Faculty Bibliography

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors' opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.

BACKGROUND:A primary goal in chest wall reconstruction ('top surgery') for trans men is achieving a symmetrical, aesthetically pleasing position of the reconstructed male NAC. In the context of existing surgical techniques for top surgery, the ability to achieve this goal is limited. METHODS:The senior author's technique for component NAC creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March 2015 to October 2016. RESULTS:Average patient age was 30.64 years, with an average BMI of 28.54 kg/m. Eighty two percent of the sample received pre-operative testosterone therapy, and average operative time was 2 hours and 59 minutes. Average overall mastectomy specimen weight was 627.80 grams. Average length of hospital stay was 0.96 days. Average follow-up duration was 19.02 months.Complications occurred in 10% (n = 5) of patients, including seroma (4%), cellulitis (2%), hematoma (2%), and suture granuloma (2%). Only 5 patients (10%) underwent postoperative revision to adjust NAC size, projection, or symmetry. Twenty-eight patients (56%) underwent secondary revisions, including scar revisions (56%), liposuction (12%), and fat grafting (2%). CONCLUSIONS:The use of a modified nipple flap and free areolar graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male NAC, in a safe and effective manner.

BACKGROUND:Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast surgeries, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both the surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regards to scarring. METHODS:A systematic review of PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July 2017 using the search terms barbed suture combined with scar or wound. Studies were included if they were prospective evaluator-blind randomized controlled trials, closed the dermal layer of incisions using barbed sutures, and included an evaluator-blind aesthetic assessment of scarring. RESULTS:Six prospective randomized controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the 6 controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and 1 study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in 4 of the 5 studies that timed incision closure. Similar complication rates were observed in all evaluated studies. CONCLUSION/CONCLUSIONS:Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.

BACKGROUND:Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. METHODS:A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. RESULTS:Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). CONCLUSIONS:This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

BACKGROUND:Among surgical subspecialties, plastic surgery holds the highest percentage of women, and, the female contingent of board-certified plastic surgeons and trainees has grown steadily. However, their academic impact has been underestimated. We present the academic footprint of female plastic surgeons over the past 40 years. METHODS:A list of female plastic surgeons currently active at, and retired from, Accreditation Council for Graduate Medical Education-accredited plastic surgery residency programs was compiled. Each surgeon was searched on PubMed to gather their total number of publications, journals, and topics of research after completion of training. Date of publication and 5-year impact factor for each journal were recorded. Publications were organized into 10-year periods (1976 to 1985, 1986 to 1995, 1996 to 2005, and 2006 to 2016). RESULTS:One hundred fifty-five currently active and 80 retired academic female plastic surgeons were identified, who published 2982 articles in 479 peer-reviewed journals. The average 5-year impact factor was 4.093. The number of publications increased with each decade: 37 (1976 to 1985), 218 (1986 to 1995), 472 (1996 to 2005), and 2255 (2006 to 2016). The most commonly published areas were hand/nerve (22 percent), craniofacial (21 percent), and breast (20 percent). Over time, publications in hand/nerve research decreased (76, 60, 38, and 14 percent, respectively); craniofacial-related publications increased (8, 11, 18, and 23 percent, respectively); and publications in breast research increased (0, 8, 9, and 24 percent, respectively). The 2006 to 2016 period yielded the most even distribution of research topics. CONCLUSION/CONCLUSIONS:The academic contribution of female plastic surgeons has substantially increased in number and has become more evenly distributed across subspecialty topics.

BACKGROUND:Despite the growing popularity of platelet-rich plasma, existing evidence supporting its efficacy remains controversial due to the lack of large-scale studies and standardized protocols for preparation and application. This article reviews its use in facial rejuvenation, fat grafting, acne scarring, and androgenic alopecia. Emphasis is placed on comparing methods of platelet-rich plasma preparation and application across studies. METHODS:A systematic review was performed for articles published between 2006 and 2015. All clinical studies and case reports that addressed platelet-rich plasma alone and/or in combination with fat grafting for facial rejuvenation, acne scarring, or androgenic alopecia were included. RESULTS:Of the 22 articles included in the analysis, seven studies used platelet-rich plasma alone for facial rejuvenation, seven in combination with fat grafting, two for treatment of acne scarring, and six for treatment of androgenic alopecia. Individual study procedures, means of evaluation, and significant results are summarized. Although the majority of studies in this review report positive results, significant variation exists in preparation protocols and in the number and frequency of clinical treatments. CONCLUSIONS:The majority of studies report positive results for all indications evaluated in this review, but the procedure is limited by the lack of a standardized method for preparation and application of platelet-rich plasma. The extent to which significant variability in platelet-rich plasma preparation and/or application methods may affect clinical outcomes is not completely clear. In the interim, we present a consolidation of platelet-rich plasma treatment techniques and outcomes currently in use to help guide physicians in their clinical practice.

BACKGROUND: Wide variations in fat graft survival have been reported. The authors hypothesize that treating the adipose tissue on Telfa gauze creates a processed lipoaspirate with a more functional adipokine profile that improves fat graft survival. METHODS: Suction-assisted lipoaspirate was harvested from humans and was either processed by centrifugation, rolled on Telfa gauze, or left unprocessed. Progenitor cell populations were quantified and characterized by flow cytometry. Glycerol-3-phosphate dehydrogenase assay was used to measure the functional adipocytes. The lipoaspirates were grafted into (n = 45) wild-type mice and harvested to assess fat graft persistence. Vascular endothelial growth factor and platelet-derived growth factor-BB secretions were measured by enzyme-linked immunosorbent assay technique. RESULTS: Centrifuged lipoaspirate had a greater number of progenitor cells per gram of tissue than Telfa-processed and unprocessed lipoaspirate. However, Telfa-processed lipoaspirate had a greater number of functional adipocytes (0.104 U/ml) than centrifuged (0.080 U/ml) and unprocessed lipoaspirate (0.083 U/ml) on glycerol-3-phosphate dehydrogenase assay (p < 0.05). After 10 weeks of grafting, it had greater fat graft persistence (70.9 +/- 6.2 percent) than centrifuged (56.7 +/- 5.5 percent) and unprocessed lipoaspirate (42.2 +/- 2.7 percent) (p < 0.05). It also maintained a greater secretion of vascular endothelial growth factor and platelet-derived growth factor-BB at weeks 1 and 2 than centrifuged and unprocessed lipoaspirate. Furthermore, CD31 staining demonstrated an increase in vascular density of the Telfa-processed lipoaspirate at week 2 compared with the centrifuged lipoaspirate (37 +/- 1 percent and 14 +/- 4 percent per high-power field; p < 0.05). CONCLUSIONS: Lipoaspirate processing technique has a significant impact on fat graft survival rate. Increasing the number of functional adipocytes by processing the fat on Telfa gauze may augment the secretion of angiogenic and mitogenic adipokines within the graft, thereby improving its survivability. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.