Applications In Reconstructive Surgery Research Articles

A three-dimensional algorithm for precise measurement of human auricle parameters

Measurement of auricle parameters for planning and post-operative evaluation presents substantial challenges due to the complex 3D structure of the human auricle. Traditional measurement methods rely on manual techniques, resulting in limited precision. This study introduces a novel automated surface-based three-dimensional measurement method for quantifying human auricle parameters. The method was applied to virtual auricles reconstructed from Computed Tomography (CT) scans of a cadaver head and subsequent measurement of important clinically relevant aesthetical auricular parameters (length, width, protrusion, position, auriculocephalic angle, and inclination angle). Reference measurements were done manually (using a caliper and using a 3D landmarking method) and measurement precision was compared to the automated method. The CT scans were performed using both a contemporary high-end and a low-end CT scanner. Scans were conducted at a standard scanning dose, and at half the dose. The automatic method demonstrated significantly higher precision in measuring auricle parameters compared to manual methods. Compared to traditional manual measurements, precision improved for auricle length (9×), width (5×), protrusion (5×), Auriculocephalic Angle (5–54×) and posteroanterior position (23×). Concerning parameters without comparison with a manual method, the precision level of supero-inferior position was 0.489 mm; and the precisions of the inclination angle measurements were 1.365 mm and 0.237 mm for the two automated methods investigated. Improved precision of measuring auricle parameters was associated with using the high-end scanner. A higher dose was only associated with a higher precision for the left auricle length. The findings of this study emphasize the advantage of automated surface-based auricle measurements, showcasing improved precision compared to traditional methods. This novel algorithm has the potential to enhance auricle reconstruction and other applications in plastic surgery, offering a promising avenue for future research and clinical application.

Predictors of Plastic Surgery Applicant Success: An Analysis of the Texas STAR Database.

Integrated plastic surgery residency is one of the most competitive medical specialties. Although previous studies have surveyed integrated plastic surgery residency program directors regarding desired applicant characteristics, there is a paucity of literature assessing detailed application characteristics and reported match outcomes from applicants in recent application cycles. This study examines application characteristics associated with matching into integrated plastic surgery residency from 2017 to 2023. The authors accessed the Texas Seeking Transparency in Application to Residency database, which contains survey information from graduating medical students nationwide regarding residency application characteristics and specialties/programs to which applications were submitted. Characteristics of matched versus unmatched applicants between 2017 and 2023 were compared using χ2 and 2-sided, independent t tests. Univariate logistic regression models were used to assess predictors of a successful match. A total of 381 integrated plastic surgery residency applicants responded to the Texas Seeking Transparency in Application to Residency survey from 2017 to 2023. Mean United States Medical Licensing Exam Step 2 CK scores; the number of away rotations, interview offers, and honored clerkships; and Alpha Omega Alpha membership rate were significantly associated with and predictive of matching. Preference signaling of programs was associated with an increased interview offer rate. Higher board examination scores, increasing numbers of honored clerkships, away rotations, and Alpha Omega Alpha membership were identified as statistically significant predictors of matching into integrated plastic surgery residency. Prospective applicants should use this information to help guide their efforts in these areas that appear to be associated with a successful transition to residency.

From virtual to reality: Apple Vision Pro's applications in plastic surgery

From virtual to reality: Apple Vision Pro's applications in plastic surgery

Advancements in Aesthetic Breast Augmentation: Evaluating the Safety, Efficacy, and Naturalistic Outcomes of Ergonomix2 Implants.

This pioneering study evaluates the safety, efficacy, and Aesthetic outcomes of Ergonomix2 Motiva Ergonomic Implants in breast augmentation. It aims to assess their capability to offer more natural touch and dynamics, delineate the learning curve for surgical techniques, and examine their safety profile compared to Ergonomix1 implants. A prospective cohort study was conducted, comparing 31 patients who received Ergonomix2 implants with a control group of 51 patients with Ergonomix1 implants. Eligible patients were those seeking Aesthetic breast augmentation without prior surgeries or chronic illnesses. Detailed documentation of surgical techniques, implant characteristics, and patient demographics was performed. The study assessed surgical learning curve, implant positioning accuracy, and short-term and early complications. Aesthetic outcomes were evaluated using the BreastQ questionnaire and quantitative elastography. Patients with Ergonomix2 implants showed significant improvements in Aesthetic outcomes, including breast contour symmetry and natural feel. The learning curve demonstrated a decrease in surgical time and higher implant positioning accuracy. The safety profile was favorable, with a low complication rate and high patient satisfaction levels. Ergonomix2 implants exhibited enhanced softness and pliability, closely mimicking natural breast tissue, as confirmed by elastographic analyzes. Ergonomix2 implants represent a significant advancement in Aesthetic breast surgery, offering natural-feeling and dynamically adaptable outcomes. Despite the promising results, the need for specialized surgical techniques and further research on long-term safety and efficacy is emphasized. This study contributes foundational knowledge to the field of ergonomic breast implants and their application in modern plastic surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Evolving Plastic Surgery Applicant: How Far Have We Come in 30 Years?

