Search

There is a significant need for basic surgical care worldwide. In recent years, modest improvement in fulfilling this demand has been achieved through international medical mission trips from various organizations. These humanitarian endeavors and global health experiences have generated increasing interest in participating in international missions from surgical residents. However, many academic institutions currently do not have the infrastructure or desire to support surgical residents participating in medical missions. This paper aims to illustrate that careful, planned integration of medical mission trips into the residency curriculum will develop and enhance resident education and experience by fulfilling all six Accreditation Council for Graduate Medical Education (ACGME) core competencies and by benefitting the native program.

Orbital fractures are common, accounting for nearly 40% of all facial fractures. Open repair is required to restore preinjury orbital volume and relieve any extra-ocular muscle entrapment. Monitoring for postoperative intraorbital hemorrhage, and its consequent potential for visual impairment, has triggered most surgeons to observe their patients in the hospital overnight postoperatively. The real risk of postoperative hemorrhage in this patient group, however, is uncertain and the need to contain healthcare costs clear. The objective of this study was thus to determine the incidence of emergent postoperative complications in patients undergoing orbital fracture repair to determine the feasibility of performing this operation on an outpatient basis. Patients who sustained isolated orbital fractures and underwent open repair at this level-1 trauma center between January 2002 and January 2012 using International Classification of Disease-9 and Current Procedural Terminology 2012 coding were identified. Demographic data and postoperative complications were identified by reviewing the electronic medical record. Furthermore, critical analysis of available published evidence was performed. Ninety-three patients who satisfied the inclusion criteria were selected. There were no patients of an intraorbital hematoma or other immediate postoperative complications that required operative intervention. Average hospital length of stay was 0.85 days. Repair of orbital fractures on an outpatient basis appears to be safe. The theoretical risk of a complicating intraorbital hematoma seems to be between 0 and 3.2%. This can be minimized through: the use of open surgical access site and perforated floor replacement materials, careful early monitoring, education of patients, and admission of those at potentially elevated risk.

BACKGROUND: Prompt identification of significant ocular injuries in patients who sustain an orbital fracture is important to prevent any potential long-term visual sequelae. The true incidence of these injuries has not been determined, however. As a consequence, most surgeons choose to have all patients evaluated by an ophthalmologist. The objective of this study was to conclusively identify the incidence of significant ocular injuries in patients with isolated orbital fractures and to determine their predictors to guide more efficient patient care. METHODS: A prospective cohort study powered to detect a 15% incidence of ocular injuries was designed. All patients presenting to our center with computed tomography findings of an isolated orbital fracture were included and evaluated by plastic surgery and ophthalmology services. Patients were followed up for a minimum of 1 week to identify any delayed injuries. RESULTS: Eighty patients were enrolled from 2012 to 2014. There were 46 men and 34 women with a mean age of 42.8 years. Assault was the most common mechanism of injury. There were 8 ocular injuries (10%): ruptured globe (1), uveal prolapse (1), retrobulbar hemorrhage (2), hyphema (2), hemorrhagic glaucoma with hyphema (1), and scleral tear (1). Predictors for significant ocular injuries were grossly abnormal visual acuity and abnormal pupillary reactivity of the affected eye. CONCLUSIONS: The incidence of significant ocular injuries in isolated orbital fractures is lower than previously reported. Patients presenting with grossly abnormal visual acuity or abnormal pupillary reactivity are at high risk and should receive prompt ophthalmology service evaluation. Language: en

LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Perform a preoperative assessment of patients undergoing perineal and lower extremity reconstruction. 2. Describe the various tissue flaps used to perform these reconstructions and the advantages and disadvantages of each. 3. Provide appropriate postoperative care and interventions to maximize outcomes. BACKGROUND The lower extremity and perineum provide the foundation for upright posture and ambulation. These areas are made up of intricate contours with variable skin types and must withstand the functional demands of organ orifice support and weight-bearing forces. Successful reconstruction calls for careful preoperative planning and consideration of the site-specific demands. METHODS The authors reviewed literature regarding the most current treatment strategies for lower extremity and perineal reconstruction. RESULTS Perineal reconstruction is typically related to genitourinary or digestive tract abnormalities, mainly malignancies. Local and regional flaps are the mainstay of therapy, depending on their availability and the need for adjuvant therapy. Postoperatively, pressure reduction and closed-suction drainage are of major consideration. The lower extremities are prone to trauma, and these wounds often involve underlying and exposed bony abnormalities, and this must be considered in operative planning. Significant defects may be reconstructed with local or regional flaps and free-tissue transfer. The location of the wound and extent of surrounding tissue compromise are of major concern when determining flap coverage. Postoperatively, transition to ambulation and weight-bearing status is paramount. CONCLUSIONS Reconstruction of the lower extremity and perineum requires recognition of the high functional demands of these areas. Local and regional flaps and free tissue transfer allow reconstruction of complex wounds in these areas. Selecting the correct flap and navigating the postoperative recovery to arrive at functional restoration remain a significant challenge.

