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Background: A cross-sectional study was conducted to assess the comparative effectiveness of virtual visits for preoperative evaluation and surgical decision-making in three pediatric surgical subspecialties., Methods: Patients who underwent surgical procedures in the departments of Urology, Ophthalmology, and Plastic and Oral Surgery at a tertiary care pediatric hospital over a one-year period during the COVID-19 pandemic were included. Patients were assigned to one of three clinical pathways based on their preoperative visit(s): only in-person visit(s) (IP), a combination of in-person and virtual visit(s) (IP/VV), and only virtual visit(s) (VV). Demographics, procedure information, and patient experience survey results were collected. We then assessed variations in procedure types and patient experience scores in these three patient groups., Results: There were 431 patients who completed the modified patient experience survey. The most common procedures were circumcision (17%), excision of lesion (16%), and strabismus repair (11%). Survey results were positive, with 90% of participants rating that they would recommend the service to others. No significant differences were found among groups in their demographics, overall care rating, and duration between preoperative clinic visit and procedure. Post-hoc power analysis indicated 87% power to detect a 10% difference in survey ratings between IP and VV cases, confirming non-inferiority in patient satisfaction for virtual preoperative visits., Conclusion: This study demonstrated the non-inferiority of preoperative virtual visits in three pediatric surgical subspecialties as measured by patient experience scores. Additional studies with more granular scope are necessary to further elucidate telemedicine's safety and efficacy for select diagnoses., Level of Evidence: III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Vascular malformations that circumferentially surround end or near-end arteries are challenging to manage. Minimally invasive treatment options such as sclerotherapy can directly damage these vessels and cause ischemia. Surgical resection is desired without sacrificing or injuring a patent artery, especially in end organs like the upper limb. Microsurgical resection of these lesions provides a viable option for treatment., Methods: The records of nine patients who presented with vascular malformations that circumferentially surrounded an artery in the upper limb were reviewed. The main indications for surgical intervention were pain or persistent growth. In each case, microsurgical technique using a microscope and microsurgical instruments was used to dissect the lesions free from the affected end arteries. Four digital arteries, three radial arteries, one brachial artery and one palmar arch were involved., Results: There were six venous malformations, two fibro-adipose vascular anomalies, and one lymphatic malformation. There were no cases of distal ischemia, bleeding, or functional compromise. Two patients experienced delayed wound healing. After a minimum follow-up of 1 year, only one patient experienced a small area of recurrence but had no pain., Conclusions: Microsurgical dissection using a microscope and microsurgical instruments is a viable technique for resection of difficult vascular malformations that surround major arterial channels in the upper limb. This technique allows preservation of maximum blood supply while treating problematic lesions., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns., Methods: The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed., Results: There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon ( P = .007), fewer required surgery ( P < .001)., Conclusions: Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

