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PRSonally Speaking
Monday, April 07, 2014
 
At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.
 
When the article is published in print with the May issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.
 
This week we present the introduction to "Effects of Hypotensive Anesthesia on Blood Transfusion Rates in Craniosynostosis Corrections." by Fearon et al.


Abstract
Purpose: Hypotensive anesthesia is routinely utilized during craniosynostosis corrections to reduce blood loss. Utilizing Near-Infrared Spectroscopy, we noted cerebral oxygenation levels often fell below recommended levels. Intrigued by these observations we sought to measure the effects of hypotensive
versus standard anesthesia on blood transfusion rates.
 
Methods: 100 children undergoing craniosynostosis corrections were prospectively randomized into two groups: a target mean arterial pressure of either 50 mmHg, or 60 mmHg. Caregivers were blinded (aside from anesthesiologists) and strict transfusion criteria were followed. Multiple variables were
analyzed and appropriate statistical testing was performed.
 
Results: The hypotensive and standard groups appeared similar without statistically significant differences in: mean age (46.5 vs. 46.5 months), weight (19.25 vs. 19.49 kgs.), procedure (anterior remodeling (34 vs. 31) vs. posterior (19 vs. 16)), and preoperative hemoglobin levels (13 vs. 12.9gm/dl.). Intraoperative mean arterial pressures differed significantly (56 vs. 66 mmHg, p<0.001). The captured
cell saver amount was lower in the hypotensive group (163 vs. 204 cc., P = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 vs. 9.3 gm. /dl.). Fifteen of 100 patients (15%) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive (9/53, 17.0%) and standard anesthesia (6/47, 13%) groups (P = 0.056).
 
Conclusions: We were unable to find any significant difference in transfusion requirements between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension.

 
The full article will be published with the May 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

Thursday, April 03, 2014

By Henry Hsia, MD

 

It had been two weeks now. Her implant was gone and she was looking at me from where she sat on the exam table.  Even though she had known it could happen, had signed the consent form indicating I’d told her that this could happen, I could tell from the look she was giving me that she never expected it would actually happen.

 

I knew better, but I admit I hadn’t expected it would happen either, especially to her and now.  Several months had passed since the implant was placed.  She didn’t smoke, never had radiation for her breast cancer, and had done everything I asked.  She’d been doing well and at her last routine visit a month ago I’d congratulated her on making it through the reconstruction gauntlet.  Back then, she had sat on that exam table looking at me with a smile of relief and gratitude.

 

But that was then.  Some time after that visit I got the call she had redness and some drainage.  During the ensuing flurry of evaluation and discussion, I had her focus on making sure the infection didn’t get worse and threaten her health.  And with that in mind, we decided the implant couldn’t be salvaged and had to come out.  The explantation had gone smoothly and she completed her antibiotics.  She was doing well, except….

 

“So what’s next?”  That’s what her look now seemed to ask me.  At her initial consultation, she’d been adamantly not interested in autologous reconstruction.  She didn’t want the added scars, the possible donor site morbidity, etc.  And the last few weeks hadn’t changed her mind about that.  But she also wasn’t willing to accept a bra prosthesis as a long-term solution.  She wanted to try the implant again.  I didn’t think that was a good idea without better tissue coverage.  We were at an impasse.

In the end pressed for time, I punted the question to a future visit, telling her we had to wait a few months anyway.  I’m sure it wasn’t the most satisfying answer for her and the lack of a clear plan left me in a frustrated mood.  I was still feeling that sour mood when a few days later I found myself at the Plastic Surgery Research Council meeting in New York City.  

 

"Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family"

 

Even though I’ve always enjoyed going to these and other plastic surgery meetings, it’s been getting harder and harder each year to go, what with the squeeze of ever increasing expectations for clinical productivity and family commitments.  As I wandered among the scientific sessions, my phone was a constant distraction as it buzzed with photos of my young daughters that my loving wife was sending from their weekend trip away along with text messages like “Check out what you’re missing!”

