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Objective This study sought to evaluate the perspectives of surgical program directors regarding the change of USMLE Step 1 to pass/fail grading. Design Validated electronic survey. Setting Vanderbilt University Medical Center Department of Plastic Surgery. Participants Program directors of all ACMGE-accredited General Surgery, Integrated Vascular Surgery, Integrated Thoracic Surgery, and Integrated Plastic Surgery residency programs. Results The overall response rate was 55.5%. Most PDs (78.1%) disagreed with the scoring change. Only 19.6% believe this change will improve medical student well-being. For 63.5% of PDs, medical school pedigree will become more important, and 52.7% believe it will place international medical graduates at a disadvantage. Only 6.2% believe Step 2 CK should also be pass/fail, while 88.7% will increase the weight of Step 2 CK and 88.4% will now require Step 2 CK score submission with the electronic residency application service. Conclusions While well-intentioned, changing USMLE Step 1 to pass/fail may have unintended consequences and may disadvantage certain groups of applicants. The emphasis on Step 1, and resulting test-taking apprehension, will likely shift to Step 2 CK. Proponents of equitable evaluation should direct their efforts toward increasing, not decreasing, the number of objective measures available for student assessment.

Summary Background Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical outcomes and PROs. Study design The Mastectomy Reconstruction Outcomes Consortium Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial, and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body mass index, radiation timing, and chemotherapy. Results Expander-implant-based breast reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. nonusers (22.9% vs. 16.4% and p = 0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p = 0.02). No significant ADM effects were observed for breast satisfaction, psychosocial, sexual, and physical well-being within any subgroups. Conclusion In immediate expander-implant-based breast reconstruction, ADM was associated with a greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.

Objective Measures Needed A large majority of U.S. residency program directors do not agree with changing scoring on the USMLE Step 1 exam to pass/fail, and they believe that scores on the Step 2 C...

Background The Plastic Surgery Milestones Project was implemented in 2014 to establish standards for competency based resident education. In restructuring educational activities under the Milestones, various pedagogical tools have been revised. However, these standards have not yet been applied to the Plastic Surgery In-Service Training Examination. The purpose of this study was to determine the representation of the various components of the Plastic Surgery Milestones Project, on the In-Service Training Examination. Methods All questions from the 2014 ‐ 2018 In-Service Examinations were evaluated within the framework of the current Plastic Surgery Milestones. Using content analysis, each Examination question was mapped to a single Milestone. Descriptive analysis of Milestone subject area and Core Competency breakdown, as well as year to year trends, were performed. Results Of the 1,150 questions analyzed, there was an unequal representation of individual Milestones (0-7.4%). Of the 36 Plastic Surgery Milestones, 10 represented more than 50% of the PSITEs while 8 Milestones had less than 1% representation. The most common subject area was Head and Neck (12.7%) and least common was Reconstruction of the Trunk and Perineum. Among Core Competencies, more than half (50.4%) tested Patient Care while Interpersonal and Communication Skills was the lowest represented, 0.2%. Conclusions The Plastic Surgery In-Service Examination tests a variable proportion of Milestones. Currently, the PSITE is not well integrated with competency based education in spite of a shift towards such a training model. Going forward, the PSITE may include an associated Milestone with each question in order to better incorporate Competencies into this important annual evaluation metric.