The American College of Surgeons' National Surgical Quality Improvement Project-Pediatric Data manages a multicenter dataset for monitoring outcomes in pediatric surgical care. We explored trends in outcomes in the most frequently sampled current procedural terminology codes related to craniofacial and cleft lip and palate (CLP) surgical procedures over a 7-year period., Methods: We used National Surgical Quality Improvement Project-Pediatric Data on 28,147 pediatric patients who underwent plastic surgical procedures between January 1, 2012, and December 31, 2018. Eighteen relevant current procedural terminology codes were selected and sorted into two procedure groups: CLP and craniofacial. For each group, we explored trends in readmission, reoperation, extended length of stay, morbidity, and racial and ethnic variation., Results: The proportion of readmissions following CLP repair saw a significant reduction per year (from 3.6% to 1.7%). African American or Black CLP patients had significantly higher rates of readmission and extended length of stay when compared to the overall cohort. Asian and White CLP patients had significantly lower rates of experiencing an extended length of stay. For craniofacial cases, extended length of stay decreased significantly per year (from 7.7% to 2.8%). One possible driver of this change was a decrease in transfusion rates during the study period from 59% to 47%., Conclusions: Pediatric CLP and craniofacial cases saw significant improvements in safety, as indicated by reductions in readmission and extended length of stay. Given the racial differences observed, especially among CLP patients, continued research to identify and address systems of racism in health care remains a priority., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: The effect of physical-distancing policies and school closures on pediatric health has been a topic of major concern in the United States during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to assess the immediate impact of these public policies on patterns of head and facial trauma in the pediatric population., Materials and Method: The Pediatric Health Information System (PHIS) was queried to identify patient encounters at 46 children's hospitals across the United States in 2016-2020. Encounters were included if resultant in ICD-10 diagnosis for head or facial trauma in a child under 18 between April 1 and June 30 in 2020 (first COVID-19 school closures) and during the same period in the previous 4 years (for comparison)., Results: A total of 170,832 patient encounters for pediatric head and facial trauma were recorded during the study period, including 28,030 (16.4%) in 2020 and 142,802 (83.6%) in 2016-2019. Patient encounters declined significantly in 2020 among children of all age groups relative to previous years. Relative reductions were greatest in children aged 11 to 17 (middle/high school) and 6 to 10 (elementary school), at -34.6% (95% confidence interval: -23.6%, -44%; P <0.001) and -27.7% (95% confidence interval: -18.4%, -36%; P <0.001). Variation in relative reductions by race/ethnicity, sex, and rural/urban status were not statistically significant., Conclusions: Physical-distancing policies and school closures at the start of the COVID-19 pandemic correlated with significant reductions in pediatric head and facial trauma patient encounters. As in-person activities resume, reductions in head and facial trauma during the pandemic may indicate a range of possible preventable injuries in the future., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Gender-affirming surgery is a critical component of transgender health care, but access information is limited. The study aim was to assess workforce capacity to perform gender affirming bottom surgeries (GABSs) in the United States., Methods: A questionnaire was administered via email, phone call, or fax from February to May 2020 to 86 practices identified as performing GABS by searching 10 Web-based databases with standardized keywords. Questions assessed training capacity, surgical capacity, and surgeon experience., Results: Thirty-two of 86 practices responded, 20 met the inclusion criteria. Practices were identified in 15 states, with an average 2.4 (SD, 1.3) surgeons performing GABS per year. States with the greatest number of total providers offering GABS were Illinois (n = 21), Texas (n = 10), and Massachusetts (n = 13). No significant correlation between number of GABS types offered and geographic population density (r = -0.40, P = 0.08), or between number of providers and geographic population density (r = 0.19, P = 0.44). Vaginoplasty was most frequently performed, with the longest waitlists and highest number of waitlist additions per month. Phalloplasty was the second most common procedure, and waitlist additions per month exceeded provider capacity to perform the procedure. Most surgeons performing GABS were plastic surgeons and urologists, whereas obstetricians/gynecologists performed the majority of hysterectomies., Conclusions: This study demonstrated a shortage of providers with requisite training and experience to provide GABS. Although more robust studies are needed to better characterize the relationship between the number of patients seeking GABS and available providers, these findings indicate a need for improved training., Competing Interests: Conflicts of interest and sources of funding: The authors did not receive any funding for this study. They have no financial disclosures or conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients., Methods: This retrospective cohort study included hospital billing/medical record queries of (1) procedures performed under conscious sedation/general anesthesia and (2) laboratory-confirmed COVID-19 (+) cases from April 6, 2020, to June 15, 2020. Descriptive analyses were performed for demographic, procedural, symptom, and COVID-19 test result data obtained from medical records. Bivariate analyses examined associations between SARS-CoV-2 test results and symptom, demographic, and procedural data., Results: Among 2900 surgical cases, median (interquartile range) age was 8.1 (12.8) years. The majority were male (n = 1609, 55.5%), white (n = 1614, 55.7%), and not Hispanic/Latino (n = 1658, 57.2%). Additionally, 85.4% (n = 2412) of cases were non-emergent. Fifteen COVID-19 (+) cases were identified, for a 0.5% positivity rate. COVID-19 positivity was not associated with sex, American Society of Anesthesiologists physical status, or preoperative symptom status. Notably, 92.9% (n = 13) of COVID-19 (+) cases were asymptomatic. COVID-19 (+) patients were significantly older (15.6 years) than COVID-19 (-) patients (8.0 years). Patients who were not white, were Hispanic/Latino, or had a relatively lower economic status, were more likely to test positive., Conclusions: Preoperative symptom screenings insufficiently identified COVID-19 (+) patients. During outbreaks, testing protocols should be implemented to identify COVID-19 (+) patients. Future research should examine if observations are similar for other variants, and how health disparities associate with COVID-19., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The thumbs of patients with Apert syndrome are characteristically short and radially deviated, contributing to functional hand impairment. The authors report a two-staged technique for distraction lengthening of the Apert thumb using a robust cohort of pediatric patients., Methods: The authors retrospectively reviewed medical records of pediatric patients with Apert syndrome who underwent thumb distraction lengthening between 1999 and 2019. The technique was two-staged: (1) application of uniplanar distractor and phalangeal osteotomy, followed by (2) distractor removal, bone grafting, and fixation. Clinical records, preoperative and postoperative radiographs, and photographs were reviewed., Results: Twenty-two patients (41 thumbs) with Apert syndrome were identified and treated (mean age at initial distraction, 11.5 years). A mean distraction gap of 31.3 mm was achieved over a median time of 40.0 days. The mean healing index was 26.3 days per centimeter. The thumbnail complex was lengthened a median length of 3.0 mm. The median follow-up time was 5.0 years, with complications occurring in 36.4 percent (eight out of 22) of patients. A delayed bone union occurred in one patient, and rotational malunion occurred in one patient., Conclusion: Although long-term outcomes data are needed, thumb distraction lengthening following syndactyly release in patients with Apert syndrome is safe and should be considered to augment the overall appearance and functionality of the hand., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Summary: Syndactyly is one of the most common congenital differences treated by hand surgeons. Although dozens of techniques for syndactyly release have been described, a reliable method is based on a dorsal rectangular flap for commissure construction and a combination of interdigitating zigzag flaps and skin grafts for digital coverage. In this article, the authors present a detailed description of syndactyly release emphasizing principles integral to successful outcomes., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Parkes Weber syndrome is a vascular malformation overgrowth condition typically involving the legs. Its main features are diffuse arteriovenous fistulas and enlargement of the limb. The condition has been associated with pathogenic germline variants in RASA1 and EPHB4 We report two individuals with Parkes Weber syndrome of the leg and primary lymphedema containing a somatic KRAS variant (NM&#95;004985.5:c.35G > A; p.Gly12Asp). KRAS variants, which cause somatic intracranial and extracranial arteriovenous malformations, also result in Parkes Weber syndrome with lymphatic malformations., (© 2021 Eng et al.; Published by Cold Spring Harbor Laboratory Press.)

