Benjamin Chang

The modified V-Y dorsal metacarpal flap for repair of syndactyly without skin graft.

Background: Syndactyly repairs that use full-thickness skin grafts risk graft-related complications. The dorsal V-Y advancement flap offers a method of syndactyly release that can eliminate the need for full-thickness skin grafts in some cases of simple syndactyly. Methods: A retrospective case series of all patients undergoing syndactyly release without skin grafting performed by the senior author (B.C.) between 1998 and 2007 was conducted. All outpatient and inpatient charts were reviewed for pertinent patient demographics and clinical outcomes, including the incidence of web creep, hypertrophic scarring, flexion contracture, infection, angulation deformity, limited range of motion, ischemia, and need for reoperation. Results: A total of 28 syndactylies were included in the study: 25 simple incomplete and three simple complete. Mean follow-up time was 4.2 years. Mean operative time was 68 minutes. Two patients (7.1 percent) experienced postoperative complications; both were corrected by subsequent revision. Conclusion: The dorsal V-Y advancement flap without skin graft is an effective method of repair primarily in simple incomplete syndactyly.

Fibula free flap reconstruction of the pelvis in children after limb-sparing internal hemipelvectomy for bone sarcoma.

Background: Neoadjuvant chemotherapy has improved the treatment of bone sarcomas, making wide resection with limb salvage frequently possible. However, resection of iliac tumors without reconstruction causes pelvic instability and significant leg length discrepancy. Free vascularized bone autograft reconstruction represents a potentially optimal method for iliac reconstruction because of the faster healing time and rapid hypertrophy of the grafts. Furthermore, living incorporated autograft may be more durable in the setting of radiation therapy or chemotherapy. The purpose of this study was to characterize the successful reconstruction of the pelvis in children using a triangular double-barrel fibula free flap following limb-sparing internal hemipelvectomy for sarcoma. Methods: A retrospective review of the operative records and patient charts was performed with identification of patient characteristics, operative details, postoperative outcomes, complications, and need for additional procedures. Results: Four patients were identified who underwent fibula free flap reconstruction of the hemipelvis following type I resection with preservation of the hip joint. The mean age of the patients was 13.4 years, with a mean follow-up of 7.2 years. Flap survival was 100 percent, no postoperative infections occurred, and there were no local recurrences. All four patients returned to independent ambulation. The female patient was ultimately able to bear two children. One patient required epiphysiodesis for leg length discrepancy. Conclusions: An “A-frame” double-barrel fibula free flap can be used effectively for reconstruction of the type I internal hemipelvectomy defect. It permits a return to ambulation and minimizes leg length discrepancy and other complications, which may be critical in the immature pediatric skeleton.

The Impact of National Institutes of Health Funding on Scholarly Productivity in Academic Plastic Surgery.

Background: The h-index is an objective measure of an investigator’s scholarly impact. The purpose of this investigation was to determine the association between scholarly impact, as measured by the h-index, and the procurement of National Institutes of Health (NIH) grant funding among academic plastic surgeons. Methods: This was a case-control study of NIH-funded plastic surgery faculty identified on the RePORTER database. Non-NIH–funded faculty from the top 10 NIH-funded programs served as a control group. The mean h-index was calculated from Scopus (Elsevier, London, United Kingdom) and compared by funding status, academic rank, and terminal degree(s). The relationship between h-index and career NIH funding was elucidated via Spearman’s correlation coefficient. Results: NIH-funded faculty had higher h-indices than nonNIH–funded faculty (23.9 versus 9.9, p < 0.001), an effect that persisted when controlling for academic rank. Higher rank correlated with higher h-indices and predicted greater NIH funding (p < 0.05). The h-index did not vary by terminal degree (p > 0.05), but investigators with a master’s degree exhibited a trend toward greater NIH funding. Higher h-indices correlated with greater NIH funding (r = 0.481, p < 0.001). Conclusions: A strong relationship exists between scholarly impact and the procurement of NIH funding. Faculty with greater funding had greater scholarly impact, as measured by the h-index, which suggests that this tool may have utility during the NIH grant application process.

