Plastic Surgery Service Research Articles

Mentorship amid the Madness: The Value of National Mentorship Programs in Plastic Surgery amid the COVID-19 Pandemic.

Coronavirus disease of 2019 (COVID-19) has spread rapidly throughout the world, and the impact on global and national health care, including plastic surgery, has been dramatic and unpredictable. Plastic surgery departments and divisions went into limbo after the American College of Surgeons, American Society of Plastic Surgeons, and The Aesthetic Society, advised that elective and nonessential cases be canceled.1 All large plastic surgery meetings were canceled. Aspiring plastic surgeon trainees are among those affected by the pandemic; the Association of American Medical Colleges called for a halt in all clinical rotations of at least 4 weeks’ duration in the 2020/2021 application cycle, a critical time for fourth-year medical students applying to integrated plastic surgery programs.2 Medical students typically dedicate April to September rotating as subinterns on the plastic surgery service at their home institution and at several “away institutions” throughout the United States. Away rotations play a significant role in the plastic and reconstructive surgery match process; 67 percent of successful applicants in a given year participated in a rotation at the institution they matched into.3 Students also attend national meetings for the opportunity to present their research, meet renowned faculty members across the country, and receive feedback on their application and performance. Often faculty, residents, and students at such events become lifelong colleagues and mentors.4,5 These opportunities are now no longer available for students applying in the current COVID-19 pandemic. Plastic surgery residency applicants applying in the 2020/2021 cycle era are facing the daunting unknown with more limited opportunities for meeting influential individuals in the field. Students at institutions that do not have a plastic surgery home program may be affected the most. Consequently, mentorship of future trainees is arguably more important than ever, as it provides prospective applicants with a unique opportunity to connect students with faculty across the country to discuss research and personal career development and to expand one’s network of mentors and colleagues. In 2015, the Plastic Surgery Research Council established a formal mentorship program with the goal of facilitating relationships between trainees and senior figures and of fostering unique guidance regarding career development. Medical student members and plastic surgery applicants can be paired with mentors across the nation from diverse backgrounds, and mentors can provide invaluable advice electronically regarding research endeavors and residency applications. With the current restrictions imposed by the evolving COVID-19 pandemic, electronic mentee-mentor interactions may be the only chance that prospective plastic surgery residents have to appreciate and converse with faculty and residents from different institutions, We thus want to emphasize the value of mentorship relationships and formal mentorship programs such as that offered by the Plastic Surgery Research Council. It is critically important to connect medical students/trainees with faculty members to help them learn the nuances of plastic surgery programs in institutions across the nation. Reaching beyond the classroom and expanding our horizons can help us confront the realities we could not have anticipated. DISCLOSURE The authors have no potential conflicts of interest to disclose.

Decline in Medicare Utilization and Reimbursement Rates in Ophthalmic Plastic and Reconstructive Surgery: 2010-2019.

Analysis of current and past reimbursement patterns for federally funded programs is crucial to develop sustainable future payment models. The Centers for Medicare and Medicaid Services Physician Fee Schedule was used to evaluate 26 common ophthalmic plastic and reconstructive surgery (OPRS) procedures. From 2010 to 2019, compound annual growth rate, total percent change, and annual percent change were calculated using inflation-adjusted reimbursement rates. Centers for Medicare and Medicaid Services' Physician/Supplier Procedure Summary was used to assess the surgical volume of the 26 procedures in ophthalmology and plastic surgery services. From 2010 to 2019, total billed surgical procedures in OPRS decreased by 57.0%, affecting both ophthalmologists (-54.3%) and plastic surgeons (-80.1%). Over the study period, inflation-adjusted reimbursement rates decreased by 5.6%. Compound annual growth rate was -0.66%, and annual percent change was -0.62%. From 2010 to 2013, reimbursement rates increased by 1.8% each year. In contrast, from 2013 to 2019, reimbursement rates decreased by 1.7% each year (P < 0.0001). From 2010 to 2019, Medicare utilization has substantially declined for OPRS procedures. Inflation-adjusted Medicare reimbursement rates have decreased for the majority of common procedures since 2013. Surgeons and policymakers need to be aware of these trends to ensure future availability of subspecialty surgical services.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a UK oncology and reconstructive surgery service – benchmarking the data

