Abstract: Objectives: Within the United States, plastic surgery is a difficult field to match into for both US and international medical graduates. While the number of available residency positions has grown in recent years, this has not been mirrored by an equal increase in the number of international medical graduates who match. Furthermore, there are few reliable resources to guide international medical graduates who are interested in matching into US-based programs, so the process is often even more difficult and unpredictable than for US applicants. Methods: An anonymous survey was distributed electronically to international medical graduates who successfully matched into independent and integrated US plastic surgery residency programs. The survey assessed qualities such as medical school performance, test scores, research experience, and other relevant applicant information, and χ2 analysis was done to compare the survey results for integrated and independent track international medical graduates. Results: International medical graduates who successfully match tend to rank high and score well in their medical school classes, score between 230 and 250 on USMLE step 1 and 2CK tests, and have a mean of 2 years of research experience before applying to the match. International medical graduates in the independent track tend to have higher step 1 scores, whereas international medical graduates in the integrated track tend to have more research experience and additional nonmedical degrees. Conclusions: This is a survey-based overview that describes the characteristics of successfully matched international medical graduates. Limitations of this study include the inability to identify and survey the unsuccessful applicants as well as poor response rate of the successful candidates in the independent pathway who successfully matched.

Abstract: Objective: Microsurgical education is an integral aspect of plastic surgery training. Like most traditional surgical education models, microsurgical skills are taught on an apprenticeship model. This study aims at evaluating microsurgery skill acquisition within an integrated plastic surgery residency using electromagnetic hand-motion analysis and a global rating scale. Methods: This is a cross-sectional study of an integrated plastic surgery residency program. Participants performed microsurgical arterial anastomoses on cryopreserved rat aortas. Hand-motion analysis was recorded using a trakSTAR hand-motion tracker. Total time to complete the task, number of hand movements, and path length (mm) were recorded. Participant videos were graded using a subjective global rating scale (scored 0-100). Results: The data demonstrated construct validity, as hand-motion analysis outcome measures statistically varied according to the level of skill. Mean global rating scale scores increased with level of experience but lacked statistical significance. Conclusions: These data suggest that the objective assessment of hand motion is a valid tool for the evaluation of microsurgical skill. It is more accurate and reflective of the level of skill than a global rating scale. Identifying the predictive validity of hand-motion analysis will be a useful tool to establish clinical safe training and practice thresholds, and the application of both assessment tools simultaneously can yield better evaluation.

Abstract: Objective: Infantile digital fibromatosis is a rare benign childhood tumor, infrequently cited in the literature. Hallmarks include nodular growths exclusive to fingers and toes and the presence of eosinophilic cytoplasmic inclusions on histology. This article aims to exemplify diagnoses of infantile digital fibromatosis and possible treatment options. Methods: A computerized English literature search was performed in the PubMed/MEDLINE database using MeSH headings "infantile," "juvenile," "digital," and "fibromatosis." Twenty electronic publications were selected and their clinical and histological data recorded and used to compile a treatment algorithm. Results: A 9-month-old male child was referred for a persistent, symptomatic nodule on the third left toe. A direct excision with Brunner-type incisions was performed under general anesthesia. The procedure was successful without complications. The patient has no recurrence at 2 years postsurgery and continues to be followed. Histological examination revealed a proliferation of bland, uniformly plump spindle cells with elongated nuclei and small central nucleoli without paranuclear inclusions consistent with fibromatosis. Conclusions: Asymptomatic nodules should be observed for spontaneous regression or treated with nonsurgical techniques such as chemotherapeutic or steroid injection. Surgical removal should be reserved for cases with structural or functional compromise.

Abstract: Objective: Observational studies are essential for ensuring patient safety, decreasing complications, and developing better surgical techniques and implants. The primary objective of this study is to demonstrate the safety and efficacy of Sebbin breast implants in both augmentation and reconstruction cohorts. Methods: This prospective, multicenter, observational 10-year study conducted in France included 205 patients (385 implants) who underwent breast augmentation (n = 166) or reconstruction (n = 39) with Sebbin round silicone gel implants. Data on patient demographics, surgical details, and complications were collected. Results: Median patient age was 39 years; 20.5% of patients were smokers. The augmentation cohort included 166 patients (81.0%); the reconstruction cohort, 39 patients (19.0%). Median implant volume was 280 ml; 91.2% of implants were textured, and 8.8% were smooth. Average patient follow-up was 63 months. The most frequent surgical approach in the Augmentation Cohort was periareolar (72.4%), with 45.5% submuscular and 51.5% subglandular placements. All patients received antibiotic prophylaxis, and postoperative antibiotic therapy was given to 39.5% of patients (average 4.8 days). Drainage was performed in 59.5% of patients (average 2.9 days). Of the reconstruction cohort, 64.1% had preoperative radiotherapy. Nine patients had Baker III/IV capsular contracture (3 bilateral; 4 had a history of radiotherapy) and 7 patients had implant rupture; 41 patients underwent explantation. No cases of double capsule, late seroma, or anaplastic large cell lymphoma occurred. Conclusions: This study found an excellent safety profile and very low capsular contracture rate with breast augmentation and reconstruction using Sebbin round silicone gel implants.