Background: Inconsistency in results and outcomes between presented abstracts and corresponding published articles can negatively affect clinical education and care. The objective of this study was to describe the frequency of clinically meaningful change in results and outcomes between abstracts presented at the American Association of Plastic Surgeons annual conference and the corresponding published articles, and to determine risk factors associated with discrepancies., Methods: All abstracts delivered as oral presentations at the American Association of Plastic Surgeons conference (2006-2016) were reviewed. Results and outcomes were compared with those in corresponding articles. We defined clinically meaningful discrepancy as any change in the directionality of an outcome, or a quantitative change in results exceeding 10%., Results: Four hundred eighty-six abstracts were identified. Of these, 63% (N = 305) advanced to publication. Of the published studies, 19% (N = 59) contained a discrepancy. In 85% of these (N = 50), discrepancies could not be explained by random variation. Changes in sample size were associated with heightened risk for a discrepancy (OR 10.38, 95% CI 5.16-20.86, P < 0.001). A decrease in sample size greater than 10% increased the likelihood of a discrepancy by 25-fold (OR 24.92, 95% CI 8.66-71.68, P < 0.001), whereas an increase in sample size greater than 10% increased the likelihood of a discrepancy by eight-fold (OR 8.36, CI 3.69-19.00, P < 0.001)., Conclusions: Most discrepancies between abstract and published article were not due to random statistical variation. To mitigate the possible impact of unreliable abstracts, we recommend abstracts be marked as preliminary, that authors indicate whether sample size is final at time of presentation, and that changes to previously reported results be indicated in final publications., Competing Interests: Disclosure: The authors have no financial interest in relation to the content of this article., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background:  Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands., Methods:  Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined., Results:  Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3-18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb ( n  = 17) and index ray ( n  = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe ( n  = 7), fifth toe ( n  = 9), great toe polydactyly ( n  = 2), thumb polydactyly ( n  = 1), and second toe ( n  = 1). All transfers survived. Revisions included tenolysis ( n  = 2), repeat fixation for nonunion or malunion ( n  = 2), and fusion for instability ( n  = 3)., Conclusion:  Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV., Competing Interests: None declared., (Thieme. All rights reserved.)

Indications for lower extremity reconstruction in children are unique because most result from congenital conditions (eg, constriction ring, lymphedema, syndactyly, nevi, vascular anomalies). Like adults, pediatric patients also suffer from effects following extirpation and trauma. Principles of reconstruction are based on the condition and type of deformity. The pediatric population typically has fewer comorbidities than adults that can negatively affect outcomes (eg, diabetes, peripheral vascular disease), although children can be less compliant with postoperative care. Growth, development, appearance, and postoperative compliance are variables that especially influence operative management of children., Competing Interests: Disclosure The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The value of gender-affirming genital surgery (GAGS) has been established for certain transgender or gender non-conforming patients. This study aimed to determine the availability of GAGS by state and region in the United States, and to query possible associations of access to care with healthcare legislation and local market size., Methods: This was a cross-sectional study reporting on the distribution of hospitals and private practices offering GAGS in the United States. A list of prospective gender surgeons was compiled from 18 online databases. All surgeons were individually verified and were excluded if they did not perform phalloplasty, metoidioplasty, or vaginoplasty. Pertinent legislative and transgender or gender non-conforming population data were derived from the Movement Advancement Project and the Williams Institute., Results: Seventy-one practices in the United States offered GAGS in 2019. Forty-seven percent of states did not have a practice offering GAGS. A large prospective transgender or gender non-conforming market size increased the odds of GAGS availability in a state more than did local healthcare legislation supporting insurance coverage for gender-affirming care in 2019., Conclusions: Access to gender-affirming genital surgery was highly disparate in 2019. Factors that predicted access to care, including state healthcare legislation and prospective market sizes, may indicate strategies for overcoming disparities., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men's equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty., Aim: To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction., Methods: We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors., Main Outcome Measures: Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula., Results and Conclusion: A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique. Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Summary: Pollicization can be performed for secondary thumb reconstruction after traumatic injury or for primary thumb construction in cases of congenital thumb hypoplasia. Given the complexity of this operation, intimate familiarity with the involved anatomy and surgical principles is key to successful surgical outcomes. In this Video Plus article, the authors present a step-by-step approach to pollicization in case of Blauth type IIIB thumb hypoplasia., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Proper management of Spitz nevi continues to be debated, with treatment ranging from observation to surgery. To better characterize the outcome of surgical procedures performed for incomplete initial excision or biopsy, we sought to ascertain the histopathological presence of residual Spitz nevi in a set of surgical specimens., Methods: We retrospectively reviewed 123 records with histologically-confirmed Spitz nevus. Data concerning treatment, clinical features, histopathological margin involvement, and presence of residual lesion on subsequent procedural specimens were collected., Results: Fifty-three percent of lesions (n = 65) were initially sampled by shave or punch biopsy, and the remainder (n = 58) were formally excised without initial biopsy. The rates of re-excision for involved margins were: shave biopsy (92.2%), punch biopsy (78.6%), and formal excision (13.8%). In total, 61.0% of patients who underwent an initial procedure of any kind had involved margins, but only half of those re-excised for involved margins (57.6%) had histologically residual lesion on repeated excision. A significantly higher proportion of initial punch biopsies (90.9%) resulted in residual lesion (in secondary excision specimens) when compared with shave biopsy (48.9%) and formal excision (62.5%; P < 0.05)., Conclusions: Findings suggest that clinicians may consider shave biopsy over punch biopsy for diagnosing suspected lesions, when indicated and appropriate. Given the rarity of malignant transformation and the frequency of residual nevus, observation may be reasonable for managing pediatric patients with histologically-confirmed Spitz nevi, who are post initial biopsy or excision despite known histopathological margin involvement., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction., Methods: This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016., Results: Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%)., Conclusions: This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement., Study Design: We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included., Results: Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1., Conclusions: Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Fibroadipose vascular anomaly (FAVA) is an intramuscular vascular malformation that has been recently described as a distinct clinical entity. The clinical, radiological, and histopathological characteristics of FAVA in the upper extremity are reviewed., Methods: This was a retrospective case series of upper-extremity FAVA lesions., Results: We reviewed 19 patients with FAVA of the upper limb. Pain, stiffness, swelling, and flexion contractures were the most common presentations. Except for one lesion confined to the hand, all lesions either presented with or developed a contracture within 10 years. Ten patients underwent surgical debulking. Six required tendon transfer reconstruction and 3 necessitated a free functional muscle transfer., Conclusions: Fibroadipose vascular anomaly in the upper extremity requires an accurate diagnosis and may benefit from early referral to a multidisciplinary vascular anomaly center with experienced hand surgeons. Compression garments, propranolol, and sclerotherapy seem to be ineffective. Surgical resection focused on symptomatic regions with appropriate reconstruction may have benefit in salvage of limbs with compromised function., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The term "intramuscular hemangioma capillary type" (IHCT) refers to a fast-flow vascular lesion that is classified as a tumor, although its phenotype overlaps with arteriovenous malformation (AVM). The purpose of this study was to identify somatic mutations in IHCT., Methods: Affected tissue specimens were obtained during a clinically indicated procedure. The diagnosis of IHCT was based on history, physical examination, imaging and histopathology. Because somatic mutations in cancer-associated genes can cause vascular malformations, we sequenced exons from 446 cancer-related genes in DNA from 7 IHCT specimens. We then performed mutation-specific droplet digital PCR (ddPCR) to independently test for the presence of a somatic mutation found by sequencing and to screen one additional IHCT sample., Results: We detected somatic mutations in 6 of 8 IHCT specimens. Four specimens had a mutation in MAP2K1 (p.Q58&#95;E62del, p.P105&#95;I107delinsL, p.Q56P) and 2 specimens had mutations in KRAS (p.K5E and p.G12D, p.G12D and p.Q22R). Mutant allele frequencies detected by sequencing and confirmed by ddPCR ranged from 2 to 15%., Conclusions: IHCT lesions are phenotypically similar to AVMs and contain the same somatic MAP2K1 or KRAS mutations, suggesting that IHCT is on the AVM spectrum. We propose calling this lesion "intramuscular fast-flow vascular anomaly."