The British Association of Oral and Maxillofacial Surgery is soon to implement the Quality Outcomes in Oral in Maxillofacial Surgery (QOMS) to provide a platform for quality management across the specialty in the UK. The initial oncology and reconstruction audits for QOMS involves data collection on specific procedures and metrics. The aim of this report is to determine their appropriateness using extant audit datasets in our institution that overlap substantially with the QOMS audits. Pre-existing datasets comprising information on patients treated for oral cavity SCC with curative intent were analysed. Data on surgical margins, lymphadenectomy lymph node yield, delay between surgery and adjuvant radiotherapy, duration of hospital stay, and complications including flap failures were analysed. All statistical analyses were performed with SPSS 25. Run charts describing longitudinal data were generated using SPC for Excel version 6. Twenty three patients (3.1%) of 701 resections had a positive surgical margin reported. Seventeen (4.3%) of patients had less than 18 LNs in the ND specimen analysed. Mean time to start date of adjuvant therapy was 62 days. Only 9% of patients commenced adjuvant therapy within 6 weeks. The median duration of stay was 18 days. In 1153 free flaps a failure rate of 4.3% was identified. A total of 1349 complications (CD I-V) were recorded in the 1111 patients undergoing major surgery with free flap reconstruction. The QOMS selected metrics for oncology and reconstruction are clinically relevant, readily measurable, and likely to be actionable by the surgical team.

Malpractice Cases in Breast Surgery: An Assessment of Litigation Involving Surgeons.

Improving patient safety and quality are priorities in health care. The study of malpractice cases provides an opportunity to identify areas for quality improvement. While the issues surrounding malpractice cases in breast cancer are often multifactorial, there are few studies providing insight into malpractice cases specifically related to common breast cancer surgical procedures. We sought to characterize the factors in liability cases involving breast cancer surgery. Closed cases from 2008 to 2019 involving a breast cancer diagnosis, a primary responsible service of general surgery, surgical oncology, or plastic surgery, and a breast cancer procedure were reviewed using data from the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System database, a national repository of professional liability data. A total of 174 malpractice cases were reviewed, of which 41 cases were closed with payment. Plastic surgeons were most commonly named (64%, 111/174), followed by general surgeons (30%, 53/174), and surgical oncologists (6%, 10/174). The most common allegation was error in surgical treatment (87%, 152/174), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infections represented the top five injury descriptions. On average, indemnity payments were larger for high clinical severity cases. Technical skills, followed by clinical judgment, were the most commonly named contributing factors. The average payment per case was $130,422. Malpractice cases predominantly involve technical complications related to plastic surgery procedures. Better understanding of the malpractice environment involving surgical procedures performed for breast cancer may provide practical insight to guide initiatives aimed at improving patient outcomes.

Point Blank: A Retrospective Review of Self-inflicted Gunshot Wounds to the Hand.

A paucity of literature exists specifically examining self-inflicted (SI) gunshot wounds (GSWs) to the hand and wrist, which impart greater energy and have a higher risk of adverse events than non-self-inflicted (NSI) GSWs. We retrospectively reviewed records of patients who presented to our plastic surgery service after sustaining acute GSWs involving the hand and wrist between 2016 and 2018. We identified 60 patients who sustained GSWs involving the hand and wrist; 17 (28%) were SI, and 43 (72%) were NSI. Within the SI group, 100% of patients were Caucasian, with an average age of 54 years. Within the NSI cohort, 77% of patients were Black, 19% were Caucasian, and 4% identified as other. While not statistically significant, we noted a substantial increase in patients requiring operative intervention in the SI cohort (65% SI vs 37% NSI, P = .08). There was a statistically significant increase in patients requiring more than 1 operation in SI patients (24% SI vs 5% NSI, P = .04). Patients who sustained SI injuries were also more likely to present with acute carpal tunnel syndrome requiring urgent surgical release and to develop wound infections (12% vs 0%, P = .08). Self-inflicted GSWs involving the hand and wrist are associated with greater morbidity than their low-energy NSI counterparts. Individuals presenting with SI GSWs are more likely to be older, to require multiple operations, to develop infections, and to present with acute carpal tunnel syndrome requiring urgent surgical decompression.

