Publications by authors named "Amanda A Gosman"

59 Publications

Philanthropy in Plastic Surgery: Best Practices and Measuring Impact.

Plast Reconstr Surg 2021 Sep;148(3):687-694

From the Division of Plastic Surgery, University of Massachusetts Medical School; Department of Plastic and Reconstructive Surgery, The Ohio State University; ConnectMed International; and Division of Plastic Surgery, University of California, San Diego.

Background: Philanthropy in plastic surgery supports research, clinical care, academic infrastructure, and education in the United States and internationally. Plastic surgeons have opportunities to innovatively address unmet needs in their local and global communities by forming philanthropic nonprofit organizations.

Methods: The authors queried three national philanthropic databases (Charity Navigator, Guidestar, and ProPublica) for Internal Revenue Service 990 form tax return information related to philanthropic plastic surgery organizations. The authors analyzed the financial information publicly available about current plastic surgery philanthropic organizations and their funding sources.

Results: Seventy-three federally tax-exempt groups identified plastic surgery as their primary area of work to the Internal Revenue Service in 2019, and 52 of those organizations said they engaged in clinical and/or educational philanthropy.3 In 2017, a total of $158.5 million was donated to these groups in cash and noncash donations including equipment and time. Analyses of 6 years (2013 to 2018) of tax records from groups that provide plastic surgery clinical, research, or educational philanthropy reveal that government grants provide very little funding for this work. Eighty-six percent of money raised for these groups in 2017 was collected by means of direct donations. Money obtained from fundraising events contributed 2 percent to their total monies raised in 2017 on average and 8 percent came from noncash gifts.

Conclusions: A broad body of academic research is reviewed here that guides best practices and measuring a group's impact and outcomes. The details of a philanthropic group's organization and finances directly influence the impact of their work and, as such, are worthy of our sustained attention.
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http://dx.doi.org/10.1097/PRS.0000000000008280DOI Listing
September 2021

Discussion: Mentorship in Plastic Surgery: A Critical Appraisal of Where We Stand and What We Can Do Better.

Plast Reconstr Surg 2021 Sep;148(3):678-679

From the Division of Plastic Surgery, University of California, San Diego.

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http://dx.doi.org/10.1097/PRS.0000000000008296DOI Listing
September 2021

Applicant Preferences for Virtual Interviews: Insights from the 2020-21 Integrated Plastic Surgery Application Cycle.

Plast Reconstr Surg Glob Open 2021 Jul 29;9(7):e3732. Epub 2021 Jul 29.

The Ohio State University Department of Plastic and Reconstructive Surgery, Columbus, Ohio.

Background: The COVID-19 pandemic created an unprecedented residency application cycle that required the use of virtual interviews. The inaugural class of applicants participating in virtual interviews were surveyed concerning their preferences and suggestions for future application cycles.

Methods: A survey was distributed to 349 individuals who applied for an integrated plastic surgery residency position at three institutions during the 2020-21 application cycle. Responses were analyzed to determine the most popular attributes of virtual interviews.

Results: Response rate was 44%. Eighty-six percent of applicants valued having time to consider their interview offers before scheduling; however, nearly one-third felt the instructions provided by programs lacked clarity and did not abide by the American Council of Academic Plastic Surgeons guidelines. Eighty-two percent of applicants valued having a preinterview social, and most preferred smaller breakout rooms organized by themes. A short interview day (less than three hours) was associated with less applicant familiarity with the program, its people, and its location when compared with medium (three to seven hours) and long (more than seven hours) interview days ( < 0.001 for all). Eighty percent of applicants preferred an interview day where they were placed into interview rooms by a program coordinator.

Conclusions: The virtual interview format can be optimized in many ways to benefit both applicants and programs. The data presented in this article provide suggestions for future iterations of virtual interviews.
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http://dx.doi.org/10.1097/GOX.0000000000003732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322511PMC
July 2021

How to Get Consistently Good Results in Cleft Lip Repair.

Plast Reconstr Surg Glob Open 2021 Jul 12;9(7):e3677. Epub 2021 Jul 12.

Division of Plastic Surgery, UC San Diego, San Diego, Calif.

