Asra Hashmi

How Informative are the Plastic Surgery Residency Websites to Prospective Applicants

OBJECTIVE To evaluate the comprehensiveness of plastic surgery program websites. DESIGN American Medical Association interactive database was accessed for the list of integrated plastic surgery programs, in June 2015. Since then, 67 plastic surgery program websites were accessed and searched for the presence or absence of 31 criteria, which were further grouped into 5 categories: First, program contact information; second, training and research; third, program setup; fourth, benefits and facilities; and fifth, information for applicants. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA test was used for comparison. RESULTS Only 25% (17) program website had information available on more than two-thirds (21 or more of 31) of the criteria. The 3 least factors commonly available by program websites were: operative log (10%), contract (10%), and information on night float (25%). The 3 most commonly available factors included: coordinator information (92%), number of residents (92%), and comprehensive faculty list (88%). Less than 50% of the programs provided information regarding fellowship opportunities, active and previous research projects, and operative logs. There was no difference in amount of information on program websites when analyzed for program size or program geographic location. CONCLUSION Programs should consider revising their websites to include aforementioned 31 criteria. This would make applicants and potential resident physicians better informed of the programs before the interview process such that they would be more likely to apply to only those programs that match their specific aspirations.

Publication Trends in Craniofacial Distraction: A Bibliometrical Analysis

Purpose: The purpose of this study was to analyze the craniofacial distraction literature published over the last 50 years and to determine various trends in publications. Methods: A literature search was conducted in November and December 2015. The date search range was 1965 to 2015. Databases searched included Medline, Web of Science, Biosis, SciELO, Data Citation, and Zoologic Records. Data were collected on distraction type, author specialty, date of publication, country, state (if United States), number of citations, journal name, journal type, and Le Fort type (for midfacial distractions). Results: Total number of craniofacial distraction publications was 1729. Cranial distraction accounted for (11%), midfacial (11%), and mandibular (78%). Largest increase in publications was in the 1990s, with 48 publications from 1991 to 1995 rising to 261 publications from 1996 to 2000. Among the cranial distraction publications, Plastic and Reconstructive Surgery (PRS) (67%) were the most frequent authors but among the midfacial and mandibular distraction publications, Oral and Maxillofacial Surgery (OMFS) were the most frequent authors (68% and 64%, respectively). Total number of citations was 26,281 with OMFS (50.4%) and PRS (37%) being cited most frequently. Oral and Maxillofacial Surgery was cited most for mandibular and midfacial distraction, and PRS was cited most for cranial distraction. Conclusion: Research on craniofacial distraction has significantly increased since the 1970s, with mandibular distraction accounting for the majority of this rise. Among specialties, OMFS and PRS account for the majority of the literature. The United States leads the publication. Authors tend to publish distraction literature in their corresponding journal specialty, with the exception of PRS who publishes most frequently in OMFS journals.

The Role of Preoperative Imaging in the Management of Nonsyndromic Lambdoid Craniosynostosis

Background: The necessity of imaging for patients with craniosynostosis is controversial. Lambdoid synostosis is known to be associated with additional anomalies, but the role of imaging in this setting has not been established. The purpose of this study was to evaluate the impact of preoperative imaging on intraoperative and postoperative management among patients undergoing operative intervention for lambdoid craniosynostosis. Methods: A retrospective review of patients undergoing cranial vault remodeling for lambdoid craniosynostosis between January 2006 and 2014 was conducted. Patient demographics, age at computed tomography scan, age at surgery, results of the radiologic evaluation, operative technique, and modification of the diagnosis following the radiologic studies were analyzed. A pediatric neuroradiology and the surgical team interpreted the radiographs. The primary outcome was change in intraoperative or postoperative management based on imaging results. Results: A total of 11 patients were diagnosed with lambdoid synostosis. Of these patients, 81.8% had abnormalities on imaging relevant to operative planning. The most common anomalies were Chiari I malformation (45%) and venous anomalies of the posterior fossa (36%). Preoperative imaging altered the management of 9 (81.8%) patients. Closer follow-up was required for 6 patients (54%). Suboccipital decompression was performed in 4 patients (36%). Venous anomalies were found in 4 patients (36%). The diagnosis was changed from positional plagiocephaly to lambdoid synostosis in 2 patients (18%). Conclusions: Given the frequency and significance of radiographic abnormalities in the setting of lamboid synostosis, preoperative imaging should be considered during the operative planning phase as it can affect postoperative and intraoperative management.

