Background Traditionally, verbal discussions, CT scans, and two-dimensional (2D) diagrams are used pre-operatively to help caregivers develop a better understanding of craniosynostosis. Given advancements in three-dimensional (3D) printing, this technology provides an improved way to visualize patient-specific skull anatomy. This study aims to assess the impact of 3D-printed skull models on caregiver understanding of craniosynostosis. Methods A randomized controlled trial was performed on caregivers of patients who came to our institution for craniosynostosis surgery. One week prior to the surgery, caregivers completed a survey that included anatomical labeling, true/false understanding, surgical fear, and patient-provider communication questions. Caregivers were randomly assigned to three groups: no model, generic skull model, and patient-specific skull model. On the day of surgery, all caregivers were provided a standardized 10-min educational session on craniosynostosis pathophysiology, skull suture anatomy, and basic surgical approach. Caregivers randomized to a model group were also given a 3D-printed model to interact with during the session. Subsequently, all caregivers repeated the same survey. Survey responses were compared using paired t-tests. Results Twenty-three caregivers completed the study: eight had no model, eight received a generic model, and seven received a patient-specific model. Caregivers who interacted with a 3D-printed model demonstrated significant improvement in their anatomical labeling scores ( P = 0.01). All caregivers showed improvement in their scores on the craniosynostosis knowledge true/false section. Conclusions Caregivers across all groups demonstrated improved understanding of craniosynostosis. Caregivers who received 3D-printed models achieved greater anatomical understanding, highlighting the benefits of 3D-printed models for craniosynostosis caregiver education.

Background: Craniosynostosis management involves various surgical options early in a patient's life. Nevertheless, few three-dimensional (3D) tools exist to help caregivers comprehend craniosynostosis anatomy and surgical options. This study aims to assess the efficacy of 3D animated videos for enhancing craniosynostosis education in caregivers. Methods: We created 3D animated videos describing anatomy and surgical options (eg, fronto-orbital advancement, posterior vault reconstruction) for three craniosynostosis diagnoses: bicoronal, metopic, and sagittal. In a cross-sectional survey, caregivers rated their understanding of craniosynostosis on 10-point Likert-scales, labelled anatomic sutures, and answered true/false general (eg, “The sutures have fused too early”) and diagnosis-specific (eg, “The distractors are not removed after surgery”) craniosynostosis knowledge questions. Respondents were then shown an animated video and asked the same set of questions after watching the video. Results: A total of 69 craniosynostosis caregivers (mean age 35 years, 73% Caucasian, 64% female) completed the survey. After watching the video, caregivers self-rated their understanding of craniosynostosis as significantly higher (mean score difference: 2.62, P < .01). Caregivers also scored significantly higher on the general and diagnosis-specific knowledge questions (mean score difference: 1.27, P < .01). Conclusions: Our findings indicate that our animated videos improved caregiver craniosynostosis understanding and knowledge. These findings may inform how surgeons approach future caregiver craniosynostosis education.

