Fernando A. Herrera

Recent trends in resident career choices after plastic surgery training.

AbstractThe purpose of this study is to determine the initial career choice of plastic surgery residents after completion of training during the last five years and to identify any factors that may influence choice of career path. Demographic data were obtained from graduates of Accreditation Council for Graduate Medical Education (ACGME)-accredited US plastic surgery residency programs between the years of 2005 and 2010. The type of practice and pursuit of fellowship were recorded for each graduate. Sex, age at graduation, marital status, dependents, advanced degrees, previous research, type of training program, primary residency, and length of plastic surgery training were also documented. Comparison of outcomes between the two plastic surgery training pathways (integrated vs independent) was analyzed. Data were collected for 424 graduates from 37 different training programs. Of these programs, 11% were from the West coast, 32% from Midwest, 33% from East coast, and 24% from the South. Seventy-nine percent of residents were male, mean age at graduation was 35 (2.89) years. Forty-nine percent of residents were married, 30% had one or more dependents, 6% had advanced degrees, and 18% had previous research experience. Fifty-eight percent of graduates were from independent programs. Forty-eight percent of residents pursued private practice immediately after graduation, 8% pursued academic practice, 41% pursued specialty fellowships, and 3% had military commitments. Most of the residents chose to pursue private practice on completion of residency. Independent residents were significantly more likely to pursue private practice immediately compared to integrated/combined residents. No other factors were significant for practice choice.

Do telemedicine wound care specialist consults meet the needs of the referring physician? a survey of primary care providers

The purpose of our study was to determine the factors that influence the use of telemedicine consultation by primary care physicians (PCPs) in the management of patients with problem wounds. A short questionnaire was administered to thirty-six PCPs who referred to our Wound Care Program within one year. Participants were asked to rate the importance of specific concerns and benefits regarding the role of wound care surgical specialist (WCSS) and the use of telemedicine consults prior to possible face-to-face consultation. Sixty percent of respondents felt comfortable with telemedicine consultation based on recommendations alone. The total number of patients referred for telemedicine consult was 230, and face-to-face consultation with a WCSS was offered and arranged for 30% of patients. The perception of shared decision making, streamlining patient care, and an opportunity for followup were all highly ranked benefits. The majority of PCPs (93%) agreed that telemedicine wound care consult is a useful tool in their practice and would continue to use the telemedicine consult service.

Bilateral Upper Extremity Vascular Injury as a Result of a High-Voltage Electrical Burn

High-voltage electrical burns are rare but cause devastating injuries, resulting in potential limb loss and major morbidity and mortality. These injuries are more insidious than flame burns in that the extent of the injury is not obvious at first glance. Damage to underlying muscle, nerve, and vessels may occur, resulting in limb-threatening ischemia and delayed hemorrhage. The management of such injuries remains controversial and can be challenging for the vascular and reconstructive surgeon. We present a case of high-voltage electrical injury to bilateral upper extremities resulting in limb-threatening ischemia, review the literature on the management of such injuries, and propose an algorithm to guide the management of these devastating injuries.

Cost comparison of open fasciectomy versus percutaneous needle aponeurotomy for treatment of Dupuytren contracture.

BackgroundMany surgical options exist for the treatment of Dupuytren contracture. Little has been written regarding their financial implications. The purpose of this study was to compare the immediate direct costs of open fasciectomy to percutaneous needle aponeurotomy (NA) for the surgical treatment of Dupuytren contracture. Materials and MethodsA retrospective review was performed comparing patients treated with open fasciectomy (group 1) to patients treated with percutaneous NA (group 2) for the treatment of Dupuytren disease from 2008 to 2010. Financial and medical records were reviewed. Direct cost of treatment was calculated from hospital billing records, including surgical, anesthesia, and facility fees. Statistical analysis was performed using unpaired t test. ResultsTwenty-four patients received open segmental palmar and/or digital fasciectomy (group 1). Average preoperative metacarpophalangeal joint flexion contracture was 30 degrees, and proximal interphalangeal joint flexion contracture was 42 degrees. Group 2 consisted of 24 patients. Average preoperative metacarpophalangeal flexion contracture was 31 degrees, and proximal interphalangeal flexion contracture was 27 degrees. Mean cost for group 1 was

Simultaneous double second toe transplantation for reconstruction of multiple digit loss in traumatic hand injuries.

11,240 and mean cost for group 2 was

Facial reanimation by staged, split masseter muscle transfer.

4657 (P < 0.0001). Immediate postoperative contracture correction was similar between both. Two complications occurred in group 1 (wound dehiscence and nerve injury); no complications in group 2. ConclusionsPercutaneous NA is associated with decreased direct costs in the short-term compared to traditional open fasciectomy with comparable deformity correction.

