Plastic Surgery Training Programs Research Articles

Cosmetic Surgery Training in Plastic Surgery Residency Programs.

Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors. A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education-approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures. Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures. There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.

Hand Surgery Resources Exceed American Health Literacy.

The National Institutes of Health, American Medical Association, and US National Library of Medicine recommend that educational material for patients be written at a sixth-grade reading level. The purpose of this study is to assess the complexity of hand surgery information on academic plastic and orthopedic surgery websites. An online search was performed for all hand surgery patient education materials provided by institutions with plastic and orthopedic surgery training programs. Readability analyses were conducted using the Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Index, Gunning Fog Score, Automated Readability Index, and Coleman-Liau Index. A 2-tailed z test was used to compare means. Seventy-six institutions with both plastic and orthopedic surgery training programs were identified; 42 had educational material available online. The average readability for all hand-related information was at the 11.92 grade reading level. Information regarding de Quervain tenosynovitis had the highest grade level for all plastic surgery procedures (13.45). Hand arthritis had the highest grade level for all orthopedic surgery procedures (12.82). Ganglion cysts had the lowest grade level for both plastic and orthopedic surgery (10.15 and 11.01, respectively; P = .12). Carpal tunnel release was the most commonly described procedure overall. There were no differences in text complexity among geographic regions. Online patient resources for common hand ailments are too complex for the average patient to understand. Efforts should be made to provide materials at the recommended sixth-grade reading level to improve patient education and improve the physician-patient relationship.

Minimally Invasive Aesthetic Procedures: An Update on a Decade-Old Prediction.

AbstractIn 2007, the senior author (G.S.K.) published a commentary on the importance of incorporating minimally invasive aesthetic procedures into facial plastic surgery practices and training programs. The now decade-old prediction suggested that failing to perform minimally invasive aesthetic procedures placed facial plastic surgeons at risk of practice “phase out.” By not providing the most current options that patients' desire, we may lose patients to outside providers willing to perform those procedures. The aim of this article is to provide an update on this perspective by putting forth the results of the most up-to-date data on practice patterns with regard to minimally invasive aesthetic procedures.

Facial Plastic Surgery Patient Resources Exceed National Institute Recommendations.

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P < 0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P < 0.001, P = 0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

Progressive Surgical Autonomy in a Plastic Surgery Resident Clinic.

Background:Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC.Methods:A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey.Results:Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 (P = 0.026). Graduated residents’ survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases.Conclusion:The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Abstract P16. Trends in Operative Performance for Independent and Integrated Plastic Surgery Residents: How Soon Do Independent Residents Catch Up?

Purpose: This study aimed to differentiate between integrated (PGY4-PGY6) and independent (PGY1-PGY3) plastic surgery residents regarding their operative competency and evaluate whether any discrepancy exists between these groups during plastic surgery training. Methods: We compared independent and integrated plastic surgery residents at our institution using operative performance data from the Operative Entrustability Assessment (OEA), a validated assessment tool that provides residents with real-time feedback about their operative performance and documents that performance at point-of-care. Independent PGY1, PGY2, and PGY3 were categorized as PGY4, PGY5, and PGY6, respectively. We analyzed OEA evaluator scores for the two groups over time, using Wilcoxon rank-sum test to compare groups. Results: During 2013–2016, 2,570 OEAs were completed for residents at PGY4-6. Of these, 1,389 (54.1%) were logged by independent and 1,181 (46%) by integrated residents. OEA evaluator scores were slightly lower for independent track residents throughout the first three quarters of PGY4 (p<0.001, p<0.001, and p=0.029, respectively). However, this difference was no longer statistically significant during the fourth quarter of PGY4 (p=0.220). As residents progressed in their training, this difference also was not detectable at PGY 5 (p= 0.781) or PGY 6 (p= 0.524). Conclusion: OEA data demonstrates independent plastic surgery residents perform slightly lower than their integrated colleagues during the first three quarters of their first year. However, they readily demonstrate a statistically comparable level of competency after this period, indicating minimal drawbacks to incorporating independent residents with integrated residents in plastic surgery training programs.