Background: Autologous breast reconstruction is a valuable option for many patients. But, various clinical factors, including cancer laterality, post-mastectomy radiation therapy (PMRT), and tissue expander (TE) plane placement, may cause variability in the quality of the recipient internal mammary arteries and veins (IMA/V). Notably, prepectoral TE placement is becoming more widely used for improved post-operative outcomes. However, the biomechanical benefit of staging prepectoral TE over traditional subpectoral TE is not well characterized. We aimed to clinically and histomorphometrically correlate the impact of TE location and other clinical factors on IMAs/IMVs. Methods: We conducted a prospective cohort study of 34 patients (63 breasts) across two institutions undergoing autologous flap reconstruction. These patients were placed in five groups: 1) prepectoral TE, non-irradiated, 2) prepectoral TE, irradiated, 3) subpectoral TE, non-irradiated, 4) subpectoral TE, irradiated, or 5) no TE, which served as the control group. Intraoperatively, 3-4 mm full-thickness segments of bilateral IMAs/IMVs were obtained. Vessel thickness was measured with Masson-Trichome stains and elastin/collagen ratios were measured with VVG stains. Results: We evaluated differences in vessels based on laterality to cancer side, radiation history, and TE plane placement. Demographic and intraoperative details were not significantly different between patients. Ipsilateral IMVs to the side of the cancer had a significantly higher elastin/collagen ratio compared to IMVs from the contralateral side of the cancer or from prophylactic mastectomy breasts (p=0.04). Radiation was associated with greater IMV thickness on both ipsi- and contra-lateral IMVs compared to patients whose breasts were not radiated (ipsilateral radiation: 101 µm, contralateral radiation: 113 µm, non-radiated: 71 µm, p=0.02). Compared to vessels from prepectoral TE or no TE breasts, IMAs and IMVs from subpectoral TE breasts had significantly higher intima thickness (subpectoral: 25 µm, prepectoral: 12 µm, no TE: 10 µm, p<0.05) and vein thickness (subpectoral: 113 µm, prepectoral: 72 µm, no TE: 82 µm, p=0.03). Conclusion: We identified that subpectoral TE placement before autologous breast reconstruction is associated with increased IMA/IMV wall thickness, suggestive of greater fibrosis and vessel remodeling. Choosing a prepectoral TE placement for staged reconstruction after mastectomy may avoid the clinical effects on recipient vessel morphology and reduce poor post-operative outcomes.

Background Medical students applying to residency, including those from underrepresented groups, strongly value cultural fit and program diversity. Program websites and social media are thus an influential information source for prospective applicants and recruitment tool for residencies. We evaluated whether and how integrated plastic surgery residency program websites and social media display commitments to diversity online. Methods We evaluated program websites for 8 predetermined diversity elements, (1) nondiscrimination and (2) diversity statements, (3) community resources, (4) faculty and (5) resident biographies, (6) faculty and (7) resident photographs, and (8) resident resources, and assessed Instagram accounts for diversity-related images, captions, and hashtags. Our analysis used Mann-Whitney U, chi-squared, and t tests; significance level was P < 0.05. Results We reviewed 82 program websites with a mean of 3.4 ± 1.4 diversity elements. Resident (n = 76, 92.7%) and faculty photographs (n = 65, 79.3%) and resident biographies (n = 43, 52.4%) were the most common. Seventy programs (85.4%) had Instagram accounts, the majority of which (n = 41, 58.6%) shared content related to diversity in race, ethnicity, gender, and/or sexual orientation. Programs located in smaller cities were more likely to have ≥4 website diversity elements (P = 0.014) and mention diversity on Instagram (P = 0.0037). Programs with women chairs/chiefs were more likely to mention diversity on Instagram (P = 0.007). Conclusions In the age of virtual recruitment, program websites and social media should provide sufficient information, described in our diversity element checklist, to help prospective applicants determine fit from a diversity perspective. Residents, who often contribute to program social media, and women chairs/chiefs may be critical to driving diversity promotion.

Background: Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes. Methods: An institutional review board–approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P ≤ 0.05 was considered statistically significant. Results: Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05). Conclusions: Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Background Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic. Methods We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic. Results Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81). Conclusion Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

