury Surveillance System database from 2011 to 2020. Craniofacial injuries were isolated and organized into 5-year age groups beginning with 5 to 9 years and ending with 25 to 29 years of age. Data was further stratified by location and type of injury. Injury types specifically reported in this study included concussion, contusion, fracture, and laceration.Distribution of injuries across age groups differed significantly between baseball and softball ( P0.001). When comparing the 10 to 14 year old group to the 15 to 19 year old group, we found that concussions and head contusions comprise a significantly greater proportion of all injuries in softball than in baseball. Conversely, facial fractures, facial lacerations, and mouth lacerations comprise a significantly greater proportion ofinjuries in baseball than in softball.Future prospective studies aiming to better characterize the within-game nature of these reported CFIs would certainly be beneficial in guiding the baseball and softball communities toward consideration of implementing maximally efficacious updates to current safety equipment standards.

Use of facial mask coverings has been a strong Centers for Disease Control and Prevention recommendation as an essential mitigation measure in the spread of the SARS-CoV-2 novel coronavirus (COVID)-19 virus. Face mask utilization has been shown to induce changes in the skin microclimate, especially around the perioral and perinasal regions. This results in increased mask adjustments and development of friction between masks and the underlying skin. The authors report novel findings of 2 individuals with skin cancer who underwent facial reconstruction during the COVID-19 pandemic. They encountered untoward sequelae of facial flap pressure necrosis due to the use of face mask coverings. These individuals were ultimately successfully treated with local wound care. One individual experienced auricular implant extrusion and flap loss. It is critical that reconstructive surgeons be aware of potential complications and the need for potential revision surgeries due to the use of face masks, and educate their patients to properly position the protective face masks based on the type of reconstruction performed. Plastic surgeons might also reconsider reconstructive management options in light of these additional obstacles.

Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.

INTRODUCTION Hockey is a sport of high speeds, projectiles, and slick surfaces. A scenario is ripe for craniofacial injuries. Annually, over 1 million Americans, with many more abroad participate in organized hockey. This number continues to grow at youth, amateur and professional levels. Following the characterization of groups with the highest incidence of hockey-related craniofacial injuries, our goal is to propose guidelines for the acute management of hockey-related craniofacial injuries in amateur settings. METHODS This study follows a 10-year retrospective cohort design, examining hockey-related craniofacial injury data derived from the National Electronic Injury Surveillance System database. Within the NEISS data, patients were stratified by age, gender, and ethnicity to allow for analysis and comparison between groups. RESULTS Sample data consisted of 2,544 hockey-related craniofacial injuries treated in US emergency departments between 2010 and 2019. Majority of the injuries included in this analysis involved patients within the 12-18-year-old age group (53.8%). Of the diagnoses, concussion was the most frequent hockey-related craniofacial injury (39.9%). Dental injuries represented the least (1%). In the 12 to 18 age group, the diagnoses concussion, fracture, and laceration differed significantly from the null hypothesis of equality of proportions across all injury types (P

BACKGROUND Number of female athletes continues to exponentially increase in all sports; however, available literature detailing craniofacial injuries remains scarce. Compared to male athletes, female athletes may experience different types of injuries. These may be related to sex differences such as craniofacial pain and dimensions. Thus, this study assesses the type of sport and craniofacial injuries that pediatric and adolescent female athletes sustain. METHODS National Electronic Injury Surveillance System was analyzed for all hospital admissions for young female athletes (5-24 years old) experiencing a sports-related craniofacial injury. These included contusions and abrasions, lacerations, fractures, and hematomas. Following sports were analyzed for craniofacial injury: basketball, golf, soccer, ice skating, swimming, softball, horseback riding, volleyball, field hockey, and football. RESULTS Most of the sports-related craniofacial injury occurred in female athletes who are between 10 and 19 years old. Across all age groups, softball (34.9%), basketball (28.1%), and soccer (15.6%) caused majority of the craniofacial injuries. The most common presenting craniofacial injury types were contusions and abrasions as well as lacerations. CONCLUSIONS There is a need for improved protective gear, such as face shields and low-impact balls, especially in softball and basketball. Physicians should consider the differences in female versus male and child versus adult injury pattern when treating female athletes in order to prevent long-term complications, such as scarring and depression. Overall, sports-related craniofacial injuries among female athletes need to be further examined as the epidemiology of their injuries and their health needs are unique.