Plastic Surgery Chief Resident Clinics Facilitate Progressive Surgical Autonomy and Continuity of Care

BACKGROUND As plastic surgery education continues to shift toward competency-based training, increased documentation of progressive educational achievement is required.1,2 The Plastic Surgery Milestone Project provides a “framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency.”3 Chief resident clinics (CRCs) are thought to catalyze the achievement of these milestones by providing greater liberty for residents to act as primary caregivers, build longitudinal patient relationships, practice operative autonomy, and follow through with plans of care.4 Cosmetic CRCs have received much attention in the literature,4,5 but reports are lacking for general plastic surgery CRCs (PCRCs), which may be more relevant in training safe plastic surgeons competent in common on-call scenarios. We demonstrate the achievement of Plastic Surgery Milestone Project competencies, such as supervised surgical autonomy and continuity of care, in a PCRC model. METHODS A retrospective review of all patients seen in a PCRC from October 1, 2010, to October 1, 2015, was conducted. PCRC is supervised by the Department of Plastic Surgery, University of Tennessee College of Medicine attending surgeons, although primarily run by chief residents in an accredited independent plastic surgery training program. Ten years of graduated chief residents were queried through an anonymous online survey to assess trainees’ perception of the education value of PCRC on a 5-point Likert scale. RESULTS One thousand one hundred forty-four patients were seen in 3390 PCRC visits overall, averaging 11.9 per week, including 4.0 (33.6%) “new” and 2.4 (20.2%) emergency department referrals. Six hundred fifty-three operations were performed by 23 residents, including 10 graduating chiefs. Resident operative autonomy averaged 2.3/5 (SD = 1.6), 2.6/5 (SD = 1.5), and 2.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. One-way analysis of variance displayed a significant difference in operative autonomy by training level [F(2, 608) = 4.71, P < 0.0093], and Tukey post hoc analysis showed a significant change between postgraduate years 6 and 8 (P < 0.01). Mandible fracture repair (N = 172) represented the most common procedure performed from PCRC. Closed reduction of mandible fracture (4.4/5, SD = 1.1), lesion excision (4.3/5, SD = 1.2), open repair of orbital fracture (4.1/5, SD = 1.1), and closed reduction of nasal bone fracture (4.0/5, SD = 1.5) displayed the highest operative autonomy, whereas pedicled and free tissue flaps (2.1/5, SD = 1.3) exhibited the lowest. Resident continuity of care was maintained in 93.5% of cases and averaged 3.9 (SD = 2.6) appointments over 14.1 weeks (SD = 26.5). One hundred percent of graduated chiefs responded to the survey, which showed satisfaction for operative case exposure (4.1/5, SD = 1.0), pre- (4.5/5, SD = 0.5), intra- (4.4/5, SD = 0.5), and postoperative (4.4/5, SD = 0.5) autonomy, contribution to medical knowledge (4.7/5, SD = 0.5), and core competencies practice (4.3/5, SD = 0.8). CONCLUSIONS PCRCs enable trainees to practice supervised surgical autonomy and continuity of care and provide a forum for the demonstration of progressive milestone achievement. We believe that the experience gained in PCRCs is vital for the development of competent plastic surgery graduates.

Abstract: Impact of an Online Event Reporting System on Resident Complication Reporting in Plastic Surgery Training: Addressing the Practice-Based Learning and Improvement Core Competency