This article serves as a practical guide for plastic surgeons focusing on repair of primary cleft lip and nasal deformity. We discuss the key anatomic disruption present in cleft lip and nasal deformity and the goals of primary repair. In addition, our preferred surgical technique for unilateral and bilateral cleft lip and nasal deformity is summarized along with technical pearls and pitfalls.
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http://dx.doi.org/10.1097/GOX.0000000000003677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274742PMC
July 2021

A Single-Center Retrospective Review of Perioperative Complications and Reoperation Rates Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Coronal Craniosynostosis.

J Craniofac Surg 2021 Jun 30. Epub 2021 Jun 30.

Division of Plastic Surgery, UC San Diego Rady Children's Hospital UC San Diego School of Medicine, San Diego, CA.

Background: Unilateral coronal craniosynostosis (UCS) is the third most prevalent form of craniosynostosis. Traditional treatment of UCS has been achieved with fronto-orbital advancement and cranial vault remodeling (FOAR), but utilization of cranial distraction osteogenesis (DO) techniques has increased. This study aims to compare perioperative complications and reoperation trends in FOAR versus DO techniques at a single institution.

Methods: An Institutional Review Board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Patients were those that have undergone FOAR or DO with an anterior rotational flap technique as previously described. Indications for secondary procedures included: contour deformities, relapse, surgical site infection, and persistent cranial defects.

Results: Eighty-one patients with UCS were identified, 64 patients underwent FOAR and 17 patients underwent DO. When perioperative characteristics were compared, patients who underwent DO were younger in age, however, there was no significant difference in transfusion requirement or length of stay between patient cohorts. Surgery time was increased in DO patients. When perioperative complications were compared, more intraoperative dural tears were observed in the FOAR cohort. When unplanned reoperation rates were compared, patients who had undergone FOAR had a statistically significant higher reoperation rates at 5 years of follow up. When including routine distractor removal as a reoperation, reoperative rate was increased in the DO cohort. No difference in reoperation rates was noted at 5 years following index operation.

Conclusions: The safety profile of DO is similar to that of traditional FOAR techniques for treatment of UCS. Longer-term follow-up studies are needed to elucidate whether outcomes are durable, but the unplanned reoperation rate in DO is less than that of FOAR at 5 years and presents several advantages that warrants its use in patients with UCS.
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http://dx.doi.org/10.1097/SCS.0000000000007831DOI Listing
June 2021

Prevalence of Workforce Diversity Research Among Surgical Specialties in the United States: How Does Plastic Surgery Compare?

Ann Plast Surg 2021 Jun 25. Epub 2021 Jun 25.

From the Department of Surgery, Division of Plastic Surgery School of Medicine, University of California San Diego, San Diego, CA Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA Division of Plastic Surgery Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, CA.

Background: Plastic surgeons are not as diverse as expected in relation to the increasingly diverse patient and medical student population. The authors assess the state of diversity in 8 primary surgical specialties in the United States and evaluate trends in research interest in diversity over the past 30 years.

Methods: Articles regarding diversity in surgery from 1990 to 2020 were systematically reviewed. The Association of American Medical Colleges Physician Specialty Data Reports and the Accreditation Council for Graduate Medical Education Data Resource Books provided resident/fellow and faculty data from 2011 to 2016. Trends were analyzed over time per specialty.

Results: From 1990 to 2020, a total of 199 publications related to diversity were identified among the various surgical specialties. Orthopedic surgery had significantly more publications per year compared with other specialties (P < 0.05). Every specialty demonstrated a significant increase in publications about diversity over time (P < 0.05). A majority of publications were related to sex rather than underrepresented in medicine topics. The proportion of female surgeons was significantly higher for plastic surgery than for orthopedic surgery and neurosurgery (P < 0.001). Plastic surgery exhibited the highest growth rate in female residents (+1.6% per year, P < 0.001). The proportion of underrepresented minorities composing surgical trainees has not significantly increased in any surgical specialty between 2011 and 2016 (P > 0.05).