Background Telemedicine use has expanded rapidly since the COVID-19 pandemic in order to adhere to social distancing protocols and has been met with much enthusiasm. However, less is known about the use of telemedicine in sports and exercise medicine (teleSEM) and its utility to treat emergent craniofacial injuries. Given how common facial trauma is among athletes and its possible complications, incorporation of telemedicine in sports-related injuries may prove to be quintessential for athletes and coaches. Methods A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through December 2020 with multiple search terms related to telemedicine in sports and trauma care. Results Overall, teleSEM is appreciated by both patients and physicians alike. Studies show that the satisfaction rate among patients and physicians are high. Sports-related telemedicine visits can help improve resource utilization and total costs. Facial trauma studies also reveal that the level of concurrency of treatment options between telemedicine visits and in-person consultations is almost perfect. Further, there are many additional ways that teleSEM can be implemented in treating injured athletes, including possible collaboration between athletic coaches and physicians as well as mobile device applications. Telemedicine may be particularly useful in treating acute injuries in low-resourced areas with limited equipment and training. Conclusion Telemedicine has been widely employed for sports-related injuries and in traumatic care. Patients and providers alike have noted its utility over other methods of communication with physicians. Our findings suggest that telemedicine has a significant potential in treating sports-related injuries and improving the efficiency of diagnoses and treatments. It may enhance outcomes for participants in athletic events. This may become a key aspect of determining whether a player can return to immediate competition.

INTRODUCTION With a following of over 825 million people, basketball currently ranks amongst the world's most popular sports. Despite a number of concussion awareness and player safety protocols that have been implemented at the professional level of organized play, a standardized, layperson-friendly algorithm for the acute management of basketball-related craniofacial injuries does not appear to presently exist. METHODS This 10-year retrospective cohort study was conducted using the National Electronic Injury Surveillance System database to examine basketball-related craniofacial injuries from 2010 to 2019. Within the National Electronic Injury Surveillance System dataset, factors including patient age, gender, diagnosis, injury type, and injury location were included in our analysis. RESULTS Overall, 22,529 basketball-related craniofacial injuries occurred between 2010 and 2019 in players ages 5 to 49 years old. Adolescent (12-18-year-old) and young adult (19-34-year-old) age groups had the highest incidence of craniofacial injuries. The adolescent cohort experienced a significantly greater proportion of concussions and lower proportion of both facial lacerations and fractures compared with the within group null hypothesis of equal proportions (P

INTRODUCTION Soccer is a global sport played by millions annually with an increasing popularity in the United States. Game is played by a wide range of participants from all ages and levels of competition. This scenario leads to a potential disparity in the injury profile based on quantifiable demographics. As the game continues to grow, injury detection and side-line assessment must change as well. METHODS Utilizing a national injury database, a retrospective cohort study was conducted using 10 years of data collected from randomly selected emergency departments across the United States. Patient demographics, injury sites, and diagnosis were recorded. Diagnoses examined included concussion, contusion or abrasion, dental injury, fracture, hematoma, hemorrhage, internal injury, and laceration. RESULTS Highest percentage of craniofacial injuries was observed in soccer players between the ages of 12 and 18. In ages 6 to 11 the most common injuries were contusions and dental injuries, with a significantly low number of fractures. Within the age group of 12 to 18 the highest percentage of injuries was concussions. Finally, the highest percentage of injury in the ages of 19 to 34 were fractures and lacerations. DISCUSSION There is a shift in injury profile as the age of soccer players increases and the level of play becomes faster-paced. In youth players, there is a higher percentage of soft tissue injury. Older players are more likely to suffer a higher degree of injury including fractures, concussions, and lacerations. This suggests a great utility for a layperson-friendly educational intervention initiative applicable to all demographics for the sport of soccer.

Nasal cracking is the habit of applying pressure to one's nose until hearing a popping noise or feeling a release of pressure. Clinicians are mostly unaware of it as it is a lesser known habit that has been popularized on social media. Most often it is harmless, however sometimes it can lead to adverse consequences such as pain, bruising, bleeding, and/or breathing problems. In this case study, a patient is evaluated and treated for nasal cracking that led to a septal hematoma.