Purpose: Many transgender men seek surgical interventions to create male genitalia. Currently, there is no standardized tool to assess individual goals and expectations for such reconstructive genital surgery. The purpose of this study was to develop and pilot a genital affirmation surgical priorities scale (GASPS) in transgender men seeking metoidioplasty and/or phalloplasty. Methods: The research team developed the GASPS and piloted it with 63 patients seeking reconstructive genital surgery. The scale was constructed after a comprehensive literature review identified key areas of importance, including size, erogenous and tactile sensation, interest in penetrative sex, ability to urinate standing up, and maintenance of orgasmic function. Results were then tabulated and analyzed to look for trends. Results: Sixty three consecutive patients, mean age 24.98 years (standard deviation [SD]=5.87), were administered the assessment. On the 5 point Likert scale, patients were most concerned about being able to stand to urinate (mean=4.38, SD=1.06) and erotic sensation (mean=4.21, SD=0.8). The ability to engage in penetrative intercourse (mean=3.98, SD=1.34), tactile sensation (mean=3.93, SD=1.01), and penis length (mean=3.37, SD=1.18), and girth (mean=3.09, SD=1.20) were not universally considered to be important and responses varied widely. Most patients (86%) stated they had a history of being able to orgasm, and 8% did not know. Feedback suggested that scale use helped patients clarify goals for surgery. Conclusion: GASPS use confirmed the diversity of patient priorities and the importance of individualized goal assessment. It also confirmed previous reports that standing to urinate is a major genital affirmation motivation for many transgender men., Competing Interests: No competing financial interests exist., (© Oren Ganor et al. 2019; Published by Mary Ann Liebert, Inc.)

Background: To use time-driven activity-based costing methodology to compare the costs of routine pediatric plastic surgical patient visits with and without a physician scribe., Methods: Pediatric plastic surgical clinic visits at a tertiary care facility with the following diagnoses were studied: skin lacerations, skin lesions, and plagiocephaly. Two plastic surgeons saw patients individually either with or without a scribe over a 10-month period. The time that the scribe and physician spent on the patient was recorded, including the duration of the clinic visit and time spent creating, dictating, reviewing, and signing the note. An average appointment activity time for each measurement component was produced, and a capacity cost rate was introduced to derive the cost per minute for a scribe and physician. Sensitivity analysis and paired t -test were conducted to analyze the results., Results: A total of 45 cases with a physician scribe were observed with an average appointment activity time of 12.83 minutes (4.97 min for the scribe, 0.92 min for the physician, and 6.95 min combined). A total of 72 cases without a physician scribe were observed with an average appointment activity time of 12.01 minutes. The total attributable cost saving per appointment was $13.82 when a physician scribe was utilized., Conclusion: Time-driven activity-based costing methodology showed that the use of a physician scribe reduced cost per office visit by substituting physician time for a less expensive resource., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Verrucous venous malformation is a rare vascular anomaly that presents as a deep purple skin stain and evolves into a larger scaly, keratotic lesion that can bleed and cause pain. Because of its similarity to other vascular lesions, it is often misdiagnosed and treated incorrectly. Ten patients with hand verrucous venous malformations evaluated between 1990 and 2017 were reviewed. Diagnosis was confirmed with histopathology. Six patients were initially misdiagnosed and two patients were incorrectly treated. Eight patients had excision procedures. Immunostaining for glucose transporter 1 protein was positive in all specimens that underwent staining. Most (three of four) of the patients with isolated small lesions remained disease free postoperatively, but those with larger lesions experienced recurrence or continued growth. Early recognition of verrucous venous malformation is important because nonsurgical ablative techniques are ineffective; the optimal treatment is surgery. Level of evidence : IV.

