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Branchial cleft anomalies are congenital head and neck lesions that arise from incomplete maturation of the branchial apparatus during fetal development. The branchial arches are the precursors of the face, neck and pharynx, and disturbances in embryogenesis can present clinically as cysts, sinus tracts, and fistulas in predictable anatomic locations. However, there remains controversy regarding the precise embryogenesis of branchial cleft anomalies with several competing theories. These lesions often evade diagnosis in early childhood and may present in a delayed fashion after multiple failed interventions. Various diagnostic modalities have been described to facilitate clinical workup. Definitive treatment is complete surgical excision of the lesion. We present a comprehensive review of the literature along with several illustrative cases that highlight the unique challenges of diagnosis and surgical management of branchial cleft anomalies.

Craniofacial development requires precise spatiotemporal regulation of multiple signaling pathways that crosstalk to coordinate the growth and patterning of the skull with surrounding tissues. Recent insights into these signaling pathways and previously uncharacterized progenitor cell populations have refined our understanding of skull patterning, bone mineralization and tissue homeostasis. Here, we touch upon classical studies and recent advances with an emphasis on developmental and signaling mechanisms that regulate the osteoblast lineage for the calvaria, which forms the roof of the skull. We highlight studies that illustrate the roles of osteoprogenitor cells and cranial suture-derived stem cells for proper calvarial growth and homeostasis. We also discuss genes and signaling pathways that control suture patency and highlight how perturbing the molecular regulation of these pathways leads to craniosynostosis. Finally, we discuss the recently discovered tissue and signaling interactions that integrate skull and cerebrovascular development, and the potential implications for both cerebrospinal fluid hydrodynamics and brain waste clearance in craniosynostosis.

Implementation of patient-reported outcomes (PROs) represents a critical barrier to their widespread use and poses challenges to workflow and patient satisfaction. The authors sought to implement PRO surveys into surgical practice and identify principles for successful and broader implementation.Outpatient surgical encounters from 2016 through 2019 related to hernia, breast surgery, or postbariatric body contouring were assessed with the Abdominal Hernia-Q, BREAST-Q, or BODY-Q surveys, respectively. Outcomes were implementation rates per quarter and time to optimal implementation (≥80%). Successful implementation principles were identified during the first implemented PRO instrument and applied to subsequent ones. Logistic regression models were used to estimate increase in rate of implementation per quarter by instrument controlling for clinic volume. Risk-adjusted generalized linear models determined predicted mean differences in total clinic time and patient satisfaction.A total of 1206 encounters were identified. The overall survey implementation rate increased from 15% in the first quarter to 90% in the last quarter ( P0.01). Abdominal Hernia-Q optimal implementation was reached by 15 months. Principles for successful implementation of PROs were workflow optimization, appropriate patient selection, staff engagement, and electronic survey integration. Consistent application of these principles optimized time to optimal implementation for BREAST-Q [9 months; 18.1% increase in implementation per quarter (95% CI, 1.5 to 37.5); P0.01] and BODY-Q [3 months; 56.3% increase in implementation per quarter (95% CI, 26.8 to 92.6); P = 0.03]. Neither patient clinic time ( P = 0.16) nor patient satisfaction differed during the implementation of PROs process ( P = 0.98).Prospective implementation of PROs can be achieved in surgical practice without an adverse effect on patient satisfaction or workflow. The proposed principles of implementation may be used to optimize efficiency for implementation of PROs.

Objective This study assesses the user burden, reliability and longitudinal validity of the Abdominal Hernia-Q (AHQ), a novel ventral hernia (VH) patient-reported outcomes measure (PROM). Background We developed and psychometrically validated the AHQ as the first VH-specific, stakeholder-informed PROM. Yet, there remains a need to assess the AHQ's clinical applicability and further validate its psychometric properties. Methods To assess patient burden, pre- and post-operative patients were timed while completing the corresponding AHQ form. To measure test-retest reliability, a subset of patients completed the AHQ within a week of initial completion, and consecutive responses were correlated. Lastly, patients undergoing VH repair were prospectively administered the pre- and post-operative AHQ forms, the Hernia-Related Quality of Life Survey (HerQLes) and the Short Form-12 (SF-12) both preoperatively and at postoperative intervals, up to over a year after surgery. Quality-of-Life (QoL) scores were correlated from the three PROMs and effect sizes were compared using analysis of normal variance (ANOVA). Results Median response times for the pre- and post-operative AHQ were 1.1 and 2.7 minutes, respectively. The AHQ demonstrates high test-retest reliability coefficients for pre- and post-operative instruments (r = 0.91, 0.89). The AHQ appropriately and proportionally measures expected changes following surgery and significantly correlates with all times points of the HerQLes and SF-12 MS and 4/5 (80%) SF12-PS. Conclusion The AHQ is a patient-informed, psychometrically-validated, clinical instrument for measuring, quantifying and tracking PROMs in VH patients. The AHQ exhibits low response burden, excellent reliability, and effectively measures hernia-specific changes in QoL following VHR.