Soccer is a global sport played by millions annually with an increasing popularity in the United States. Game is played by a wide range of participants from all ages and levels of competition. This scenario leads to a potential disparity in the injury profile based on quantifiable demographics. As the game continues to grow, injury detection and side-line assessment must change as well.Utilizing a national injury database, a retrospective cohort study was conducted using 10 years of data collected from randomly selected emergency departments across the United States. Patient demographics, injury sites, and diagnosis were recorded. Diagnoses examined included concussion, contusion or abrasion, dental injury, fracture, hematoma, hemorrhage, internal injury, and laceration.Highest percentage of craniofacial injuries was observed in soccer players between the ages of 12 and 18. In ages 6 to 11 the most common injuries were contusions and dental injuries, with a significantly low number of fractures. Within the age group of 12 to 18 the highest percentage of injuries was concussions. Finally, the highest percentage of injury in the ages of 19 to 34 were fractures and lacerations.There is a shift in injury profile as the age of soccer players increases and the level of play becomes faster-paced. In youth players, there is a higher percentage of soft tissue injury. Older players are more likely to suffer a higher degree of injury including fractures, concussions, and lacerations. This suggests a great utility for a layperson-friendly educational intervention initiative applicable to all demographics for the sport of soccer.

Deformity and tissue loss involving the craniomaxillofacial region occurs frequently as a result of trauma, oncologic resection, or a congenital malformation. In order to maximize the patient's quality of life, reconstruction of the craniomaxillofacial skeleton must seek to restore aesthetics as well as function. Advances in diagnostic technology, surgical technique, instrumentation, and innovative biomaterials used have transformed the way reconstructive surgeons approach their patients' needs. From the advent of alloplastic reconstruction, surgeons have sought the ideal material for use in craniomaxillofacial surgery. Substances such as metals, ceramics, glasses, and more recently resorbable polymers and bioactive materials have all been utilized.While autologous bone has remained widely-favored and the gold standard, synthetic alternatives remain a necessity when autologous reconstruction is not readily available. Today, alloplastic material, autografting via microvascular tissue transfer, hormone and growth factor-induced bone formation, and computer-aided design and manufacturing of biocompatible implants represent only a fraction of a wide range of options used in the reconstruction of the craniomaxillofacial skeleton. We present a brief review of the materials used in the repair of deformities of the craniomaxillofacial skeleton as well as a look into the potential future direction of the field.

Entrepreneurial skills are important for physicians, especially plastic surgeons. Nevertheless, these skills are not typically emphasized during residency training. Evaluate the extent of business training at plastic surgery residency programs as well as means of enhancing business training. A 6-question online survey was sent to plastic surgery program directors for distribution to plastic surgery residents. Responses from residents at the PGY2 level and above were included for analysis. Tables were prepared to present survey results. Hundred and sixty-six residents including 147 PGY2 and above residents responded to our survey. Only 43.5% reported inclusion of business training in their plastic surgery residency. A majority of residents reported they do not expect on graduation to be prepared for the business aspects of plastic surgery. Additionally, a majority of residents feel establishment of a formal lecture series on the business of plastic surgery would be beneficial. Results from our survey indicate limited training at plastic surgery programs in necessary business skills. Plastic surgery residency programs should consider incorporating or enhancing elements of business training in their curriculum. 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 .

The risk of venous thromboembolism (VTE) in patients undergoing bilateral breast reduction surgery remains unknown. This study aimed to determine VTE incidence and risk factors in this patient cohort.American College of Surgeons National Surgical Quality Improvement Program (2010-2014) was used to identify women undergoing bilateral breast reduction. Demographic factors, comorbidities, and incidence of postoperative VTE were evaluated. Bivariate and risk-adjusted multivariate logistic regressions were performed to determine factors associated with the development of postoperative VTE.A total of 5371 cases were identified. The mean age was 43.7 years (SD ± 13.9 years). The rate of VTE was 0.22%, with 0.17% rate of pulmonary embolism and 0.07% rate of deep venous thrombosis requiring treatment. Patients who suffered VTE were older (52.4 ± 12.8 vs. 43.7 ± 13.9 years, p 0.05), had longer length of stay (1.7 ± 2.9 vs. 0.4 ± 2.1 days, p 0.05), and had higher rates of blood transfusion (8.3% vs. 0.4%, p 0.01) and reoperation (16.7% vs. 2.0%, p 0.01). Risk-adjusted multivariate analysis demonstrated that older age (OR 1.05, 95% CI 1.01-1.10), postoperative blood transfusion (OR 12.1, 95% CI 1.3-112.0) and unplanned return to the operating room (OR 6.7, 95% CI 1.3-34.8) were independent risk factors for developing postoperative VTE.In bilateral breast reduction surgery, older patients, patients requiring blood transfusion, and patients who have unplanned return to the operating room are at an increased risk of developing postoperative VTE. These factors can be considered for patient risk-stratification and perioperative decision-making regarding VTE prevention.