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) has identified practice-based learning and improvement (PBLI) as a core competency in resident education. PBLI involves systematically analyzing current practices and implementing changes with the goal of quality improvement. In surgical care, complication reporting is an essential component of PBLI as adverse events are analyzed in morbidity and mortality (M&M) conference for quality improvement. The purpose of this study is to develop and evaluate an intervention for complication reporting, and compare this to current practice, in a plastic surgery training program. METHODS AND MATERIALS: This is a pre- and post-intervention comparative effectiveness study evaluating resident reporting of complications and adverse patient events on a plastic surgery service in a teaching hospital. The pre-intervention and post-intervention cohorts consisted of all patients having surgery on the pediatric plastic surgery service during two separate 3-month blocks bridged by a transition period for intervention implementation. In the pre-intervention group, resident reporting of complications was consistent with current practices at our institution where the chief resident on service reports complications prior to bi-monthly M&M conferences. Division leadership, in conjunction with patient safety experts, then developed an online event reporting system (ERS) and implemented policy initiatives to facilitate resident utilization of ERS in all clinical settings. The post-intervention group included all residents on service utilizing the ERS for complication reporting at the time of the event and the ERS was synchronized to generate data for M&M conference. A trained surgical reviewer recorded all complications for patients throughout the six-month study period and this served as the reference standard. Fisher’s exact test was used for binary comparisons. RESULTS: There were 32 complications detected in 219 patients from June-August, 2015 and 35 complications detected in 202 patients from October-December, 2015. Compared to this reference standard, the proportion of complications reported by residents for M&M conference in the pre-intervention group was 28.1% (9/32 events reported). After the intervention, the proportion of complications reported by residents increased to 91.4% (32/35 events reported) (P < 0.05). CONCLUSIONS: An intervention utilizing an online event reporting system led to significant improvements in complication reporting by plastic surgery residents in an academic teaching hospital. Implementation of an event reporting system can enhance practice-based learning and quality improvement, addressing an ACGME core competency. DISCLOSURES/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

What Effect Does Self-Citation Have on Bibliometric Measures in Academic Plastic Surgery?

Research productivity plays a significant role in academic promotions. Currently, various bibliometric measures utilizing citation counts are used to judge an author's work. With increasing numbers of journals, numbers of open access publications, ease of online submission, and expedited indexing of accepted manuscripts, it is plausible that an author could influence his/her own bibliometric measures through self-citation. The purpose of this study was to determine the impact of self-citation in academic plastic surgery. A cohort of full-time academic plastic surgeons was identified from 9 U.S. plastic surgery training programs. For all included faculty, academic rank was retrieved from department/division websites, and bibliometric measures were assessed using a subscription bibliographic citation database (Scopus, Reed Elsevier, London, UK). Bibliometric measures included the Hirsch index (h-index, the number of publications h which are cited ≥ h times), total number of publications, and total number of citations. The h-index and total number of citations were collected with and without self-citations. Percent changes in the h-index and total citations were calculated after removal of self-citations and compared across academic ranks and levels of research productivity (total publications, h-index, and total citations). The study cohort consisted of 169 full-time academic plastic surgeons. The h-index and total citations experienced decreases of 2.8 ± 5.0% (P < 0.0001) and 4.5 ± 4.6% (P < 0.0001), respectively, after correction for self-citation. More than half of the cohort (n = 113, 67%) did not experience a change in the h-index after removal of self-citations. These decreases did not vary across academic rank. Surgeons who self-cited at rates greater than 5% were 9.8 times more likely (95% confidence interval, 4.5-21.9; P < 0.001) to have their h-index change as a result of self-citation (after adjusting for academic rank). There were weak correlations between percent decreases in the h-index and total citations and various biblimoteric measures (total publications, h-index, total citations; r < 0.32). Self-citation has a minor impact on common bibliometric measures in academic plastic surgery. The influence of self-citation is consistent across academic ranks and increasing levels of bibliometric measures, suggesting that authors are not manipulating the system with increasing experience.