Background Cervical dystonia is a disabling medical condition that drastically decreases quality of life. Surgical treatment consists of peripheral nerve denervation procedures with or without myectomies or deep brain stimulation (DBS). The current objective was to compare the efficacy of peripheral denervation versus DBS in improving the severity of cervical dystonia through a systematic review and meta-analysis. Methods A search of PubMed, MEDLINE, EMBASE, and Web of Science electronic databases was conducted in accordance with PRISMA guidelines. Preoperative and postoperative Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores were used to generate standardized mean differences and 95% confidence intervals (CIs), which were combined in a random-effects model. Both mean percentage and absolute reduction in TWSTRS scores were calculated. Absolute reduction was used for forest plots. Results Eighteen studies met the inclusion criteria, comprising 870 patients with 180 (21%) undergoing DBS and 690 (79%) undergoing peripheral denervation procedures. The mean follow-up time was 31.5 months (range, 12–38 months). In assessing the efficacy of each intervention, forest plots revealed significant absolute reduction in total postoperative TWSTRS scores for both peripheral denervation (standardized mean difference 1.54; 95% CI 1.42–1.66) and DBS (standardized mean difference 2.07; 95% CI 1.43–2.71). On subgroup analysis, DBS therapy was significantly associated with improvement in postoperative TWSTRS severity (standardized mean difference 2.08; 95% CI 1.66–2.50) and disability (standardized mean difference 2.12; 95% CI 1.57–2.68) but not pain (standardized mean difference 1.18; 95% CI 0.80–1.55). Conclusions Both peripheral denervation and DBS are associated with a significant reduction in absolute TWSTRS total score, with no significant difference in the magnitude of reduction observed between the 2 treatments. Further comparative data are needed to better evaluate the long-term results of both interventions.

Learning objectives After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns. Summary Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.

Background Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. Objective This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. Design This study is a retrospective chart review. Settings Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. Patients Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. Interventions Immediate autologous flap reconstruction was performed after abdominoperineal resection. Main outcome measures The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. Results Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. Limitations This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. Conclusions In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. El rol de la reconstruccin con colgajo autlogo en pacientes con enfermedad de crohn sometidos a reseccin abdominoperineal ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomatica que se someten a una reseccion abdominoperineal pueden experimentar una curacion posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de aposito molestos y un aumento del dolor posoperatorio. Cuando se realiza una reseccion abdominoperineal por razones oncologicas, ocasionalmente se realiza una reconstruccion con colgajo autologo para optimizar los resultados de la curacion y reconstruccion de la herida. Sin embargo, no se ha establecido la funcion de la reconstruccion con colgajo despues de la reseccion abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstruccion con colgajo en pacientes con enfermedad de Crohn sintomatica sometidos a reseccion abdominoperineal. Presumimos que los pacientes con reconstruccion inmediata con colgajo despues de la reseccion abdominoperineal demostraran una mejor curacion de la herida.DISENO:Revision retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institucion se identificaron entre 2010 y 2018 mediante una combinacion de los codigos de Terminologia actual de procedimientos, Clasificacion internacional de enfermedades 9 y Clasificacion internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a reseccion abdominoperineal solamente (APR-solo = 20) y reseccion abdominoperineal con reconstruccion con colgajo (APR-colgajo = 20).INTERVENCION (ES):Reconstruccion inmediata con colgajo autologo despues de la reseccion abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fistula, en comparacion con los pacientes del grupo APR-solo. Un numero menor de pacientes tendio a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 dias (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. Tambien hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparacion con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clinicas electronicas. Tamano de muestra pequeno y estudio de una sola institucion.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstruccion inmediata del colgajo despues de la reseccion abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Ademas, la reconstruccion con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Background We conducted a segmental volumetric analysis of pre-operative brain magnetic resonance images (MRIs) of glioblastoma patients to identify brain- and tumor-related features that are prognostic of survival. Methods Using a dataset of 210 single-institutional adult glioblastoma patients, total volumes of the following tumor- and brain-related features were quantified on pre-operative MRIs using a fully automated segmentation tool: tumor enhancement, tumor non-enhancement, tumor necrosis, peri-tumoral edema, grey matter, white matter, and cerebrospinal fluid (CSF). Their association with survival using Cox regression models, adjusting for the well-known predictors of glioblastoma survival. The findings were verified in a second dataset consisting of 96 glioblastoma patients from The Cancer Imaging Archive and The Cancer Genome Atlas (TCIA/TCGA). Results CSF volume and edema were independently and consistently associated with overall survival of glioblastoma patients in both datasets. Greater edema was associated with increased hazard or decreased survival [adjusted hazard ratio (aHR) with 95% confidence interval (CI): 1.34 [1.08–1.67], p = 0.008 (institutional dataset); and, 1.44 [1.08–1.93], p = 0.013 (TCIA/TCGA dataset)]. Greater CSF volume also correlated with increased hazard or decreased survival [aHR 1.27 [1.02–1.59], p = 0.035 (institutional dataset), and 1.42 [1.03–1.95], p = 0.032 (TCIA/TCGA dataset)]. Conclusions Higher brain CSF volume and higher edema levels at diagnosis are independently associated with decreased survival in glioblastoma patients. These results highlight the importance of a broader, quantitative brain-wide radiological analyses and invite investigations to understand tumor-related causes of increased edema and possibly increased CSF volume.