Craniofacial fracture patterns in all terrain vehicle injuries

The objective of this study is to review a single institutions 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.

How often is the superficial inferior epigastric artery adequate? An observational correlation

BackgroundFacial paralysis of the lower face presents severe functional and aesthetic disturbance to patients. The gamut of facial paralysis correction is diverse and must be tailored to the patient. When nerve repair or free functional muscle transfer is unavailable, regional muscle transfer has become a staple in surgical management of facial paralysis. Previous masseter transfers relied on orbicularis oris attachment, which may be atrophic, adhered, or lengthened. Using fascia lata grafts, we describe the senior author’s method of staged, split masseter transfer as a reliable method for reanimating the lower third of the face in appropriate candidates. MethodsThe staged, split masseter muscle transfer is a 3-part repair. The first stage places a hemioral fascia lata graft to act as an anchor reinforcement. The second stage transfers the split masseter muscle, suturing to the fascia lata reinforced oral commissure. The third stage, a reefing procedure, is performed 6 to 10 months later under local anesthesia to reinforce attachments. ResultsSix patients underwent the staged, split masseter muscle transfer. Mean age was 43 (15–67) years. Mean time to surgery from onset of deficit was 174 months (3 months to 65 years). All patients had significant improvement over preoperative symptoms. Symmetry was restored in repose. On movement, commissure excursion went from 0 to 6.67 mm in the superolateral vector. Of the 6 patients, 5 required an average of 1.5 outpatient revisions to achieve satisfactory results on average of 4.67 (4–127) months after the final stage. ConclusionsThe staged, split masseter transfer is useful for restoring subtle reanimation in patients presenting with facial paralysis. The staged, split masseter transfer provides bulk and restores both static and dynamic function. We present a case series demonstrating excellent long-term functional results.

The Dixie Cup Technique for Salvaging Limb Length and Preserving Nerve Continuity in the Mangled Lower Extremity

BackgroundA multicenter, retrospective study was conducted to determine the frequency and distribution of craniofacial fractures sustained from all terrain vehicle (ATV) accidents. MethodsMedical records of all patients presenting to 2 trauma centers with ATV-related craniofacial trauma from 2001 to 2013 were reviewed. Patient notes and radiographic images were analyzed for detailed craniofacial injury data. The identified fractures were classified as: frontal/skullbase, naso-orbital, maxilla/zygoma, and mandible. In addition, patient demographic information, length of stay, airway status, intensive care unit stay, Glasgow coma scale, use of safety equipment, associated traumatic brain injury, and surgical intervention were compiled. ResultsOne hundred fifty-six patients with craniofacial fractures secondary to ATV accidents presented from 2001 to 2013. The incidence of craniofacial fractures found in patients with ATV injuries was 12.2%. Sixty-one patients (39.1%) suffered frontal/skullbase fractures, 98 (62.8%) naso-orbital fractures, 62 (39.7%) maxillary/zygoma fractures, and 35 (22.4%) mandibular fractures. Forty-one patients (26.3%) required surgical intervention to correct their craniofacial injuries. ConclusionsThe most common craniofacial fractures experienced in ATV injuries are naso-orbital fractures. The correlation of nonuse of safety equipment and associated traumatic brain injuries displays the importance of using helmets when operating ATVs. Future studies can be conducted examining ATV-related upper extremity injuries, among others.

Remote Injuries and Outcomes After Distal Radius Fracture Management

The superficial inferior epigastric artery (SIEA) arises from the common femoral artery 2e3 cm below the inguinal ligament, and passes through the femoral sheath turning, superiorly and laterally over the inguinal ligament at its midpoint. As the vessels ascend up the anterior abdominal wall, they penetrate Scarpa’s fascia and lie in the superficial subcutaneous tissue. The superficial inferior epigastric artery flap takes advantage of this arterial system to the lower abdominal wall and allows for transfer of abdominal skin and subcutaneous tissue without violating the rectus fascia or abdominal musculature. The SIEA flap does not violate the rectus sheath or muscle and, when available, serves as a less morbid option for reconstructing soft tissue defects with easier dissection and a lower rate of donor site complications. Unfortunately, published reports on the superficial system are inconsistent and indicate that these vessels may be too small in calibre and length for use in microsurgical reconstruction. We discuss our observational experience of the SIEA vasculature in 64 abdominal and groin dissections prior to free tissue transfer. When performing free tissue transfer using the abdomen and groin as donor sites, we routinely explore the superficial system to determine its suitability to support microvascular flaps. The pedicle calibre is