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:Patient satisfaction surveys are an increasingly important part of health care, influencing the practice of physicians. Press Ganey has developed tools to assess physician and department performance that are used by 50 percent of hospitals in the United States and over 10,000 health care organizations. The authors sought to evaluate the factors that influence patient satisfaction in plastic surgery patients both locally and nationally. METHODS:A 24-item Press Ganey survey was distributed to patients of 686 participating plastic surgeons nationwide, including those at the authors' home institution. The responses from January to December of 2016 were analyzed retrospectively with Pearson correlation coefficients. The items "likelihood to recommend provider" and "likelihood to recommend practice" were correlated to all other items of the survey, as these items have been shown to be surrogates for overall satisfaction. RESULTS:There were 411 survey responses from patients in the Northwell Health System and 36,836 responses from patients nationally. Items that were not well correlated (r < 0.5) with "likelihood to recommend practice" or "provider" were items such as wait time and courtesy of registration staff. The items that were best correlated (r > 0.8) with "likelihood to recommend practice" or "provider" were the patient's confidence in the care provider and the provider's concern for questions. All correlations were statistically significant (p < 0.001). CONCLUSION/CONCLUSIONS:In an evolving patient centric culture, the patient's confidence and trust of the provider is more important than perception of the provider's office environment to maintaining patient loyalty and market share.

Introduction& Objective: Penile inversion vaginoplasty (PIV) is the standard operation for genital reconstruction in transwomen. Despite usually providing an excellent aesthetic result, the technique can be complicated by vaginal stenosis and inadequate depth, particularly in transwomen with limited penile and scrotal tissue. Vascularized peritoneal flaps have been used to augment vaginal depth in neovaginal creation in patients with congenital vaginal agenesis.Here, we review our experience with the novel application of peritoneal flaps in penile inversion vaginoplasty in transwomen, to augment the neovaginal apex with well-vascularized tissue.
Method(s): Between 2017 and 2018, 20 female-to-male patients were identified who underwent a robotically assisted PIV using peritoneal flaps. In brief, approximately 5cm by 5cm peritoneal flaps are raised from the anterior rectum and posterior bladder to create the apex of the neovagina and serve as an attachment for inverted penile skin and scrotal skin graft. Patient demographics, medical comorbidities, intra-operative details, peri-operative complications, and neovagina measurements served as primary outcome measures.
Result(s): In our cohort of 20 patients, average age at time of surgery was 33.5+/-11.2 years. Average length of procedure was 319.3+/-41.6 minutes and the average inpatient stay was 5 days. Average length of follow up was 54.6+/-42.1 days and at most recent follow up, vaginal depth and width were measured to be 12.83+/-1.1 cm and 2.85+/-.3 cm respectively. The peritoneal flap added an additional 5 cm of depth. There were no complications related to peritoneal flap harvest.
Conclusion(s): Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Neovaginal depth can be limited by available donor tissue. With increased use of puberty blockade, we believe that there will be an increase in women presenting with limited natal tissue. While intestinal flaps or extragenital skin grafts have been used when there is inadequate penile and scrotal skin, there can be considerable donor site morbidity. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a wellvascularized apex without additional donor morbidity

The unique anatomical characteristics of the forearm region make it especially popular as a free flap donor site for craniofacial soft-tissue reconstruction. The free ulnar forearm flap is less hirsute and allows for better concealment of donor site scar as compared with its radial counterpart. Despite these factors, the free radial forearm flap remains more popular among reconstructive surgeons. Through the presented case series, we hope to emphasize the versatile nature of the free ulnar forearm flap in addressing various craniofacial soft-tissue defects. Following institutional review board approval, a retrospective review of the senior authors' clinical experience performing microvascular free ulnar forearm flap reconstruction of craniofacial soft-tissue defects was performed. A total of 10 patients were identified through our review. Soft-tissue defect locations included lower eyelid (n = 2), tongue and floor of mouth (n = 2), lower lip (n = 2), palatopharyngeal area (n = 1), nose (n = 1), and palate (n = 1). Trauma was the most common defect etiology (n = 5), followed by malignancy (n = 4), and iatrogenic injury in 1 case. All patients demonstrated good aesthetic and functional outcomes related to vision, speech, and oral intake at follow-up when applicable. The free ulnar forearm flap is a versatile reconstructive option that can be used to address a wide spectrum of craniofacial soft-tissue defects and offers numerous advantages over its radial counterpart.

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.