Background The neurosurgery match is among the most competitive across all specialties. As a result, numerical Step U.S. Medical Licensing Examination Step 1 scores have historically played a major role in selecting applicants for interviews. With the anticipated change in Step 1 scoring to pass/fail will come significant ramifications for how program directors (PDs) screen and select applicants. The present study characterized the responses of PDs to the change in U.S. Medical Licensing Examination Step 1 scoring and its consequences on medical students applying to neurosurgery. Methods After receipt of an institutional review board exemption, a validated 19-item survey was electronically distributed to 99 PDs of neurosurgery training programs as a part of a national study across 30 residency specialties. Descriptive statistical analyses were performed, and statistical significance was determined by nonoverlapping 95% confidence intervals. Results A total of 48 responses were obtained (48.5%). Most PDs were men, with a mean age of 52 years, and, on average, had served 7.4 years as a PD. Most PDs (79%) disagreed with binary Step 1 scoring. Most (85%) believed the change will make objective comparison of applicants more difficult, and 83% reported they will begin to require Step 2 clinical knowledge scores with application submission. More than one half (71%) believed medical school reputation will become more important in resident selection. Only 15% believed that pass/fail Step 1 scoring will improve medical student well-being. Conclusion Binary Step 1 scoring represents a significant change in medical student evaluations, with consequences for the neurosurgery residency application process. The results from the present study might help guide PD practices and prepare medical students for the anticipated changes to the application process.

Background: Carpal tunnel release (CTR) is the most common hand surgery operation performed in the United States. While serious complications are rare, they can be life-altering to patients. In some cases, patients will pursue malpractice claims against the surgeon. This study aimed to understand the patient, procedure, and surgeon factors involved in CTR malpractice litigation. Methods: The Westlaw legal database was queried for all recorded CTR malpractice cases resulting in jury verdicts and settlements. Only cases directly related to injury after CTR were included in this study. Cases were reviewed to determine plaintiff demographics, defendant training, liability, injury, outcomes, and monetary awards. Results: Ninety-two unique cases were identified. Plaintiffs were predominantly female (n = 65, 71%). Most surgeons were orthopedic-trained (n = 37, 52%). Only 27% of defendants (n = 19) were hand fellowship-trained. Only 19% of cases resulting in a monetary award were against surgeons who had hand fellowship training. The majority of cases (n = 61, 66%) were found in favor of the defendant. Monetary awards averaged $305 923 (range = $12 000-1 338 147), while settlements averaged $266 250. Alleged liability was most for surgeon negligence (n = 69, 75%) with a third of cases resulting in monetary awards. Median nerve injury was claimed in 41 cases (45%), with 17 (41%) resulting in monetary awards. Conclusion: Although CTR is generally safe and effective, some patients will experience complications. Median nerve injury was the most common reason for successful litigation in this study. Adequate training and experience in hand surgery may lower the risk of injuries resulting in successful malpractice suits.

Background Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts. Objectives The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study. Methods A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. Results A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications. Conclusions The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries. Level of Evidence 2.