Background Major shifts in health care systems worldwide have occurred because of coronavirus disease 2019 (COVID-19). With nearly half of all Americans now having a history of COVID-19 infection, there is a pressing need to better understand the importance of prior COVID-19 infection as a potential surgical risk factor. The aim of this study was to investigate the impact of a history of prior COVID-19 infection on patient outcomes after autologous breast reconstruction. Methods We performed a retrospective study using the TriNetX research database, which contains deidentified patient records from 58 participating international health care organizations. All patients who underwent autologous breast reconstruction between March 1, 2020, and April 9, 2022, were included and were grouped based on history of a prior COVID-19 infection. Demographic, preoperative risk factors, and 90-day postoperative complication data were compared. Data were analyzed by propensity score–matched analysis on TriNetX. Statistical analyses were performed by Fisher exact, χ 2 , and Mann-Whitney U tests as appropriate. Significance was set at P values of <0.05. Results Patients with a history of autologous breast reconstruction within our temporal study window (N = 3215) were divided into groups with (n = 281) and without (n = 3603) a prior COVID-19 diagnosis. Nonmatched patients with prior COVID-19 had increased rates of select 90-day postoperative complications, including wound dehiscence, contour deformities, thrombotic events, any surgical site complications, and any complications overall. Use of anticoagulant, antimicrobial, and opioid medications was also found to be higher in those with prior COVID-19. After performing propensity-score matching, each cohort consisted of 281 patients without statistically significant differences between any baseline characteristics. When comparing outcomes between matched cohorts, patients with a history of COVID-19 had increased rates of wound dehiscence (odds ratio [OR], 1.90; P = 0.030), thrombotic events (OR, 2.83; P = 0.0031), and any complications (OR, 1.52; P = 0.037). Conclusions Our results suggest that prior COVID-19 infection is a significant risk factor for adverse outcomes after autologous breast reconstruction. Patients with a history of COVID-19 have 183% higher odds of postoperative thromboembolic events, warranting careful patient selection and postoperative management.

Background Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs.Methods A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t -tests, Chi-square analysis, and multivariate logistic regression.Results Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p < 0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p < 0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p < 0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p < 0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p < 0.05), longer hospital stays (2.2 days longer, p < 0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p < 0.05).Conclusion Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

OBJECTIVE: The purpose of this study is to (1) gather US medical student attitudes regarding pass or fail score reporting of the USMLE Step 1 exam and (2) investigate the impact of this new policy on specialty interest and redistribution of efforts to enhance individual competitiveness. DESIGN: This is a cross-sectional analysis of US medical students surveyed from July to October 2020. Surveys were administered on social media and via medical school email list serv. Data were analyzed using Student t test and Chi-squared statistic, alpha = 0.01. SETTING: Data analysis was conducted at Johns Hopkins University in Baltimore, Maryland. PARTICIPANTS: This study included a sample of 852 students enrolled in US medical schools. RESULTS: The plurality of students (39.0%) was in favor of the new policy; 30.9% of students were opposed. Students interested in highly competitive specialties (HCS) and students who scored 240 or higher on Step 1 ("high scorers") were more likely to oppose the policy compared with HCS-disinterested students and students who scored below 240 ("sub-240 scorers"). If students were to hypothetically take Step 1 with pass or fail scoring, most students report that they would dedicate less time studying than they had for the numerical exam (72.7%) and more time preparing for Step 2 CK (70.5%) and conducting research in HCS (59.6%). Sub-240 scorers would be more likely to apply to a more competitive specialty (44.4%). Nearly half of HCS-interested post-Step 1 students would be more likely to dual apply (48.7%), the majority of which were also high scorers (89.5%). CONCLUSIONS: Students expressed polarized opinions regarding pass or fail Step 1 score reporting. Time spent studying for Step 1 may be displaced toward Step 2 CK and research. Residency programs in both HCS and nonHCS can expect an increase in applicant pool size and diversity. ( J Surg Ed 79:397-408. (c) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Traditional approaches to lower face contouring involve ostectomy of the mandibular angle or body. More recently, nonsurgical techniques have gained popularity, including neurotoxin injection to the masseter muscle. This study aims to evaluate layperson perceptions of patient attractiveness and personality traits following lower face contouring using either surgical or nonsurgical treatment. Methods: In this survey study distributed via Amazon's Mechanical Turk, respondents viewed a series of 14 patient images obtained in clinic before and after surgical or nonsurgical jawline slimming, or without any facial aesthetic procedure. Respondents rated changes in attractiveness and personality trait scores between the before and after image (score: -50 to 50, with 50 representing the greatest posttreatment increase and 0 representing no change). We used descriptive statistics and multivariable regression to determine differences in respondent ratings between patient images. Results: A total of 415 respondents (mean age 38 years, 50.6% female) successfully completed the survey. Compared to patients who underwent nonsurgical treatment, those who received surgery had significantly greater increases in perceived attractiveness (P < 0.001), femininity (P < 0.001), friendliness (P < 0.001), intelligence (P < 0.001), trustworthiness (P < 0.001), financial wealthiness (P < 0.001), dominance (P < 0.01), and self-esteem (P < 0.001). Gonial angles increased and jaw widths decreased following both surgical and nonsurgical intervention, with no statistically significant difference between treatment groups. Conclusions: From the layperson perspective, surgical compared to nonsurgical jawline contouring offers greater improvements in perceptions of attractiveness and favorable personality traits.