 

Then, looking up from my wife’s latest salvo of guilt-laden cuteness, I saw a poster entitled “The Lateral Intercostal Artery Perforator (LICAP) Flap for Outpatient Total Breast Reconstruction”.  Forgetting my family (for just a moment), I immediately thought of my patient and went up and started chatting with the authors who were standing there.  This flap wasn’t something I’d thought of during my patient’s visit earlier that week, and it was wonderfully fortuitous and timely to come across this particular poster.  Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family. 

We had a great discussion and I left the poster looking forward to seeing my patient again.  Even though I couldn’t be sure, at least I had a feasible option to offer that I thought she just might be willing to accept.  Whatever frustrations and qualms I had about coming to the meeting had melted away.  I stood there among the poster presentations and all the exciting and innovating work around me and felt a reinvigorated sense of optimism.  Now this is why I go to meetings like the PSRC! 

 

I took a selfie among the posters and shot it back to my bemused wife with the message “Hey, check out what YOU are missing!”


Monday, March 31, 2014
by Jon Ver Halen, MD FACS
 
Comment on “Assessment of Resident Microsurgical Skill Using an Online Video System.” By Taylor NW, Webb K, Neumeister MW, Bueno RA. Plast Reconstr Surg. 2014 Jan.
 
I first want to congratulate the authors on a fascinating application of technology to resident education.  Two aspects of the study, microsurgery and education, are topics very dear to me.  Microsurgery is unique in that simulators are likely to play a greater role in the acquisition of surgical skills with the increasing role of patient safety. In addition, with the increasing transparency and standardization of graduate medical education, having a “video record” of a given trainee’s (or practicing physician, in the instance of MOC) performance could feasibly become a standard evaluation tool.  My only suggestion is that microsurgical performance in the operating room is rarely as straightforward as sewing two vessels together, end to end. Vessel exposure, alignment and positioning, and design of the vessel inset all have relevance to the success of a given anastomosis (and hence flap). Thus, I do not think it is sufficient to just assess a given trainee’s facility with device handling and suturing.  At my previous position, we trialed an in situ device for skills training, and we varied scenarios (end to end, end to side, vessel mismatch).  I suggest that such varied clinical scenarios become part of the microsurgical skills training curriculum.
 
I have a second reason for addressing this article.  Using technological aides as a “virtual presence” is here to stay, and we will either be early adopters, or “late laggards”.  For instance, “virtual patient visits,” vis-à-vis phone calls, secure emails, or remote patient access to his or her own medical record rose from 4.1 million in 2008 to 10.5 million in 2013. Moreover, you can obtain an MBA, PhD, Bachelors and/or Masters degree, and professional degrees (law school, veterinary school) entirely online. You can even become a Count of Sealand, or a Lord in the Scottish Highlands with a simple online application.  The Plastic Surgery Education Network also offers updates and technical pearls with regard to surgical techniques and topics in plastic surgery. 
 
Recently, planning started for a Global On Line Fellowship in Head and Neck Surgery and Oncology. The goals for the undertaking are noble: outside of major medical centers, care for head and neck cancer is fragmented and irregular, and it is not realistic to expect every practicing surgeon or oncologist to take a year (or more) from their personal and professional lives to obtain specialized training. The vast majority of any medical education is based on knowledge acquisition, and I suppose there is no reason you can’t learn that from a book, online lectures, tests and/or remote tutorials.  But what about surgical skills acquisition? To date, there are no disciplines requiring a component of manual dexterity, which can be completed solely online (e.g., auto mechanic, aircraft pilot, nursing, scuba diving). The standard for this new program is a two-month “observership” at a pre-determined high volume center for head and neck oncology. Is this reasonable? Prerequisites for the program include:
 
1. A minimum of five years of surgical training and Board certification or its equivalent in their country of residence, in the specialty of general surgery, otolaryngology, plastic surgery, maxillofacial surgery, or similar field.
2. Certification and letter of support from the head of the institution where the candidate conducts his/her clinical activities indicating a commitment by the candidate to the specialty of head and neck surgery and oncology.
 