Abstract: Readability of Online Patient Resources for Head &amp; Neck Procedures

INTRODUCTION: Patient education is essential in enhancing the therapeutic alliance, patient satisfaction, and clinical outcomes. The NIH and AMA recommend that information be written at a sixth-grade reading level; 1,2 however, online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial procedures found on academic plastic surgery and otolaryngology websites. MATERIALS AND METHODS: An internet search was performed of all academic hospitals that had both plastic surgery and otolaryngology training programs. An average word and syllable count was performed for each procedure. Readability analyses were performed using the Flesh-Kincaid Grade Level, SMOG Index, Gunning-Fog Score, Automated Readability Index, and Coleman-Liau Index. National society websites for both plastic surgery and otolaryngology were used as controls. A two-tailed z-test was used to compare scores, and statistical significance was set at p < 0.05. RESULTS: Sixty-three programs were identified, and 42 had educational material. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (p < 0.001, p = 0.04).The overall average readability for all information was at a 10th grade reading level, and the average Flesch-Kincaid readability score was 10.4 and 10.5 for plastic surgery and otolaryngology, respectively (p=0.45). CONCLUSION: Online resources for facial procedures are more complex than the recommended reading levels. This represents an obstacle to online patient education, and attention to this aspect of patient education could benefit patients seeking medical information online. DISCLOSURES/FINANCIAL SUPPORT:No disclosures. REFERENCES: 1. How to write easy-to-read health materials. MedlinePlus. How to write easy-to-read health materials. Available at: http://www.nlm.nih.gov/medlineplus/etr.html. Updated November 30, 2015. Accessed January 20, 2016. 2. Weiss B. Health Literacy: A Manual for Clinicians. Chicago: American Medical Association, American Medical Foundation; 2003.

Comprehensive Observations of Resident Evolution: A Novel Method for Assessing Procedure-Based Residency Training.

Assessment of surgical skills in the operating room remains a challenge. Increasing documentation requirements of the Accreditation Council for Graduate Medical Education are necessitating mechanisms to document trainee competence without hindering operative turnover. The authors created a comprehensive electronic resource to facilitate plastic surgery training program compliance with changes mandated by Next Accreditation System Milestones and the ACGME. In 2013, the authors implemented the Comprehensive Observations of Resident Evolution, or CORE, a Web-based tool to assess plastic surgery residents. It comprises a rapid electronic assessment of resident operating room performance completed after each surgery; a data dashboard displaying graphical summaries of resident progress by case, Milestone, or current procedural terminology code; and an electronic Milestones tracker (MileMarker), which enables ongoing trainee assessments. From January through October of 2014, 24 residents completed nearly 1300 Operative Entrustability Assessments. Thirty-eight percent of residents reported more immediate feedback regarding operative performance. The assessment demonstrates construct validity, which distinguishes novice residents from experienced residents. Individual case data identify resident-specific operative strengths and weaknesses. Using assessment data, the first two Clinical Competency Committee reviews were 81 percent and 87 percent shorter than Milestones pilot test site reports (average, 11.5 and 8 minutes versus 60 minutes per resident, respectively). Comprehensive Observations of Resident Evolution is capable of capturing operative performance data on all operating room cases by primary current procedural terminology code. It increases immediate attending/trainee feedback and assessment transparency, enables trainee self-monitoring, and informs end-of-rotation reviews, programwide assessments, and tailoring of training to address specific needs. It is a valuable resource for tracking resident progress in real-time while maintaining compliance with evolving ACGME requirements.

Does Formal Research Training Lead to Academic Success in Plastic Surgery? A Comprehensive Analysis of U.S. Academic Plastic Surgeons

It is currently unknown whether formal research training has an influence on academic advancement in plastic surgery. The purpose of this study was to determine whether formal research training was associated with higher research productivity, academic rank, and procurement of extramural National Institutes of Health (NIH) funding in plastic surgery, comparing academic surgeons who completed said research training with those without. This was a cross-sectional study of full-time academic plastic surgeons in the United States. The main predictor variable was formal research training, defined as completion of a postdoctoral research fellowship or attainment of a Doctor of Philosophy (PhD). The primary outcome was scientific productivity measured by the Hirsh-index (h-index, the number of publications, h that have at least h citations each). The secondary outcomes were academic rank and NIH funding. Descriptive, bivariate, and multiple regression statistics were computed. A total of 607 academic surgeons were identified from 94 Accreditation Council for Graduate Medical Education-accredited plastic surgery training programs. In all, 179 (29.5%) surgeons completed formal research training. The mean h-index was 11.7 ± 9.9. And, 58 (9.6%) surgeons successfully procured NIH funding. The distribution of academic rank was the following: endowed professor (5.4%), professor (23.9%), associate professor (23.4%), assistant professor (46.0%), and instructor (1.3%). In a multiple regression analysis, completion of formal research training was significantly predictive of a higher h-index and successful procurement of NIH funding. Current evidence demonstrates that formal research training is associated with higher scientific productivity and increased likelihood of future NIH funding.