Purpose: Despite the interplay between orthodontics and orthognathic surgery, trainees in plastic surgery and oral and maxillofacial surgery do not receive formal training in orthodontics and associated hardware. This study aims to help surgical trainees better understand the role of orthodontic treatment in achieving enhanced dental occlusion and alignment and optimize surgical decision making. Methods: A review of recent literature was conducted to consolidate current practices for the use of orthodontic devices commonly used in orthognathic surgical patients. Results: Orthodontic treatments may be preventive, interceptive, and/or corrective. Braces and clear aligners are popular devices used to correct tooth positioning via 3 orders of control: first (“in-out” and rotation), second (mesio-distal angulation or “tip”), and third order (inclination or torque). Further, various treatments exist for skeletal and dental malocclusions, which may occur in transverse (crossbites, narrow arches) and/or sagittal (over/underbites) planes. Palatal expanders such as the Hyrax or Haas assist in correction of transverse deficiencies. Appliances for sagittal corrections typically take advantage of patient’s remaining growth and include a variety of headgear types (cervical, high-pull, occipital, reverse-pull), functional appliances (fixed or removable), or simply the use of interdental elastics. Conclusion: As patients are increasingly seeking orthodontic care in conjunction with surgery, it is important for surgical trainees to develop a strong understanding of the various orthodontic devices used.

BACKGROUND:Resident aesthetic clinics (RACs) provide plastic surgery residents with hands-on aesthetic surgery training. Although RACs have demonstrated successful surgical outcomes without compromising patient care, few studies have evaluated the efficacy or educational value of RACs to increase resident confidence and competence in procedures. In addition, clinic structures vary widely among institutions, with each clinic offering a unique patient volume, caseload, and degree of resident autonomy that impacts the clinic's educational value. This systematic review identifies existing RAC practices, compares clinic structures, and proposes a curriculum framework to maximize educational value for residents.METHODS:Following PRISMA guidelines, we performed a systematic review of plastic surgery residency training program RACs. We queried PubMed, Embase, and Web of Science from January 2000 to April 2020. Eligible articles were original articles that discussed RAC structure and educational value. Data abstracted included details on clinic structure (eg, volume, location, cost, clinic operations) and trainee-perceived educational value (eg, resident satisfaction, resident confidence in procedures).RESULTS:Of 1199 identified publications, 10 met the inclusion criteria: 6 single-site studies and 4 national survey studies. Among the single-site studies, annual volumes ranged from 22 to 68 patients/year and 35 to 81 cases/year. Resident aesthetic clinics were all staffed by full-time academic faculty (100%); one-third also were staffed by adjunct faculty and 17% also by community plastic surgeons. Resident involvement varied by hours in clinic and degree of autonomy. The survey studies found that RACs increase resident confidence and competence in performing aesthetic procedures and identified critical challenges to RAC implementation (eg, financial viability, continuity of care) that limited RAC educational value. Based on this review's findings, we propose a 6-step RAC curriculum framework for training programs seeking to establish an RAC and maximize the clinic's educational value.CONCLUSIONS:Resident aesthetic clinics are increasingly important for providing plastic surgery residents with aesthetic training. Patient and case volume, degree of resident autonomy, and clinic attending physicians are critical determinants of the educational value of RACs. We hope our findings can aid plastic surgery training programs in better organizing educational and sustainable RACs.