Hospital social workers were asked to complete the LGBT-DOCSS, a validated self-assessment of clinical competence, attitudes, and knowledge about working with lesbian, gay, bisexual (LGB), and transgender patients. As a group, they held positive attitudes about LGBT patients (Mean 6.9/7, SD .22) but were less confident about their knowledge (Mean 5.9/7, SD 0.96) and clinical preparedness (Mean 5.0/7, SD 1.24). In addition, providers felt significantly less competent about working with transgender than LGB patients. Factors that affected domains of self-assessed competence including experience working with LGB or transgender patients and the year training was completed.

The management of phalangeal and metacarpal fractures continues to evolve. Nonoperative or less invasive techniques, limiting the need for soft tissue dissection and resultant stiffness, are being developed and becoming more popular. The competing forces of fracture stability to optimize healing and early mobilization to optimize function need careful balancing. As imaging, equipment, and techniques improve, hand surgeons can tailor individualized care to the unique needs of each patient., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is no consensus for esophageal reconstruction in the pediatric population. Long defects are commonly repaired with gastric pull-up or colonic interposition; however, jejunal interposition offers several potential advantages in children. One historical concern with jejunal interposition has been the risk of flap infarction following transposition. The use of neck and intrathoracic vessels to "supercharge" the jejunum has been reported in adults. This study reports outcomes of supercharged jejunal interposition in pediatric and young adult patients with long esophageal defects., Methods: The authors reviewed the medical records of patients who underwent supercharged jejunal interposition for esophageal reconstruction at their institution from 2013 to 2017. The authors collected data pertaining to patient characteristics, operative technique, and postoperative outcomes., Results: Twenty patients, 10 female and 10 male, aged 1.4 to 23.8 years, underwent esophageal reconstruction with supercharged jejunal interposition and were followed for a median of 1.4 years. Seventeen patients had a primary diagnosis of long-gap esophageal atresia, and three required reconstruction following caustic ingestion. Eighty percent of patients had undergone prior attempts at surgical reconstruction. Postoperatively, all conduits demonstrated coordinated peristalsis, and no flap losses were noted. Major complications occurred in seven patients, stricture dilation was performed in four patients, and there was no mortality., Conclusions: Jejunal interposition with supercharging can be safely performed for management of long esophageal gaps in the pediatric setting; it is useful where the stomach or colon has been used previously or is unavailable. Long-term outcome studies are required to determine whether jejunal interposition provides a more durable and safe conduit than gastric pull-up or colonic interposition over time., Clinical Question/level of Evidence: Therapeutic, IV.

As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital's ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital's mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center's services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Replantation and revascularization in the pediatric extremity has unique challenges that provide a fertile field of research and clinical experience. Children regenerate peripheral nerves rapidly, resulting in good sensory and motor function. They adapt well to functional deficits and mismatch errors of reinnervation. The technical aspects of microsurgical care in children can be challenging because the structures are small. Additional technical challenges include preservation of growth centers, prevention of vasospasm, protection of the reconstruction, and psychosocial care. Despite these challenges, children show excellent functional outcomes with minimal complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The goal of this study was to determine upper-extremity function and health-related quality of life in a cohort of adults with Apert syndrome., Methods: Twenty-two adults with Apert syndrome completed the Disabilities of the Arm, Shoulder, and Hand survey; the 36-Item Short-Form Health Survey; and a semistructured interview. One surgeon administered the Jebsen Hand Function Test and measured sensation, joint motion, and strength., Results: Median Disabilities of the Arm, Shoulder, and Hand score was 16.9, which indicated slightly greater disability than the population norm of 10.1. Median 36-Item Short-Form Health Survey scores were 54.5 for mental health and 57.0 for physical health-both more favorable than population norms. Total Jebsen Hand Function Test scores for dominant hand were 69.2 seconds for men and 64.7 seconds for women versus 37.8 seconds for population norms of both sexes. More complex syndactyly resulted in worse metacarpophalangeal joint motion but no significant difference in Disabilities of the Arm, Shoulder, and Hand; 36-Item Short-Form Health Survey; or other functional results. There was no difference in self-reported outcomes between patients with four (n = 8) versus five digits (n = 14) in each hand., Conclusions: In this cohort of adults with Apert syndrome, self-reported assessment of disability was more favorable than measured functional data would suggest. Despite significant functional deficits, the participants in this study had adapted remarkably well.

Background: Central conducting lymphatic anomalies (CCLA) may cause chylous leaks and protein-losing enteropathy (PLE) owing to dysfunction of the central lymphatic channels. Most of the treatment strategies for these conditions are palliative and provide transient improvement., Methods: We treated 14 patients with intractable chylous leak and/or PLE using a novel technique of lymphaticovenous bypass of the terminal portion of the thoracic duct. Chylous leaks occurred in multiple different anatomic sites. All patients had CCLA and failure of thoracic duct emptying demonstrated by preoperative intranodal lymphangiography., Results: Five patients had complete resolution of symptoms, and two patients had partial improvement. There were no major complications. Of 5 patients with PLE, only one improved after lymphaticovenous bypass. Repeat traditional lymphangiography was performed in 4 patients who did not improve, demonstrating patency of the bypass in all cases with persistent sluggish drainage. One patient had repeat MR lymphangiography that did not show the thoracic duct well., Conclusions: Bypass of the terminal thoracic duct is a novel procedure that offers improvement and a chance of cure for some patients with devastating manifestations of CCLA who lack other effective therapeutic options., Level of Evidence: IV., (Copyright © 2018. Published by Elsevier Inc.)