Successfully Integrating Research into Plastic Surgery Training Programs.

Successful integration of research into the educational mission of a plastic surgery residency program requires the support and dedication of the faculty members to create a culture that promotes innovation, discovery, and advancement of the field of plastic surgery. Dedicated research time during plastic surgery training is beneficial to both the resident and training program. Regardless of whether residents plan to pursue an academic career or enter private practice, participating in research provides an opportunity to develop skills to think critically and mature professionally. In this article, we review the benefits of resident research to both the trainee and training program and discuss strategies to overcome barriers to integrating research into the curriculum.

Development of an Operative Performance Rating System for Plastic Surgery Residents

PURPOSE A standardized measure of operative performance is an essential component of the Patient Care Competency and is critical to the training of plastic surgery residents. The Operative Performance Rating System (OPRS) developed and validated by the Department of General Surgery at Southern Illinois University consists of procedure-specific evaluations for resident intraoperative performance. The OPRS provides an objective measure of procedure-specific resident performance that is not currently being assessed in plastic surgery training programs. The purpose of this study is to describe OPRS for plastic surgery residents and propose methodology for assessing the reliability, validity, and feasibility of this instrument. METHODS Ten procedure-specific rating instruments were developed for sentinel cases, each consisting of critical procedure-specific steps based on literature review and faculty focus group consensus. Sentinel cases were chosen based on review of the American Council of Graduate Medical Education Milestones and resident logs of the most commonly performed plastic surgery procedures, both at our institution and nationally. The degree of guidance required from the attending surgeon is recorded for each step. General operative performance competency is evaluated from validated items developed by the University of Toronto.1 All items use a 5-point Likert scale with behavioral anchors. The OPRS assessments will be incorporated into the internet-based resident management platform New Innovations. Sentinel procedures for evaluation will be identified on a weekly basis by the residency coordinator, based on resident operative assignments (postgraduate year 2–6) organized by the chief resident. OPRS assessment forms will be available electronically immediately following the procedures, with an e-mail reminder notification 24 hours later to help encourage compliance. In addition, resident self-assessment using the same OPRS will be conducted and correlated with faculty OPRS evaluations. Each OPRS assessment will be evaluated for internal consistency reliability and inter-item correlation. Inter-rater reliability will be measured by faculty assessment of videotaped sentinel procedures using the appropriate OPRS instrument. Performance variation based on resident PGY level will be analyzed using 1-way analysis of variance. Feasibility will also be determined based on attending and resident response rates and time to completion for the OPRS evaluations, as well as a short written survey to assess resident and attending satisfaction and obtain feedback following OPRS implementation. CONCLUSIONS A web-based OPRS provides timely and objective feedback to improve residents’ technical and decision-making skills, as demonstrated by the experiences of other surgical specialties.2 This instrument will provide both formative and summative resident feedback, encouraging faculty and residents to focus on demonstrated competencies and areas for improvement.3 Furthermore, resident operative performance can be monitored across time and residents, allowing program directors to have a long-term objective method of evaluating resident technical performance.3 A reliable and valid OPRS may provide a feasible method of intraoperative assessment that could be implemented across all plastic surgery training programs.

Patient Attitudes Toward Resident Participation in Cosmetic vs Reconstructive Outpatient Consultations

The goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic. All new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation. The study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio. The survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patient's attitudes about a range of factors, such as resident sex and seniority. In total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were. Although there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

The scope of practice of hand surgery within plastic surgery: the ACAPS national survey to assess current practice and develop educational guidelines.