Background Oncologic resection of the scalp confers several obstacles to the reconstructive surgeon dependent upon patient-specific and wound-specific factors. We aim to describe our experiences with various reconstructive methods, and delineate risk factors for coverage failure and complications in the setting of scalp reconstruction. Methods A retrospective chart review was conducted, examining patients who underwent resection of fungating scalp tumors with subsequent soft-tissue reconstruction from 2003 to 2019. Patient demographics, wound and oncologic characteristics, treatment modalities, and outcomes were recorded and analyzed. Results A total of 189 patients were appropriate for inclusion, undergoing a range of reconstructive methods from skin grafting to free flaps. Thirty-three patients (17.5%) underwent preoperative radiation. In all, 48 patients (25.4%) suffered wound site complications, 25 (13.2%) underwent reoperation, and 47 (24.9%) suffered from mortality. Preoperative radiation therapy was an independent risk factor for wound complications (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.1-7.3; p = 0.028) and reoperations (OR, 4.45; 95% CI, 1.5-13.2; p = 0.007). Similarly, the presence of an underlying titanium mesh was an independent predictor of wound complications (OR, 2.49; 95% CI, 1.1-5.6; p= 0.029) and reoperations (OR, 3.40; 95% CI, 1.2-9.7; p= 0.020). Both immunosuppressed status (OR, 2.88; 95% CI, 1.2-7.1; p= 0.021) and preoperative radiation therapy (OR, 3.34; 95% CI, 1.2-9.7; p= 0.022) were risk factors for mortality. Conclusion Both preoperative radiation and the presence of underlying titanium mesh are independent risk factors for wound site complications and increased reoperation rates following oncologic resection and reconstruction of the scalp. Additionally, preoperative radiation, along with an immunosuppressed state, may predict patient mortality following scalp resection and reconstruction.

Background Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction. Methods The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction. Results Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis. Conclusion Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction. Clinical question/level of evidence Therapeutic, IV.

BACKGROUND Cutaneous mold infections occur infrequently but can be life-threatening in immunocompromised children. The literature regarding its surgical management is limited. This study aims to describe the surgical management and outcomes of cutaneous mold infections in immunocompromised children. METHODS Hospitalized patients receiving a skin biopsy at a single pediatric hospital in 2003 to 2017 were identified. Inclusion criteria were immunocompromised status, younger than 21 years, and surgical excision of a confirmed cutaneous mold infection. Patient information, details of immunosuppression, operative details, and 6-month postoperative and disease outcomes were collected. RESULTS Seventeen patients (21 lesions) were identified with an average age of 6.8 years (range = 0.2-19.5 years). Affected anatomic regions included limb (15, 71%), chest (2, 10%), axilla, back, abdomen, and head (1 or 5% each). Excisions occurred, on average, within 1.7 days of initial biopsy (range = 0-7 days). When specified, margins were 0.5 to 2.0 cm, and surgeons used intraoperative fungal detection techniques in 8 cases (47%). Definitive closure was achieved by secondary intention/dressings changes (9, 43%), skin graft (7, 33%), a skin substitute (2, 10%), immediate primary closure (2, 10%), and delayed primary closure (1, 5%). Overall, 14 patients were alive 6 months after resection (82%). CONCLUSIONS This study is the first to critically evaluate the methodology for surgical resection of cutaneous fungal infections in immunocompromised children. We suggest timely excision once diagnosed with, at minimum, 0.5-cm margins and intraoperative pathologic study when considering surgical treatment for this rare but serious infection.

Background Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. Objectives The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. Methods A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. Results In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. Conclusions The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

BACKGROUND The abdomen is a common donor site in autologous breast reconstruction. The authors aimed to determine whether pregnancy following autologous breast reconstruction increases the risk of incisional hernia repair. METHODS All women younger than 50 years who underwent abdominally based autologous breast reconstruction between 2005 and 2016 were identified. Patients with less than 20 months of follow-up were excluded. Demographics, operative details, outcomes, incisional hernia repair occurrence, and pregnancy history were analyzed. RESULTS Five hundred nineteen patients underwent autologous breast reconstruction with 890 free flaps [free transverse rectus abdominis musculocutaneous, n = 645 (72.5 percent); deep inferior epigastric perforator, n = 214 (24.0 percent); pedicled transverse rectus abdominis musculocutaneous, n = 18 (2.0 percent); and superficial inferior epigastric artery, n = 13 (1.5 percent)]. Average follow-up was 57.2 months (range, 9.5 to 312.8 months). Fourteen women became pregnant, with mean postpregnancy follow-up of 31.2 months (range, 5.4 to 70.8 months; pregnancies, n = 18). Age of nonpregnant patients (mean, 43.1 years; range, 20.6 to 50.0 years) was higher than that of pregnant patients (mean, 32.1 years; range, 27.1 to 37.9 years) (p < 0.0001); in univariate analysis, age was not associated with incisional hernia repair. Twelve pregnant patients (66.7 percent) underwent cesarean delivery. No statistically significant differences existed between groups regarding flap type and closure technique. Zero pregnant patients underwent incisional hernia repair, compared with a 6.1 percent incisional hernia repair rate in nonpregnant patients (p = 0.339). In multivariate analysis, prior incisional hernia, hematoma, fascial dehiscence, and reoperation predicted incisional hernia repair. CONCLUSION The authors' results demonstrate that there may not be an increased risk of incisional hernia repair associated with pregnancy following autologous breast reconstruction despite additional weakening of the abdominal wall. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