Preoperative pulmonary rehabilitation for marginal-function lung cancer patients

Background This study aimed to evaluate the impact of preoperative pulmonary rehabilitation in lung cancer patients undergoing pulmonary resection surgery with marginal lung function. Methods Short-term outcomes of 42 patients with forced expiratory volume in 1 s < 1.6 L who underwent lung resection between 01/2006 and 12/2010 were reviewed retrospectively. They were divided into group A (no preoperative pulmonary rehabilitation) and group B (receiving pulmonary rehabilitation). In group B, a second set of pulmonary function tests was obtained. Results There were no significant differences in terms of sex, age, race, pathologic stage, operative procedure, or smoking years. Mean forced expiratory volume in 1 s and diffusing capacity for carbon monoxide in group A was 1.40 ± 0.22 L and 10.28 ± 2.64 g∙dL−1 vs. 1.39 ± 0.13 L and 10.75 ± 2.08 g∙dL−1 in group B. Group B showed significant improvement in forced expiratory volume in 1 s from 1.39 ± 0.13 to 1.55 ± 0.06 L (p = 0.02). Mean intensive care unit stay was 6 ± 5 days in group A vs. 9 ± 9 days in group B (p = 0.22). Mean hospital stay was 10 ± 4 days in group A vs. 14 ± 9 days in group B (p = 0.31). There was no significant difference in morbidity or mortality between groups. Conclusion Preoperative pulmonary rehabilitation can significantly improve forced expiratory volume in 1 s in some marginal patients undergoing lung cancer resection. However, it does not improve length of stay, morbidity, or mortality.

Abstract: A Comparison of Intracranial Volumes in Normal Children and Patients with Metopic Craniosynostosis

PURPOSE: Non-syndromic craniosynostosis is associated with a multitude of language deficits. Early detection and prevention is essential for language remediation in these cohorts. The current standard assessment, the Bayley Scales of Infant Development (BSID), provides little predictive value for long-term development. Auditory event-related potentials (ERPs), in particular the mismatch negativity (MMN), measure passive neurological responses to speech sounds and suggest a promising avenue for analyzing infant speech development, particularly in craniosynostosis. We now provide long-term follow up neurocognitive assessment of patients with midline synostosis (sagittal and metopic) in comparison to BSID and ERP testing in infancy.

No Place like Home: Is There Selection Bias in Plastic Surgery Residency Match Process?

1 I plastic surgery is among the most competitive specialties in medicine. In 2015, there were 67 integrated plastic surgery residency programs, offering 148 training positions, with 206 applicants for these positions.1 Geography plays a significant role in applicants’ decision as to where to apply. An association between residents’ matriculated medical school and residency program has been identified in several surgical specialties, including ophthalmology, general surgery, and otorhinology.2–4 Although many factors contribute to the success of an applicant in matching into a plastic surgery program, the role of geography in the match has not been explored. American Medical Association’s interactive database was accessed for the list of integrated plastic surgery programs in June 2015. Sixty-seven plastic surgery program Web sites were accessed and data were collected. Programs were categorized based on US census bureau-designated regions, namely Northeast, Midwest, South, and West, and number of residency positions available. One-way Analysis of Variance (ANOVA) and Student’s t test were used for comparison with P value of <0.05 considered as statistically significant. Four hundred seventy-three residents belonging to 43 programs, which had complete listing of residents available on their Web sites, were identified. Ninety-three (19.6%) residents attended the medical school affiliated with their residency program. This is similar to the trends seen with otolaryngology residency match where 20% of the residents attended the program affiliated with their medical school.3 Larger programs, with 11 or more residents, were found to have a higher proportion of residents attending the program affiliated with their medical school compared with smaller programs, with less than 11 residents (24.2% versus 14.8%) (Table 1) (P value = 0.03). Interestingly, geographic bias also differed with regions. Northeast had the highest proportion of residents from the same region (57.7%), whereas the West had the lowest proportion (13.2%; P value < 0.0003) (Table 2). It is important to note that residents who matched at programs in the West versus those that matched in the Northeast had no statistically significant difference in availability of plastic surgery residency program affiliated with their medical school of graduation. In conclusion, in integrated plastic surgery residency programs, one fifth of residents attend the same program as their matriculated medical school. Geographic association between residency program and medical school is strongest for the residents in the Northeast and weakest for those in the West. We believe this geographic bias has implications for applicants in the match as it appears that medical students in the Northeast and those from large programs are more likely to match at a program affiliated with their medical school of graduation compared with other regions. These data may also be relevant to the few undergraduate students who have an interest in plastic surgery. Whether our findings are secondary to program or applicant preference is unclear, but our analysis sheds light on some biases that may be exceedingly relevant to aspirants of plastic surgery.

Effect of Preoperative Molding Helmet in Patients With Sagittal Synostosis

Background: In our practice, the authors found that molding helmet used for plagiocephaly preoperatively, in patients with sagittal synostosis, decreased bathrocephaly, forehead bossing, and improved posterior vertex, as well as Cephalic Index (CI). This prompted us to investigate the impact of preoperative molding helmet in patients with sagittal synostosis. Methods: A prospective study was performed on patients undergoing surgical correction of sagittal synostosis, over a 5-year period. Patients were categorized into 2 groups. “No Helmet group” only had surgical correction, and “Helmet group” had preoperative molding helmet, prior to surgical correction. Cephalic Index for the 2 groups was compared using t-test. Results: There were 40 patients in the No Helmet group and 18 patients in the Helmet group. For No Helmet group, mean CI at presentation, immediately preoperative, and postoperatively was 0.70 (±0.045), 0.70 (±0.020), and 0.80 (±0.030), respectively, and for Helmet group, it was 0.69 (±0.023), 0.73 (±0.036), and 0.83 (±0.036), respectively. There was no statistically significant difference between CI of the 2 groups at presentation (P = 0.45). Comparison of postoperative CI did show a statistically significant difference between the groups (P = 0.01). For Helmet group, on comparison of CI at presentation and preoperative CI (after helmet therapy), a statistically significant improvement in CI was observed (P = 0.0004). Conclusion: Our results suggest that preoperative molding helmet can decrease bathrocephaly, forehead bossing, and improve posterior vertex as well as CI, prior to surgery and thus can be used as a valuable adjunct in patients with sagittal synostosis.