3. A complete list of operative procedures performed during the preceding year showing a significant proportion of head and neck cancer/tumor cases, (over 50%) where the candidate was either the operating surgeon or first assistant.
4. Commitment of the candidate to complete the Fellowship by a letter of intent and commitment for the required time and effort to complete the Fellowship.
 
Is board certification, and a “significant proportion of head and neck cancer/tumor cases” a reasonable surrogate for traditional, apprenticeship-style learning? If you complete this program, does that mean that you are a fully-trained head and neck surgical oncologist? I would anticipate that the degree/certificate does not confer some type of equivalency for US Medical Boards, such that foreign medical graduates could obtain a US license. Regardless of the details, it is clear that the global medical training paradigm is changing. As a specialty, to what extent do we want to adopt these changes? In addition, how can existing (and evolving) technologies be leveraged to improve our specialty and our patients’ lives?

Monday, March 31, 2014
PRSonally Speaking invites you to discuss controversial or popular papers from the pages of PRS in these periodic blog posts. In order to open the conversation to the entire Plastic Surgery community, the hot topic articles featured as sneak peeks in PRSonally Speaking last month and the articles featured in press releases will be FREE for two months as a special promotion.
 
Help us get the word out by inviting non-subscriber colleagues, students and residents to read these FREE hot articles and share their comments below.
    We also feature short-term free articles throughout the month of April. Please read and discuss the following articles:

      Read, share and discuss these hot articles through the month of April and beyond, courtesy of PRS. Your thoughts, opinions and ideas are very important to the on-going conversation.

      In addition to reading the articles for free above, you can also watch the free video discussion:

      Daniel A. Del Vecchio, M.D., M.B.A., discusses the April Cosmetic article "Aesthetic Applications of Brava-Assisted Megavolume Fat Grafting to the Breasts: A 9-Year, 476-Patient, Multicenter Experience" by Khouri et al. 

      Also, please read this month's special supplement for free as well: AAPS 2014 Abstract Supplement 4S

      The free articles from the two most recent months, can always be readily found on the bottom of our homepage where you see the following logo:


      Wednesday, March 26, 2014
       
      At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.
       
      When the article is published in print with the April issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.
       
      This week we present the introduction to "Treatment of infantile haemangiomas with propranolol - clinical guidelines" by Szychta et al.

      Introduction. Infantile haemangioma (IH) is vascular tumour and requires treatment in lesions manifested by potentially dangerous symptoms. Several publications reported that involution of IH could be accelerated by propranolol, but used only invalidated subjective measures of assessment. We aimed to validate objectively the aesthetic results after propranolol treatment for IH, and to produce protocol of therapy, including optimal timing for introduction, pre-treatment preparation, dosage, frequency of visits, duration and patient safety.

      Methods. For the non-randomized comparative cohort study we enrolled 60 patients treated with propranolol. Medical 2D photographs, taken pre- and post-treatment, were analyzed subjectively by three plastic surgery consultants and objectively with computer program. Aesthetic results were analyzed using the following parameters: subjective overall outcome, subjective colour fading and objective colour fading. Reliability of subjective and objective methods were quantified and compared, as described with accuracy and repeatability. Volumetric parameters were obtained from 3D scans taken pre- and post-treatment and analyzed objectively with computer program. Numerous patients' data were recorded from the medical notes.

      Results. Our study proved high efficiency of propranolol in treatment of IH, as assessed with the objective measures for the first time. We outlined optimal protocol of treatment, including introduction, dosage, duration and cessation of therapy.

      Conclusions. Propranolol is an effective, well tolerated and safe first-line treatment for proliferative haemangioma. Therapy should be commenced early, continued with the target dosage of 2mg/kg/day in 3 divided doses through proliferative phase of IH and stopped gradually.
       
      The full article will be published with the April 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.
      About the Blog

      Plastic and Reconstructive Surgery

      PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

      The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.

      Contributors

      Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

      Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

      Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

      Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

      Jon Ver Halen, MD is currently an Assistant Professor in the Department of Plastic Surgeryat the University of Tennessee Health Science Center, in Memphis. He also acts as Program Director for the plastic surgery residency. His practice focuses on oncologic reconstruction.

      Tech Talk Bloggers

      Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

      Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.