This study compared complications between subciliary and transconjunctival approaches to the infraorbital rim/orbital floor, using systematic review and meta-analysis.A systematic review with meta-analysis was conducted according to PRISMA guidelines. An electronic search in PubMed, Embase, and Cochrane Library was performed. Randomized controlled and controlled (retrospective or prospective) clinical studies, with the aim of comparing subciliary to transconjunctival approaches in the management of infraorbital rim/orbital floor fractures, were included. Outcome variables were lower lid malposition including ectropion, entropion, scleral shows, canthal malpositions, and others complications. An odds ratio (OR) of outcome variables, using a Mantel-Haenszel (M-H) test with 95% confidence intervals (95% CIs), was calculated using Comprehensive Meta-analysis Software. A descriptive analysis of postoperative complications was also presented.The subciliary approach had a significantly higher incidence of ectropion and scleral show when compared with the subconjunctival approach (p 0.001). The subconjunctival approach had a significantly higher incidence of entropion than the subciliary approach (p 0.001).Both the subciliary and the transconjunctival approaches are associated with specific complications. Overall, the transconjunctival approach shows the lowest incidence of complications.

INTRODUCTION Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking. METHODS National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence. RESULTS Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37). CONCLUSION While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.

Summary Background Reduction mammaplasty is one of the most common reconstructive procedures performed by plastic surgeons. Over 100,000 procedures are performed annually. Although important for relieving the painful symptoms associated with macromastia, complication rates of this procedure are not insignificant. They are reported in up to half the cases. Reported risk factors for adverse outcomes include obesity, preoperative wound infection, and advanced American Society of Anesthesiologists status. Smoking has been described as a risk factor for breast reduction. There is disagreement in the literature regarding the effect of smoking on patient outcomes. To further describe and investigate smoking as a risk factor, we undertook the largest multicenter retrospective study on this subject. Methods Data on 13,984 patients was identified from the 2009–2014 American College of Surgeons National Surgical Quality Improvement Program . Smoker and nonsmoker cohorts were compared to assess unadjusted differences in demographics, comorbidities, intraoperative details, 30-day outcomes, and readmission rates. Univariate analysis was performed using chi-square or Fisher's exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications and readmission. Odds ratios were computed at the 95% confidence interval. Results After adjusting for potential confounders, smokers had a higher likelihood of any wound complication (OR 1.72; p = 0.001) following reduction mammaplasty compared to nonsmokers. Conclusion Smoking has been shown to be a significant risk factor for wound complications following reduction mammaplasty. Comprehensive preoperative counseling and documentation should be performed with patients who smoke regarding the potential for increased risk of adverse outcomes.

BACKGROUND The aim of this study was to explore the impacts of gynecomastia on adolescents, explore the surgical and psychological success of mastectomy, and evaluate the adequacy of insurance guidelines and coverage. METHODS American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical database from 2010 to 2014 was evaluated for current procedural terminology codes 19300 and 19303, representing mastectomies for gynecomastia and complete mastectomies respectively to compare surgical site complications. RESULTS Of 1132 procedures for mastectomy for gynecomastia 1.5% of patients (n = 17) were associated with postoperative superficial surgical site complications. In the same timeframe, a total of 33,124 procedures for simple, complete mastectomy performed with a postoperative surgical complication rate of 2.2% (n = 721). Results of a Chi-squared goodness of fit χ (1, N = 34,997) = 2.10, P > 0.05 suggests no statistically significant difference between incidence of surgical site complications for a mastectomy for gynecomastia versus typical mastectomy. DISCUSSION High surgical success rate, coupled with significant improvements in psychosocial functioning suggests that mastectomy is a highly effective intervention for adolescents with gynecomastia. However, due to vague and inadequate coverage and evaluation criteria surgery is often not performed. This paper offers a framework for developing a quantitative system by which to evaluate surgical candidates by adopting well-established guidelines currently in use for reduction mammoplasties and suggests further analysis into a cost/benefit analysis for coverage of the procedure.

Rhinophyma is a phenotypic subtype of rosacea affecting the nose. It is characterized by phymatous changes, skin thickening/fibrosis, glandular hyperplasia, and chronic inflammation. Treatment of severe rhinophyma is predominantly surgical excision with closure by secondary intention. Amniotic membrane has been used to promote wound healing, fibrosis, and inflammation. In this case study, the authors present a 63-year-old male with longstanding rhinophyma treated with surgical excision with intraoperative placement of amniotic membrane.