There is no consensus among plastic surgeons regarding what constitutes the scope of hand surgery practice. Due to this lack, there is a wide variability in what hand surgery procedures plastic surgery resident will see and participate in during the course of training. We assessed what faculty members of plastic surgery training programs felt were contained within the scope of practice of hand surgery. A survey was sent to all members of the American Council of Academic Plastic Surgeons. Respondents reported size of department, faculty fellowship training, hand surgery call coverage, and amount of elective hand surgery within their training program. They also identified what procedures were within the scope of hand surgery. Ninety-three responses were received. Thirty-five respondents were certified or eligible for the surgery of the hand examination. Twenty-five respondents had 0 or 1 surgery-of-the-hand surgeon among their faculty. Thirty-nine departments/divisions performed 10 or fewer elective hand surgeries per week. Seventy-eight percent of groups taking hand call reported that all faculty members took hand call regardless of whether they had hand fellowship training. Although nearly all cover hand and wrist infections, only 49% provide care for distal radius fractures. In many residency programs, hand surgery exposure is in the setting of trauma and emergencies. The inclusion of complex elective hand surgeries within a plastic surgery practice and residency program allows residents to see the full spectrum of hand surgery. This allows them to make an informed decision regarding whether to seek subspecialty training and continue the participation of plastic surgeons in the full spectrum of hand surgery.

Outcomes in Post Bariatric Body Contouring Procedures with Respect to Surgical Specialties

BACKGROUND: Correlated with the increasing utilization of bariatric surgery is an increasing demand for body contouring surgery.1 More than 330,000 body contouring procedures were performed in 2012. The purpose of this study is to evaluate the outcomes of body contouring procedures as they relate to provider specialty training (general surgeon versus plastic surgeon) as an independent predictor. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2010 for all identifiable body contouring cases. Appropriate Current Procedural Terminology codes were used to identify body contouring procedures of the abdomen and breast, including suction assisted lipectomy. Pre-operative risk factors were identified and a multivariate analysis was used to investigate risk-adjusted outcomes, specialty comparisons, and predictors of morbidity. RESULTS: A total of 2,632 patients were included. Most were women (n=2,317). The mean age was 47.4 years. Sixty eight point five (68.5) percent of the patients were white, 7.4 percent were African American and 8.78 percent were Hispanic. The abdominal contouring procedures were the most common making up 71.7 percent. One thousand eight hundred nine (68.5 percent) cases were done by plastic surgeons and 823 (31.2 percent) cases were done by general surgeons.Overall complications were reported in 236 (9.0 percent) patients, multivariate logistic regression revealed differing outcomes based on surgical specialty. Cases performed by general surgeons were associated with increased overall complication rates (OR 1.9, p=O.OO),wound infections (OR 1.9, p=O.OO), and returns to the operating room (OR 2.3, p=O.OO) when compared with the outcomes of plastic surgeons. Post-operative mean length of stay was significantly higher (OR 2.0, p=O.OO) for cases performed by general surgeons (2.3 days) compared to cases performed by plastic surgeons (0.73 days). CONCLUSION: The apparent complication rate increase associated with general surgeons performing body contouring procedures suggests the need for specialized skill and training.2 Optimal execution of these burgeoning complex procedures, with lesser morbidity, seems to be a byproduct of the nation’s plastic surgery training programs. Additionally, the outcomes in this study might lend objectivity to contentious and unsettled debates, legislation3 and oversight regarding patient safety issues3-5 and “turf wars” (amongst specialty groups) as they pertain to these challenging aesthetic procedures.