The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates.Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p0.05.In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393).This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates.Therapeutic, III.

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

Background:. As early as 2022, United States Medical Licensing Examination Step 1 results will be reported as pass or fail, rather than as 3-digit numeric scores. This survey examines the perspectives of plastic surgery applicants and program directors (PD) regarding this score reporting change. Methods:. A 24-item survey was distributed to integrated applicants from the 2018–19 and 2019–20 application cycles. An analogous 28-item survey was sent to integrated and independent plastic surgery training program directors. Data were analyzed using summary tables and marginal homogeneity tests. Results:. 164 applicants (33.2%) and 64 PDs (62.1%) completed the survey. Most applicants (60.3%) and PDs (81.0%) were not in favor of the score reporting change. As a result of binary scoring, a majority of respondents anticipate that residency programs will use Step 2 CK scores to screen applicants (applicants: 95.7%, PDs: 82.8%), prioritize students from more prestigious medical schools (applicants: 91.5%, PDs: 52.4%), and that dedicated research time will become more important (applicants: 87.9%, PDs: 45.3%). Most applicants (66.4%) and PDs (53.1%) believe that there will be an increase in plastic surgery applicants. Applicants and PDs anticipate that the top 3 metrics used by programs when deciding to offer an interview will change as a result of binary Step 1 scoring. Conclusions:. Most plastic surgery applicants and PDs do not support the change in United States Medical Licensing Examination Step 1 scoring to pass or fail. The majority believe that other metrics (such as Step 2 CK scores, research experience, and medical school reputation) will become more important in the application process.

Background Recent data have demonstrated that mechanical thrombectomy (MT) is beneficial for patients presenting within zero to six hours of symptom onset after stroke. However, transferring all patients with possible strokes for endovascular therapy and MT would be inefficient and costly. We conducted a case-control study to identify a subset of the National Institutes of Health Stroke Scale (NIHSS) to identify patients with large-vessel occlusion (LVO) to a high degree of specificity, in order to select those patients for whom transfer is most appropriate. Methods Acute code stroke alerts presenting to a comprehensive stroke center from 2012 to 2013 (779) and corresponding NIHSS were collected. All patients had vascular imaging and 125 demonstrated LVO (cases) and were compared to 272 small-vessel strokes and stroke mimics (controls). Demographics of both groups and modified receiver operating characteristic (ROC) curves were generated for each combination of three NIHSS items to optimize specificity of LVO for those who would benefit from MT. Results The average NIHSS of cases was higher than controls (12.5 vs. 6.5, p Conclusion We present a validated three-question subset of the NIHSS for those who would benefit from MT with a high degree of specificity.

Background: Cerebral vasospasm and sodium and fluid imbalances are common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and cause of significant morbidity and mortality. Studies have shown the benefit of corticosteroids in the management of these sequelae. We have reviewed the literature and analyzed the available data for corticosteroid use after SAH. Methods: PubMed, EMBASE, and Cochrane electronic databases were searched without language restrictions, and 7 observational, controlled clinical studies of the effect of corticosteroids in the management of SAH patients were identified. Data on sodium and fluid balances, symptomatic vasospasm (SVS), and outcomes were pooled for meta-analyses using the Mantel-Haenszel random effects model. Results: Corticosteroids, specifically hydrocortisone and fludrocortisone, decreased natriuretic diuresis and incidence of hypovolemia. Corticosteroid administration is associated with lower incidence of SVS in the absence of nimodipine, but does not alter the neurological outcome. Conclusions: Supplementation of corticosteroids with mineralocorticoid activity, such as hydrocortisone or fludrocortisone, helps in maintaining sodium and volume homeostasis in SAH patients. Larger trials are warranted to confirm the effects of corticosteroids on SVS and patient outcomes.