Conclusions: Although diversity representation in surgery has somewhat improved, the rate is too slow to match the growing diversity of the US population. Outcomes have been disparate between specialties and demonstrate greater increases in sex equality relative to ethnic/racial equality. Evidence-based interventions need to be developed and implemented.
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http://dx.doi.org/10.1097/SAP.0000000000002868DOI Listing
June 2021

The Influence of Academic Pedigree on Integrated Plastic Surgery Resident Training Location.

J Surg Educ 2021 May 5. Epub 2021 May 5.

Division of Plastic Surgery, Department of Surgery, UC San Diego Health Center, San Diego, California. Electronic address:

Introduction: Plastic surgery residencies are among the most competitive programs for graduate medical education. While board scores and research output are well-studied indicators of match success, no studies describe the association between an applicant's medical school ranking and subsequent residency ranking.

Methods: A cross-sectional study of integrated plastic surgery residents for the 2019 to 2020 academic year was performed. Integrated plastic surgery residency programs were ranked according to 2020 Doximity Residency Navigator. AAMC-affiliated allopathic medical schools were ranked according to US News & World Report 2020 Best Medical Schools. Multiple regression analysis was used to determine if academic pedigree predicted placement at highly competitive plastic surgery residency programs.

Results: A total of 914 residents across 69 integrated plastic surgery residency programs were included. Ten medical schools accounted for 169 (18.4%) of all trainees. 159 (16.5%) matched at their home program for residency. Medical school ranking and medical school-affiliated integrated plastic surgery program ranking were significant predictors of match success and future residency competitiveness. The presence of an affiliated plastic surgery residency program predicted total number of medical school graduates who matriculated into plastic surgery residency (p < 0.0005). Graduates of top-ranked schools represented a disproportionate number of current plastic surgery residents (Top 10 program: 12.5%, Top 20: 24.1%, Top 40: 40.9%, Top 50: 49.1%).

Conclusions: Both medical school ranking and home plastic surgery program ranking appeared to influence match success and future residency training program competitiveness. This is the first study to demonstrate these associations.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.021DOI Listing
May 2021

Orbital Volumetric Analysis in Patients With Unicoronal Craniosynostosis: A Comparison Between Distraction Osteogenesis and Fronto-Orbital Advancement.

Ann Plast Surg 2021 05;86(5S Suppl 3):S367-S373

Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, Los Angeles, CA.

Background: Unicoronal craniosynostosis is associated with orbital restriction and asymmetry. Surgical treatment aims to both correct the aesthetic deformity and prevent the development of ocular dysfunction. We used orbital quadrant and hemispheric volumetric analysis to assess orbital restriction and compare the effectiveness of distraction osteogenesis with anterior rotational cranial flap (DO) and bilateral fronto-orbital advancement and cranial vault remodeling (FOAR) with respect to the correction of orbital restriction in patients with unicoronal craniosynostosis.

Methods: A retrospective review of all patients with a diagnosis of unicoronal craniosynostosis and treated with either DO or FOAR from 2000 to 2019 was performed. Preoperative and postoperative total orbital volumes, as well as quadrant and hemispheric volume ratios, were calculated from 3-dimensional head computed tomography scans. Selected preoperative and postoperative orbital measurements, including the maxillary length of the orbit (MLO; zygomaticofrontal suture to the top of zygomatic arch) and the sphenoid length of the orbit (SLO; the top of sphenoid suture to the top of zygomatic arch), were also obtained.

Results: Data were available for 28 patients with unicoronal craniosynostosis. Mean preoperative total orbital volume was significantly smaller on the synostotic side compared with the nonsynostotic side (10.94 vs 12.20 cm3, P = 0.04). Preoperative MLO and SLO were significantly longer on the synostotic side compared with the nonsynostotic side (MLO: 20.26 vs 17.75 mm, P < 0.001; SLO: 26.91 vs 24.93 mm, P = 0.01). Distraction osteogenesis and FOAR produced significantly different changes in orbital quadrant and/or hemispheric volume ratios on the nonsynostotic side but not on the synostotic side.