Plastic surgery training has undergone tremendous change and transitioned through many models over the years, including independent, combined, and integrated. This study evaluates how these changes and others have affected plastic surgery applicants' demographics and academic qualifications over the last 30 years. Data on applicant demographics and academic qualifications were extracted from multiple sources including the National Resident Matching Program, the American Association of Medical Colleges, and cross-sectional surveys of plastic surgery applicants for the years 1992, 2005, 2011, and 2022. Data were compared using pairwise χ2 goodness of fit tests. The sex distribution of plastic surgery applicants changed significantly over the last 30 years: whereas men predominated in 1992 (86% male vs 14% female), by 2011, the distribution was nearly equal (54% male vs 46% female in both 2011 and 2022, P < 0.001).The racial makeup of applicants also changed over time (P < 0.05). White applicants decreased from 73% in 1992 to 55% in 2011, and 53% in 2022. While there was an increase in Asian (7% to > 17% to > 20%) and other (13% to > 14% to > 21%) applicants over time, whereas the proportion of Black applicants remained stagnant (5% to > 6% to > 8%).Applicants with prior general surgery experience declined precipitously over the years: 96% in 1992, 64% in 2005, 37% in 2011, and 26% in 2022 (P < 0.001). When compared with 1992, Alpha Omega Alpha status increased significantly in 2011 (36% vs 12%, P < 0.05) but did not change considerably in 2005 (22%) and 2022 (23%). Research experience increased dramatically over the years, with the proportion of applicants with at least one publication going from 43% in 1992, to 75% in 2005, to 89% in 2011, and to 99% in 2022 (P < 0.001). Applicant interest in academic plastic surgery did not change considerably over the years at roughly ranging from 30% to 50% of applicants (P = ns). There has been a shift in the demographics and academic qualifications of plastic surgery applicants over the last 3 decades. Understanding this evolution is critical for reviewing and evaluating the makeup of our specialty, and enacting changes to increase representation where necessary.

Bioengineering of vascularized porcine flaps using perfusion-recellularization

Large volume soft tissue defects greatly impact patient quality of life and function while suitable repair options remain a challenge in reconstructive surgery. Engineered flaps could represent a clinically translatable option that may circumvent issues related to donor site morbidity and tissue availability. Herein, we describe the regeneration of vascularized porcine flaps, specifically of the omentum and tensor fascia lata (TFL) flaps, using a tissue engineering perfusion-decellularization and recellularization approach. Flaps were decellularized using a low concentration sodium dodecyl sulfate (SDS) detergent perfusion to generate an acellular scaffold with retained extracellular matrix (ECM) components while removing underlying cellular and nuclear contents. A perfusion-recellularization strategy allowed for seeding of acellular flaps with a co-culture of human umbilical vein endothelial cell (HUVEC) and mesenchymal stromal cells (MSC) onto the decellularized omentum and TFL flaps. Our recellularization technique demonstrated evidence of intravascular cell attachment, as well as markers of endothelial and mesenchymal phenotype. Altogether, our findings support the potential of using bioengineered porcine flaps as a novel, clinically-translatable strategy for future application in reconstructive surgery.

Realtime assessment of vascular occlusion and reperfusion in animal models of intraoperative imaging – a pilot study