Abstract: Introduction: Leaving the abdominal cavity open is a well-described and frequently utilized technique in the treatment of severe intra-abdominal sepsis. Irrigation through a negative pressure wound therapy device is a technique employed to assist in the closure of wounds as well as the reduction of bacterial contamination. Furthermore, hypochlorous acid has been found to be safe and effective in microorganismal elimination from extremity wounds. There is no literature regarding the infusion of hypochlorous solution into the abdominal cavity for intra-abdominal sepsis or mucopurulent abscesses or biofilm. Objectives: A 47-year-old man with granulomatosis polyangiitis was started on weekly rituximab. After 4 infusions, skin sloughing, ultimately diagnosed as toxic epidermal necrolysis, developed. During the hospital course, he developed sepsis and bowel perforation necessitating an exploratory laparotomy. The abdomen was left open with a temporary abdominal closure using the Abthera open abdomen negative wound therapy device; however, the abdomen remained infected with visually diffuse, thickening mucopurulence despite multiple washouts. Therefore, a VAC Vera-Flo irrigation device was combined with the Abthera open abdomen negative wound therapy device and cyclical irrigation of hypochlorous acid. After 72 hours, the purulence visually was improved and no adverse events were recorded with the placement of intra-abdominal hypochlorous acid. Conclusions: The combination of two medical devices for the intra-abdominal instillation of irrigation is considered "off-label use" from the manufacturer's recommendations. In addition, the repeated instillation of hypochlorous acid solution has not been described but was noted to have visually decreased the contaminated effluent within the intra-abdominal fluid.

Abstract: Purpose: Gunshot injuries to the face that result in fractures of the underlying skeleton present a challenge in management. The goal of this study was to evaluate patterns of facial fractures as a result of gunshot injuries and strategies for management. Methods: A retrospective review of facial fractures resulting from gunshot injuries in a level 1 trauma center was performed for the years 2000 to 2012. Data were collected for patient demographics, fracture distribution, concomitant injuries, and surgical management strategies. Results: A total of 190 patients sustained facial fractures from a gunshot injury. The average age was 29.9 years, and 90% were male. Sixteen injuries were self-inflicted. The most common fractures were of the mandible and the orbit. Uncontrolled hemorrhage was noted on presentation in 68 patients; 100 patients were intubated on arrival. The average Glasgow Coma Scale score on arrival was 11.9. Concomitant injuries included skull fracture, intracranial hemorrhage, and intrathoracic injury. Surgical management was required in 89 patients. Nine patients required soft-tissue coverage. Thirty patients expired. Conclusion: Gunshot injuries to the face resulting in fractures of the underlying skeleton have high instances of morbidity and mortality. Life-threatening concomitant injuries can complicate management of facial fractures in this population.

Abstract: Objective: This study evaluated the self-timed trial training for laparoscopic suturing. Methods: The set task involved grasping the suture, aligning the needle with a needle holder, passing the suture, making 3 knots, holding the 2 tails of the suture with one grasper, and cutting them. Trainees were given an instruction for suturing and reducing their suturing time. The same instruction was given 3 months later. Suturing times for the first and second trials and the last trial after the second instruction of the 9 trainees were measured. Results: Their mean suturing times were statistically significantly shorter after instruction (before instruction: 276.7 ± 43.4 seconds, after instruction: 177.4 ± 46.1 seconds; P = .0035). Four trainees were trained twice during the second instruction. Their suturing times were shorter than those of the other trainees, and the standard deviation decreased (120.5 ± 21.2 seconds, P = .017). Conclusion: A self-timed trial training for laparoscopic suturing using a dry box makes training interesting and motivates trainees.