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction. Nationwide inpatient sample database (2008–2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization. Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p

BACKGROUND This study assessed hemostatic function in cancer patients at high risk for venous thromboembolism. METHODS Thirty-eight female patients (age, 53 ± 9 years) undergoing immediate postmastectomy reconstruction were prospectively studied with informed consent. Blood was sampled preoperatively, on postoperative day 1, and at 1 week follow-up. Rotational thromboelastography clotting time, α-angle (clot kinetics), clot formation time, and maximum clot firmness were studied with three different activating agents: intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D. Thromboprophylaxis was unfractionated heparin plus sequential compression devices if not contraindicated. Hypercoagulability was defined by one or more parameters outside the reference range. RESULTS Preoperatively, 29 percent of patients were hypercoagulable, increasing to 67 percent by week 1 (p = 0.017). Clotting time, clot formation time, and α-angle remained relatively constant over time, but maximum clot formation increased in intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (all p < 0.05). Body mass index was 28 ± 5 kg/m, 23 percent received preoperative chemotherapy, and 15 percent had a history of tobacco use, but there was no association between these risk factors and hypercoagulability. CONCLUSIONS Despite perioperative thromboprophylaxis, two-thirds of patients undergoing combined tumor resection and reconstructive surgery for breast cancer were hypercoagulable 1 week after surgery. Hypercoagulability was associated with increased clot strength mediated by changes in platelet and fibrin function. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Background Cleft lip and palate are the most common craniofacial congenital malformations. Timing of the nasal repair remains somewhat controversial. Some authors perform a combined nasal and lip repair in infancy while others advocate for a staged repair with the nasal component occurring later in childhood. Frequently, secondary repair is needed to address residual nasal deformities in early adulthood. Conchal cartilage has become increasingly popular as a source of cartilage for secondary reconstruction. Donor site morbidities include hematoma formation, scar formation, and wound healing complications. To the best of the authors' knowledge, there is 1 previous report of a full through-and-through conchal defect as a complication of auricular cartilage graft harvesting. The authors report an infrequently described iatrogenic conchal defect due to cartilage harvesting managed with a single-stage reconstruction using bookend flaps. Methods A 19-year-old female with a history of unilateral cleft lip and palate repair underwent secondary rhinoplasty using conchal cartilage. A bolster dressing was applied to the conchal harvest site. The patient was unable to attend her postoperative clinic visit and was eventually seen 2 months postoperatively with the bolster still in place. A full-thickness conchal defect was present when the bolster was removed. Results A pressure dressing such as a bolster is commonly used to prevent hematoma formation after conchal cartilage graft harvesting. This is routinely removed during the initial postoperative visit. Prolonged placement can result in donor site complications such as a full-thickness conchal defect. Conclusion A functional and aesthetic reconstruction of a full-thickness iatrogenic conchal defect was achieved with excellent results using a local posterior flap, and 2 anteriorly based bookend flaps for closure. To the best of the authors' knowledge, this report is the first to describe a single-stage reconstruction of an iatrogenic defect in the concha as a complication of conchal cartilage harvesting.

Pedicled breast reconstruction is a mainstay treatment for plastic surgeons. Although indications vary for each breast reconstruction technique, there exist some overlapping characteristics that may determine a successful outcome. We aimed to determine the impact flap selection has on postoperative outcomes and resource utilization.Nationwide Inpatient Sample database (2010-2011) was reviewed for cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pedicled transverse rectus abdominis myocutaneous (pTRAM; 85.72) breast reconstruction. Males were excluded. Demographic, socioeconomic, clinical factors, postoperative complications, length of stay (LOS), and total charges (TC) were assessed. Chi-squared and multivariate analyses were performed to identify independent risk factors of resource utilization and postoperative complications.A total of 29,074 cases were identified; 17,670 (61%) LD and 11,405 (39%) pTRAM. 74% percent were Caucasian, 94% insured, and 66% were treated in teaching hospitals. There were 24 mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] = 1.3), suffer from flap loss (OR = 1.4), wound infection (OR = 1.6), wound dehiscence (OR = 2.2), and hematoma (OR = 1.3), P 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR = 6.9), suffer from systemic infection (OR = 1.8), pneumonia (OR = 5.0), or pulmonary embolism (OR = 29.2), P 0.05. Risk-adjusted multivariate analysis demonstrated LD was an independent risk factor for postoperative complication (OR = 1.4) and increased TC (OR = 1.3), P 0.001. Conversely, undergoing pTRAM was an independent risk factor for increased LOS (OR = 6.3), P 0.001.Analysis of a national database found LD breast reconstruction to have higher TC and increased risk for surgical site complications. Patients undergoing pTRAM had increased risk for pulmonary complications and LOS. Procedure selection may be refined as additional characteristics are discovered using outcomes-based research.

