Ronald D. Ford

Plastic Surgery Chief Resident Clinics: The Current State of Affairs

Background: One of the goals of plastic surgery residency programs is to provide effective training in aesthetic surgery. Recently, programs have adopted the idea of chief clinics to provide senior residents with the opportunity to perform cosmetic surgery with an increased level of autonomy. The goal of this article is to characterize chief clinics currently in place and their usefulness in providing effective training in plastic surgery under the precepts set forth by the Accreditation Council for Graduate Medical Education. Methods: A survey was created focusing on six broad categories: respondent identifier, clinic structure, clinic monetary earnings, patient demographics, procedures, and educational utility. Surveys were distributed to all plastic surgery residency programs targeting current and recently graduated chief residents, and program directors. Results: A total of 123 surveys were returned. Eighty of the 88 plastic surgery residency programs (91 percent) were represented. Of the programs responding, 71.3 percent (57 programs) had a chief resident clinic. Thirty-two of the respondents (43.8 percent) reported that 100 percent of the procedures performed were cosmetic in nature. Programs differed widely on their frequency of occurrence and support staff available. A majority of respondents felt these clinics enhanced resident understanding of the six Accreditation Council for Graduate Medical Education core competencies. Conclusions: A majority of plastic surgery training programs use the chief clinic model to enhance resident education. These clinics vary in makeup and case distribution but serve as an effective way of teaching autonomy, surgical maturity, and the six Accreditation Council for Graduate Medical Education core competencies.

A new method for estimation of involved BSAs for obese and normal-weight patients with burn injury.

An accurate measurement of BSA involved in patients injured by burns is critical in determining initial fluid requirements, nutritional needs, and criteria for tertiary center admissions. The rule of nines and the Lund-Browder chart are commonly used to calculate the BSA involved. However, their accuracy in all patient populations, namely obese patients, remains to be proven. Detailed BSA measurements were obtained from 163 adult patients according to linear formulas defined previously for individual body segments. Patients were then grouped based on body mass index (BMI). The contribution of individual body segments to the TBSA was determined based on BMI, and the validity of existing measurement tools was examined. Significant errors were found when comparing all groups with the rule of nines, which overestimated the contribution of the head and arms to the TBSA while underestimating the trunk and legs for all BMI groups. A new rule is proposed to minimize error, assigning 5% of the TBSA to the head and 15% of the TBSA to the arms across all BMI groups, while alternating the contribution of the trunk/legs as follows: normal-weight 35/45%, obese 40/40%, and morbidly obese 45/35%. Current modalities used to determine BSA burned are subject to significant errors, which are magnified as BMI increases. This new method provides increased accuracy in estimating the BSA involved in patients with burn injury regardless of BMI.

Brachioplasty outcomes: a review of a multipractice cohort.

Background: Upper arm deformities secondary to massive weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures such as brachioplasty. Methods: The records of all patients who underwent a brachioplasty procedure from a multipractice medical center were reviewed. Outcomes measured included patient demographics, operative interventions, and postoperative course. Results: Ninety-six patients were analyzed. Fifty-three patients (55.2 percent) underwent a concomitant procedure, with 53.1 percent undergoing arm liposuction at the time of brachioplasty. Major and minor complications rates were 17.7 percent and 44.8 percent, respectively. Common complications included hypertrophic scarring (24.0 percent) and infection (14.6 percent). The total revision rate was 22.9 percent, with residual contour deformity (40.9 percent of revisions) and hypertrophic scarring (36.4 percent of revisions) representing the most common causes for revision. Patients who underwent a previous bariatric procedure were at an increased risk of developing a major complication (p = 0.02). Concomitant upper arm liposuction and concomitant procedures were not associated with a significantly increased complication rate. Conclusions: Brachioplasty, despite being an effective treatment for contour irregularities of the upper arm, is associated with significant revision and complication rates. Post–bariatric surgery patients should be informed of the potential for increased complications. Additional procedures performed at the time of brachioplasty do not significantly increase complications. Liposuction of the upper arm can be performed safely in conjunction with brachioplasty.

Second thoracic sympathetic ganglionectomy in sympathetically maintained pain

Twenty-four individuals with sympathetically maintained pain were treated by posterior paravertebral T2 sympathectomy following transient response to sympathetic nerve blockade. Eight surgical patients (33.4%) had causalgia, and 16 patients (66.4%) suffered with reflex sympathetic dystrophy. Overall, physical evidence of improvement was noted in 87% of surgical patients, with subjective improvement in 71%. Reflex sympathetic dystrophy patients fared better than those with causalgia. Complications were minor. The techniques employed appear safe and effective; a multidisciplinary approach with neurosurgery, physiatry, anesthesiology, psychology, and allied health services is recommended.