Abstract Background In 2014, the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) increased minimum aesthetic surgery requirements. Consequently, the resident aesthetic clinic (RAC) has become an ever more important modality for training plastic surgery residents. Objectives To analyze demographics and long-term surgical outcomes of aesthetic procedures performed at the Johns Hopkins and University of Maryland (JH/UM) RAC. A secondary objective was to evaluate the JH/UM RAC outcomes against those of peer RACs as well as board-certified plastic surgeons. Methods We performed a retrospective chart review of all patients who underwent aesthetic procedures at the JH/UM RAC between 2011 and 2020. Clinical characteristics, minor complication rates, major complication rates, and revision rates from the JH/UM RAC were compared against 2 peer RACs. We compared the incidence of major complications between the JH/UM RAC and a cohort of patients from the CosmetAssure (Birmingham, AL) database. Pearson's chi-square test was used to compare complication rates between patient populations, with a significance set at 0.05. Results Four hundred ninety-five procedures were performed on 285 patients. The major complications rate was 1.0% (n = 5). Peer RACs had total major complication rates of 0.2% and 1.7% (P = .07 and P = .47, respectively). CosmetAssure patients matched to JH/UM RAC patients were found to have comparable total major complications rates of 1.8% vs 0.6% (P = .06), respectively. At JH/UM, the minor complication rate was 13.9%, while the revision rate was 5.9%. Conclusions The JH/UM RAC provides residents the education and training necessary to produce surgical outcomes comparable to peer RACs as well as board-certified plastic surgeons. Level of Evidence: 3

Study Design: This is a literature review with 3 case studies. Objective: Intraoperative and postoperative bleeding are the most common complications of orthognathic surgery and have the potential to become life-threatening. The rarity of severe postoperative epistaxis has resulted in limited characterization of these cases in the literature. The purpose of this study is to 1) differentiate various presentations of epistaxis following orthognathic surgery in the literature, 2) identify management approaches, and 3) to synthesize a treatment algorithm to guide future management of postoperative epistaxis. Methods: A literature search of PubMed was conducted and 28 cases from 17 studies were assessed. Results: Bleeding within the first week may indicate isolated epistaxis, often resolved with local tamponade. Half of cases were attributed to pseudoaneurysm rupture (n = 14), with epistaxis onset ranging from postoperative day 6 to week 9. Angiography was used in most cases (n = 17), often as the primary imaging modality (n = 11). Nasal endoscopy is a less invasive and effective alternative to angiography with embolization. Proximal vessel ligation was used in 3 cases but is not preferred because collaterals may reconstitute flow through the defect and cause rebleeding. Repeat maxillary down-fracture with surgical exploration was described in 4 cases. Conclusions: As outlined in our management algorithm, nasal packing and tamponade should be followed by either local electrocautery or vascular imaging. Angiography with embolization is the preferred approach to diagnosis and management, whereas surgical intervention is reserved for cases of embolization failure or unavailability.

Background: Virtual surgical planning (VSP) has gained popularity for preoperative orthognathic surgery planning and is increasingly being employed by surgeons trained in plastic and reconstructive surgery (PRS) or oral and maxillofacial surgery (OMS). This review assesses the introduction of VSP as a new technology and its impact on orthognathic surgery research and practices based upon surgeon training. Methods: Two PubMed literature reviews were conducted. The first classified publications on VSP for orthognathic surgery by training (OMS- or PRS-trained surgeons) and compared focuses, timing, and journals of publications from each group of surgeons. The second evaluated how orthognathic surgery publication volumes changed with VSP introduction. English articles published from inception until January 2020 (first review) and November 2020 (second review) were included. Results: The first literature review retrieved 419 unique publications, with 188 studies selected for inclusion: 162 were published by OMS-trained principal investigators (OMS-authored) and 26 by PRS-trained principal investigators (PRS-authored). Plastic and reconstructive surgery-authored publications regarding VSP use in orthognathic surgery increased after the first publication in 2000, but at a significantly slower rate (0.2 new publications/year) than OMS-authored publications (P < 0.01). Aesthetics was discussed in significantly more PRS-authored publications (76.9% compared to 28.4% of OMS-authored publications). The second review revealed that over 80.6% of orthognathic surgery literature was published after 2008, the year VSP was first integrated into orthognathic surgery workflow. Conclusions: Following the introduction of VSP, orthognathic surgery research output has differed between PRS and OMS based on publication speed, volume, and research focuses. Further research is necessary to evaluate how VSP has impacted PRS and OMS clinical practice.