Extrahepatic biliary obstrution secondary to neuroendocrine tumor of the common hepatic duct.

Highlights • Extra hepatic biliary obstruction can be frequently caused by tumors.• Differentiation between cholangiocarcinoma and an unusual bile duct tumor such as a neuroendocrine tumor (NET) is very difficult preoperatively.• Prognosis of NET of the extrahepatic bile duct is dependent on the grade of the tumor however is markedly better than cholangiocarcinoma.• Unusual biliary tumors can not be diferentiated preoperatively from cholangiocarcinoma.

Use of intraoperative index finger pulse oximetery during radial forearm flap harvest to prevent finger ischemia for reconstruction of hand burn and crush injuries

The risk of digital vascular impairment following radial forearm flap harvest may be higher in patients with upper extremity burn or crush injury where there is a possibility of microvascular damage. Identifying patients at risk of digital ischemia following radial artery harvest is critical for preventing complications (wounds, gangrene, rest pain, claudication). It is well established that blood supply to the index finger can sometimes entirely depend on the integrity of radial artery, especially when there are no superficial palmar arch branches to index finger, or in the absence of anastomosis between deep and superficial palmar arch, making it the first finger to show signs of vascular ischemia, when radial artery is harvested [1]. Allen’s test can be used to assess palmar arch integrity. However, it does not provide ‘objective’ data on digital perfusion and it’s execution may not be possible in patients with significant hand burns/crush injuries. A variety of noninvasive and invasive tests are available to supplement physical examination. However, no consensus exists about the proper preoperative role of such tests [2]. In our institution, we supplement preoperative evaluation with intraoperative index finger pulse oximetry, especially in patients with significant hand burns/crush injuries during radial forearm flap harvest. This was utilized in three of our patients to ensure safety of radial artery harvest: first, a 37year old male with extensive burns to bilateral upper extremities, requiring left dorsal hand coverage with reverse radial forearm flap; second, a 28 year old male, with complex degloving crush injury to the right hand, requiring dorsal hand wound coverage; and third, a 71 year old female, with chemical burns to the right hand and elbow, requiring radial forearm flap coverage of the medial elbow defect. In all three patients, once the dissection of radial artery was completed, prior to ligation of the artery, radial artery was occluded using a bull dog clamp. The drop in index pulse oximetery reading was observed over 5min. Tarabadkar et al. advocated the routine use of pulse oximeter for monitoring of digits with ischemic injury, and recommended operative intervention for digits with a pulse oximetery value of <84% [3]. As such, our cut off for aborting flap harvest was set at 85%. The three patients maintained a good waveform with a pulse ox of 89–97% during the 5-min monitoring period. Decision was then made to proceed with the flap harvest. All three patients had no post operative symptoms of ischemia or finger claudication on 6 month follow up (Fig 1). Major limitation of this physiologic, non-imaging method is that the waveform and reading can vary with changes in blood pressure or anemia. However, finger pulse oximetry is inexpensive, readily available, and noninvasive. It requires minimal training and can provide an objective reading almost instantly. We propose the utilization of intraoperative index finger pulse oximetery measurement, in patients with concern for microvascular damage to the fingers following burn or crush injury, prior to radial forearm flap harvest, in order to minimize the risk of post operative finger ischemia or claudication.

Small bowel obstruction caused by self-anchoring suture used for peritoneal closure following robotic inguinal hernia repair.

Laparoscopic inguinal herniorraphy is a commonly performed procedure given the reported decrease in pain and earlier return to activity when compared with the open approach. Moreover, robotic assistance offers the operating surgeon considerable ergonomic advantages, making it an attractive alternative to conventional laparoscopic herniorraphy. Robotic herniorraphy utilizes the transabdominal preperitoneal approach where following repair peritoneal closure is necessary to avoid mesh exposure to the viscera. Self-anchoring sutures are frequently used to this end given the ease of use and knotless application. We present an unusual case of post-operative small bowel obstruction following robotic inguinal hernia repair caused by the self-anchoring suture used for peritoneal closure. This patient presented 3 days post-procedure with symptoms and cross-sectional imaging indicative of small bowel obstruction with a clear transition point. Underwent laparoscopic lysis of a single adhesive band originating from the loose intraperitoneal end of the suture leading to resolution of symptoms.