O RIGINAL A RTICLE The Present Status of Global Mission Trips in Plastic Surgery Residency Programs Trung Ho, MD, Mike Bentz, MD, y Mark Brzezienski, MS, MD, z Amanda Gosman, MD, § John Ingraham, MD, jj Michael S. Wong, MD, FACS, o and Charles Verheyden, MD, PhD Objective: The present status of global mission trips of all of the academic Plastic Surgery programs was surveyed. We aimed to provide information and guidelines for other interested programs on creating a global health elective in compliance with American Board of Plastic Surgery (ABPS) and Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME/RRC) requirements. Design: A free-response survey was sent to all of the Plastic Surgery Residency program directors inquiring about their present policy on international mission trips for residents and faculty. Questions included time spent in mission, cases performed, sponsoring organizations, and whether cases are being counted in their resident Plastic Surgery Operative Logs (PSOL). Results: Thirty-one programs responded, with 23 programs presently sponsoring international mission trips. Thirteen programs support residents going on nonprogram-sponsored trips where the majority of these programs partner with outside organizations. Many programs do not count cases performed on mission trips as part of ACGME index case requirement. Application templates for international rotations to comply with ABPS and ACGME/RRC requirements were created to facilitate the participation of interested programs. Conclusions: Many Plastic Surgery Residency programs are sponsoring international mission trips for their residents; however, there is a lack of uniformity and administrative support in pursuing these humanitarian efforts. The creation of a dynamic centralized database will help interested programs and residents seek out the global health experience they desire and ensure standardization of the educational experience they obtain during these trips. From the Division of Plastic Surgery, Baylor Scott & White Health, TX; y Division of Plastic and Reconstructive Surgery, University of Wiscon- sin School of Medicine and Public Health, Madison, WI; z Department of Plastic Surgery, University of Tennessee College of Medicine, Chatta- nooga, TN; §Director of Pediatric Plastic Surgery, University of Cali- fornia, San Diego, CA; jj Penn State Hershey, PA; and o Division of Plastic Surgery, University of California Davis School of Medicine, CA. Received December 19, 2014. Accepted for publication January 30, 2015. Address correspondence and reprint requests to Charles Verheyden, MD, PhD, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508. E-mail: cverheyden@sw.org Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofacial surgery.com). There are no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001697 Key Words: Global health, missions, plastic surgery residency (J Craniofac Surg 2015;26: 1088–1090) T he prevalence of surgical mission trips is increasing in both private and academic settings. 1 This has provided many medical and surgical residents exposure to different healthcare environments and hands-on experience in providing humanitarian care to an underprivileged population. The value of mission trips has recently been surveyed by Simmons et al 2 suggesting increased educational benefit for residents and better outcomes and quality of care for patients; however, the educational experience from all of the medical mission trips is not the same. The availability of mission trips at many institutions is presently limited by already-existing infrastructure, with little thought given to venturing outside traditional sites that have been established for many years in the past. This complacency can affect the available training opportu- nities provided to residents. Martiniuk et al 3 concluded in a literature review: ‘‘There is significant scope for improvement in mission planning, monitoring and evaluation as well as global and/ or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training in such areas as cross-communication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy and harmonization with existing government programming and transparency are needed.’’ As interest in international mission trips increases in plastic surgery, there is an increasing need for an up-to-date and more centralized coordination of efforts to assist interested residents and programs in finding resources and support necessary to pursue their humanitarian and educational goals. Tasked with the objective to improve mission planning among all of the Plastic Surgery pro- grams, the American Council of Academic Plastic Surgeons (ACAPS) Global Health Committee administered an online survey to all of the Plastic Surgery Residency programs inquiring about their present policies on international rotations and mission trips. This will establish a starting point in creating a dynamic database in which Plastic Surgery programs and sponsoring organ- izations can provide updates and necessary information for future mission trips. METHODS A 10-question free-response survey was sent to all of the Plastic Surgery Residency program directors inquiring about their present policy on international mission surgery trips for residents and faculty, summarized in Table 1. International rotation documents for Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME/RRC) and ABPS from Plastic Surgery programs with established international rotation electives were examined and The Journal of Craniofacial Surgery Volume 26, Number 4, June 2015 Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Congenital thenar hypoplasia is a rare anomaly, and even more perplexing when it is isolated to a specific muscle with associated nerve and vascular anomalies. In the present article, the authors report a case involving a 14-year-old female with unilateral absence of the abductor pollicis brevis muscle, a bifid median nerve and persistent median artery presenting with wrist pain. Comprehensive assessment, including radiographic, electromyographic and magnetic resonance imaging studies, were used to evaluate and document this anomaly.

Scar contracture is believed to be caused by the cell contractility during the remodeling phase of wound healing. Cell contractility is mediated by non-muscle myosin II (NMMII) and actin, but the temporal-spatial expression profile of NMMII isoforms A and B (IIA and IIB) during the remodeling phase and the role of NMMII in scar fibroblast tissue remodeling are unknown. Human scar tissue immunostained for IIA and IIB showed that both isoforms were highly expressed in scar tissue throughout the remodeling phase of repair and expression levels returned to normal after the remodeling phase. Human scar tissue immunostained for β-, γ- and α-smooth muscle actin showed that all isoforms were consistently expressed throughout the remodeling phase of repair. The β- and γ-smooth muscle actin were widely expressed throughout the dermis, but α-smooth muscle actin was only locally expressed within the dermis. In vitro, fibroblasts explanted from scar tissue were shown to express more IIA than fibroblasts explanted from normal tissue and scar fibroblasts contracted collagen lattices to a greater extent than normal fibroblasts. Blebbistatin was used to demonstrate the function of NMMII in collagen lattice contraction. In normal tissue, fibroblasts are stress-shielded from external tensile stress by the extracellular matrix. After dermal injury and during remodeling, fibroblasts are exposed to a matrix of increased stiffness. The effect of matrix stiffness on IIA and IIB expression was examined. IIA expression was greater in fibroblasts cultured in collagen lattices with increasing stiffness, and in fibroblasts cultured on glass slides compared with polyacrylamide gels with stiffness of 1 kPa. In conclusion, NMMII and actin isoform expression changes coordinately with the remodeling phase of repair, and NMMII is increased as matrix stiffness increases. As NMMII expression increases, so does the fibroblast contractility.