BACKGROUND:It is common teaching that treatment of index finger alone is a relative contraindication for arthroplasty of the proximal interphalangeal joint (PIPJ). However, limited data exist reporting the digit-specific complication of PIPJ arthroplasty for the treatment of osteoarthritis or posttraumatic arthritis. The purpose of this article is to perform a systematic review and meta-analysis of the literature to assess whether the 3 ulnar digits may bear a similar instability and complication profile. METHODS:Systematic searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases were performed for PIPJ arthroplasty specifying by digit. We reviewed both descriptive and quantitative data to: (1) report aggregate instability and instability-related complications after non-index digit PIPJ arthroplasty; and (2) perform statistical testing to assess relative rates by digit and compared with index digits. RESULTS:Computerized search generated 385 original articles. Five studies reporting digit-specific instability-related outcomes of silicone, pyrocarbon, or metal surface arthroplasty on 177 digits were included in the review. Meta-analysis demonstrated a 29% instability rate for long digits (n = 65), 6% for ring digits (n = 53), and 6% for small digits (n = 17), compared with 33% for index digits (n = 42). There was no difference in the overall deformity, instability, and complication rates of long versus index fingers ( P = .65). CONCLUSIONS:Instability-related deformity and complication rates of long finger PIPJ arthroplasty may not be different from that of the index finger. Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. Future biomechanical and clinical studies are needed.

Craniomaxillofacial congenital anomalies comprise approximately one third of all congenital birth defects and include deformities such as alveolar clefts, craniosynostosis, and microtia. Current surgical treatments commonly require the use of autogenous graft material which are difficult to shape, limited in supply, associated with donor site morbidity and cannot grow with a maturing skeleton. Our group has demonstrated that 3D printed bio-ceramic scaffolds can generate vascularized bone within large, critical-sized defects (defects too large to heal spontaneously) of the craniomaxillofacial skeleton. Furthermore, these scaffolds are also able to function as a delivery vehicle for a new osteogenic agent with a well-established safety profile. The same 3D printers and imaging software platforms have been leveraged by our team to create sterilizable patient-specific intraoperative models for craniofacial reconstruction. For microtia repair, the current standard of care surgical guide is a two-dimensional drawing taken from the contralateral ear. Our laboratory has used 3D printers and open source software platforms to design personalized microtia surgical models. In this review, we report on the advancements in tissue engineering principles, digital imaging software platforms and 3D printing that have culminated in the application of this technology to repair large bone defects in skeletally immature transitional models and provide in-house manufactured, sterilizable patient-specific models for craniofacial reconstruction.

BACKGROUND:Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. METHODS:Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. RESULTS:A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). CONCLUSIONS:Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

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.

PURPOSE/OBJECTIVE:The increasing prevalence of obesity and/or metabolic syndrome (O/MS) and diabetes mellitus (DM) remains a global health concern. Clinically relevant and practical translational models mimicking human characteristics of these conditions are lacking. This study aimed to demonstrate proof of concept of the induction of stable O/MS and type 2 DM in a Göttingen minipig model and validate both of these disease-adjusted Göttingen minipig models as impaired healing models for the testing of dental implants. MATERIALS AND METHODS/METHODS:Nine minipigs were split into 3 groups-control (normal diet), obese (cafeteria diet), and diabetic (cafeteria diet plus streptozotocin)-followed by placement of dental implants. Inflammatory markers including tumor necrosis factor α, C-reactive protein, and cortisol were recorded for each study group. Removal torque was measured, and histomorphometric analysis (bone-to-implant contact and bone area fraction occupancy) was performed. RESULTS:O/MS pigs showed, on average, a 2-fold increase in plasma C-reactive protein (P < .05) and cortisol (P < .09) concentrations compared with controls; DM pigs showed, on average, a 40-fold increase in plasma tumor necrosis factor α levels (P < .05) and a 2-fold increase in cortisol concentrations (P < .05) compared with controls. The impact of O/MS and DM on implants was determined. The torque to interface failure was highest in the control group (200 N-cm) and significantly lower in the O/MS (90 N-cm) and DM (60 N-cm) groups (P < .01). Bone formation around implants was significantly greater in the control group than in the O/MS and DM groups (P < .02). CONCLUSIONS:Both O/MS and DM minipigs express a human-like disease phenotype, and both presented bone-healing impairment around dental implants. Our finding of no significant difference between type 2 DM and O/MS in bone formation around implants provides evidence that further investigation of the impact of O/MS is warranted.