INTRODUCTION Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. METHODS Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). CONCLUSIONS Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

The World Health Organization (WHO) defines female genital mutilation (FGM) as any procedure that intentionally alters or causes injury to the female genitalia for nonmedical reasons.1 It is practiced primarily for sociocultural reasons with the greatest prevalence in western, eastern, and north-eastern African regions. It is a violation of human rights that affects approximately 200 million girls and women worldwide.1 A study carried out by the Center for Disease Control (CDC) estimated that in 2012, 513,000 women and girls in the United States were at risk for FGM, a number that has tripled in the past three decades.2 While much of that rise is due to immigration, the practice is often continued after arriving in the U.S. by taking girls abroad or to another state for the specific purpose of undergoing FGM, known as “vacation cutting.”3 The WHO classifies FGM into 4 different types, listed in Table ​Table11 and illustrated in Figure ​Figure1.1. Immediate complications from the procedure include severe pain, hemorrhage, infections, sepsis, shock, and even death.4,5 Long-term, women with FGM experience chronic pain, scarring, sexual dysfunction, chronic urinary and reproductive tract infections, as well as high rates of obstetric complications and psychological disorders.4–7 Traditional practitioners, not medical professionals, are usually the ones to perform FGM in the majority of countries.8 In these settings, it is often performed without anesthesia and without sterile instruments, thereby contributing to the high rate of complications seen. In rare cases, the medicalization of FGM has become more common; however, this practice is strongly condemned by the United Nations and others.4,8 Table 1. World Health Organization Classification of FGM

Background Deep sternal wound infections (DSWI) often require flap reconstruction to obliterate dead space and provide healthy soft tissue coverage. A better understanding of risk factors for complications after DSWI flap reconstruction may improve operative management. Methods A retrospective study (2007-2018) was conducted of all patients with DSWI after cardiothoracic procedure referred to a single reconstructive surgeon for flap reconstruction. Patient and operative factors were reviewed, including procedure types and outcomes. Predictors of morbidity and mortality rates were analyzed. Results A total of 119 patients requiring flap reconstruction for DSWI met inclusion criteria. Unilateral (49.6%) or bilateral (40.3%) pectoralis muscle flaps were performed most frequently, followed by vertical rectus abdominis myocutaneous (VRAM) (4.2%), omental (4.2%), and omental/pectoralis flap combination (1.7%). Superficial surgical site infection (SSI) was the predominant postoperative complication (17.6%). Debridement/revisional procedures were required in 19 patients (16%), and flap failure occurred in 5 (4.2%). Overall 30-day mortality was 15.1%. End-stage renal disease (P = .002), congestive heart failure (P = .049), low albumin (P = .004), cardiopulmonary bypass time (P = .0001), need for open chest (P = .020), and high American Society of Anesthesiologists Physical Status Classification (P = .003) were associated with higher mortality. By multivariate analysis, multidrug resistance was predictive of any postoperative complication (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.3-23.2; P = .018), VRAM was predictive of SSI (OR, 9.6; 95% CI, 1.4-66.4; P = .022), and end-stage renal disease (OR, 8.57; 95% CI, 1.06-69.1; P = .044) was predictive of higher mortality. Conclusions Pectoralis muscle flaps are the workhorse for complex sternal wound coverage, but complications after flap reconstruction for DSWIs remain high. In particular, end-stage renal disease, VRAM reconstruction, and multidrug-resistant infection may predict a complicated postoperative course in these patients.

Summary:. Healthcare advocacy is an important tool in the plastic surgeon’s arsenal that stands the potential to improve both patient care and the profession. However, many physicians underestimate the importance and influence that healthcare advocacy has on the profession and feel that they lack the leverage and knowledge to advocate on behalf of themselves, their practices, their patients, and their profession, all of which are untrue. Plastic surgeons are uniquely positioned to advocate based on their clinical acumen, personal experiences with patient care, and their position in the healthcare ecosystem value chain. This article aims to equip plastic surgeons with a general framework of knowledge regarding policy and advocacy. Additionally, the article outlines and discusses recent advocacy efforts related to plastic surgery, and efforts that are on the horizon to provide some context to the relevance of advocacy related to plastic surgery. Finally, we aim to empower plastic surgeons to step into the policy advocacy arena for the betterment of our patients and the professional practice of plastic surgery.