Disparities in Aesthetic Procedures Performed by Plastic Surgery Residents

Background: Operative experience in aesthetic surgery is an important issue affecting plastic surgery residents. Objectives: This study addresses the variability of aesthetic surgery experience during plastic surgery residency. Methods: National operative case logs of chief residents in independent/combined and integrated plastic surgery residency programs were analyzed (2011‐2015). Fold differences between the bottom and top 10th percentiles of residents were calculated for each aesthetic procedure category and training model. The number of residents not achieving case minimums was also calculated. Results: Case logs of 818 plastic surgery residents were analyzed. There was marked variability in craniofacial (range, 6.0‐15.0), breast (range, 2.4‐5.9), trunk/extremity (range, 3.0‐16.0), and miscellaneous (range, 2.7‐22.0) procedure categories. In 2015, the bottom 10th percentile of integrated and independent/combined residents did not achieve case minimums for botulinum toxin and dermal fillers. Case minimums were achieved for the other aesthetic procedure categories for all graduating years. Conclusions: Significant variability persists for many aesthetic procedure categories during plastic surgery residency training. Greater efforts may be needed to improve the aesthetic surgery experience of plastic surgery residents.

Technical implications in proximal forearm transplantation.

The field of vascularized composite allotransplantation has developed for more than a decade. Investigators are defining patient selection criteria, transplant indications, immunologic regimens, and tolerance. The majority of the current reported hand transplantations have been for treatment of distal forearm or hand amputations. In more proximal amputees, the functional outcome of the transplanted arm has some unique variables that require a different surgical approach. We present a single case of bilateral proximal forearm transplantation in effort to describe the unique technical considerations in this complex procedure. The surgical procedure is described in detail. At 19 months, our patient had 4/5 strength of finger and thumb flexors and protective extensor as well as 4/5 wrist flexors and extensors. Our patient had recovery of sensation. Our patient now lives independently and does her lower extremity prosthesis independently using her hands. These results are expected to continue to improve with more time. In hand transplantation, functional results have been very promising. The described approach of forearm transplantation allows the transfer of the entire functional unit, which should optimize the ultimate outcome for these more proximal injuries.

Assessment and Planning for a Pediatric Bilateral Hand Transplant Using 3-Dimensional Modeling: Case Report

Children are not typically considered for hand transplantation for various reasons, including the difficulty of finding an appropriate donor. Matching donor-recipient hands and forearms based on size is critically important. If the donors hands are too large, the recipient may not be able to move the fingers effectively. Conversely, if the donors hands are too small, the appearance may not be appropriate. We present an 8-year-old child evaluated for a bilateral hand transplant following bilateral amputation. The recipient forearms and model hands were modeled from computed tomography imaging studies and replicated as anatomic models with a 3-dimensional printer. We modified the scale of the printed hand to produce 3 proportions, 80%, 100% and 120%. The transplant team used the anatomical models during evaluation of a donor for appropriate match based on size. The donors hand size matched the 100%-scale anatomical model hand and the transplant team was activated. In addition to assisting in appropriate donor selection by the transplant team, the 100%-scale anatomical model hand was used to create molds for prosthetic hands for the donor.

Soft-tissue optimization of limb salvage with knee endoprosthesis: the 10-year experience at the Children's Hospital of Philadelphia.