Background Plastic surgery is one the most competitive residency programs. Data on match trends for plastic surgery residencies and traits of successful applicants are necessary for individuals applying into this highly desirable specialty. Aim Analyze recent trends in the independent and integrated match as well as to describe attributes of successful applicants. Methods Data from National Resident Matching Program and San Francisco Match Program for 2007 to 2014 were compiled and analyzed. Statistical analysis and figure creation were performed using the R software package. For bivariate associations, χ or Fisher's exact test was used. Results The number of available integrated plastic surgery positions through National Resident Matching Program has increased since 2007, whereas the number of independent residencies offered through the SF Match has steadily decreased. The average Step 2 scores, The number of research presentations, publications, abstracts, and the percent of students ranking plastic surgery only have increased. In a break from previous trends, percent of applicants with Alpha Omega Alpha (AOA) membership and mean Step 1 board scores decreased. United States medical school applicants who matched were more likely to be AOA members and graduates from a top 40 medical school. There was no significant association between having an additional academic degree and successfully matching into integrated plastic surgery. Conclusions Integrated plastic surgery residency programs continue to be highly competitive, with overall increasing research experience, but slightly lower Step 1 scores and AOA membership than that in previous years. If the trend of decreasing independent and increasing integrated positions continues, the applicant only interested in plastic surgery may find the integrated pathway a more feasible option.

Purpose This study aims to review the incidence and outcomes for children with superficial spreading melanomas (SSM) using population-based data. Methods The Surveillance, Epidemiology, and End Results database (1974-2009) was analyzed for all patients less than 20 years of age diagnosed with SSM. Results Overall, 724 patients were identified. The annual age-adjusted incidence was 1.78 cases per 1,000,000 in 2009. Most patients were adolescents (N = 620, 85.6%), girls (N = 478, 66.0%), and Caucasian (N = 670, 92.5%). Most tumors were located on the trunk (N = 308, 42.5%) or lower extremities (N = 160, 22.1%). Overall and disease-specific survivals were 95.6% and 97.6%, respectively. Lymph node positivity decreased disease-specific survival among patients undergoing lymph node dissection (86% vs. 100% for negative lymph nodes, P = 0.001). Conclusions Incidence of SSM increased in the early part of the study, but has remained relatively stable over the past 2 decades. Girls are at higher risk of development of the disease. Outcomes for children with SSM are very favorable.

To improve surgical capacity in developing countries, we must take a multifaceted approach that addresses all aspects of surgery in a hospital. Foreign non-governmental organizations with expertise and resources can play a role in helping to build surgical capacity in developing countries. Episodic surgical missions can contribute to reducing the burden of the disease, but must be coupled with training of local staff to assure capacity for the future. Lack of human resources and proper infrastructure should be addressed as part of the capacity-building process. Longitudinal educational programs improve the training of local staff over time. Scaling up from episodic surgical trips to building and maintaining fully functioning surgical capacity requires sustained and repeated interventions from a large group of stakeholders. Through partnerships with local government and nongovernmental organizations, each partner can amplify the effectiveness of the other to meet the challenges of complex surgical care in low-resource settings.

An important teaching tool and overall humanitarian good, medical mission trips are a common theme among health care professionals. These trips encompass large potential for education, global health progress, and cultural exposure, but the logistics of planning and execution are just as great and if not given serious consideration can limit success. This article sets out to explain the importance of planning and to provide specifics that are unique to surgical hand mission trips. Establishing trustworthy relationships, adapting to the host nation's limited resources, and preparing the proper surgical procedures for the particular areas' most common surgical needs are all discussed in this article.

The objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care.