Conclusions: Before correction, patients with unicoronal craniosynostosis have significantly smaller total orbital volumes on the synostotic side compared with the nonsynostotic side and significantly greater MLO and SLO on the synostotic side compared with the nonsynostotic side. There is no significant difference between DO and FOAR with regard to correcting the observed orbital restriction in these patients.
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http://dx.doi.org/10.1097/SAP.0000000000002816DOI Listing
May 2021

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review.

Cleft Palate Craniofac J 2021 Feb 25:1055665621995047. Epub 2021 Feb 25.

Division of Plastic Surgery, Department of Surgery, University of California, San Diego, La Jolla, CA, USA.

Background: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice.

Primary Aim: To provide a qualitative systematic review analysis of long-term outcomes after PABG.

Materials And Methods: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings.

Results: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice.

Conclusion: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.
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http://dx.doi.org/10.1177/1055665621995047DOI Listing
February 2021

Analysis of Actual Versus Predicated Intracranial Volume Changes for Distraction Osteogenesis Using Virtual Surgical Planning in Patients With Craniosynostosis.

Ann Plast Surg 2021 05;86(5S Suppl 3):S374-S378

Rady Children's Hospital.

Introduction: The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management.

Methods: All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests.

Results: Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012).

Conclusions: Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients.
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http://dx.doi.org/10.1097/SAP.0000000000002759DOI Listing
May 2021

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair.

Ann Plast Surg 2021 05;86(5S Suppl 3):S360-S366

From the Division of Plastic Surgery, University of California.

Purpose: The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

Methods: A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

Results: A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

Conclusions: There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.
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http://dx.doi.org/10.1097/SAP.0000000000002747DOI Listing
May 2021

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction.

World J Surg 2021 Apr 16;45(4):1102-1108. Epub 2021 Jan 16.

Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.

Introduction: In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction.

Methods: The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant.

Results: There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01).

Discussion: A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.
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http://dx.doi.org/10.1007/s00268-020-05915-2DOI Listing
April 2021

A Posterior Rotational Flap Technique Using Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis.

J Craniofac Surg 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

School of Medicine, University of California Division of Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla Rady Children's Hospital San Diego, San Diego, CA.

Introduction: The craniofacial asymmetry seen in unilateral lambdoid craniosynostosis may not be effectively treated by posterior cranial vault remodeling, endoscopic suturectomy, and helmet therapy, or suturectomy and distraction osteogenesis alone due to limitations in soft-tissue envelope expansion and relapse of the deformity. The authors report a series of unilateral lambdoid craniosynostosis patients treated with a posterior rotational cranial-flap technique using internal distraction osteogenesis.

Methods: Posterior cranial vault reconstruction combined with internal distraction was used, aided by preoperative virtual surgical planning. An in situ posterior rotational flap osteotomy was utilized to maximize dural preservation. Primary outcome measures included age-adjusted volume change and age-adjusted percent volume change per mm distraction. Distraction characteristics and perioperative characteristics were also assessed.

Results: A total of 5 patients were identified. Mean predistraction intracranial volume was 1087.5 cc (SD  = 202.3 cc) and mean postdistraction included intracranial volume was 1266.1cc (SD  = 131.8cc). Mean age-adjusted percent included intracranial volume change was 14.1% (SD  = 9.6%), and mean percent intracranial volume change per mm distraction was 0.43%/mm distraction (SD  = 0.37%/mm distraction). One patient developed a distractor site infection postoperatively that was treated successfully with oral antibiotics. All patients had a Whitaker score of 1 at one year follow up.

Conclusions: Posterior cranial vault remodeling using osteogenesis and a rotational cranial flap technique with dural preservation can be effectively used to maximize bone flap viability and limit postoperative relapse in patients with unilateral lambdoid craniosynostosis. Long term analysis as well as comparison to open techniques will need to be interrogated.
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http://dx.doi.org/10.1097/SCS.0000000000007421DOI Listing
January 2021

A Comparison of Intracranial Volumes and Metopic Index in Patients With Isolated Metopic Ridge, Metopic Craniosynostosis, and Normal Healthy Children.

J Craniofac Surg 2021 Jan-Feb 01;32(1):108-112

UC San Diego Division of Plastic Surgery.