BACKGROUND: Achieving caregiver understanding of craniosynostosis is a critical component of surgical care. Caregivers must navigate the emotional challenges of a congenital diagnosis, conceptualize skull anatomy, and make decisions on surgical treatment. Recent advances in three-dimensional (3D) printing and augmented reality (AR) have made medical model creation more accessible to providers. As a result, 3D-printed and AR anatomical models have been shown to improve communication between surgeons and caregivers for a variety of disease processes. Given these technological advancements, this study aims to compare the utility of 3D-printed versus AR models for craniosynostosis caregiver education. METHODS: Caregiver perspectives on three models were compared in this survey: 3D-printed, AR, and two-dimensional (2D) diagram. 2D diagrams were sourced from schematic diagrams found in the literature. 3D-printed and AR models were generated from preoperative cranial CT scans of patients with bicoronal, sagittal, and unicoronal craniosynostosis. A DICOM Viewer (Inobitec LLC) was used to export CT scans into virtual 3D meshes, which were smoothed and post-processed in MeshMixer (AutoDesk) to ensure 3D printability. 3D-printed models were printed using a Prusa MK3S (Prusa Research) printer in white PET-G plastic. To view the model in AR, the mesh was uploaded to Augment, a mobile AR platform. All models were incorporated into a Qualtrics survey distributed to caregivers through popular Facebook craniosynostosis support groups in February 2021. The survey presented the three models in random order. Caregivers were asked to rate how innovative and realistic each model felt on a five-point Likert scale. Caregivers also ranked the three models in terms of usefulness in learning about craniosynostosis, ability to ease caregiver anxiety, and ability to increase caregiver trust in surgeons. Caregiver ratings for the three models were compared using one-way ANOVA tests. RESULTS: A total of 73 self-identified craniosynostosis caregivers completed the survey [mean age 32 ± 5 years, majority White (94%) and women (71%)]. ANOVA testing demonstrated that caregivers ranked 3D-printed and AR models significantly higher than 2D models for learning about craniosynostosis anatomy (P < 0.05) and increasing their trust in surgeons (P < 0.05). In terms of easing caregiver anxiety, the AR model, but not the 3D-printed model, was found to be more effective than the 2D model. Both the unicoronal and bicoronal AR models were rated as more innovative (P < 0.05) and more realistic (P < 0.05) than their respective 2D models. 3D-printed models were seen as equally realistic and innovative compared with AR or 2D models. CONCLUSIONS: Our findings indicate that both 3D-printed and AR models can enhance caregiver understanding of craniosynostosis anatomy more so than 2D models. Based on this information, we recommend surgeons consider the unique advantages of these models as a powerful communication tool during patient consultations for improved caregiver understanding of craniosynostosis.

Abstract Background Benchtop microsurgical training models that use digital tools (smartphones, tablets, and virtual reality [VR]) for magnification are allowing trainees to practice without operating microscopes. This systematic review identifies existing microscope-free training models, compares models in their ability to enhance microsurgical skills, and presents a step-by-step protocol for surgeons seeking to assemble their own microsurgery training model. Methods We queried PubMed, Embase, and Web of Science databases through November 2020 for microsurgery training models and performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We collected data including training model characteristics (cost, magnification, and components) and outcomes (trainee satisfaction, image resolution, and faster suturing speed). We also conducted a complimentary Google search to identify commercially available microscope-free microsurgical training models or kits not reported in peer-reviewed literature. Results Literature search identified 1,805 publications; 24 of these met inclusion criteria. Magnification tools most commonly included smartphones (n = 10), VR simulators (n = 4), and tablets (n = 3), with magnification ranging up to ×250 magnification on digital microscopy, ×50 on smartphones, and ×5 on tablets. Average cost of training models ranged from $13 (magnification lens) to $15,000 (augmented reality model). Model were formally assessed using workshops with trainees or attendings (n = 10), surveys to end-users (n = 5), and single-user training (n = 4); users-reported satisfaction with training models and demonstrated faster suturing speed and increased suturing quality with model training. Five commercially available microsurgery training models were identified through Google search. Conclusion Benchtop microsurgery trainers using digital magnification successfully provide trainees with increased ease of microsurgery training. Low-cost yet high magnification setups using digital microscopes and smartphones are optimal for trainees to improve microsurgical skills. Our assembly protocol, “1, 2, 3, Microsurgery,” provides instructions for training model set up to fit the unique needs of any microsurgery trainee.