Abstract Objectives Intraoperative monitoring of blood flow (BF) remains vital to guiding surgical decisions. Here, we report the use of SurgeON™ Blood Flow Monitor (BFM), a prototype system that attaches to surgical microscopes and implements laser speckle contrast imaging (LSCI) to noninvasively obtain and present vascular BF information in real-time within the microscope’s eyepiece. Methods The ability of SurgeON BFM to monitor BF status during reversible vascular occlusion procedures was investigated in two large animal models: occlusion of saphenous veins in six NZW rabbit hindlimbs and clipping of middle cerebral artery (MCA) branches in four Dorset sheep brain hemispheres. SurgeON BFM acquired, presented, and stored LSCI-based blood flow velocity index (BFVi) data and performed indocyanine green video angiography (ICG-VA) for corroboration. Results Stored BFVi data were analyzed for each phase: pre-occlusion (baseline), with the vessel occluded (occlusion), and after reversal of occlusion (re-perfusion). In saphenous veins, BFVi relative to baseline reduced to 5.2±3.7 % during occlusion and returned to 102.9±14.9 % during re-perfusion. Unlike ICG-VA, SurgeON BFM was able to monitor reduced BFVi and characterize re-perfusion robustly during five serial occlusion procedures conducted 2–5 min apart on the same vessel. Across four sheep MCA vessels, BFVi reduced to 18.6±7.7 % and returned to 120.1±27.8 % of baseline during occlusion and re-perfusion phases, respectively. Conclusions SurgeON BFM can noninvasively monitor vascular occlusion status and provide intuitive visualization of BF information in real-time to an operating surgeon. This technology may find application in vascular, plastic, and neurovascular surgery.

19. Exploring the 6-Year Trend in Dedicated Research Years Among Matched Integrated Plastic and Reconstructive Surgery Applicants

19. Exploring the 6-Year Trend in Dedicated Research Years Among Matched Integrated Plastic and Reconstructive Surgery Applicants

Independent Plastic Surgery Match Regional Trends Comparing In-person and Virtual Interview Cycles.

There is a trend toward matching in a different region than previous training for the independent plastic surgery match cycles from 2019 to 2021, which differs from the trend to match within the same region for integrated plastic surgery programs. Notably, residency interviews transitioned from in-person to virtual in 2020 due to the coronavirus pandemic. Therefore, we compared in-person versus virtual interview match trends from 2019 to 2023. Zip codes and regions of each successfully matched plastic surgery applicant's medical school, residency, and plastic surgery program were gathered from publicly available data for the 2019 and 2020 in-person interview cycles and 2021, 2022, and 2023 virtual interview cycles. Although regions did not differ significantly in the proportions of positions each year (P = 0.85), there was a trend toward fewer positions in each region from 2019 to 2022. Overall, applicants were more likely to match in a different region as their medical school or residency during virtual compared with in-person interviews (P = 0.002 and P = 0.04). Applicants matched to programs further from their medical school zip code in virtual interview years (P = 0.02). There was no significant difference in distance between surgical residencies and plastic surgery residencies between the two time periods (P = 0.51). Trends toward matching into a different region than prior training after the switch to virtual interviews could be attributed to applicant accessibility to interview broadly. However, this could also be due to the decreased number of independent residency positions over the years, requiring applicants to move regions and travel further from where they began their training.

Preference Signaling and the Integrated Plastic Surgery Match: A National Survey Study

Rooted in economics market strategies, preference signaling was introduced to the Plastic Surgery Common Application (PSCA) in 2022 for integrated plastic surgery residency applicants. This study surveyed program and applicant experience with preference signaling and assessed how preference signals influenced likelihood of interview invitations. Two online surveys were designed and distributed to all program directors and 2022-2023 applicants to integrated plastic surgery. Opinions regarding the utility of preference signaling were solicited, and the influence of preference signals on likelihood of interview offers was assessed. All integrated plastic surgery programs. All 88 program directors and 2022-2023 applicants to integrated plastic surgery. A total of 45 programs and 99 applicants completed the survey (response rates, 54.2% and 34.2%, respectively). Overall, 79.6% of applicants and 68.9% of programs reported that preference signals were a useful addition to the application cycle. Programs reported that 41.4% of students who sent preference signals received interview offers, compared to 84.6% of home students, 64.8% of away rotators, and 7.1% of other applicants; overall, students who signaled were 5.8 times more likely to receive an interview offer compared to students who were not home students and did not rotate or signal. After multivariable adjustment, programs with higher Doximity rankings, numbers of away rotators, and numbers of integrated residents per year received more preference signals (all p < 0.05). Applicants and programs report that preference signaling was a useful addition to the integrated plastic surgery application cycle. Sending preference signals resulted in a higher likelihood of interview offers among nonrotators. Preference signaling may be a useful tool to reduce congestion in the integrated plastic surgery application cycle.

Using Auricular Cartilage-fascia Composite Tissue Free Grafting Technique to Improve Cartilage Survival Outcomes.