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

Postoperative hematomas are one of the most frequent complications following aesthetic surgery. Identifying risk factors for hematoma has been limited by underpowered studies from single institution experiences.To examine the incidence and identify independent risk factors for postoperative hematomas following cosmetic surgery utilizing a prospective, multicenter database.A prospectively enrolled cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major hematomas requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis was used to identify potential risk factors for hematomas including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures.Of 129,007 patients, 1180 (0.91%) had a major hematoma. Mean age (42.0 ± 13.0 years vs 40.9 ± 13.9 years, P0.01) and BMI (24.5 ± 5.0 kg/m2 vs 24.3 ± 4.6 kg/m2, P0.01) were higher in patients with hematomas. Males suffered more hematomas than females (1.4% vs 0.9%, P0.01). Hematoma rates were higher in patients undergoing combined procedures compared to single procedures (1.1% vs 0.8%, P0.01), and breast procedures compared to body/extremity or face procedures (1.0% vs 0.8% vs 0.7%, P0.01). On multivariate analysis, independent predictors of hematoma included age (Relative Risk [RR] 1.01), male gender (RR 1.98), the procedure being performed in a hospital setting rather than an office-based setting (RR 1.68), combined procedures (RR 1.35), and breast procedures rather than the body/extremity and face procedures (RR 1.81).Major hematoma is the most common complication following aesthetic surgery. Male patients and those undergoing breast or combined procedures have a significantly higher risk of developing hematomas.2.

Infants in the US are routinely screened for risk of neurodevelopmental impairment due to neonatal jaundice using transcutaneous bilirubinometry (TcB). In low-resource settings, such as sub-Saharan Africa, TcB devices are not common, however, mobile camera-phones are now widespread. We provide an update on the development of TcB using the built-in camera and flash of a mobile phone, along with a snap-on adapter containing optical filters. We will present Monte Carlo Extreme modeling of diffuse reflectance in neonatal skin, implications in design, and refined analysis methods.

Background In-service training examinations (ITEs) are used to assess residents across specialties. However, it is not clear how they are integrated with the Accreditation Council for Graduate Medical Education Milestones and competencies. Objective This study explored the distribution of specialty-specific milestones and competencies in ITEs for plastic surgery and orthopaedic surgery. Methods In-service training examinations were publicly available for plastic surgery (PSITE) and orthopaedics (OITE). Questions on the PSITE for 2014–2016 and the OITE for 2013–2015 were mapped to the specialty-specific milestones and the 6 competencies. Results There was an uneven distribution of milestones and competencies in ITE questions. Nine of the 36 Plastic Surgery Milestones represented 52% (341 of 650) of questions, and 3 were not included in the ITE. Of 41 Orthopaedic Surgery Milestones, 7 represented 51% (201 of 394) of questions, and 5 had no representation on the ITE. Among the competencies, patient care was the most common (PSITE = 62% [403 of 650]; OITE = 59% [233 of 394]), followed by medical knowledge (PSITE = 34% [222 of 650]; OITE = 31% [124 of 394]). Distribution of the remaining competencies differed between the 2 specialties (PSITE = 4% [25 of 650]; OITE = 9% [37 of 394]). Conclusions The ITEs tested slightly more than half of the milestones for the 2 specialties, and focused predominantly on patient care and medical knowledge competencies.