Fractures of the pediatric zygoma are uncommon and are often associated with high-impact trauma, as evidenced by the relatively increased prevalence of concomitant injuries observed in these patients. Despite advances in the prevention, diagnosis, and management of pediatric craniofacial injuries, data regarding zygomatic fractures in children remain poorly established. The diagnosis of zygomatic disruption is more difficult in children and requires the maintenance of a high index of suspicion on behalf of the surgeon. Early recognition and implementation of appropriate therapy are critical and depend on the acquisition of a thorough history and physical examination as well as the accurate interpretation of computed tomographic imaging. Options for management depend on fracture severity and can range from observation or closed reduction in nondisplaced or only minimally displaced fractures, to open reduction and internal fixation in fractures that are comminuted or severely displaced. Currently, there is a lack of level I evidence evaluating the long-term consequences associated with pediatric zygomatic fractures and their management. A review of the epidemiology, clinical characteristics, diagnosis, and management of pediatric zygomatic fractures is essential for optimizing function and aesthetic outcomes in children who sustain these injuries. Language: en

In general, university-based global health initiatives have tended to focus on expanding access to primary care. In the past, surgical programs may have been characterized by sporadic participation with little educational focus. However, there have been some notable exceptions with plastic surgery volunteer missions. We offer another model of regularly scheduled surgical trips to rural Haiti in plastic and general surgery. The goal of these trips is to reduce the burden of surgical disease and ultimately repair every cleft lip/palate in Haiti. Another principal objective is to accelerate the training of American residents through increased case load and personal interaction with attending surgeons in a concentrated period. Diversity of the case load and the overall number of surgeries performed by residents in a typical surgical trip outpaces the experiences available during a typical week in an American hospital setting. More importantly, we continue to provide ongoing training to Haitian nurses and surgeons in surgical techniques and postoperative care. Our postoperative complication rate has been relatively low. Our follow-up rates have been lower than 70% despite intensive attempts to maintain continued communication with our patients. Through our experiences in surgical care in rural Haiti, we were able to quickly ramp up our trauma and orthopedic surgical care immediately after the earthquake. Project Medishare and the University of Miami continue to operate a trauma and acute care hospital in Port au Prince. The hospital provides ongoing orthopedic, trauma, and neurosurgical expertise from the rotating teams of American surgeons and training of Haitian surgeons in modern surgical techniques. We believe that surgical residencies in the United States can improve their training programs and reduce global surgical burden of disease through consistent trips and working closely with country partners.

Advances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.

Of the 1% to 2% of newborns that are born with congenital defects, 10% of these are born with upper extremity malformations. Although many classification systems have been developed, the most widely used classification system was developed by Swanson. This system categorizes the congenital upper extremity malformations according to the embryonic process that has failed to develop. Congenital hand malformation is a broad category that is broken down into 7 subclasses. This review will focus on congenital hand defects and their associated craniofacial syndromes. The topics will include failure of formation, failure of differentiation, duplication, overgrowth, undergrowth, constriction band syndromes, and generalized skeletal abnormalities.

Skull-based osteomyelitis, which is a true bony infection, originates from a chronic, inadequately treated infection. Because of the complex craniofacial skeletal anatomy and associated aesthetic concerns, osteomyelitis of the craniofacial skeleton must be uniquely managed and is more difficult to treat than osteomyelitis of other bones of the body. It is thought that osteomyelitis is decreasing in prevalence due to broad-spectrum antibiotic treatment; however, it still remains a challenging clinical entity in developing countries and lower socioeconomic areas.

Orthognathic surgery, as it relates to the maxilla, attempts to correct underlying skeletal deformities as well as improve function. In addition, it has the potential to significantly alter the central aesthetic unit of the face, the nasolabial region. A key to achieving a good functional as well as aesthetic result involves both comprehensive surgical planning and an understanding of the effects that orthognathic surgery of the maxilla will have on the soft tissues within the nasolabial region. The LeFort I osteotomy is one of the most commonly performed techniques to correct maxillary dentofacial deformities. The effects of nasal and labial changes after a LeFort I osteotomy, including widening of the alar bases of the nose, changes in the nasal tip, and flattening and thinning of the upper lip, have been previously reported by other authors. This article will discuss the nasolabial region and discuss steps involved in performing a comprehensive aesthetic evaluation, as well how the LeFort I osteotomy may produce specific changes related to the external nasal morphology. In addition, emphasis will be given to the lips, and the effects of reduction and augmentation procedures will be discussed as they relate to the nasolabial region.