Auricular cartilage graft has a wide range of applications in plastic and reconstructive surgery. However, there is still a risk of absorption of the grafts over time. Intrinsic postauricular fascia (IPF) with a rich vascular network may play an important role in the nutrition and repair of auricular cartilage. This study aimed to investigate the effect of IPF on the survival viability of free auricular cartilage grafts. 24 auricular cartilages were obtained from 6 New Zealand white rabbits which were divided into the cartilage-fascia composite graft group (FC group, n=12) and the cartilage without fascia group (C group, n=12). Two groups of cartilage were implanted into each side of the subcutaneous pocket of the rabbit's dorsum. The rabbits were sacrificed after 3 months and all cartilage grafts were obtained. Macroscopic observation, histopathological staining, and biomechanical testing were performed on all specimens. There were significant differences between the 2 groups regarding proliferating chondrocytes, apoptotic chondrocytes, vascularization, and matrix collagen. Compared to the auricular cartilage grafts without fascia, the auricular cartilage-fascia composite grafts had more neovascularization, proliferative chondrocytes, and type II collagen, with a homogeneous cartilage matrix and no obvious areas of heterogeneous staining. Young's modulus and ultimate tensile strength of cartilage were reduced in both groups compared to pretransplantation, but the composite graft group was superior to the fascia-free group. Auricular cartilage-fascial composite tissue free graft could improve cartilage survival outcomes with higher viability and mechanical properties.

The Keystone Perforator Island Flap: Review of Utility and Versatile Clinical Applications.

The keystone perforator island flap (KPIF) was described almost a decade ago. However, this flap has only recently been recognized for its advantages in various clinical applications in plastic surgery. A better understanding of the versatility of KPIFs can help promote the widespread adoption of this technique for complex wounds in various anatomical regions. A retrospective chart review was conducted of patients undergoing KPIFs from December 2018 to March 2022 at the authors' home institution. The indications, surgical approaches, patient characteristics, and outcomes were extracted for review and analysis. A total of 12 patients (ages 13-86 years) underwent reconstruction with KPIFs for oncologic and nononcologic defects. By anatomic region, three cases involved the upper back, six involved the lumbosacral region, one involved the perineum, and two involved the midfoot. Half of the patients (n = 6) had failed previous attempts at wound closure. The mean defect size was 13.8 × 10.0 cm for the upper back lesions, 13.7 × 4.8 for the lumbosacral defects, and 3.5 × 2.0 for the metatarsal wounds. Median follow-up time for all patients was 7.5 months (IQR: 4-10.5). On follow-up, there was 100% flap survival. KPIFs are a simple, safe, and suitable option for reconstructive closure of defects in many anatomical areas, including wounds complicated by previous failed closure attempts, with low complication risk profile.

Identifying Barriers Faced by Applicants without a Home Residency Program when Matching into Plastic Surgery.

Background  Applying into plastic surgery (PS) is competitive. Lacking a home residency program (HRP) is another barrier. Our goal is to characterize challenges faced by PS applicants without HRPs and identify solutions. Methods  Surveys were designed for current integrated PS residents and applicants in the 2022 Match without HRPs. Surveys were distributed electronically. Only U.S. allopathic graduate responses were included. Results  Of 182 individuals surveyed, 74 responded (39%, 33 residents, 41 applicants). Sixty-six percent reported feeling disadvantaged due to lack of an HRP. Seventy-six percent of applicants successfully matched. Of these, 48% felt they required academic time off (research year) versus 10% of unmatched applicants. Ninety-seven percent of matched applicants identified a mentor versus 40% of unmatched applicants ( p  < 0.05). Matched applicants identified mentors through research (29%) and cold calling/emailing (25%). Matched versus unmatched applicants utilized the following resources: senior students (74 vs. 10%, p  < 0.05) and social media (52 vs. 10%, p  < 0.05). Among residents, 16 had PS divisions (48%). Thirty-six percent with divisions felt they had opportunities to explore PS, compared with 12% without divisions. Residents without divisions felt disadvantaged in finding research (94 vs. 65%, p  < 0.05), delayed in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%) and letters of recommendation (31 vs. 24%). Conclusion  PS residents and applicants without HRPs reported feeling disadvantaged when matching. The data suggest that access to departments or divisions assists in matching. We identified that external outreach and research were successful strategies to obtain mentorship. To increase awareness for unaffiliated applicants, we should increase networking opportunities during local, regional, and national meetings.

A Comparison of Otolaryngology Residency Applicants Over Time and to Other Surgical Applicants.