Rebuilding Global Plastic Surgery Services and Safeguarding Workforce Density after COVID-19.

A recent report has found that approximately 150,000 health care workers have been infected with the SARS-CoV-2 virus, resulting in more than 1400 deaths.1 Of the 32 reported deaths of doctors in the United Kingdom due to coronavirus disease of 2019 (COVID-19), one was a plastic surgeon.2 Although the loss of any colleague is tragic, this pandemic will have an unprecedented and disproportional effect on low-income and middle-income countries and our collective global surgery aspirations. Recently, an extensive scoping review of health care workers’ COVID-19–related infections and deaths worldwide was published.1 Interestingly, the majority of documented health care worker deaths were seen in specialties not routinely associated with exposure to oronasal secretions, thereby highlighting the risk to all surgeons, including our plastic surgery community.1 While in the United Kingdom there are approximately 900 plastic surgeons, with over one surgeon per 100,000 people, the majority of countries worldwide are not as well equipped. For example, in Malawi, there are only three qualified plastic surgeons, representing 0.01 surgeons per 100,000 people.3 These figures are consistent across the multitude of low- and middle-income countries. The implications, therefore, of COVID-19 on the plastic surgery workforce in such countries are striking, with one death in Malawi representing a loss of 33 percent of the qualified plastic surgeons. The Lancet Commission on Global Surgery revealed the importance of an adequate surgical, obstetric, and anesthesia workforce density, due to a clear positive association between surgical, obstetric, and anesthesia workforce density and reduced morbidity and mortality rates and increased life expectancy.4The Lancet commission’s target of at least 20 surgical workers per 100,000 aimed to provide equality in health system staffing and patient outcomes.4 However, as many of our plastic surgery colleagues around the world (and particularly in low- and middle-income countries) are working exclusively as COVID-19 doctors, plastic surgery units are being converted to COVID units (e.g., the biggest plastic surgery specialist hospital in the world, with 500 beds and based in Dhaka, Bangladesh, is currently used solely for COVID-19), and personal protective equipment remains sparse and supply chains broken, we must act swiftly and in unison to safeguard global plastic surgery.5 The current global consequences of COVID-19 and restrictions in travel have strained traditional means of workforce training and attempts to improve surgical, obstetric, and anesthesia workforce density. However, biopsychosocial, economic, and ethical arguments should continue to compel us to overcome these challenges. Moving forward, we must focus on promoting safe working practices and preventative measures (such as advocating for safe and resilient personal protective equipment supply chains) and supporting our plastic surgery colleagues in low- and middle-income countries. Plastic surgery training in low- and middle-income countries must continue, and may require further development of our virtual teaching, e-learning, webinar, and simulation resources. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains.

Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense. A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process. A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually. An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.

783 Brachial Plexopathy Secondary to Prone Position Used in The Treatment of a Ventilated Patient With COVID-19: A Case Report and Service Improvement Recommendations

IntroductionProne position has been recommended by many authorities as part of the management of ventilated patients with COVID-19. However, proning with concurrent use of sedation and muscle relaxants carries the hypothetical risk of brachial plexus injuries, thought to be due to stretch and compression of the abducted shoulder.CaseWe report the case of a long-stay critical care patient who required frequent proning due to SARS-CoV-2 infection, and who presented with new right upper limb weakness. This case was referred to our local plastic surgery service and an injury to the upper trunk of the right brachial plexus was confirmed on nerve conduction studies.RecommendationsFollowing this case, we made adaptations to our local practice and modified our prone-specific SSKIN bundle (originally created to prevent pressure sores) to include a section on ‘Nerves’, with an accompanying diagram. We dubbed this the SSKINN bundle. This ensured safe prone positioning. We encourage other hospitals to put in place similar interventions.ConclusionsWe present this as a pathology to consider in patients proned during the COVID-19 pandemic; and recommend checking for signs of focal neurological deficits of the upper limb upon removal of paralysis and sedation, with early referral of suspected cases.