Measuring Surgical Competency in Facial Trauma

Surgical education is in a period of significant change. Assessment of surgical competency is imprecise compared with cognitive knowledge and judgment. A surgical competency measurement tool may be useful for plastic surgery training programs and certification societies. We present a validation study of a novel measurement instrument for arch bar placement and dental wire handling. An Arch Bar Placement Assessment Scale (ABPAS) was created via consensus by 2 craniofacial and 2 maxillofacial surgeons. Residents and faculty members of plastic and maxillofacial surgery (n = 20) then placed an arch bar on the lower jaw of a skull model. Performances were video recorded without revealing identities. Two study groups were created based on subjects experience level: group 1 (n = 10) previously placed fewer than 25 arch bars; group 2 (n = 10) previously placed more than 25 arch bars. Two craniofacial surgeons used the ABPAS to blindly grade surgical performance. The ABPAS consisted of a 48-point rating scale that included a 23-point task-specific work list and a 25-point global rating scale. Pearson coefficient showed limited intraobserver (P = 0.97) and interobserver (P = 0.95) variance of test scores. The ABPAS demonstrated superior performance in group 2 in the task-specific work list [12.6 (5.5) vs 17.6 (1.5), P = 0.02], global rating scale [17.4 (4.4) vs 22 (2.1), P = 0.01], and ABPAS score [30 (9.8) and 39.6 (3.2), P = 0.01]. The ABPAS is a novel measurement tool which assesses technical surgical skill and can identify surgical competency in arch bar placement and dental wire handling. This tool may have future use in residency training and continuing education.

Dr WRN Lindsay

I have known Dr Lindsay for 40 years. He was my teacher, mentor, role model and, ultimately, my partner in the Ross Tilley Burn Centre (Toronto, Ontario). I got to know him really well. He was an excellent teacher. I was his resident for six months in 1975 at the Wellesley Hospital (Toronto, Ontario). He worked very hard. He had a very busy Toronto practice. He also ran a clinic in Sudbury (Ontario) every month and a clinic in Oshawa (Ontario) every two weeks. There were no plastic surgeons in those areas at that time. I don’t think he slept very much. Dr WRN Lindsay I was born and raised on a mushroom farm in rural British Columbia in total poverty. I somehow got to the University of Toronto Medical School and then through the plastic surgery training program. That took 10 years. During that time, I lived in various rooming houses, usually in less than desirable areas. I didn’t have a car and sometimes had difficulty raising funds for food. Working with Dr Lindsay provided a new and unique experience. It was a different time and a different place. We didn’t have a call schedule. You were the resident for six months. If you wanted time off, then you would have likely been considered a wimp. Even then, you would have missed some cases. Dr Lindsay made up for all our hard work. Two weeks into the rotation, he brought me a box with all his medical books. “Keep them for the next 6 months and read up on all our cases” he said. As his resident, you were never a student – you were his associate. He asked questions regularly. If your answer was not correct, then he would simply say “Well, that’s a thought”. You knew damn well that you had better come up with something better for the next question. He never aspired to that ‘disciplinary’ method of teaching that was sometimes seen with other surgeons of that era. Dr Lindsay had just opened his surgical clinic in 1975. After our hospital rounds every Saturday morning, we would go to his clinic for soup and to plan the cases for the next week. He actually took me out to dinner on several occasions to places that I had never even imagined! At the end of my rotation, he sent me to a major meeting in Chicago. “It’s a huge meeting and I think you will learn a lot. Don’t worry, I will pay for it!” Dr Lindsay was a modest man of enormous stature. He was the Chief of Plastic Surgery at the Wellesley hospital for more than 20 years. He laid the foundation for Toronto’s first adult burn centre. From 1984 through 2001, Dr Lindsay, Dr Leith Douglas and I supervised the care of more than 2000 patients with major burns at that centre. Dr Lindsay was also a founder of cosmetic plastic surgery in Canada. In those days, cosmetic surgery was ‘relegated to the back room’. If you performed any cosmetic surgery, then you certainly didn’t tell anyone about it, particularly at the university level. Dr Lindsay made this branch of surgery respectable. For 20 years, he staged the annual “Symposium on Cosmetic Plastic Surgery” at the University of Toronto. The top plastic surgeons from around the world would present lectures, which were attended by plastic surgeons from all over North America. Dr Lindsay was also a pioneer when he built his surgical facility in 1975. He had a hospital license and provided care to cancer patients alongside his cosmetic patients. Dr Lindsay and I ultimately worked together as partners in the burn centre for 15 years. He always asked me to call him ‘Bill’, but I never could. He had reached that level of respect and dignity where I could never call him anything but ‘Dr Lindsay’. When he retired, he passed his surgical facility along to me. I have continued to see many of his patients over the years. His patients worshipped him. Whenever his name comes up, their response is always the same: “He was a wonderful, lovely, nice, kind man, and always a gentleman”. Dr Lindsay has now passed from this world to a better one. The real reward in life is the journey. The journey is the reward – all those things that happen along way. Dr Lindsay’s journey has been remarkable. He touched many people. He actually changed their lives. He made an incredible difference. Dr Lindsay, may you rest in peace, sir.