Understand how otolaryngology residency applicant characteristics have changed over time and compare them to those of other surgical subspecialties. Retrospective analysis of academic, extracurricular, and application data in the Texas Seeking Transparency in Application to Residency databases. Applicants to otolaryngology, neurological surgery, ophthalmology, plastic surgery, urology, and orthopedic surgery applicants from 2019 to 2023. Kruskal-Wallis, Wilcoxon rank sum, Fischer's exact, and Mann-Whitney U tests were used to compare temporal, match-based, and subspecialty differences in applicant characteristics. Across 4 match cycles and 541 otolaryngology applicants, significant differences were found in the average number of honored clerkships per applicant (P = 0.044), the percentage of matched applicants (P = 0.017), and the average number of research experiences (P < 0.001), peer-revied publications (P = 0.002), applied programs (P < 0.001), and interviews received (P = 0.041). Relative to their unmatched counterparts, matched applicants frequently received more interviews, belonged to higher academic quartiles, and were more likely to belong to academic honor societies (all P < 0.05). Matched applicants exhibited significant differences in the number of research experiences (P = 0.002), peer-reviewed publications (P = 0.004), and applied programs across cycles (P < 0.001). Relative to applicants from other surgical subspecialties, otolaryngology applicants exhibited high amounts of extracurricular involvement, were on par in terms of research output, and received a low proportion of interviews despite applying to a high number of programs. Matching into otolaryngology has become increasingly competitive and is as competitive as peer surgical subspecialties. Strong academic performance, judicious program signaling, increased research involvement, and holistic factors like letters of recommendation may help applicants successfully match.

Synthesis and Characterization of Hydroxyapatite-Ag Nanocomposites Using Areca Nut Peel Bioreductors (Areca catechu L.) for Antibacterial Applications

Calcium Hydroxyapatite (HAp, Ca10(PO4)6(OH)2) is an important material utilized in bone, tooth enamel, and dentin. In this study, areca nut peel bioreductors (Areca catechu L.) were used to synthesize HAp-Ag nanocomposites using green synthesis method. The effect of polyvinyl alcohol (PVA) amount on the structure and morphologies of the synthesized HAp-Ag nanocomposites were investigated. The XRD showed that the crystal size of synthesized HAp-Ag nanocomposites is 1-100 nm with a degree of crystallinity above 60%. SEM images showed that the particles of HAp-Ag nanocomposites were nano-sized with uneven spherical shape. The antibacterial activity test was carried out against Staphylococcusaureus and Escherichia coli using the disc diffusion test. The result showed that AgNPs incorporated in modified HAp inhibited Gram-negative bacteria more efficiently than Gram-Positive bacteria. Based on the antibacterial test results, the hydroxyapatites were effective against all tested microorganisms. Therefore, it can be considered as an antimicrobial biomaterial that can be used in implant and reconstructive surgery applications.

The Modern Integrated Plastic Surgery Applicant Pays 150% More Than Their Counterparts Four Years Ago

Background: Integrated plastic surgery residency positions are among the most difficult to obtain. We examine trends in the number of applicants, applications per applicant, and cost over the past five match cycles. Methods: In total, 2166 applicants to integrated plastic surgery programs were included. The American Association of Medical Colleges and Electronic Residency Application Service databases were examined to determine applicant trends for the years 2017 to 2021. Results: In 2017, there were 564 applicants for integrated plastic surgery residency positions, and in 2021, there were 416 (26% decrease). Across this same time period, the number of applications per applicant nearly doubled (97%) from 30 in 2017 to 59 in 2021, resulting in a 45% increase in the total number of applications. The largest increase in applications per applicant was seen between 2018 and 2019, a 70% increase. From 2017 to 2021, a 10% increase in the number of female applicants and a 43% decrease in the number of male applicants was observed. Cost of applications per applicant increased by 146%, from $514 in 2017 to $1265 in 2021. Total application costs in 2021 were $526,323, an 81% increase from 2017. The future value of these expenditures equals an economic burden of $801,855, assuming a 10-year term student loan at a conservative 4.3% interest rate. Conclusions: Despite substantial decreases in the number of applicants, the number of applications and resulting cost of applications have increased by large margins since 2017. This is representative of the increasingly competitive plastic surgery application process.

Augmented and Virtual Reality Applications in Facial Plastic Surgery: A Scoping Review.