Use of Flaps in Orthopedics in a Peripheral Trauma Center in Nepal without Plastic Surgery Services

Background: Soft tissue cover after surgical debridement, skeletal stabilization is an integral part of optimal management of high-velocity orthopedic injuries and orthopedic infections which is preferably done in collaboration with plastic surgeons. In our peripheral hospital, since plastic surgery service is not available, it has been our practice as orthopedic surgeons to be involved in the comprehensive surgical care of such patients including flap cover of the resulting soft-tissue defect. We reviewed the results of our flaps from June 2013 to May 2015 which were exclusively done by orthopedic surgeons. Materials and Methods: All patients from June 2013 to May 2015 with an open fracture or orthopedic infections who underwent flap cover of any kind in both the upper and lower limbs were retrospectively reviewed. Results: We had thirty-eight flaps in 36 patients. Two were lost to follow-up. There were eight (22.22%) upper limb flaps and 28 (77.77%) lower limb flaps. Average follow-up was 3 months (6 weeks–12 months). The average age was 35 years (17 years–65 years). Ten (27.7%) of the patients had flap done for infection and the rest 26 (72.2%) for an open fracture. The dimension of the flap ranged from 1 cm × 1 cm to 15 cm × 16 cm. Thirty-one out of thirty-six (83.33%) of the flaps healed primarily. Six (16.66%) patients had minor complications. There was no total flap loss. Conclusion: Comprehensive care of soft-tissue defects by orthopedic surgeons themselves seem to be a viable option with good outcome and acceptable complications in orthopedic trauma and infections when plastic surgery service in not available.

Revisiting the Pedicled Gastrocnemius Flap for Orthoplastic Limb Reconstruction

INTRODUCTION: Gastrocnemius muscle flap is performed in a combined approach of the orthopaedic and plastic team for limb reconstruction in the developed countries. However, this practice is not readily available in Malaysia because of the smaller numbers of plastic surgery services in government hospitals. This study reviews the outcome of the gastrocnemius flap performed by the orthopaedic team. MATERIALS AND METHODS: Thirty-two patients underwent gastrocnemius flap surgery with a mean age of 35.3 years (range 13-82). The flaps were done to cover the upper third (22), upper half (4), knee (2), distal femur (2) and the popliteal fossa (1). The initial problems were open fracture (21), infection following plating (5), necrotising fasciitis (3), degloving injury (1), pin site infection (1) and melioidosis (1). Five patients were having underlying Diabetes mellitus, 3 Hepatitis B, 2 HIV and 1 Hepatitis C infections. RESULTS: There was no flap necrosis. Complications include persistence infection in 3 patients which required advancement of the flap (1) and additional fasciocutaneous flap (2) to cover the wound breakdown. All fractures achieved union but one patient with infection following double plating for tibial plateau fracture developed chronic osteomyelitis. One patient develops transient peroneal nerve palsy following the lateral gastrocnemius transfer. Both patients who had patella ligament reconstruction with gastrocnemius flap develop knee stiffness. CONCLUSIONS: Gastrocnemius flap is a reliable and safe procedure in salvaging the leg from amputation related to open fractures and infections in orthopaedic surgery. It should be one of the options for the operative procedure thought during the orthopaedic training.

The Coronavirus (COVID-19) Effect on Public Sentiments Regarding Elective Plastic Surgery in the United States.

Background:The SARS-CoV-2 coronavirus (COVID-19) has challenged the US's healthcare systems to adapt and innovate on multiple fronts. As the course of the COVID-19 pandemic changes, we explore the US public sentiments on resuming previously postponed elective plastic surgery procedures.Methods:A prospective national survey of one thousand US adults was conducted to study public perception of elective plastic surgery procedures during the COVID-19 pandemic. Binomial logarithmic multivariable regression modeling was employed to study the response data.Results:Nine hundred seventy-three participants were included in study. The majority (86.6%) believed elective plastic surgery should continue during the COVID-19 pandemic. Most (79.6%) would not delay obtaining plastic surgery more than 6 months. Participants expressed concerns of contracting COVID-19 at elective surgery centers (67.5%) or at hospitals (68.5%). Participants who reside in the Midwest (odds ratio [OR] 2.3, P < 0.05) and participants between the ages of 41 and 60 years old (OR 2.8, P < 0.03) were more likely to resume elective plastic surgery. Participants who had undergone a COVID-19 test (OR 0.13, P < 0.04), contracted the COVID-19 infection (OR 0.26, P < 0.03), or were older than 60 years (OR 0.41, P < 0.02) were less likely to resume elective plastic surgery.Conclusion:The majority of the US adult participants (1) agree with resuming elective plastic surgery services, (2) but harbor some concerns of contracting COVID-19 during their procedures, and (3) agree with the majority of safety protocols taken to prevent the spread of COVID-19.

