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Study Design: Survey study. Objective: Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson’s opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries. Methods: Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn’s test. Results: The majority of respondents were supportive of FVCA in 10 out of 11 statements ( P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma ( P > 0.01). Conclusions: This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents’ acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure’s accessibility to a wider range of individuals.

OBJECTIVE Patients requiring intrathecal baclofen (ITB) therapy are at high risk for surgical site infections (SSIs) given their poor functional status. After years of a nominal infection rate, there was an inexplicable increase in ITB pump infections at the authors’ institution and multiple investigations offered no solution. Use of intraoperative topical antibiotics is well-documented in the orthopedic literature and was considered for ITB pump insertion. In this study, the authors investigated whether intraoperative vancomycin and tobramycin powder at the ITB pump site could reduce SSIs. METHODS Operative and infection data were collected and analyzed retrospectively to determine the efficacy of this change. Patients were stratified into three cohorts (1998–2009, 2010–2012, and 2013–2021) to better understand the trends before and after implementation of intraoperative topical antibiotics. Each cohort had similar demographics. RESULTS One hundred fifty-four patients underwent 272 ITB pump procedures between 1998 and 2021 (131 in 1998–2009, 49 in 2010–2012, and 92 in 2013–2021) for cerebral palsy (69.5%), spastic quadriparesis due to traumatic brain injury (7.1%), anoxic brain injury (6.5%), and other causes (16.9%). Infection rates were reduced from a high of 32% in 2010–2011 to 3.8% over the last 2.5 years (p = 0.0094). There were no adverse effects from the use of topical antibiotics. CONCLUSIONS In the setting of an intractable rise in ITB pump infections, the addition of intraoperative topical antibiotics significantly reduced postoperative infections in a high-risk population. One could appreciate a significant drop each year in the rate of infections after the institution of intraoperative topical antibiotics. The reduction in SSIs significantly improved the long-term outcomes for these patients.

Traumatic paracentral corneal perforations may lead to irregular astigmatism and opacification from lamellar grafts. We present an alternative surgical technique using a Tenon patch graft and a conjunctival flap.A 42-year-old man presented with a 1-mm paracentral corneal perforation 6 weeks after penetrating trauma by a metallic foreign body. A region of Tenon fascia was excised and sutured to cover the perforation, and a conjunctival flap was then created and sutured over this Tenon graft. A bandage contact lens was placed postoperatively. Serial imaging was conducted to document healing including optical coherence tomography (OCT) and slit lamp photography.At postoperative day 1, uncorrected distance visual acuity (UDVA) was hand motion, the anterior chamber was formed, and OCT revealed Tenon fascia and conjunctiva covering the defect. By postoperative week 2, the leak resolved and UDVA was 20/30. At postoperative week 4, UDVA improved to 20/20, the Tenon graft was noted to be undergoing contraction, and a single feeder vessel remained prominent in the conjunctival flap. By postoperative month 4, UDVA was 20/25 and only mild paracentral cornea clouding was noted. Initial, focal steepening and thickening normalized by month 4 leaving mild, normal astigmatism. OCT revealed integration of the Tenon graft into the corneal stroma.For paracentral corneal perforations, a Tenon patch graft in conjunction with a conjunctival flap may aid healing with favorable postoperative refractive outcomes.

BACKGROUND While the goal of facial vascularized composite allotransplantation (FVCA) is to provide patients with improved physical and social function, no study has evaluated layperson perception of social acceptance and perceived career success of patients with FVCA. The purpose of this study was to determine how FVCA changes social acceptance and perceived career success of patients with facial disfiguration. METHODS Eight hundred fifteen laypersons were surveyed through Mechanical Turk to evaluate their perceptions of patients with FVCA. Respondents were shown facial photographs of patients pre-FVCA, post-FVCA, and matched controls and evaluated these photos on 26 items of perceived social acceptance and career success. Responses were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS Both male and female post-FVCA photos were perceived as significantly more socially accepted and professionally successful than their pre-FVCA photos in at least 21 out of 26 items (P

BACKGROUND Traditional approaches to lower face contouring involve ostectomy of the mandibular angle or body. More recently, nonsurgical techniques have gained popularity, including neurotoxin injection to the masseter muscle. This study aims to evaluate layperson perceptions of patient attractiveness and personality traits following lower face contouring using either surgical or nonsurgical treatment. METHODS In this survey study distributed via Amazon's Mechanical Turk, respondents viewed a series of 14 patient images obtained in clinic before and after surgical or nonsurgical jawline slimming, or without any facial aesthetic procedure. Respondents rated changes in attractiveness and personality trait scores between the before and after image (score: -50 to 50, with 50 representing the greatest posttreatment increase and 0 representing no change). We used descriptive statistics and multivariable regression to determine differences in respondent ratings between patient images. RESULTS A total of 415 respondents (mean age 38 years, 50.6% female) successfully completed the survey. Compared to patients who underwent nonsurgical treatment, those who received surgery had significantly greater increases in perceived attractiveness (P