Importance: A growing number of transgender patients are receiving gender-affirming hormone treatments. It is unclear whether the evidence supports the current practice of routinely discontinuing these hormones prior to surgery., Objective: To determine how medications used in cross-sex hormone treatment (CSHT) affect perioperative risk., Evidence Review: A series of searches were carried out in PubMed and Excerpta Medica Database to identify articles using each of the terms testosterone, estrogen, estradiol, oral contraceptive, spironolactone, cyproterone acetate, finasteride, dutasteride, leuprolide, goserelin, and histrelin, in combination with the terms surgery, perioperative, thrombosis, thromboembolism, and operative. The search was not restricted to perioperative outcomes in transgender populations because many surgeons routinely discontinue hormone use prior to surgery in this population, which makes it impossible to study how hormones affect outcomes. Additional sources were also identified from the texts of reviewed articles. Articles were excluded if they were animal studies or case reports, did not explicitly discuss surgical outcomes, or were restricted to removal of hormonally sensitive tissues., Findings: Eighteen articles addressing perioperative outcomes were identified by this systematic review, including 1 on CSHT, 12 on estrogens and progesterones, 1 on testosterone, and 4 on spironolactone and antiandrogens. Data were limited, but use of exogenous testosterone was not found to be associated with an increased risk of venous thromboembolism or other complications during surgery. Moderate evidence suggests that spironolactone is not associated with negative surgical outcomes. The data linking estrogen use and thrombosis is inconsistent in the perioperative period and does not address the types of estrogens most often used for CSHT., Conclusions and Relevance: Current evidence does not support routine discontinuation of all CSHT prior to surgery, particularly given the lack of information on risks associated with resuming these medications after they have been stopped. Evidence suggests there is no need to discontinue either testosterone or spironolactone, although their association with perioperative outcome quality has not been studied in depth. Most of the evidence that supports discontinuation of estrogen prior to surgery is based on oral estrogen regimens that are not typically used in transgender patients, and even with those formulations, there are conflicting reports on perioperative risk. Further research is needed to determine the safety of continuing hormone treatment and elucidate risks of short-term discontinuation.

Vascular anomalies encompass a wide variety of clinical conditions involving the vasculature. Over the past several decades, the terminology has changed as our understanding of these conditions has improved. A well-accepted classification scheme has evolved with constant additions, updates, and revisions. Imaging techniques have also advanced with greater resolution and a better understanding of the correlation between imaging, clinical behavior, and natural history. Meanwhile, the treatment of these conditions has also changed, with greater focus on minimally invasive techniques as opposed to radical surgery. Despite these changes, surgical intervention remains a high-value option for select patients. With greater understanding of the molecular basis of these diseases, medical treatment has improved especially in severe cases where options remain limited. A multidisciplinary approach to comprehensive patient care usually yields the best outcome and is strongly encouraged., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: We report a technique in the management of the type III Apert hand. The proposed approach facilitates the creation of a 5-fingered hand in 3 stages., Methods: We reviewed records of patients with Apert syndrome and type III hands surgically treated at our institution from 1995 through 2014. In all cases, syndactyly release was performed in 3 stages with prioritization of the border digits. In addition, limited retrograde, axial osteotomies between the phalangeal segments of the conjoined index, middle, and ring fingers were performed during the first stage. Medical records were reviewed for demographics, clinical presentation, operative findings, and postoperative outcomes., Results: Twelve pediatric patients with type III hands underwent syndactyly release. Median patient age was 10.0, 15.8, and 29.6 months at operative stages 1, 2, and 3, respectively. A thumb and 4 fingers were achieved for all but 1 hand. The median duration of hospital stay was 2 days for each stage. No infections or major complications were observed., Conclusions: We demonstrate this method as a safe and effective means of creating 5 digits in the Apert patient with type III hands. Our opinion is that the additional aesthetic and functional gains offset the requirement of a 3-stage approach., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: A variety of surgical techniques exist to manage long-gap esophageal atresia (LGEA), including gastric pull-up (GPU), colonic interposition (CI), jejunal interposition (JI), and distraction lengthening. Salvage reconstruction for late failure of any conduit type is a complex surgical problem fraught with technical difficulty and significant risk. Jejunal interposition can be used as a salvage procedure in the management of LGEA. However, the opposing requirements of conduit length and adequate perfusion make the procedure technically challenging. Chronic comorbidities and abdominal and thoracic adhesions may further complicate these cases., Methods: We report a technique for the management of 3 late treatment failures of LGEA using pedicled JI in conjunction with 2 additional arterial and venous anastomoses, or double supercharging. For 2 patients who presented with failed CI, pedicled JI was performed and supercharged to internal mammary vessels as well as vasculature preserved from the prior colonic flap mesentery. The third patient presented with failed GPU and underwent pedicled JI that was supercharged caudally to the gastroepiploic vessels and cranially to the left common carotid artery., Results: No flaps were lost in any patients. Median operation time was 16.5 hours. Patients were monitored postoperatively in the intensive care unit for a median of 23 days, extubated after 14 days, and discharged at 41 days. Postoperatively, all patients tolerated an oral diet by discharge and continue to enjoy oral intake of all food consistencies without dysphagia or aspiration. Follow-up time spanned 2 to 4 years (average, 3.3 years). One patient required dilatations and temporary stent for stricture, and another required removal of prominent sternal wires; otherwise, no additional procedures were performed., Conclusions: Although technically difficult, double supercharged JI should be considered as a salvage operation to restore esophageal continuity after CI or GPU failure for LGEA, when there are otherwise limited reconstructive options.