Background Ventral hernia repair (VHR) is a commonly performed surgical procedure. Unfortunately, long-term prospective information about quality of life and outcomes after VHR has been challenging to obtain. Decoupling follow-up from clinical visits via patient-reported outcomes (PROs) has been proposed as a means of achieving better long-term assessments after VHR. The Americas Hernia Society Quality Collaborative (AHSQC) is a national quality improvement (QI) effort in hernia repair that uses PROs to obtain long-term follow-up. However, the modality of PRO engagement to maximize participation has not been well established. A formal QI initiative was undertaken to determine if long-term PRO follow-up could be increased at a single AHSQC site by adding telephone communication to email communication for long-term postoperative VHR assessment. Methods Between September 2015 and July 2016, the long-term (greater than 1 year) AHSQC PRO completion rates after VHR at our institution were analyzed using plan-do-study-act cycles. Two interventions were implemented: contacting patients by telephone and changing timing of telephone calls. Results Two hundred thirty-two patients were identified, of whom 99 (42.7%) met eligibility criteria. Before this initiative, the long-term PRO completion rate was 16.3% in postoperative VHR patients. The completion rate after introducing telephone calls (intervention 1) was 35.7% and after changing the timing of telephone calls (intervention 2), was 55.1%. The mean participation rate was 45.4% (± 9.7%). Conclusions A telephone-based approach markedly improved long-term PRO participation rates in postoperative VHR patients. Ultimately, a combination of email and telephone communication may be necessary to achieve higher levels of PRO follow-up in the VHR population.

Introduction/purpose Flow diversion has allowed cerebrovascular neurosurgeons and neurointerventionalists to treat complex, large aneurysms, previously treated with trapping, bypass, and/or parent vessel sacrifice. However, a minority of aneurysms remain that cannot be treated endovascularly, and microsurgical treatment is too dangerous. However, balloon test occlusion (macro and micro), micro WADA testing, ICG, intra-angiography and intra-operative monitoring are all available to clinically test the hypothesis that vessel sacrifice is safe. We describe a dual-institution series of aneurysms successfully treated with parent vessel occlusion (PVO). Materials/methods Prospectively collected databases of all endovascular and open cerebrovascular cases performed at Maine Medical Center and Vanderbilt University Medical Center from 2011 to 2013 were screened for patients treated with primary vessel sacrifice. A total of 817 patients were screened and 17 patients were identified who underwent parent vessel sacrifice as primary treatment. Results All 17 patients primarily treated with PVO are described below. Nine patients presented with SAH, and 3/17 involved anterior circulation. Complete occlusion was achieved in 15/17 patients. In the remaining 2 patients, significant reduction in the aneurysm occurred. Modified Rankin Score (mRS) of 0, signifying complete independence, was achieved for 16/17 patients. One patient died due to an extracranial process. Conclusions Parent vessel sacrifice remains a viable and durable solution in select ruptured and unruptured intracranial aneurysms. Many adjuncts are available to aid in the decision making. In this small series, patients naturally divided into vertebral dissecting aneurysms, giant aneurysms and small distal aneurysms. Outcomes were favorable in this highly selected group.

To quantify the proportion of academic neurosurgeons practicing in the United States who acquired residency training outside of the United States and compare their training backgrounds and academic success with those who received their residency training in the United States.We identified 1338 clinically active academic neurosurgeons from 104 programs that participated in the neurosurgery residency match in the United States in January-February 2015. Their training backgrounds, current academic positions, and history of National Institutes of Health (NIH) grant awards between 2005 and 2014 were retrieved from publicly accessible sources.Eighty-four U.S. academic neurosurgeons (6.3%) received their residency training in 20 different countries outside of the United States/Puerto Rico, representing all major regions of the world. The majority trained in Canada (n = 48). We found no major differences between the foreign-trained and U.S.-trained neurosurgeons in male:female ratio, year of starting residency, proportion with positions in medical schools ranked in the top 15 by the U.S. News and World Report, general distribution of academic positions, and proportion with an NIH grant. Compared with U.S.-trained academic neurosurgeons, foreign-trained academic neurosurgeons had a significantly higher proportion of Ph.D. degrees (32.1% vs. 12.3%; P0.0001) and held more associate professorships (34.5% vs. 23.1%; P = 0.02). The academic practices of the foreign-trained neurosurgeons were widely distributed throughout the United States.A small group of U.S. academic neurosurgeons (6.3%) have acquired residency training outside of the United States, representing all major regions of the world. Their general demographic data and academic accomplishments are comparable to those of U.S.-trained neurosurgeons.