A growing body of literature demonstrates the clinical promise of dehydrated human amnion/chorion membrane (dHACM), a cryopreserved tissue product derived from placental amniotic membrane, to enhance post-operative wound healing. The purpose of this study is to review the potential of dHACM to facilitate post-surgical and myelomeningocele wound repair. A comprehensive literature search of PubMed was conducted to identify studies investigating dHACM use in pediatric and surgical wound care published from inception to October 2020. For each study, patient characteristics, wound characteristics, and outcomes following dHACM application were documented and assessed. Of the 190 articles reviewed, 15 publications were included in the final analysis. Results demonstrated that the average wound healing time varied across clinical indications (e.g., 14 days for trauma reconstruction to 116 days for Moh’s surgery repair). Across indications, pediatric patients had shorter healing periods compared to adults (P four weeks old) were documented in both adult (n = 3) and pediatric (n = 2) wound repair publications; all chronic surgical wounds demonstrated complete wound closure with dHACM. No complications from dHACM use were reported. Advantages of dHACM included increased patient satisfaction, cost-savings, and faster wound healing. We then present two cases of myelomeningocele wound repair facilitated successfully by dHACM. Overall, dHACM proves to successfully expedite wound repair in pediatric patients with chronic or complicated wounds such as those from myelomeningocele repair. It is important for surgeons to consider wound duration, size, and patient age to better predict graft success in enhancing wound repair.

Background Benchtop microsurgical training models that use digital tools (smartphones, tablets, and virtual reality [VR]) for magnification are allowing trainees to practice without operating microscopes. This systematic review identifies existing microscope-free training models, compares models in their ability to enhance microsurgical skills, and presents a step-by-step protocol for surgeons seeking to assemble their own microsurgery training model. Methods We queried PubMed, Embase, and Web of Science databases through November 2020 for microsurgery training models and performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We collected data including training model characteristics (cost, magnification, and components) and outcomes (trainee satisfaction, image resolution, and faster suturing speed). We also conducted a complimentary Google search to identify commercially available microscope-free microsurgical training models or kits not reported in peer-reviewed literature. Results Literature search identified 1,805 publications; 24 of these met inclusion criteria. Magnification tools most commonly included smartphones (n = 10), VR simulators (n = 4), and tablets (n = 3), with magnification ranging up to ×250 magnification on digital microscopy, ×50 on smartphones, and ×5 on tablets. Average cost of training models ranged from $13 (magnification lens) to $15,000 (augmented reality model). Model were formally assessed using workshops with trainees or attendings (n = 10), surveys to end-users (n = 5), and single-user training (n = 4); users-reported satisfaction with training models and demonstrated faster suturing speed and increased suturing quality with model training. Five commercially available microsurgery training models were identified through Google search. Conclusion Benchtop microsurgery trainers using digital magnification successfully provide trainees with increased ease of microsurgery training. Low-cost yet high magnification setups using digital microscopes and smartphones are optimal for trainees to improve microsurgical skills. Our assembly protocol, “1, 2, 3, Microsurgery,” provides instructions for training model set up to fit the unique needs of any microsurgery trainee.

Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States.Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants.Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P0.001).The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.

BACKGROUND There is growing public concern surrounding breast implant safety. In fact, the U.S. Food and Drug Administration recently proposed changes to breast implant labeling, which include a boxed warning. Given such efforts to increase transparency on breast implant safety, this study assessed laywomen's perceptions of breast implant safety, and the impact of proposed changes to breast implant labeling on laywomen's decision-making regarding breast implants. METHODS This was a cross-sectional investigation of women recruited through Amazon Mechanical Turk. Discrete choice modeling was used to query opinions on breast implants after viewing proposed labeling changes. Chi-square and analysis of variance were used for subgroup analyses, and McNemar analyses were used to assess changes in participants' responses. RESULTS The authors received 500 survey responses. At baseline, 353 participants (70.6 percent) considered breast implants to be at least somewhat safe. After viewing the proposed boxed warning, 252 participants (50.4 percent) responded that they would be less likely to receive implants. In fact, a significantly greater proportion of participants considered breast implants to be either unsafe or very unsafe after viewing suggested changes to implant labeling than at baseline (58.4 percent versus 28.8 percent; p = 0.001). By the end of the survey, willingness to consider alternative options for breast augmentation/reconstruction increased significantly from baseline. CONCLUSIONS Improved labeling can enhance laywomen's understanding of breast implant safety and can impact decision-making. However, greater scrutiny of breast implants should not prevent women who need implants from receiving them. Transparency and objectivity in the surgeon-patient dialogue can ensure the appropriate use of medical devices such as breast implants.

