Ashit Patel

Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer: Review of the Literature and Evidence-Based Guidelines.

Background: Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management. Methods: A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation. Results: A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use. Conclusions: Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.

Reply: Vaginal Labiaplasty: Current Practices and a Simplified Classification System for Labial Protrusion.

Background: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices. Methods: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles. Results: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined. Conclusions: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.

Residency characteristics that matter most to plastic surgery applicants: a multi-institutional analysis and review of the literature.

PurposeThe National Residency Matching Program Match is a very unique process in which applicants and programs are coupled to each other based on a ranking system. Although several studies have assessed features plastic surgery programs look for in applicants, no study in the present plastic surgery literature identifies which residency characteristics are most important to plastic surgery applicants. Therefore, we sought to perform a multi-institutional assessment as to which factors plastic surgery residency applicants consider most important when applying for residency. MethodsA validated and anonymous questionnaire containing 37 items regarding various program characteristics was e-mailed to 226 applicants to New York University, Albany, University of Michigan, and University of Southern California plastic surgery residency programs. Applicants were asked to rate each feature on a scale from 1 to 10, with 10 being the most important. The 37 variables were ranked by the sum of the responses. The median rating and interquartile range as well as the mean for each factor was then calculated. A Wilcoxon signed rank test was used to compare medians in rank order. ResultsA total of 137 completed questionnaires were returned, yielding a 61% response rate. The characteristics candidates considered most important were impressions during the interview, experiences during away rotations, importance placed on resident training/support/mentoring by faculty, personal experiences with residents, and the amount of time spent in general surgery. The characteristics candidates considered least important were second-look experiences, compensation/benefits, program reputation from Internet forums, accessibility of program coordinator, opportunity for laboratory research, and fellowship positions available at the program. ConclusionsApplicants value personal contact and time spent in general surgery when selecting residency programs. As the number of integrated programs continues to grow, programs will benefit from learning what factors their applicants value most.

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon

Background The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Methods Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Results Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm2 (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm2 (P = 0.039), although this association was not seen among flaps greater than 500 cm2. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. Conclusions This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

An Evaluation of Remuneration Patterns in Academic Plastic Surgery.

RESULTS: Eighty-five out of the 282 ACAPS members (30.1%) responded to the survey (Table 1). Eighty participants (94%) reported having mainly a reconstructive practice. The majority of survey participants (69.1%) had a base salary plus a bonus based either on collections or WRVUs (Figure 1). Sixtythree percent of plastic surgeons in the survey received less than

Endoscopic-Assisted Radial Forearm Free Flap Harvest: A Novel Technique to Reduce Donor Site Morbidity

50 as a compensation per WRVU. Sixty-four percent of respondents had benchmark WRVUs of 5000-9000. Seventy-one percent of academic plastic surgery practices reported having an average collection of

The layered anatomy of the jawline

500,000-

The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers

1,000,000. Sixty-four percent of practices reported a starting salary of

The Crisis of Deficiency in Emergency Coverage for Hand and Facial Trauma: Exploring the Discrepancy Between Availability of Elective and Emergency Surgical Coverage

225,000-

Abstract: Matching into Plastic Surgery

300,000 for new hires out of fellowship. Eleven percent of participants were compensated for taking call, and another 30.5% of participants were compensated for participation in committees, research and publications. Fourteen percent received bonuses based on patient satisfaction and 15.8 % received bonuses based on quality metrics. Seventeen percent of practices reported having a free-standing aesthetic center, with none of the facility fee contributing to their compensation.