Innovation in rural workforce strategies by a national surgical society

Health services exist to address the health needs of the community. But in Australia at present there are not enough detailed data to tell us to what extent, community by community, our highly regarded health system is meeting those needs. We know that demand for health care services is growing faster than the overall economy, and that we no longer have a general shortage of doctors, but most problematically there is a significant geographic maldistribution of those doctors away from rural and regional areas.iFor plastic surgery services, there is very little understanding of what the aggregate needs of rural communities are, or how these needs vary by community. We know by anecdote that there is significant inequity in plastic surgery services and that rural and regional locations often have unfilled positions and diminished services. We note that 80 per cent of specialist plastic surgeons live and work wholly within the five largest Modified Monash level 1 (MM1) Australian cities.1 Only 8.5 per cent of specialist plastic surgeons are permanently based outside those five cities. We also note that this is a more serious negative divergence than other comparable surgical specialties.While we briefly explore the basis for some ‘innovative’ solutions in this paper, we are constantly reminded that a prerequisite of any ‘solution’ should be an in-depth study of what Australian rural communities need or want in terms of plastic surgery services.

Changes in the Oral Health-Related Quality of Life in Infants With Cleft Lip and/or Palate Before and After Surgical Treatment.

To assess oral health-related quality of life (OHRQoL) changes before and after the primary surgical treatment in infants with cleft lip and/or palate (CL/P). Quasi-experimental study. A total of 106 infants with CL/P younger than 2 years undergoing primary surgical treatment in the Plastic Surgery Service of the Instituto Nacional de Salud del Niño in Peru. The parent/caregiver answered a questionnaire about OHRQoL named the Peruvian version of the Early Childhood Oral Health Impact Scale (P-ECOHIS) in the pretreatment (baseline) and follow-up post-treatment. The total score of P-ECOHIS and their 2 sections (child impact and family impact) in the baseline and each follow-up period post-treatment scores were assessed. As well as, the type of the CL/P on OHRQoL, standardized effect sizes (ES) based on mean total change scores (difference between baseline and 12th month) were analyzed. Improvements in infant's OHRQoL after treatment were reflected in each follow-up period P-ECOHIS score compared to the baseline score. The total P-ECOHIS scores decreased significantly from 28.07 (baseline) to 7.7 (12th month; P < .0001), as did the individual domain scores (P < .0001). There were significant differences in the baseline and follow-up post-treatment scores of infants who reported improvement of the OHRQoL (P < .0001). The ES was large (3.79). The cleft lip had an improvement in the OHRQoL at 12th month post-treatment (P < .0001). Primary surgical post-treatment resulted in significant improvement of the infant's OHRQoL with CL/P.

Patterns of Pediatric Facial Fractures.