SUMMARY Surgeons are exposed to occupational hazards daily. Risks include chemical, biological, and physical hazards that place providers at risk of serious harm. Departmental policies or written guides to help pregnant surgeons navigate the hospital are lacking. In response to the scarcity in the literature, the authors have summarized current guidelines and recommendations to aid surgeons in making an informed decision. In addition, the authors present a brief narrative of the impact of these exposures during pregnancy and methods of transmission and, where relevant, include specialties that are at risk of these exposures.

Mya Abousy,1 Andy Schilling,1 Mary Qiu,2 Grant A Justin,3 Fatemeh Rajaii,1 Ximin Li,1 Fasika A Woreta1 1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of Ophthalmology, University of Chicago Medicine, Chicago, IL, USA; 3Department of Ophthalmology, Walter Reed National Military Medical Center, Bethesda, MD, USACorrespondence: Fasika A Woreta, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA, Email fworeta1@jhmi.eduPurpose: To describe ophthalmology resident experience with ophthalmic trauma cases in the U.S. Methods: We analyzed Accreditation Council for Graduate Medical Education (ACGME) case log data and de-identified case logs from US ophthalmology residency programs for residents graduating in 2018.  Current Procedural Terminology (CPT) codes documented as “Globe Trauma” and  trauma-related “Oculoplastic and Orbit” codes including lid lacerations and lateral canthotomies were analyzed.Results: 38 residency programs provided case logs (response rate: 32.2%). Residents performed an average of 7.24± 4.37 open globe repairs, 8.66± 6.94 lid laceration repairs, 0.49± 1.4 orbital fracture repairs, 1.22± 1.81 lateral canthotomies, and 0.28± 0.69 anterior chamber washouts as primary surgeon. On average, the most logged “Globe Trauma” procedure was open globe repair as primary surgeon. The more common trauma-related “Oculoplastic and Orbit” procedure was lid laceration repair as primary surgeon.  42.8% of residents did not log any lateral canthotomy procedures. Medium programs performed significantly more canthotomies than large programs (F(2166) = 6.35, p = 0.002), and large programs performed significantly more orbital fracture repairs than small and medium programs (F(2166) = 4.45, p = 0.013).Conclusion: Significant variation in globe trauma volume exists across programs. ACGME guidelines require a minimum of four globe trauma procedures for graduation, but procedures like anterior chamber paracentesis count towards this requirement. Open globe repairs, simple lid lacerations, and lateral canthotomies are basic skills every graduating resident should be competent in. Updating ACGME case log requirements for ophthalmic trauma and increasing opportunities for wet lab simulations may assist in ensuring graduating ophthalmology residents’ competency in performing these procedures.Keywords: globe trauma, ACGME, education, residency, surgical education

Owing to its rapid development, short-term and long-term effects of the COVID-19 vaccine are still not well understood. This case report highlights bilateral corneal endothelial graft rejection after administration of the Pfizer COVID-19 vaccine. A 73-year-old woman with bilateral Descemet stripping endothelial keratoplasty presented with bilateral decreased visual acuity, ocular pain, and photophobia after her second dose of the Pfizer-BioNTech COVID-19 vaccine. Two weeks after vaccine administration, the uncorrected visual acuity was 20/70 and 20/40. Central corneal thickness as measured by ultrasound was 809 and 825 µm and by Scheimfplug imaging was 788 and 751 µm at the pupil center. Slit-lamp biomicroscopy revealed quiet conjunctiva and sclera but was significant for thickened corneas with Descemet folds in both eyes. The patient was instructed to use prednisolone acetate 1% every 1 to 2 hours with Muro ointment at bedtime.