Augmented reality (AR) and virtual reality (VR) are emerging technologies with wide potential applications in health care. We performed a scoping review of the current literature on the application of augmented and VR in the field of facial plastic and reconstructive surgery (FPRS). PubMed and Web of Science. According to PRISMA guidelines, PubMed and Web of Science were used to perform a scoping review of literature regarding the utilization of AR and/or VR relevant to FPRS. Fifty-eight articles spanning 1997-2023 met the criteria for review. Five overarching categories of AR and/or VR applications were identified across the articles: preoperative, intraoperative, training/education, feasibility, and technical. The following clinical areas were identified: burn, craniomaxillofacial surgery (CMF), face transplant, face lift, facial analysis, facial palsy, free flaps, head and neck surgery, injectables, locoregional flaps, mandible reconstruction, mandibuloplasty, microtia, skin cancer, oculoplastic surgery, rhinology, rhinoplasty, and trauma. AR and VR have broad applications in FPRS. AR for surgical navigation may have the most emerging potential in CMF surgery and free flap harvest. VR is useful as distraction analgesia for patients and as an immersive training tool for surgeons. More data on these technologies' direct impact on objective clinical outcomes are still needed. N/A Laryngoscope, 2023.

Coexpression analysis of angiogenesis, proliferation, apoptosis, autophagy and SHH pathway genes involved in skin expansion

Skin and soft tissue expansion is a widely used technique in plastic surgery. However, the regulatory mechanisms associated with cellular processes involved in skin expansion are not well elucidated. In the present study, we aimed at exploring the transcriptome changes associated with skin expansion and profiling the difference in gene expression between the skin tissue in the top of the dilator and the skin tissue in the side of the dilator. A mouse model of skin expansion was established and RNA sequencing (RNA-Seq) was performed on samples collected at different time points. Differential expression analysis was performed using the DESeq2 package while STEM was used for time series clustering profiling. The regulatory networks were established and the functions of sets of genes were analyzed. The mRNA expression levels of candidate genes were validated by the quantitative RT-PCR. Among the skin tissue in the top of the dilator and normal samples at days 1, 3, 7, 14 and 28, 53 commonly upregulated and 7 commonly downregulated genes were identified while among the skin tissue in the side of the dilator and normal samples, 98 downregulated and 255 upregulated genes were identified. Genes differentially expressed among the skin tissue in the top of the dilator and normal samples were involved in coagulation and proliferation-associated pathways while those among the skin tissue in the side of the dilator and normal samples were involved in the inflammation, immune response, and defense response. Among the skin tissue in the top of the dilator and the skin tissue in the side of the dilator samples, 161 were constantly upregulated while 27 were constantly downregulated; these genes were enriched in the biological processes of cell adhesion and regulation of cell proliferation (n = 11). Furthermore, we identified that SHH signaling genes formed a coexpression regulatory network with cellular proliferation, apoptosis, autophagy and angiogenesis-related genes in the expanded skin. In conclusion, our findings can promote research and understanding of the mechanism of skin expansion and will find application in plastic surgery.

Having Social Media among Integrated Plastic Surgery Applicants: Is It Needed to Match?

Little information exists on the perceptions of integrated plastic and reconstructive surgery (PRS) residency applicants on the need for having social media (SoMe) during the application process. A cross-sectional survey study was conducted during the 2022 match cycle to assess integrated PRS residency applicants' perceptions on the role of SoMe during the match. Univariate and multivariate analyses were performed on variables of interest. Qualitative analysis was conducted on free-form responses. Seventy-nine surveys were completed (response rate: 24%). The majority of respondents were educated in the United States (92%). Instagram was the most commonly used SoMe platform (92%). Of those surveyed, 18% thought that SoMe was beneficial to the application process. Twenty-nine percent of respondents agreed that a SoMe presence increases one's chances of matching into PRS residency (41% disagreed and 30% responded neutrally). Forty-four percent endorsed stress about maintaining a SoMe presence in PRS. Having mentors who recommended maintaining a SoMe presence was associated with the belief that SoMe increases one's chances of matching [odds ratio (OR) 8.1, 95% confidence interval (CI) 1.1-40.4, P = 0.011] and stress about maintaining a SoMe presence (OR 6.3, 95% CI 1.2-33.3, P = 0.030). Applicants who did research years had lower odds of experiencing stress (OR 0.16, 95% CI 0.04-0.70, P = 0.015). The growing role of SoMe in the residency selection process may be exacerbating applicants' stress and anxiety. PRS programs may consider establishing clear policies for how SoMe will be used in evaluating candidates.

Supermicrosurgery: past, present and future.

Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.