Breast infections with atypical mycobacteria following reduction mammaplasty.

Reduction mammaplasty is one of the most common plastic surgery procedures performed in the US, with the goal of correcting symptomatic macromastia. More than 70,000 cases were performed in 2009, with few complications and low infection rates. The authors present two cases of breast infections with Mycobacterium fortuitum and one with Mycobacterium chelonei following bilateral reduction mammaplasty. Infection with these organisms is exceptionally rare following breast surgery in the absence of a prosthetic implant. All of the patients had a delayed presentation following complete wound healing and were refractory to first-line antibiotic therapy. All three required long-term antibiotics in consultation with an infectious disease specialist. The patients all required surgical drainage, and two patients also required formal operative debridement. All three patients eventually went on to complete wound healing.

Outdoor Recreational Fires: A Review of 329 Adult and Pediatric Patients

Outdoor recreational fires are a frequent occurrence during the summer months and can be associated with burns resulting in significant morbidity. Both pediatric and adult populations can be affected, and their mechanism of injury is often different. Understanding these mechanisms is important when designing prevention programs. It is the goal of this study to review our experience with outdoor recreational fires. All patients who presented to Spectrum Health Blodgett Regional Burn Unit for burns secondary to an outdoor recreational fire over an 8-year period were reviewed. Demographic data, mechanism of injury, body area involved, TBSA burned, treatments undertaken, and subsequent complications were recorded. Pediatric patients (aged 16 years and younger) were analyzed independently, and risk factors were determined. A total of 329 patients suffered burns secondary to outdoor recreational fires over the length of the study. More than 35% required inpatient treatment, with an average length of stay of 4.8 days. Hands were the most frequently affected body part, with the mean TBSA involved being 3.5%. Ninety-four patients (28.6%) required split-thickness skin grafting. The most common mechanism of injury in both adult and pediatric populations was falling into an ongoing fire. Wound infection was the most common complication. Alcohol intoxication was associated with a higher burn severity and complication rate. Pediatric patients represented 39.8% of the sample. Burns secondary to outdoor recreational fires are associated with significant morbidity. Adult prevention programs should target awareness with respect to alcohol consumption and campfires secondary to the morbidity associated with these injuries. Pediatric patients are particularly susceptible, and parents should remain diligent about campfire safety and be educated about the inherent dangers of both active and extinguished fires.

Mucormycosis of the face.

As burn wound sepsis continues to be one of the most common causes of death in burn patients, it is important to note the trend of increased involvement of fungal pathogens. Very little exists in the literature regarding management of such fungal infections. We report invasive cutaneous mucormycosis involving the face of an extensively burned patient with no prior medical history that would otherwise predispose her to such infection. Diagnosis and management are discussed leading to eventual eradication of the Mucor and survival of our patient.

The impact of antibiotic impregnated PICC lines on the incidence of bacteremia in a regional burn center.

INTRODUCTION Peripherally inserted central catheters (PICCs) have been used increasingly in burn patients who often have decreased intravascular volumes and obtaining intravascular access for resuscitative efforts can be difficult. A potentially serious complication is bloodstream infection. The purpose of our study is to examine the impact of antibiotic impregnated PICC lines on the bacteremia rate in a regional burn center. METHODS Consecutive patients admitted to the burn unit and receiving an antibiotic impregnated PICC line were included in the study. Baseline demographics and bacteremia rate was recorded. A retrospective chart review was then undertaken of the 30 consecutive patients admitted to the burn unit and receiving a PICC line prior to the study period. RESULTS Nineteen patients were enrolled over the two-year period. The bacteremia rate for the study group was 0% compared to the 50% bacteremia rate of the retrospective control group (p=<0.001). CONCLUSION Antibiotic impregnated PICC lines decrease the bacteremia rate in our burn population. This has potential benefits for both patient morbidity and mortality as well as potential cost savings for the healthcare system.

Potential costs of breast augmentation mammaplasty

BACKGROUND Augmentation mammaplasty is one of the most common surgical procedures performed by plastic surgeons. The aim of this study was to estimate the cost of the initial procedure and its subsequent complications, as well as project the cost of Food and Drug Administration (FDA)-recommended surveillance imaging. METHODS The potential costs to the individual patient and society were calculated. Local plastic surgeons provided billing data for the initial primary silicone augmentation and reoperative procedures. Complication rates used for the cost analysis were obtained from the Allergen Core study on silicone implants. Imaging surveillance costs were considered in the estimations. RESULTS The average baseline initial cost of silicone augmentation mammaplasty was calculated at

Microbial growth within saline-filled tissue expanders

6335. The average total cost of primary breast augmentation over the first decade for an individual patient, including complications requiring reoperation and other ancillary costs, was calculated at