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Background:. A previous study by the authors noted a decline in independent plastic surgery residency programs and rising applicant participation. This study provides updates on match trends and influential predictors, and gathers program leaders’ views on the future of the independent track. Methods:. Match data (2019–2022) were obtained from the San Francisco match after American Council of Educators in Plastic Surgery approval. Variables influencing match success were analyzed, and program leaders were surveyed about desirable applicant traits and program trajectories. Results:. From 2019 to 2022, 243 of 428 applicants matched. Programs and positions declined by 10% and 9.5%, respectively. Applicants rose to 42.3%, but match rates fell from 82% to 56%. Osteopathic graduates doubled, whereas international graduates increased to 53.8%. Successful matches were associated with US allopathic medical school graduates, university-affiliated general surgery residencies, eight or more interviews, United States Medical Licensing Examination scores greater than 230, and high post graduate year (PGY)1–3 American Board of Surgery In-service Training Examination scores (PGY1–64.7%, PGY2–61.2%, PGY3–60.7%; P < 0.05). Of surveyed programs, 55.6% aimed to continue running the independent track in the next year. Conversely, 7.4% planned to discontinue in the next year, 22.2% within 2–5 years, 7.4% within the next decade, and 7.4% were unsure. Conclusions:. Although support for the independent plastic surgery track remains, program participation diminishes as applicant interest increases, intensifying match challenges. Increasing number of interviews improves match potential. Program leaders display varied commitments, with looming plans for some programs to discontinue offering this track. Applicant evaluation pivots on strong recommendations, research, and test scores.

Background:. We aimed to identify how Integra bilayer wound matrix has expanded facial reconstruction options after Mohs surgery due to its reliability in both single- and dual-stage reconstruction. Methods:. A retrospective review of patients undergoing Mohs surgery and alloplastic facial reconstruction with Integra between 2012 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. Results:. One hundred thirty patients with a median age of 76 years were included. Basal cell carcinoma was the most common malignancy (39%). One hundred forty-two lesions were treated and reconstructed same-day with Integra. Lesions most commonly involved the nose (34%) and forehead (22%). The mean postoperative defect size was 26.9 cm2. An estimated 45.5% (n = 60) of defect sites underwent single-stage reconstruction with healing by secondary intention, whereas 54.5% (n = 72) underwent dual-stage reconstruction with skin graft. Integra success rate was 90.2%. Average time to re-epithelialization was 32.2 + 7.3 days. Average time to repigmentation was 169.5 + 14.6 days. The complication rate was 12.8% (n = 17), with 12 undergoing debridement, three needing new Integra graft, and seven needing new skin grafts. Average size for successful healing without complication was 26.6 cm2. Nineteen sites (13.2%) underwent aesthetic improvement procedures, with the majority occurring after dual-stage reconstruction (n = 13). Conclusions:. Integra is a reliable outpatient reconstructive option for facial Mohs defects that can increase the threshold for autologous tissue harvesting and successfully reconstruct large defects of 26.6 cm2 on average with low complication and reoperation rates.

Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.

Summary:. Thoracic duct occlusion can lead to devastating complications, resulting in recalcitrant chylothoraces, ascites, generalized lymphedema, metabolic derangement, and death. Lymphatic extravasation has traditionally been managed conservatively and, in recent years, using minimally invasive techniques, such as thoracic duct ligation and embolization. However, these measures are often limited in application and therapeutic success, resulting in chronically difficult conditions with few modalities available for definitive management. Advances in microsurgery have allowed for surgical treatment and resolution of peripherally-based lymphatic pathology, though microsurgical intervention to address central lymphatic abnormalities is scarcely described. This report is the first series detailing experiences utilizing microsurgical thoracic duct lymphovenous bypass in a refractory adult population with thoracic duct occlusion. Four patients successfully underwent the procedure, with three achieving complete resolution of symptoms. The fourth patient enjoyed partial resolution, though ubiquitous lymphatic deformities have conferred recurrent residual lower-extremity peripheral edema requiring future intervention. Postoperatively, patent anastomoses were confirmed under magnetic resonance lymphangiography. This series demonstrates the feasibility of microsurgical thoracic duct lymphovenous bypass as a promising technique in treating patients suffering from thoracic duct occlusion. This intervention is effective for recalcitrant chylothorax, chylous ascites, and generalized lymphedema, particularly when traditional and interventional radiological techniques are unsuccessful.