Dr WRN Lindsay

I have known Dr Lindsay for 40 years. He was my teacher, mentor, role model and, ultimately, my partner in the Ross Tilley Burn Centre (Toronto, Ontario). I got to know him really well. He was an excellent teacher. I was his resident for six months in 1975 at the Wellesley Hospital (Toronto, Ontario). He worked very hard. He had a very busy Toronto practice. He also ran a clinic in Sudbury (Ontario) every month and a clinic in Oshawa (Ontario) every two weeks. There were no plastic surgeons in those areas at that time. I don’t think he slept very much. Dr WRN Lindsay I was born and raised on a mushroom farm in rural British Columbia in total poverty. I somehow got to the University of Toronto Medical School and then through the plastic surgery training program. That took 10 years. During that time, I lived in various rooming houses, usually in less than desirable areas. I didn’t have a car and sometimes had difficulty raising funds for food. Working with Dr Lindsay provided a new and unique experience. It was a different time and a different place. We didn’t have a call schedule. You were the resident for six months. If you wanted time off, then you would have likely been considered a wimp. Even then, you would have missed some cases. Dr Lindsay made up for all our hard work. Two weeks into the rotation, he brought me a box with all his medical books. “Keep them for the next 6 months and read up on all our cases” he said. As his resident, you were never a student – you were his associate. He asked questions regularly. If your answer was not correct, then he would simply say “Well, that’s a thought”. You knew damn well that you had better come up with something better for the next question. He never aspired to that ‘disciplinary’ method of teaching that was sometimes seen with other surgeons of that era. Dr Lindsay had just opened his surgical clinic in 1975. After our hospital rounds every Saturday morning, we would go to his clinic for soup and to plan the cases for the next week. He actually took me out to dinner on several occasions to places that I had never even imagined! At the end of my rotation, he sent me to a major meeting in Chicago. “It’s a huge meeting and I think you will learn a lot. Don’t worry, I will pay for it!” Dr Lindsay was a modest man of enormous stature. He was the Chief of Plastic Surgery at the Wellesley hospital for more than 20 years. He laid the foundation for Toronto’s first adult burn centre. From 1984 through 2001, Dr Lindsay, Dr Leith Douglas and I supervised the care of more than 2000 patients with major burns at that centre. Dr Lindsay was also a founder of cosmetic plastic surgery in Canada. In those days, cosmetic surgery was ‘relegated to the back room’. If you performed any cosmetic surgery, then you certainly didn’t tell anyone about it, particularly at the university level. Dr Lindsay made this branch of surgery respectable. For 20 years, he staged the annual “Symposium on Cosmetic Plastic Surgery” at the University of Toronto. The top plastic surgeons from around the world would present lectures, which were attended by plastic surgeons from all over North America. Dr Lindsay was also a pioneer when he built his surgical facility in 1975. He had a hospital license and provided care to cancer patients alongside his cosmetic patients. Dr Lindsay and I ultimately worked together as partners in the burn centre for 15 years. He always asked me to call him ‘Bill’, but I never could. He had reached that level of respect and dignity where I could never call him anything but ‘Dr Lindsay’. When he retired, he passed his surgical facility along to me. I have continued to see many of his patients over the years. His patients worshipped him. Whenever his name comes up, their response is always the same: “He was a wonderful, lovely, nice, kind man, and always a gentleman”. Dr Lindsay has now passed from this world to a better one. The real reward in life is the journey. The journey is the reward – all those things that happen along way. Dr Lindsay’s journey has been remarkable. He touched many people. He actually changed their lives. He made an incredible difference. Dr Lindsay, may you rest in peace, sir.