In covering the Emergency Department, the Plastic Surgeon can be faced with the mandibular fracture patient. Although the timely repair of the fracture usually leads to normal function and appearance, occasionally the surgeon is faced with the untoward sequelae of the mandible fracture. Post-traumatic mandibular deformities include non-union, malunion, malocclusion, TMJ dysfuction, and facial asymmetry. The difficulty in treatment of these deformities can be compounded by edentulous mandibles, substance abuse, and approach controversies such as the timing of the repair and surgical versus non-surgical management. Knowledge of the post-traumatic mandibular deformities by the treating physician not only assists in their management but may also allow for their prevention.

Background: Although it is becoming more common for abdominoplasty to be performed in combination with other procedures, it has been suggested that such combined procedures may raise the risk of postoperative complications. Objective: The purpose of this study was to determine whether abdominoplasty performed in conjunction with adjunct procedures would result in an increased morbidity. Methods: A total of 102 patients who underwent abdominoplasty, either alone or combined with additional surgery, between March 2003 and March 2005 were included. A retrospective chart review following institutional review board guidelines was conducted. Combined surgeries included breast reduction, mastopexy, hysterectomy, colostomy revisions, and ventral hernia repairs. Complication rates were also correlated with body mass index (BMI). Twenty-seven patients underwent abdominoplasty alone, and 47 patients were in the abdominoplasty combined group. Complication rates of 18.5% vs. 17%, respectively, were analyzed with a t test ( P = .44) and were further stratified in relation to BMI. Results: We found a direct correlation between elevated BMI and increased complication rate. Comparison of BMI 30 (obese) revealed complication rates of 9% vs. 36%, respectively ( P < .02). Obesity in our study was a significant predictor of postoperative complications. Conclusions: It would appear that combining abdominoplasty with additional surgical procedures does not lead to increased complication rates and is safe with carefully selected patients and appropriate deep vein thrombosis prophylaxis.

To assess the efficacy of decellularized dermal grafting as an adjunct to the closure of recurrent oro-nasal fistulas. Five consecutive patients with recurrent oro-nasal fistulas were repaired with decellularized dermal grafting sandwiched between oral and nasal flaps of a von Langenbeck palatal repair. All patients had previously undergone a minimum of three prior palatal repairs with the recurrence of their oro-nasal fistula in the post-alveolar area. Decellularized dermal graft was placed between the nasal mucosa and the levator veli palatine muscle. Patients were followed postoperatively and assessed for infection, dehiscence, signs of rejection, and fistula recurrence. All patients were followed for an average of three months. Clinical examination revealed no recurrence of their oro-nasal fistula nor associated symptoms of nasal reflux. Decellularized dermal grafts were not rejected nor extruded from the site of surgical repair. Decellularized dermal graft should be considered for use in the treatment of recurrent oro-nasal fistula after cleft palate repair. We would also like to encourage further clinical study.

Congenital breast anomalies represent a relatively common set of disorders encountered by pediatric plastic surgeons with a spectrum of severity that ranges widely from the relatively benign polythelia to the very complex disorders such as Poland's syndrome and tuberous breast deformities. While the former can be treated in a single surgical setting with minimal morbidity, the more complicated disorders often require a staged reconstructive algorithm. Some disorders also require a multidisciplinary management for both workup and management. Although rarely a source of functional morbidity, these physical deformities are often a significant source of psychological stress for the adolescent male or female who feels alienated from their peers. The purpose of this article is to review the most common congenital breast disorders including the diagnosis, workup, and management especially the timing of surgical intervention as guided by normal developmental milestones.

Background In the majority of cases, infantile hemangiomas are not associated with any other abnormalities. Occasionally, they may indicate the presence of systemic malformations. PHACE syndrome includes the coexistence of hemangioma, posterior fossa brain abnormalities, arterial anomalies, coarctation of the aorta, cardiac defects, and eye abnormalities. We report a case of a 2-month-old female with PHACE syndrome who also had sinus pericranii. Clinical case A 2-month-old girl was seen for a plaque-like, segmental, midfacial hemangioma, with recurrent hemorrhages, noted at birth. As part of the PHACE syndrome, she had a midline facial hemangioma, absent corpus callosum, hypoplastic internal carotid artery, and an abnormal tortuous dysplastic basilar artery. Digital subtraction angiography showed sinus pericranii. The patient underwent successful endovascular embolization of the hemangioma that prevented further bleeding. Conclusion Sinus pericranii is a rare finding that has not, to our knowledge, been previously associated with PHACE syndrome. Central nervous system, not only posterior fossa, abnormalities are frequently encountered in PHACE syndrome. Endovascular embolization of the facial hemangioma in our patient was a useful therapy.