Background:. The purpose of this study was to evaluate participants from the in-person Penn Flap Course (PFC) and virtual PFC to determine if the virtual PFC increased diversity in culture, sex, education, and surgical specialties internationally and within the United States. Our hypothesis is that the virtual PFC increases diversity internationally and within the United States. Methods:. A retrospective descriptive comparison was performed between participants from the in-person PFC from the years 2017 to 2019 and virtual PFC in 2020. Frequency maps were generated to determine differences in participation of cultures, sexes, education, and specialties internationally and within the United States. Net Promoter Scores (NPSs) were used to assess participant satisfaction with the virtual course. Results:. The in-person PFC included 124 participants from the years 2017 to 2019, whereas the virtual PFC included 770 participants in the year 2020. Compared to the in-person course, the virtual course included more cultures (countries: 60 versus 11; states: 35 versus 22), women (countries: 38 versus 7; states: 23 versus 9), students/researchers (countries: 24 versus 0; states: 9 versus 0), residents (countries: 44 versus 5; states: 26 versus 15), fellows (countries: 21 versus 2; states: 21 versus 9), attendings (countries: 34 versus 8; states: 16 versus 11), plastic surgery (countries: 54 versus 9; states: 31 versus 18), orthopedic surgery (countries: 12 versus 5; states: 11 versus 9), and other specialties (countries: 19 versus 1; states: 8 versus 2). Our overall NPS for the virtual PFC totaled 75%, categorized as “world class” based on global NPS. Conclusion:. A virtual interface for a flap course increased participation and diversity of culture, sex, education, and specialties internationally and within the United States with “world class” participant satisfaction.

Background:. Management of traumatic lower extremity injuries requires a skill set of orthopedic surgery and plastic surgery to optimize the return of form and function. A systematic review and meta-analysis was performed comparing demographics, injuries, and surgical outcomes of patients sustaining lower extremity traumatic injuries receiving either orthoplastic management or nonorthoplastic management. Methods:. Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and GRADE certainty evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were systematically and independently searched. Nine studies published from 2013 through 2019 compared 1663 orthoplastic managed patients to 692 nonorthoplastic managed patients with traumatic lower extremity injuries. Results:. Orthoplastic management, compared to nonorthoplastic management likely decreases time to bone fixation [standard mean differences: −0.35, 95% confidence interval (CI): −0.46 to −0.25, P < 0.0001; participants = 1777; studies = 3; I2 = 0%; moderate certainty evidence], use of negative pressure wound therapy [risk ratios (RR): 0.03, 95% CI: 0.00–0.24, P = 0.0007; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence] with reliance on healing by secondary intention (RR: 0.02, 95% CI: 0.00–0.10, P < 0.0001; participants = 189; studies = 2; I2 = 0%; moderate certainty evidence), and risk of wound/osteomyelitis infections (RR: 0.37, 95% CI: 0.23–0.61, P < 0.0001; participants = 224; studies = 3; I2 = 0%; moderate certainty evidence). Orthoplastic management likely results in more free flaps compared to nonorthoplastic management (RR: 3.46, 95% CI: 1.28–9.33, P = 0.01; participants = 592; studies = 5; I2 = 75%; moderate certainty evidence). Conclusion:. Orthoplastic management of traumatic lower extremity injuries provides a synergistic model to optimize and expedite definitive skeletal fixation and free flap-based soft-tissue coverage for return of extremity form and function.

Summary:. Anterolateral thigh (ALT) free flaps have become reliable options for head-to-toe reconstruction. Although perforator anatomy is fairly predictable, in cases of eccentric perforator location, we proposed shifting the entire flap laterally and preserving a medial bipedicled flap between the original incision and the new medial flap margin. This facilitates primary donor site closure instead of harvesting a flap larger than anticipated. We conducted a retrospective chart review of ALT flaps performed between 2007 and 2019 and identified patients who underwent bipedicled closure of the donor site. Demographics, flap characteristics, and surgical technique were evaluated. Six patients had bipedicled donor site closure related to primary perforators located lateral to the original flap design. The mean defect size was 91 cm2, and bipedicled flap width ranged from 4 to 6 cm. All donor sites were closed primarily. Five of the donor thigh sites healed without complications, and 1 patient had superficial delayed healing of the medial bipedicled incision, which healed with local wound care. The ALT has become an invaluable flap in microsurgical reconstruction, yet it is not without limitations. Primary donor site closure is generally not feasible for larger flaps, thus necessitating skin grafting of the donor site and/or prolonged wound care. Our technique facilitates primary closure of the donor site in patients who otherwise would have required harvest of a larger than necessary flap based on eccentric perforator anatomy. The medial bipedicled flap is straightforward, reproducible, and allows for modifications of the original flap design to better fit the defect.