Abstract: Introduction: Facial giant congenital melanocytic nevus represents a major cosmetic deformity for the child and parents and is a challenge for the plastic surgeons to achieve best cosmetic results. Herein, we present a case of single-stage surgical reconstruction using partial-thickness scalp skin graft aided with Matriderm dermal substitute for a facial giant congenital melanocytic nevus. Methods: An 8-year-old boy presented with a facial giant congenital melanocytic nevus without leptomeningeal involvement. A single-stage complete excision of the nevus was performed. A split-thickness skin graft, 12/1000-inch thick, was then harvested from the anterior scalp region for reconstruction. A 1-mm Matriderm dermal substitute was first applied, on which functional subunit skin graft was then secured to cover the defect. Eyelid reconstruction was reconstructed separately using full-thickness postauricular skin grafts. Results: Histopathology of the excised specimen confirmed the diagnosis of congenital melanocytic nevus, with no evidence of melanoma. The donor area healed with a favorable scar and no donor site morbidity or complications such as alopecia or hypertrophic scar. The postoperative result was satisfactory with minimal residual nevus around the eye, and the patient was fully satisfied with the cosmetic and functional results. Discussion and Conclusions: Resection of facial congenital melanocytic nevi, followed by single-stage reconstruction using Matriderm and skin graft from the scalp, is an excellent and fast reconstructive method with promising aesthetic outcomes and greater improvement in physiological outcome, especially in the pediatric population.

Abstract: Objective: Subdermal contraceptive implants are a well-established method of contraception. Aside from common side effects such as irregular menstrual periods, headaches, and weight gain, rarer complications related to their insertion and removal have been reported. These include traumatic peripheral neuropathy after procedures to remove nonpalpable implants. Only 2 cases of ulnar neuropathy after insertion of a contraceptive implant have been described in the literature, one which resolved spontaneously and another in which postoperative recovery was not described. We report a case of acute ulnar nerve neuropathy in a patient postinsertion of a contraceptive implant who achieved symptom resolution after prompt referral and treatment at a specialist plastic surgery center. Methods: A 22-year-old, right-hand-dominant woman presented 1 day postinsertion of a contraceptive implant (Implanon) in her left arm with paresthesia along the ulnar distribution of her hand and forearm, as well as shooting pain on palpating the course of the ulnar nerve. Ultrasonography found the implant to be lying in the subfascial plane of the inner arm. Results: The implant was found lying in the perineurium of the ulnar nerve, causing ulnar nerve neuropathy. A review 3 months after removal of the implant showed near-complete resolution of her symptoms. Conclusions: Complications related to implantable contraceptives may lead to significant morbidity. Appropriate training for health care professionals administering the devices is essential, as well as early referral to a specialist center to prevent permanent damage.

Abstract: Brooke-Spiegler syndrome is a condition involving multiple skin tumors that develop from structures associated with the skin (skin appendages), such as sweat glands and hair follicles. People with Brooke-Spiegler syndrome may develop several types of tumors, including growths called spiradenomas, trichoepitheliomas, and cylindromas. Spiradenomas develop in sweat glands. Trichoepitheliomas arise from hair follicles. The origin of cylindromas has been unclear; while previously thought to derive from sweat glands, they are now generally believed to begin in hair follicles. The tumors associated with Brooke-Spiegler syndrome are generally noncancerous (benign), but occasionally they may become cancerous (malignant). Affected individuals are also at increased risk of developing tumors in tissues other than skin appendages, particularly benign or malignant tumors of the salivary glands.

Abstract: Objective: This paper discusses the various surgical techniques and outcomes associated with management of buried penis syndrome. Methods: Presented is the case of a 49-year-old man with morbid obesity, leading to massive panniculus and buried penis. We review our technique for reconstruction of the buried penis and treatment of the overlying large panniculus. Literature search was conducted to review current techniques in correcting buried penis syndrome. Results: The patient underwent a successful panniculectomy with removal of all excess skin and tissue. Thoughtful planning and coordination between plastic surgery and urology were paramount to externalize the penis for an excellent functional and cosmetic result. Conclusions: Management of a buried, hidden penis is complex and difficult. Patients are often obese and have poor hygiene due to the inability to cleanse areas that are entrapped by excessive fat. Following removal of the overhanging panniculus, satisfactory reconstruction of a hidden penis is possible when proper care is taken to adhere the base of the penis to the pubis. Split-thickness skin grafts are often necessary but depend on the viability of the penile skin and whether it is restricting penile length. Complications with wound dehiscence and infection are not uncommon; however, patients generally recover well, are satisfied with results, and are reported to have fully regained urinary and sexual functions following surgical correction of the buried penis.