Background: Previous research has shown that patients with metopic craniosynostosis have significantly reduced intracranial volumes (ICVs) compared to normal healthy children. Furthermore, the metopic index (ratio of midfrontozygomatic diameter to maximal cranial width) has been described as an anthropometric cranial index for patients with metopic craniosynostosis. We aimed to determine whether patients with isolated metopic ridge have significantly different ICVs or metopic indices than normal children and patients with metopic craniosynostosis.

Methods: A retrospective chart review of all patients with a diagnosis of a metopic ridge or metopic craniosynostosis was performed from 2000 to 2015 at Rady Children's Hospital. Patients were grouped based on computed tomographic scans consistent with metopic craniosynostosis versus metopic ridge.

Results: Data were available for 15 metopic ridge patients, 74 metopic craniosynostosis patients, and 213 normal patients. Mean metopic ridge ICV was greater than mean metopic craniosynostosis ICV at 4 to 6 months and 7 to 12 months. Controlling for age and sex, the difference in ICV associated with metopic ridging was 197.484 cm3 and 137.770 cm3 at 4 to 6 and 7 to 12 months, respectively. Similarly, mean metopic index was significantly greater in metopic ridge patients compared to mean metopic craniosynostosis at 4 to 6 months and at 7 to 12 months.

Conclusions: Our study provides volumetric and anthropometric data to support the hypothesis that isolated metopic ridge is an intermediate phenotype between metopic craniosynostosis and normal cranial anatomy. We hope that characterizing the spectrum of disease involving premature closure of the metopic suture with regard to ICV and metopic index will aid physicians in their management of patients with isolated metopic ridge.
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http://dx.doi.org/10.1097/SCS.0000000000007044DOI Listing
June 2021

The Plastic Surgery Residency Interview Revisited: Virtual Interviews and Beyond.

Plast Reconstr Surg 2020 11;146(5):1209-1211

From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Hospital; the Division of Plastic Surgery, University of California, San Diego; the Division of Plastic Surgery, Baylor College of Medicine; the Department of Plastic Surgery, New York University Langone Medical Center; and the Dallas Plastic Surgery Institute.

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http://dx.doi.org/10.1097/PRS.0000000000007321DOI Listing
November 2020

Analysis of Narcotic Use in Isolated Facial Fractures: Potential Targets for a Narcotic Reduction Protocol.

J Craniofac Surg 2020 Oct 12. Epub 2020 Oct 12.

Division of Plastic Surgery, University of California, San Diego Health Center, La Jolla and San Diego.

Anecdotal evidence suggests that patients with isolated traumatic facial fractures have high narcotic usage, yet there is a lack of literature delineating this relationship. This study aimed to characterize total amount and factors predictive of narcotic usage following isolated traumatic facial fracture. Study participants (n = 35) were predominantly male (91.4%), mean age 40.5, Caucasian (34.3%), suffered some form of assault (62.9%), and remained hospitalized for an average of 3.0 days. Average morphine milligram equivalent (MME) use in the inpatient setting was 967.6 for operative (n = 30) and 37.5 for nonoperative (n = 5) patients. Average total narcotic use across inpatient and outpatient settings was 1256.6 MME for operative and 105 MME for nonoperative patients. Operative intervention predicted a significant difference in total inpatient narcotic usage (P = 0.009). For patients who underwent surgical intervention, significant variations in narcotic usage were found based on mechanism of injury (24-hour postoperative, P = 0.030), but not injury severity or number of procedures. Specifically, individuals suffering highly traumatic fractures (eg, gunshot wound) demonstrated increased total postoperative narcotic usage of 1194.1 MME (P = 0.004). Interestingly, non-narcotic analgesic use including acetaminophen and lidocaine-epinephrine resulted in significantly lower narcotic usage in the postoperative setting. These findings suggest a role for narcotic-reducing enhanced recovery after surgery protocols in the setting of isolated facial trauma.
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http://dx.doi.org/10.1097/SCS.0000000000007185DOI Listing
October 2020

Improving the Standardized Letter of Recommendation in the Plastic Surgery Resident Selection Process.