Purpose: The purpose of this study was to evaluate the safety and efficacy of preoperative percutaneous n-butyl cyanoacrylate (nBCA) embolization of venous malformations in children., Material and Methods: Clinical data were retrospectively reviewed in children who underwent embolization using nBCA followed by resection of venous malformations., Results: A total of 17 embolizations were performed in 14 patients (9 females, mean age: 5.5 years; median age: 3 years; range 0.1-16 years). The venous malformations involved the lower extremity and the knee joint (n = 7), the trunk (n = 4), head and neck (n = 2), and hand (n = 1). n-Butyl cyanoacrylate was diluted with iodized oil at a ratio of 1:3 to 1:5. The mean and median volume of nBCA per procedure were 2.1 and 2 mL, respectively (range: 0.5-8 mL). There were no complications associated with the procedures. The mean and median time between final embolization and resection were 3.6 and 2 days, respectively. All children underwent successful resection of the symptomatic lesions. The estimated mean and median blood loss were 75 and 50 mL, respectively (range: 5-350 mL). The postprocedure course was uneventful, the days to discharge ranged between 1 and 6 days (mean 3 days)., Conclusion: Initial results suggest that preoperative percutaneous n-butyl cyanoacrylate embolization of venous malformations is safe and effective in children, with the potential for minimizing blood loss and inpatient stay.

Background: Surgical cancellations that occur within 1 day of the procedure (ie, late cancellations) disrupt the efficiency of the operating room. The aim of the present study was to identify the factors associated with late cancellations in a tertiary pediatric surgical practice., Methods: We reviewed the medical records of patients treated by plastic and oral surgery services at our institution from 2010 to 2015. We collected data pertaining to the timing and reasons for cancellation. Reasons for cancellation were retrospectively classified by the investigators as either "preventable," "possibly preventable," "unpreventable," or "undocumented." We also measured the frequency of cancellations based on type of surgery., Results: Of 10,730 scheduled operating room cases, 444 (4.1%) were cancelled within 24 hours of the procedure. Sixty-seven percent (297/444 cases) were cancelled on the same day as the planned procedure, and the remaining cases were cancelled the day prior after 1 PM. Forty-two percent of cancellations were deemed preventable, and 45.3% of cases were deemed possibly preventable. The majority of procedures were cancelled because of illness (44%), inadequate fasting (9%), and parental inconvenience (7%). The highest frequency of cancellation was found in skin lesion (36%) followed by dentoalveolar (14%) and cleft lip and palate (12%) cases., Conclusions: In our study, most late surgical cancellations were preventable or possibly preventable. The timing of the cancellation is important because those that occur near the scheduled procedure time disallow adequate and timely redistribution of operating room resources and personnel. Analyzing and addressing the preventable and possibly preventable causes outlined in this study will significantly improve efficiency and patient access.

Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors' study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors' study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.

Background: Although fingertip injuries are common, there is limited literature on the epidemiology and hospital charges for fingertip injuries in children. This descriptive study reports the clinical features of and hospital charges for fingertip injuries in a large pediatric population treated at a tertiary medical center., Methods: Our hospital database was queried using International Classification of Diseases, Revision 9 (ICD-9) codes, and medical records were reviewed. Frequency statistics were generated for 1807 patients with fingertip injuries who presented to the emergency department (ED) at Boston Children's Hospital (BCH) between 2005 and 2011. Billing records were analyzed for financial data., Results: A total of 1807 patients were identified for this study; 59% were male, and the mean age at time of injury was 8 years. Most commonly, injuries occurred when a finger was crushed (n = 831, 46%) in a door or window. Average length of stay in the ED was 3 hours 45 minutes, 25% of cases needed surgery, and, on average, patients had more than 1 follow-up appointment. About one-third of patients were referred from outside institutions. The average ED charge for fingertip injuries was $1195 in 2014, which would amount to about $320 430 each year (in 2014 dollars) for fingertip injuries presenting to BCH., Conclusion: Fingertip injuries in children are common and result in significant burden, yet are mostly preventable. Most injuries occur at home in a door or window. Although these patients generally heal well, fingertip injuries pose a health, time, and financial burden. Increased awareness and education may help to avoid these injuries.

Executive Summary: Hospitals in the United States have started collecting information related to the patient experience with the objective of improving overall patient satisfaction. Between 2012 and 2015, the authors collected data from 2,875 patient satisfaction surveys. The purpose of this study was to analyze the effects of several variables-wait time, physician courtesy, administrative staff courtesy, patients' opportunity to ask questions, and patients' understanding of the answers-on a patient satisfaction score. A linear regression model was used to analyze the effects of these variables on patient satisfaction. All variables but one were significantly associated with patient satisfaction in the multivariable model. Healthcare provider courtesy was the strongest predictor of patient satisfaction; a score of "excellent" was associated with a 2.63-point (95% confidence interval [2.36, 2.90]) increase on a 5-point scale for patient satisfaction compared with a courtesy score of "poor." These findings suggest that patients had a positive experience when physicians and staff members were courteous.