Background The COVID-19 pandemic has led to the widespread adoption of video calling. A parallel growth in aesthetic surgery demand has been documented. Objectives The authors sought to identify associations between video call engagement and aesthetic surgery attitudes. Methods We distributed a cross-sectional survey via Amazon Mechanical Turk in November 2020. Respondents were asked to report their time spent video calling, video calling applications and features (eg, virtual backgrounds) they utilized, and aesthetic surgery attitudes employing the 15-item Acceptance of Cosmetic Surgery Scale (ACSS; higher scores indicate greater acceptance). ACSS scores were compared between video call users and non-users employing t tests. Pearson’s correlation coefficient was employed to quantify associations between ACSS scores and time spent on calls and multivariable analysis to estimate associations between video call engagement and ACSS scores. Results A total of 295 respondents (mean age, 37.6 years; 49.5% female) completed the survey. Across all video call applications surveyed, video call users had higher ACSS scores than non-users. Increased time respondents spent looking at their own face on video call was moderately associated with higher ACSS scores (r = 0.48, P < 0.01), whereas time spent looking at another person’s face was not associated with a change in ACSS scores (r = 0.09, P = 0.11). Increased video call utilization was associated with higher ACSS scores. Conclusions Increased video calling utilization is associated with increased acceptance of aesthetic surgery. Although the clinical significance of ACSS scores can be better elucidated, plastic surgeons should consider the effects of video calling on patient motivations for aesthetic surgery in the COVID-19 era.

Vascular anastomoses typically involve a handsewn technique requiring significant surgical training, expertise, and time. The aim of our systematic review was to identify and describe sutureless vascular anastomosis techniques. We performed a systematic review of all sutureless vascular anastomosis technologies published in MEDLINE, PubMed, Embase, CINAHL, Cochrane, Web of Science, and Scopus Library databases and a patent review using US Patent and Trade Office Application, US Patent and Trademark Office Patent, Google Patents, Lens, Patent Quality Through Artificial Intelligence, SureChEMBL, and E-Space Net. Data from inclusion studies and patents published between January 1, 1980 and July 15, 2021 were abstracted to describe their category, anastomosis type and configuration, study types, and advantages and disadvantages encountered with each technology. Two hundred eleven original studies and 475 patents describing sutureless vascular anastomosis technologies were identified. In the literature, stents/stent-grafts/grafts (n = 61), lasers (n = 53), and couplers (n = 27) were the predominant device categories. In the patent review, adhesive technologies (n = 103), stents/stent-grafts/grafts (n = 68), and mechanical connectors (n = 61) predominated. The majority of studies involved in vivo animal studies (n = 193); 32.2% (n = 68) of investigations involved human trials; and 17.9% (n = 85) of patent technologies were approved by the US Food and Drug Administration. The main advantages described for sutureless anastomosis technologies included faster procedure time and greater patency rates compared with handsewn anastomoses. The main disadvantages included reduced vessel compliance, stenosis, leakage, and device costs. The appeal of sutureless technology is substantiated by numerous animal trials, but their use in humans remains limited. This may be a reflection of strict regulatory criteria and/or vascular complications associated with currently available technologies.