The aim of this study was to assess patterns of maxillofacial trauma in the pediatric population in Atlanta. This information is important to help guide management and allocate resources for treatment of maxillofacial injuries at Children's Healthcare of Atlanta (CHOA). This study was a retrospective chart review of children who presented from 2006 to 2015. Inclusion criteria were: (1) age 18 years old or younger, (2) presentation to emergency department, (3) diagnosis of maxillofacial fractures, and (4) evaluation by Oral and Maxillofacial Surgery, Otolaryngology, or Plastic Surgery services. Medical records were reviewed to record demographic, mechanism of injury, fracture location, and yearly incidence of injury. Descriptive statistics were computed to summarize findings and overall trends. During the study period, 39,833 patients were identified. Of them, 1995 met the inclusion criteria. The majority were male (n = 1359, 68%) with an average age of 9.4 years old (range of 1 month to 18 years old). Mechanisms of injury were motor vehicle collisions (MVC) (n = 597, 29.9%), fall (n = 565, 28.3%), sports injury (n = 317, 15.9%), pedestrian struck (n = 215, 10.8%), assault/abuse (n = 204, 10.2%), other (n = 81, 4.1%), or gunshot wound (n = 16, 0.8%). Fracture sites were mandible (n = 519, 26%), complex (n = 479, 24%), nasal (n = 419, 21%), dentoalveolar (n = 279, 14%), orbital (n = 259, 13%), and maxilla (n = 40, 2%). Males had a higher incidence of assault than females (n = 185, 91% of assaults). The incidence of maxillofacial trauma increased with age with a peak incidence in 13 to 16-year-olds (n = 566, 28.3%). During the years examined, there was an upward trend in MVCs as the etiology with a peak incidence of facial fractures due to MVCs occurring in 2015. All other mechanisms remained constant during this time period. There was an increase in pediatric facial fractures secondary to motor vehicle collisions from 2007 to 2015 despite improvements in regulations, traffic safety, and technology.

Advancing the Specialty of Plastic Surgery While Helping and Supporting Other Surgical Services at an Academic Medical Center.

While helping and supporting other surgical services at our academic medical center, we noticed that many clinical problems presented to our plastic surgery team are truly unique and challenging. Many of the necessary reconstructive procedures, performed by the senior author, had never been published in plastic surgery textbooks or the literature before. Because of the plastic surgeon's creative problem-solving ability, we use reconstructive treatment plans that also innovate and advance the field of plastic surgery. In this case series, we share our experience with creative solutions for the management of novel and challenging clinical problems faced by our plastic surgery service. The resultant and effective solutions for each challenging case have all been published in reputable plastic surgery journals by the senior author. Once published, our inventive reconstructive solutions can be harnessed by other plastic surgeons and trainees and new standardized techniques or solutions for these unique and challenging clinical problems can be established. Ultimately, plastic surgeons can evolve their specialty through helping and supporting other surgical services at an academic medical center by establishing innovative solutions for ever arising challenging clinical problems. Once again, the plastic surgery team in a tertiary hospital supports many surgical services so that more complex surgical procedures can be performed safely and complications from other surgical services can be managed successfully. Therefore, adequate support for a plastic surgery service, by the hospital or department, is critical in developing a strong plastic surgery program at an academic medical center.

Keloid of Ears: Recurrence and Its Complications

In this case report, we present a male patient who arrived at the hospital for the first time at the age of 8 with giant keloids in both ears and diagnosed by the Dermatology and Plastic Surgery as having the “Disease of Jorge Lobo”, which is a fungal infection due to the story of the endemic characteristics. After the first surgical intervention, he received guidance from the team for keloids and left the hospital using elastic mesh and a request to change the place where he lived to reduce his contact with the fungi. Fourteen years later, the patient returned to the Plastic Surgery Service having even larger keloids in both ears, twice the size than the first time. We did the second surgical intervention to remove it, but with the patient’s commitment that he would correctly comply with the guidelines determined by the surgical team. After finishing all the steps and a post-operative for the case, we observed the satisfaction and the increase of the patient’s mood, happier and without the embarrassment of that physical defect.

Epidemiological trends of severe burns, 2009–2019: A study in the service of burns in Albania