Abstract: Background: Minimally invasive cosmetic procedures are the most commonly performed aesthetic techniques by plastic surgeons. Patients are interested in a pain-free experience. Surgeons desire patient satisfaction and time-efficient utilization of office staff and resources. Clinical evidence exists for use of vapocoolant technology to reduce pain associated with intravenous cannulation in the pediatric population and in hemodialysis patients. Applying vapocoolant technology to facial rejuvenation is a novel approach to decrease pain associated with neurotoxin or filler injection. Methods: A randomized, prospective study was conducted, testing 15 subjects receiving filler injections and another 15 patients receiving neurotoxin injections using a split-face model. The vapocoolant spray used was composed of a 95:5 ratio of 1,1,1,3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane. Within each group, individual patients randomly received injection (filler or neurotoxin) alone versus injection (filler or neurotoxin) plus vapocoolant on an equivalent half of his or her face. An independent examiner recorded from each patient on a scale of 1 to 10 perceived pain for injection alone versus injection plus vapocoolant spray. Results were calculated as a percentage change of pain scores experienced after injection for each person between the control (nonvapocoolant) and treatment (vapocoolant) sides of the face. Results: Vapocoolant spray at the time of cosmetic facial injections leads to a 59% decrease in perceived pain score with neurotoxin injections (range, 0%-100% change) and 64% decrease in perceived pain score with filler injections (range, 0%-100% change). These results were statistically significant with P < .05. Conclusion: Vapocoolant spray reduces pain associated with facial rejuvenation procedures.

Abstract: As illustrated by this case, cutaneous PG of the hand is a diagnosis of exclusion. Though rare, an index of suspicion should be maintained as PG can present similarly to other conditions in the hand such as fulminating infection and malignancy, that would traditionally be managed surgically. Inappropriate surgical debridement of PG in the hand can, however, lead to persistent and worsening ulceration and poor outcomes, such as digital amputation, so should be avoided. Although international diagnostic criteria are yet to be established, prompt diagnosis is essential in avoiding significant clinical consequences.

Abstract: Introduction: The techniques used to fixate osteotomized segments of bone have evolved alongside the treatment of craniosynostosis. The use of nonresorbable metal plates and screws offered a method of rigidly stabilizing repositioned segments of bone. Several reports specify the tendency for these fixation systems to "migrate" transcranially. Methods: We present a unique case of a patient who initially underwent treatment of multisuture craniosynostosis utilizing titanium miniplates at 6 months of age. At 16 years of age, the patient was returned to the operating room with complaints of pain and contour irregularities, and intracranial migration of the screws and plates was observed. Results: The hardware was extracted and the cranium reconstructed. Symptoms resolved and bony contour was improved. Conclusion: The craniofacial surgeon considering metal plate fixation in the pediatric population should be aware of the possibility for transcranial plate and screw migration.

Abstract: Introduction: New options are needed to improve wound healing while preventing excessive scar formation. Temporary primary dressings are important options in topical wound management that allow the natural healing process. Methods: We evaluated a novel primary dressing consisting of a biosynthetic, variable porosity, matrix-containing gelatin and Aloe Vera extract and a derivative dressing coated with the anti-scarring agent salinomycin for their ability to promote cell growth, reduce myofibroblast formation, and regulate cytokine production. In addition, salinomycin-coated primary dressings were tested for antimicrobial activity. Results: Both primary wound dressings permitted cell growth and attenuated TGFβ-induced scar-forming myofibroblast formation. The primary wound dressings also reduced IL-6 production by 50%, IL-8 by 20%, MCP-1 by 75%, and GRO by 60% in human mesenchymal stem cells treated with TGFβ. Salinomycin coating of the dressing showed antimicrobial activity by preventing Staphylococcus aureus growth. Conclusions: Both primary wound dressings support the growth of human fibroblasts and stem cells, as well as reduce inflammatory cytokine production, demonstrating their potential to serve as temporary wound dressings.

Abstract: Objective: Mesenchymal in origin, solitary fibrous tumors are primarily seen within the pleura of the lung or in serosal-lined body cavities. Constituting 1% to 2% of all soft-tissue tumors, solitary fibrous tumors are rare entities, especially when found in extrapleural and in superficial locations. A review of PubMed MEDLINE literature for superficial solitary fibrous tumors revealed 71 reports in case reports and small case series. Methods: In this report, we describe a 74-year-old man with an extrapleural superficial solitary fibrous tumor, as well as present a review of the current published literature to date. Results: We present the clinical course, surgical procedure, histopathological features, and treatment options, as well as present a compilation of the published data on superficial solitary fibrous tumors. Conclusions: Based on the current literature, solitary fibrous tumors are more common in middle-aged women and in the head and neck region. Diagnosis of solitary fibrous tumors requires tissue sampling and staining for immunohistochemical markers. Management of these tumors is based on wide local excision with histologically negative margins. If negative margins cannot be surgically achieved, adjuvant therapies including radiation have been described. With extrapleural manifestations of solitary fibrous tumors seldom reported in the literature, it is our hope that reporting these unusual instances will raise awareness of such disease manifestations and allow for earlier diagnosis and treatment.