Purpose Limb salvage in bone sarcomas requires resection and joint and soft-tissue reconstruction. Suboptimal coverage can lead to prosthesis infection, subsequent hardware exposure, or loss with eventual amputation. In the pediatric sarcoma population, it is essential to not only have viable soft-tissue coverage but one that minimizes donor site morbidity and maximizes function and growth over time. Methods This is a retrospective review of all sarcoma patients with primary gastrocnemius and soleus muscle flap coverage of modular knee endoprosthesis over the 10-year period between 1997 and 2007. All patients had resection of the skin at the tibial biopsy site prior to their primary tumor resection surgery. After resection of the knee joint and proximal tibia with clear margins, the bony defect was reconstructed with an endoprosthesis. The gastrocnemius and soleus muscles were then independently rotated to cover the prosthesis and the patellar tendon. Results Eleven patients (10 male, 1 female) with an average age of 13 years (range, 10–17) underwent resection of proximal tibia. Pathology included osteosarcoma in 9 patients, Ewing in 1, and spindle cell sarcoma in 1 patient. All patients had endoprosthetic coverage by gastrocnemius and soleus flaps; 4 patients had additional split-thickness skin graft over the gastrocnemius. The average level of tibial resection was 16.5 cm distal to the articular surface of the proximal tibia. Mean soft-tissue mass volume resected with bone was 157 cm3. There was one flap failure that was reconstructed with a rectus abdominis free flap. Average follow-up was 32 months (range, 8–92 months). Two patients succumbed to metastatic disease. In this series, there was no limb loss or hardware exposure or infection. All patients achieved independent ambulation. Functionally, patients were evaluated based on the Musculoskeletal Tumor Society scale. The average score was 29 (out of a perfect score of 30). Two patients had transient foot drop that resolved with ankle foot orthosis use. Anticipated leg length discrepancy was detected in 3 patients who underwent opposite limb epiphysiodesis with ultimate limb equalization. Conclusion Soft-tissue reconstruction with gastrocnemius and soleus muscle flap coverage decreases wound complications and hardware exposure while maintaining function in the pediatric population.

Anesthetic management of the first pediatric bilateral hand transplant.

PurposeThe purpose of this case report is to describe the anesthetic and case management of the first vascularized composite allograft pediatric bilateral hand transplant.Clinical detailsOur patient was an eight-year-old male with a medical history of Staphylococcus aureus sepsis at one year of age that resulted in end-stage renal disease as well as bilateral upper and lower extremity amputations. After referral for bilateral hand transplantation, the transplantation team, with expertise in all aspects of perioperative care (surgery, anesthesiology, nephrology, renal transplantation, pediatric intensive care, and therapeutic pharmacy), was consulted to help develop anesthetic and other perioperative protocols for surgery. Prior to activation of the transplantation team, the lead surgeon evaluated potential donors by comparing a three-dimensional printed model of the recipient’s forearm with the donor’s upper extremities to ensure an adequate match. The anesthesia team inserted bilateral ultrasound-guided infraclavicular catheters to provide a sympathetic block to facilitate blood flow to the upper extremities and to provide both intraoperative and postoperative pain control. The patient remained in the operating room for 13 hr 37 min for a surgical time of ten hours 39 min. He remained in the hospital for 34 days after the procedure and was then transferred to an inpatient rehabilitation facility for a further 15 days. The patient is currently doing well in a postoperative rehabilitation program. He has demonstrated motor power to the hands using the forearm muscles but is not expected to reach his maximum sensory function for at least one to two years.ConclusionThis report describes the anesthetic management of the first pediatric bilateral hand transplant. This procedure required considerable preoperative planning and communication between various teams to ensure all resources needed to deliver the care for this complex and novel transplant surgery were readily available.RésuméObjectifL’objectif de cette présentation de cas est de décrire la prise en charge anesthésique et la gestion du cas de la première greffe bilatérale des mains chez un enfant à partir d’une allogreffe de tissu composite.Détails cliniquesNotre patient était un garçon de huit ans présentant des antécédents médicaux de sepsis dû à un staphylocoque doré contracté à l’âge d’un an, qui a entraîné une insuffisance rénale terminale ainsi que l’amputation bilatérale des membres supérieurs et inférieurs. Après son aiguillage pour une greffe bilatérale des mains, l’équipe de transplantation, forte d’une vaste expertise en soins périopératoires (chirurgie, anesthésiologie, néphrologie, transplantation rénale, soins intensifs pédiatriques et pharmacie thérapeutique), a été consultée afin de mettre au point des protocoles anesthésiques et périopératoires pour la chirurgie. Avant de réunir l’équipe de transplantation, le chirurgien responsable a évalué les donneurs potentiels en comparant un modèle imprimé en trois dimensions de l’avant-bras du récipiendaire aux membres supérieurs du donneur afin de garantir une bonne correspondance. L’équipe anesthésique a inséré des sondes infraclaviculaires bilatérales par échoguidage afin de réaliser un bloc sympathique qui faciliterait l’apport sanguin aux membres supérieurs et contrôlerait la douleur pendant et après l’opération. Le patient est resté en salle d’opération pendant 13 h 37 min, et la chirurgie a duré 10 h 39 min. Il est resté à l’hôpital 34 jours après l’intervention, puis a été transféré à un centre de réadaptation pour patients hospitalisés pour 15 jours supplémentaires. Le patient se porte actuellement bien et participe à un programme de réadaptation postopératoire. Il a démontré un pouvoir moteur aux mains en utilisant les muscles des avant-bras, mais on ne s’attend pas à ce qu’il atteigne sa fonction sensorielle maximale avant au moins un ou deux ans.ConclusionCe compte rendu décrit la prise en charge anesthésique de la première greffe bilatérale des mains chez un enfant. Cette intervention a nécessité une planification et une communication préopératoires importantes entre diverses équipes afin de s’assurer que toutes les ressources nécessaires à prodiguer les soins optimaux pour cette chirurgie de greffe complexe et innovante soient immédiatement disponibles.

Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam

BACKGROUND The Plastic Surgery In-Service Training Exam (PSITE) is a multiple-choice examination taken by plastic surgery trainees to provide an assessment of plastic surgery knowledge. OBJECTIVE The purpose of this study was to evaluate cosmetic questions and determine overlap with national procedural data. METHODS Digital syllabi of six consecutive PSITE administrations (2008-2013) were analyzed for cosmetic surgery topics. Questions were classified by taxonomy, focus, anatomy, and procedure. Answer references were tabulated by source. Relationships between tested material and national procedural volume were assessed via Pearson correlation. RESULTS 301 questions addressed cosmetic topics (26% of all questions) and 20 required image interpretations (7%). Question-stem taxonomy favored decision-making (40%) and recall (37%) skills over interpretation (23%, P < .001). Answers focused on treatments/outcomes (67%) over pathology/anatomy (20%) and diagnoses (13%, P < .001). Tested procedures were largely surgical (85%) and focused on the breast (25%), body (18%), nose (13%), and eye (10%). The most common surgeries were breast augmentation (12%), rhinoplasty (11%), blepharoplasty (10%), and body contouring (6%). Minimally invasive procedures were lasers (5%), neuromodulators (4%), and fillers (3%). Plastic and Reconstructive Surgery (58%), Clinics in Plastic Surgery (7%), and Aesthetic Surgery Journal (6%) were the most cited journals, with a median 5-year publication lag. There was poor correlation between PSITE content and procedural volume data (r(2) = 0.138, P = .539). CONCLUSIONS Plastic surgeons receive routine evaluation of cosmetic surgery knowledge. These data may help optimize clinical and didactic experiences for training in cosmetic surgery.

Hand allotransplantation: operating room set-up and team coordination.

Vascularized composite allotransplantion requires careful planning and precise execution. The Director of the Hand Transplant Program must coordinate many personnel including nurses, anesthesiologists, transplant coordinators, surgeons, support staff, and hospital administrators. The operation is performed only after surgical rehearsal has reinforced the specialized role of each of these team members and the workflow of equipment and personnel has been optimized.