Background: The COVID-19 global pandemic has impacted plastic surgery training in the United States, requiring unprecedented measures to prepare for potential surges in critically ill patients. This study investigates how plastic surgery programs responded to this crisis, as well as how successful these changes were, through a survey of program directors and of residents at academic training programs in the United States. Methods: Two separate anonymous online surveys were conducted via REDCap between April 16 and June 4, 2020. The first survey was distributed to program directors, and the second was distributed to plastic surgery residents. Resident responses were then subdivided for an analysis between geographic regions. Results: Of the 59 program director responses (43.7%), the majority of programs implemented a platoon approach for resident coverage. A minority did the same for attending coverage. In total, 92% transitioned to virtual didactics only. Plastic surgery residents covered alternative services at 25% of responding institutions, and an additional 68% had a plan in place for responding to personnel shortages. Overall, residents were satisfied with their program’s response in a variety of categories. When subdivided based on geographic region, respondents in the Northeast and Northwest were less satisfied with resident wellness, personal and loved ones’ safety, and program communication. Conclusions: With the possibility of a “second wave,” successful methods of academic programs adapting to the pandemic should be communicated to reduce the future impact. Increased frequency of communications between program directors and residents can improve mental health and wellness of the resident population.
Following periarterial sympathectomy, patients with recurrent digital ischemia due to vasospastic or vaso-occlusive disease have few remaining treatment options. We performed a retrospective review from 1997 to 2019 to determine the safety and efficacy of revision periarterial sympathectomy. Eleven patients were identified who underwent revision periarterial sympathectomy, performed on average 84 months after their initial procedure. Preoperatively, all patients had worsening ischemic pain and five had non-healing digital ulcers. Revision digital periarterial sympathectomy alone was performed in seven patients, while four had a more extensive sympathectomy. Mean follow-up after revision was 23 months (range 3 to 76). Eight patients had symptomatic improvement and four healed their digital ulcers. Three patients developed new ulcers during follow-up, of which two healed with conservative management and one required three digital amputations. Revision periarterial sympathectomy is effective in providing symptomatic improvement and digital ulcer healing with minimal postoperative complications. Level of evidence: IV
Introduction The impact of fat grafting on the viscoelasticity of irradiated tissues is poorly defined. We investigate the effect of subcutaneous fat grafting on postmastectomy tissue expansion in patients undergoing delayed breast reconstruction. We quantify observed viscoelastic and trophic changes of the skin envelope. We hypothesize that fat grafting changes the trophic and viscoelastic properties of the breast soft tissue envelope. Methods Postmastectomy defects delayed more than 2 years and reconstructed with subpectoral tissue expanders were prospectively studied. Control (no irradiation, no fat grafting, n = 7), fat grafted (no irradiation, fat grafting n = 8), and irradiated plus fat grafting (irradiation, fat grafting, n = 9) groups were included. Hydrostatic pressures of the tissue expanders were measured before and immediately after expansion, and again postexpansion day 1. Pressure changes calculated as “postexpansion-relaxation interval”: difference between maximal pressure at each expansion and the minimal pressure before the next expansion session. Differences were analyzed between groups. Results Hydrostatic pressure plots reflect the soft tissue ability to accommodate sequential expansion. Fat grafted breasts demonstrated a statistically significant increased postexpansion-relaxation interval versus the nongrafted control group (P < 0.0001). Irradiated plus fat grafting breasts achieve similar postexpansion relaxation interval to the control group (P = 0.597). These changes are observed at postoperative week 6. Viscoelastic changes impact the overall expansion time: the fat grafted group achieved total expansion 2 weeks earlier than the nongrafted control group (P = 0.019). The fat grafted, radiated group completed expansion in similar time interval as nongrafted control group. Conclusions Observed viscoelastic changes impact the overall expansion time. Fat grafting in nonradiated mastectomy defects allows for shorter expansion period. Fat grating in radiated postmastectomy defects allows expansion durations equivalent to nonradiated, nonfat grafted control defects. There is a delayed effect of fat grafting observed at postoperative week 6.
We present the case of a 48-year-old male who developed tissue necrosis and subsequent necrotizing fasciitis in his right upper extremity after sustaining a puncture injury from a large black locust tree (Robinia pseudoacacia) splinter. Blood and intraoperative wound cultures revealed Streptococcus constellatus and Eikenella corrodens infection. The treatment consisted of IV antibiotics, fasciotomy, and multiple debridements, which left a 30 x 5-cm defect, requiring negative pressure wound therapy with Integra Dermal Regeneration Template (Integra Lifesciences, Plainsboro Township, NJ) and, ultimately, split-thickness skin grafts. Although uncommon, plastic surgeons should be aware of tissue necrosis associated with robin toxalbumin in cases of black locust tree puncture wounds. Robin toxalbumin causes cellular death by inhibiting protein synthesis. In this patient, the toxalbumin from the black locust tree fragment led to extensive tissue necrosis, serving as the nidus for necrotizing fasciitis.
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