Background The time to detection of vascular compromise is a significant predictor of free flap salvage outcomes as early reexploration improves salvage rates. Continuous transcutaneous near-infrared tissue oximetry is an objective, quantitative method of detecting flap vascular compromise and has been shown to allow earlier reexploration and higher salvage rates than clinical assessment alone. We designed a novel text messaging system to improve communication using tissue oximetry monitoring. Methods A retrospective review was performed of a prospectively collected database of all microsurgical breast reconstructions from 2008 to 2015. A novel text messaging system was introduced in 2013 and programmed to send text messages alert when the tissue oximetry readings suggested potential flap compromise based on established thresholds. Patient demographics and complications, including rate of reexploration and flap loss were assessed. Results There were 900 autologous microsurgical breast free flaps during the study period: 614 were monitored with standard clinical monitoring and tissue oximetry compared with 286 flaps with the additional text messaging system. There were 27 unplanned returns to the operating room in the tissue oximetry group and 5 in the text messaging group with 1 complete flap loss in each group. Reexploration occurred sooner as a result of these text message alerts (17.5 vs. 26.6 hours postoperatively), however, it did not achieve statistical significance. Conclusions We were able to demonstrate the use of a novel text messaging system for tissue oximetry. This alert system shows promise in identifying impending flap loss with rapid notification of the surgical team., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The early outcomes of using jejunal interpositions to establish esophageal continuity in patients who have had a failed repair of esophageal atresia (EA) were determined., Study Design: This was a retrospective review of all patients treated at our institution with a jejunal interposition after a failed EA repair from 2010 to 2015. Demographics, anatomy encountered, operative techniques, requirement for microvascular support, and length of stay were analyzed. Outcomes measures included conduit survival, as well as feeding status at last follow-up., Results: Ten patients were reviewed. Median age at time of interposition operation was 48 months (range 8 to 276 months) and median weight was 14.2 kg (range 7.2 to 49.7 kg). Preoperative anatomy, operative techniques, and outcomes are presented. Four patients had microvascular "supercharging" for a long jejunal graft. Median follow-up was 1.5 years (range 0.5 to 5 years) with no long-term loss of graft or deaths. Six patients are eating by mouth completely, 1 by mouth primarily with supplemental night-time feeds, 1 is transitioning from tube to oral feeds, and 2 with functional grafts are fed mostly enterally due to severe oral aversion in 1 and aspiration in 1., Conclusions: Jejunal interpositions have been used for the past 5 years to establish esophageal continuity after a failed EA repair. All jejunal conduits survived and were joined to the upper esophageal segment. For shorter gaps with a longer upper esophageal pouch, a thoracic esophageal anastomosis was possible without additional vascular support. For longer interpositions into the neck, upper conduit survival might benefit from additional vascular anastomoses (ie, supercharging). To provide adequate space in the mediastinum, the first rib can be removed, as well as a portion of the manubrium to enlarge the pathway into the neck., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons National Surgical Quality Improvement Program - Pediatrics uses a risk-adjusted, case-mix-adjusted methodology to compare quality of hospital-level surgical performance. This paper aims to focus quality improvement efforts on diagnoses that have large patient volume and high morbidity for pediatric plastic surgery., Methods: Frequency statistics were generated for a cohort of patients under age 18 who underwent plastic surgery procedures at participating National Surgical Quality Improvement Program - Pediatrics hospitals from January 1, 2011 to December 31, 2012., Results: Cleft lip and palate procedures were the leading contributor to serious adverse events (45.00%), and the second largest contributor to composite morbidity (37.73%) as well as hospital-acquired infections (21.23%)., Conclusions: When focusing resources for relevant data collection and quality improvement efforts, it is important to consider procedures that are both substantial volume and result in relatively higher morbidity. A balance must be made between what is relevant to collect and what is feasible given finite resources. Cleft lip and/or palate procedures might provide an ideal opportunity for coordinated efforts that could ultimately improve care for pediatric plastic surgery patients.

Verrucous venous malformation (VVM), also called "verrucous hemangioma," is a non-hereditary, congenital, vascular anomaly comprised of aberrant clusters of malformed dermal venule-like channels underlying hyperkeratotic skin. We tested the hypothesis that VVM lesions arise as a consequence of a somatic mutation. We performed whole-exome sequencing (WES) on VVM tissue from six unrelated individuals and looked for somatic mutations affecting the same gene in specimens from multiple persons. We observed mosaicism for a missense mutation (NM&#95;002401.3, c.1323C>G; NP&#95;002392, p.Iso441Met) in mitogen-activated protein kinase kinase kinase 3 (MAP3K3) in three of six individuals. We confirmed the presence of this mutation via droplet digital PCR (ddPCR) in the three subjects and found the mutation in three additional specimens from another four participants. Mutant allele frequencies ranged from 6% to 19% in affected tissue. We did not observe this mutant allele in unaffected tissue or in affected tissue from individuals with other types of vascular anomalies. Studies using global and conditional Map3k3 knockout mice have previously implicated MAP3K3 in vascular development. MAP3K3 dysfunction probably causes VVM in humans., (Copyright © 2015 The American Society of Human Genetics. Published by Elsevier Inc. All rights reserved.)

Background: Fingertip injuries are common in the pediatric population. Composite grafting is a frequently used technique for distal amputations in children given the reported success rate. We sought to study the early clinical results of composite grafting for fingertip injuries in the pediatric population., Methods: A retrospective review was performed over a 5-year period at a tertiary care pediatric hospital to identify those patients who underwent composite grafting of fingertip injuries. Patients were included if they were 18 years old or younger and sustained an injury distal to the distal interphalangeal joint (or thumb interphalangeal joint). Demographic information was recorded. Graft viability was characterized as no take, partial take, or complete take. The number of secondary procedures and number and duration of follow-up appointments were recorded. Hypothesis testing was done using ordinal logistic regression analysis., Results: Thirty-nine patients underwent fingertip composite grafting. The mean age was 5.9 years (1-18 years); there were 24 males (61.5 %) and 15 females (38.5 %). Thirteen patients had no graft take (33.3 %), 23 patients had partial take (59.0 %), and three patients had complete take (7.7 %). Only four patients underwent secondary revision (10 %). The median number of follow-up appointments was 3 and the average follow-up time was 4.5 months. Age did not appear to have a statistically significant influence on graft take., Conclusions: Fingertip composite grafts rarely take completely even in young children. Despite poor viability, however, most patients will have at least partial graft take and do not undergo additional reconstructive procedures.

Background: The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb., Methods: The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed., Results: Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue-encircled nerves., Conclusions: The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications., Level of Evidence: Level III.

Adequate soft-tissue coverage of the hand is paramount to achieve optimal aesthetic and functional results in patients with complex hand defects. In this article, the authors present four illustrative clinical cases and discuss potential reconstructive modalities. For each scenario, two surgical options are discussed: one established and one nontraditional method of reconstruction. The authors' preferred method and technical pearls for execution are presented.