Virtual surgical planning (VSP) has gained popularity for preoperative orthognathic surgery planning and is increasingly being employed by surgeons trained in plastic and reconstructive surgery (PRS) or oral and maxillofacial surgery (OMS). This review assesses the introduction of VSP as a new technology and its impact on orthognathic surgery research and practices based upon surgeon training.Two PubMed literature reviews were conducted. The first classified publications on VSP for orthognathic surgery by training (OMS- or PRS-trained surgeons) and compared focuses, timing, and journals of publications from each group of surgeons. The second evaluated how orthognathic surgery publication volumes changed with VSP introduction. English articles published from inception until January 2020 (first review) and November 2020 (second review) were included.The first literature review retrieved 419 unique publications, with 188 studies selected for inclusion: 162 were published by OMS-trained principal investigators (OMS-authored) and 26 by PRS-trained principal investigators (PRS-authored). Plastic and reconstructive surgery-authored publications regarding VSP use in orthognathic surgery increased after the first publication in 2000, but at a significantly slower rate (0.2 new publications/year) than OMS-authored publications ( P0.01). Aesthetics was discussed in significantly more PRS-authored publications (76.9% compared to 28.4% of OMS-authored publications). The second review revealed that over 80.6% of orthognathic surgery literature was published after 2008, the year VSP was first integrated into orthognathic surgery workflow.Following the introduction of VSP, orthognathic surgery research output has differed between PRS and OMS based on publication speed, volume, and research focuses.Further research is necessary to evaluate how VSP has impacted PRS and OMS clinical practice.

Cutaneous polyarteritis nodosa (cPAN) is a rare, necrotizing vasculitis involving the small- and medium-sized vessels of the dermis and subcutaneous tissues. We report a severe case of cPAN in a patient with an atypical presentation of extensive bilateral lower extremity ulcerations with full-thickness necrosis managed at a burn center. A 70-year-old female with a three-month history of necrotizing cPAN to the bilateral lower extremities underwent surgical excision and autografting at an outside hospital. Postoperatively, she had total graft loss and was begun on prednisone. In the outpatient setting, she was tapered off prednisone and subsequently began to experience an acceleration of the disease process. She was then transferred to our regional burn center for bilateral escharotomy and management of her non-healing, tender, necrotic wounds with distinctive black-brown eschar. One year later, the patient's wounds continue to decrease in size and heal with her daily regimen of 15 mg of prednisone, 50 mg of cyclophosphamide, and topical silver sulfadiazine application. With the increasing volume of non-burn wound admissions to burn centers primarily of dermatologic etiology, it becomes crucial for burn specialists to familiarize themselves with severe presentations of vasculitides, including cPAN. Further research is necessary to understand the atypical manifestations of this disease for more timely diagnosis and treatment.

Purpose: Radial free forearm flap (RFFF) phalloplasty is the most commonly-used technique for gender-affirming phalloplasty procedures. Microsurgical coaptation of the free flap nerves to branches of the genital nerves aims to provide patients with a sensate neophallus. Return of sensation in the neophallus is poorly understood and has yet to be well characterized in the literature. This study serves to describe sensation in the neophallus, which will assist in setting patient expectations for recovery and improving operative technique and planning, especially in selection of nerves for coaptation. Methods: A total of 14 patients undergoing RFFF were tested for pressure sensation in the neophallus postoperatively. Testing was conducted via 1-point static (1PS) testing using the Pressure Specified Sensory Device (PSSD). A 100g monofilament was used to screen the neophallus for sensation beginning at 3 cm distal to the base and advancing distally by 1 cm until the patient reported no sensation; the PSSD was then applied at the last point the patient reported sensation for precise pressure measurements. These measurements were taken on the right and left ventral and dorsal shaft 1 cm from the ventral and dorsal midlines, respectively. The right and left urethral meatus was also measured for sensation (representing the ulnar-most skin of the RFFF). Measurements were taken at intervals beginning as early as 1 week postoperatively; the longest patient follow-up thus far has been 17 months. Results: Of the 14 patients, 13 had tactile pressure sensation at their most recent measurement (range 1-17mos). The remaining patient did not have a measurement beyond one month postoperatively. Of the 14 patients, consistent long-term follow-up measurements were currently available for 7. Among these patients, return of any sensation was measured at an average of 69 days (12-160 days) postoperatively. The earliest time point at which a patient had any sensation was two weeks postoperatively while another patient had sensation through the full length of the neophallus measured at 2.5 months postoperatively; subsequent measurements of this patient showed a decreased threshold (increased sensitivity) for pressure sensation over time. Conclusions: Preliminary data suggests that innervation of the RFFF neophallus can be accomplished via microsurgical nerve coaptation and that recovery of sensation may occur much faster in some patients than previously thought possible. Further follow-up and a larger patient cohort is necessary to fully characterize nerve recovery and regeneration in gender-affirming phalloplasty patients.