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Background: The Plastic Surgery Milestones Project was jointly conceived by the Accreditation Council for Graduate Medical Education and the American Board of Plastic Surgery as a tool to improve granularity in resident feedback. Resident self-evaluations were compared to attending clinical competency committee evaluations to gauge resident self-perceptions and understanding of the milestones framework., Methods: Semiannual evaluations from June of 2014 to 2017 were analyzed and compared with corresponding resident self-evaluations from the 2015 to 2017 academic year at the University of Pittsburgh Medical Center. Evaluations were analyzed for overall trends in performance. The presence of systemic differences between each type of evaluation were determined using Student's t tests. Subgroup analysis using the chi-square test was performed to determine factors that may contribute to major assessment disparity (≥1)., Results: Six thousand two hundred seven milestones across 187 faculty evaluations and 3139 milestones across 106 resident self-evaluations were available for review. With the exception of postgraduate year-2 residents, residents rated themselves at a significantly lower level in the competencies of medical education and patient care. Postgraduate year, academic year timing, and Accreditation Council for Graduate Medical Education competency were associated with major assessment discrepancies., Conclusions: Overall, resident and faculty evaluations at the authors' program were concordant, which demonstrates that residents are capable of accurately assessing their own abilities and understanding the milestones framework. Areas of discordance between resident and faculty evaluations fostered discussion between residents and faculty and have led to multiple changes in the authors' program. The introduction of self-evaluation tools at other programs may provide them with similar benefits.

Soft-tissue deficits in amputation stumps can lead to significant pain and disability. An emerging treatment option is stem cell-enriched fat grafting. This is the first study assessing the potential for this treatment modality in lower extremity amputation sites. In this prospective cohort study, five injured military personnel suffering from pain and limited function at amputation sites were recruited. Fat grafting enriched with stromal vascular fraction was performed at amputation sites to provide additional subcutaneous tissue padding over bony structures. Outcomes measures included complications, demographic data, physical examination, cellular subpopulations, cell viability, graft volume retention, pain, Lower Extremity Functional Scale, Functional Mobility Assessment, 36-Item Short-Form Health Survey, and rates of depression. Follow-up was 2 years. There were no significant complications. Volume retention was 61.5 ± 24.0 percent. Overall cell viability of the stromal vascular fraction was significantly correlated with volume retention (p = 0.016). There was no significant correlation between percentage of adipose-derived stem cells or number of cells in the stromal vascular fraction and volume retention. There was a nonsignificant trend toward improvement in pain scores (3.0 ± 2.5 to 1.2 ± 1.6; p = 0.180 at 2 years). There were no significant changes in disability indexes. Results from this pilot study demonstrate that stromal vascular fraction-enriched fat grafting is a safe, novel modality for the treatment of symptomatic soft-tissue defects in traumatic lower extremity amputations. Volume retention can be anticipated at slightly over 60 percent. Further studies are needed to assess efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Background and Objectives: Massive weight loss (MWL) can result in variable contour deformities of the breasts. The Pittsburgh Rating Scale (PRS) was designed to describe the multitude of deformities after MWL and recommends operations to consider for surgical improvement. We present the first comprehensive description of breast deformities in a large sample of MWL patients, examine factors affecting the severity of deformities, and report the correlation between PRS score and surgical decision making., Methods: A retrospective review of all MWL patients presenting for breast surgery at our institution's Life After Weight Loss program from 2004 to 2015 was performed. Information including demographics, body mass indices (BMIs), method of weight loss, and type of surgical intervention was collected. Preoperative breast photographs were blinded and scored according to the PRS., Results: A total of 204 MWL patients were identified; 26% (53) scored 1, 34% (69) scored 2, and 40% (82) scored 3 on the PRS. Greater deformities were seen after weight loss from bariatric surgery versus diet and exercise alone (P = 0.031), in mastopexy versus augmentation/mastopexy (P = 0.001), and in breast reduction versus augmentation/mastopexy patients (P > 0.0001). Patients who underwent reduction mammaplasty had the greatest maximum BMI compared with other procedures (P = 0.016). The PRS scores were positively correlated to maximum BMI (P < 0.001), delta BMI (P < 0.001), and current BMI (P < 0.001)., Conclusions: Massive weight loss patients have variable, and often severe, breast deformities, and the PRS remains a valuable classification tool. Severity scores correlate with BMI, procedure, and weight loss mechanism. Similar scores between mastopexy-only and reduction mammaplasty patients may reflect a composite of personal cosmetic expectations and cost. The PRS scale should also be expanded to include breast reduction as a surgical remedy for PRS grade 3 breast deformities. Understanding breast deformities in this unique population has applications in both preoperative planning and surgical expectations for this unique patient population.