Abstract: Objective: Immediate flap reconstruction following mastectomy in patients who may require adjuvant radiation therapy can be controversial. However, exposure of vital structure or defects too large for primary closure may necessitate immediate utilization of flaps. In this setting, both functional and cosmetic outcomes must be considered. Methods: We describe a case in which the patient required a wide excision of the axillary skin and a partial mastectomy, with a resulting large axillary and lateral breast skin defect. The ipsilateral pedicled parascapular flap was used for immediate reconstruction, with primary donor site closure. Results: Seven years postoperatively, she remained disease free, contracture free, with near-normal shoulder range of motion, and good cosmesis. Conclusions: Our case supports prior studies that have demonstrated the parascapular flap to have low donor site morbidity compared with other harvest sites. Our patient did not suffer from loss of functional range of motion or limitation in physical activity. It also demonstrates the flap's utility for lateral breast and axillary coverage and its durability in the setting of adjuvant radiation therapy.

Abstract: Objective: When hands suffer burns, the tendons and digital bones are rarely injured because of the quick withdrawal reflex away from the heat source. Hence, a consensus of opinion regarding the treatment of severe hand burns with osseous blood flow deficiency has not been reached among clinicians. Methods: The patient was a 28-year-old woman whose fingers were accidentally soaked in heated cooking oil (160°C-170°C) for approximately 1 minute. The result was fourth-degree (extending to the tendon) digital burns of the distal end of the proximal interphalangeal joint with blood flow deficiency to the skin, tendon, and bone. Results: We performed immediate reconstructive surgery using an abdominal bipediceled flap. Two weeks later, after the flap was separated, all fingers showed complete range of motion, restoration of the metacarpophalangeal joint, and a high range (0°-75°) of proximal interphalangeal joint mobility with an acceptable digital length. Conclusions: Our experience shows that immediate surgery is highly preferable for deep burns of the hand to avoid delayed intractable complications and to achieve better and faster results.

Abstract: Objective: There are many approaches to nipple-areola complex reconstruction. Tissue quality and thickness, desired nipple location and size, scar position, and surgeon preference all play a role in selecting a technique. We present the rectangle-to-cube nipple flap, a new technique for challenging nipple reconstruction. A review of published techniques is compared and contrasted with this flap design. Methods: Following bilateral total skin-sparing mastectomies, a patient with breast cancer underwent breast reconstruction with tissue expanders and subsequent nipple reconstruction with the rectangle-to-cube nipple flap. An inferiorly based rectangular flap with medial and lateral extensions is designed inferior to the transverse scar. Upon elevation and rotation, the medial and lateral flaps form a cube. Results: In all cases of rectangle-to-cube nipple flaps performed at our institution, adequate nipple projection and patient satisfaction have been achieved at 2-month postoperative evaluation. Conclusion: The rectangle-to-cube nipple flap provides sustained nipple projection due to the de-epithelialized base on which the flap sits. The rectangle-to-cube nipple flap also takes advantage of a long transverse scar, and it can be extended to include longer scars for scar revisions.

Abstract: Sherise Epstein, MPH,a Christopher M. Reid, MD,a Fernando Herrera, MD,b Reid A. Abrams, MD,c and Ahmed S. Suliman, MDa,d aDivision of Plastic Surgery, Department of Surgery, UC San Diego Medical Center, San Diego, Calif; bDivision of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston; cDepartment of Orthopedic Surgery, UC San Diego Medical Center, San Diego, Calif; and dSection of Plastic & Reconstructive Surgery, VA San Diego Healthcare System, San Diego, Calif

Abstract: Objective: The descending genicular artery provides the dominant pedicle for the medial femoral condyle and medial femoral trochlear free flaps. Variations of the flap include using a skin paddle for monitoring, a vastus medialis muscle component, and the medial superior geniculate artery for the pedicle. We present a case of a 49-year-old man with a distal tibial fracture from a motor vehicle accident complicated by chronic osteomyelitis, poor soft tissue envelope, and tibial nonunion. Methods: The composite lower extremity defect was reconstructed with a chimeric myo-osseous variant of the medial femoral condyle free flap since no perforator was available to the skin and there was a large amount of dead space. Results: At 9 months postoperatively, there was successful tibial union, adequate coverage of the defect, and a return to unassisted ambulation. Conclusions: The chimeric myo-osseous variant of the medial femoral condyle free flap adds to the versatility of this flap and has application in reconstructing defects of bone that also require soft tissue coverage.