IntroductionStatistical and epidemiological data taken throughout decades show trends of the pathology of burns and its treatment. The aim of this study is to analyze the summarized epidemiological and clinical data of severe burn patients during the period 2009–2019 in order to acquire an accurate and recent picture of this pathology. This can create a basis for improving community health outcomes. Material and methodThe study retrospectively analyzes the data of severe burn patients admitted in the Intensive Care Unit (ICU) of the Service of Burns and Plastic Surgery of the University Hospital Center in Tirana, Albania, from 2009 to 2019. SPSS 23 software is used for the conduction of the Descriptive and Inferential Statistics. Statistical significance is defined as p<0.05. ResultsIncidence rate of burn admissions which need ICU treatment in our data was 5.2 patients/100,000population/year. The mean age of our population was 24.9±25.5 years. The most frequent causes of burns in all patients were scalds (49.6%) followed by flame (39.5%), electrical (5.1%), chemical (5%) and with unknown cause (0.7%). Death rate from fire and burns for the period 2009–2019 was 0.3 patients per 100,000population/year. Overall mortality was 6.8%. The ABSI, Baux and R Baux scoring system remain accurate and valuable tools in the prediction of burn patient mortality. A probability of death chart for our service has been developed based on age and BSA (%) burned which needs to validate in the future. ConclusionsEtiology of burns have changed toward an increase in proportion of flame burns especially in adults and elderly population. Survival following severe burns has improved over the past 11 years even in patients with three risk factors (age ≥60, BSA (%) burned ≥40% and presence of inhalation burn). LA 50 for all patients was 80%. LOS/BSA (%) ratio is a more valuable indicator than LOS alone. Improvement in the treatment of severe burns is a combination of preventive health care, appropriate treatment protocols and improvements in equipment and infrastructure.

New Zealand plastic and reconstructive surgery workforce: update and future projections

Objectives: Population growth in New Zealand (NZ) has occurred faster than previously forecast. As a result, previous workforce predictions are outdated and must be adjusted to ensure adequate access to plastic and reconstructive surgery (PRS) services. This paper presents an update of the PRS workforce and its projected needs, and the distribution of reconstructive surgeons (PRSn) in NZ. Methods: The number of practising PRSn and trainees, and the total medical workforce were reviewed, along with population statistics modelling with a focus on the ageing population. Comparisons were made to previous data and forecasts from 2013. Results: Previous population modelling predicted that NZ would reach five million by 2027. However, updated population data show that this figure was surpassed in 2020 and that the population will be approximately 5,374,655 in 2028. The PRS workforce has continued to grow in relation to overall population growth. The PRSn to population ratio (PRSPR) has improved since 2013 with a current ratio of approximately 1/69,000. However, a vast workforce maldistribution remains. Conclusion: The overall PRSPR in NZ appears satisfactory for the ageing population. However, the vast workforce maldistribution remains unchanged and this presents a barrier to equitable access to public PRS services, especially in provincial NZ.

Commentary on: The Influence of Photo Editing Applications on Patients Seeking Facial Plastic Surgery Services.

Commentary on: The Influence of Photo Editing Applications on Patients Seeking Facial Plastic Surgery Services.

Demographic and clinical profile of 1000 patients with thyroid eye disease presenting to a Tertiary Eye Care Institute in India.

To assess the demographic and clinical profile of thyroid eye disease (TED) presenting to a Tertiary Eye Care Institute in India. All patients who were diagnosed to have TED between the year 2007 and 2017 at the Ophthalmic Plastic Surgery Service, LV Prasad Eye Institute, were included in this retrospective observational study. The demographic details of parameters such as age, gender and laterality, presenting signs and symptoms, clinical activity at presentation, and systemic thyroid status were assessed. A total of 1000 consecutive patients of TED were evaluated in the 10-year period. Average age at presentation was 44.9years (range 8-89). Of the 1000, 529 (53%) were males, and 358 (36%) had unilateral TED. At presentation, the TED was active (time since onset ≤ 12months) in 476 (48%) cases and 71 (7%) had dysthyroid optic neuropathy. Of the 913 patients where systemic thyroid status was available at the time of presentation, 342 (37%) were euthyroid at presentation. Of the patients who were active at presentation (n = 476), 349 (70.3%) were 'Silent presenters' (Active as per timeline, but CAS ≤ 3). A prominent eye was the most common presenting symptom in 563 (64%) patients. Presenting signs in order of frequency were proptosis in 582 (58%), lower lid retraction (49%), upper lid retraction (48%), strabismus (6%), ptosis (5.5%), and corneal ulcer (1.3%). TED in India presents to the tertiary eye center with slight male preponderance. One-third (37%) are euthyroid and half (48%) are active at presentation. One-third (35%) are silent presenters, with minimal clinical activity during the active phase of TED.