J Surg Educ 2021 May-Jun;78(3):801-812. Epub 2020 Sep 29.

Division of Plastic Surgery, Department of Surgery, UC San Diego School of Medicine, San Diego, California. Electronic address:

Objective: The American Council of Academic Plastic Surgeons (ACAPS) Plastic Surgery Recommendation Form is a standardized letter of recommendation (SLOR) used in the plastic surgery resident selection process since 2012. This study aims to evaluate this form and use a multistep survey to optimize this SLOR.

Design: A 16 question survey was sent via Survey Monkey to 510 ACAPS faculty. The results of this survey were followed up with a live-response survey at the ACAPS Spring Retreat. Consensus was used to modify and create a more optimal SLOR.

Setting: This study was performed by the Division of Plastic and Reconstructive Surgery at the University of California, San Diego.

Participants: Survey respondents represented over five hundred plastic surgery faculty from a variety of subspecialties and academic programs nation-wide.

Results: The response rate to the online survey was 36%. On a scale of 1 (not useful) to 5 (very useful), letter readers and letter writers found the SLOR 3.88 and 3.90 respectively. Most respondents believed that the SLOR should be used as an adjunct to the narrative LOR. Forty-two faculties participated as respondents to the live audience questions, although over a 100 faculty were present for the discussion. Most participants agreed that independent program applicants should have a separate SLOR form, with at least 1 filled out by the Program Director of the residents' primary board. The majority (61%) of respondents supported the addition of 1-line characteristics to each applicant quality, and the change to a percentile format for assessment.

Conclusions: Letters of recommendation are vital to the resident selection process, and thus it is incumbent upon fields of medicine to consciously work on improving how these letters are written. This study outlines a 2-step process by which a SLOR was evaluated and optimized for faculty in the field of plastic surgery.
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http://dx.doi.org/10.1016/j.jsurg.2020.09.005DOI Listing
June 2021

Establishing a Virtual Curriculum for Surgical Subinternships.

Plast Reconstr Surg 2020 10;146(4):525e-527e

Division of Plastic Surgery, University of California, San Diego Health Center, La Jolla and San Diego, Calif.

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http://dx.doi.org/10.1097/PRS.0000000000007267DOI Listing
October 2020

Discussion: Melting the Plastic Ceiling: Where We Currently Stand on Measures to Support Women in Academic Plastic Surgery.

Plast Reconstr Surg 2020 09;146(3):708-709

From the Division of Plastic and Reconstructive Surgery, University of California, San Diego.

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http://dx.doi.org/10.1097/PRS.0000000000007118DOI Listing
September 2020

Electric scooter craniofacial trauma.

Laryngoscope Investig Otolaryngol 2020 Jun 7;5(3):390-395. Epub 2020 Apr 7.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery University of California San Diego California USA.

Objective: The use of standing electronic scooters associated with micromobility applications (e-scooters) has risen nationally. The aim of this study was to obtain a detailed view of soft tissue and bony craniofacial injury associated with e-scooter-related trauma.

Methods: Single-institution retrospective case series of patients presenting to a level 1 trauma center emergency department or trauma unit with documented e-scooter-related craniofacial injury.

Results: Of 203 included patients, 188 (92.6%) patients sustained craniofacial injury. One hundred thirty-one (64.5%) had exclusively soft tissue injury, 3 (1.5%) exclusively bony injury, 51 (25.1%) both soft and bony injuries, and twenty-five (12.3%) patients sustained dental injury. Aesthetic units most frequently sustaining acute soft tissue injury were the forehead (n = 106, 34.6%), scalp (n = 36, 11.8%), chin (n = 34, 11.1%), upper lip (n = 32, 10.5%), and cheek (n = 31, 10.1%). Aesthetic subunits most often sustaining acute soft tissue injury included the brow (42, 13.7%), central forehead (39, 12.7%), lateral forehead (n = 25, 8.2%), and upper lip vermillion (n = 23, 7.5%). Craniofacial osseous fracture most often occurred in the orbit (n = 42, 24.6%) and maxilla (n = 40, 23.4%). Individual osseous segments most frequently sustaining acute fracture included the anterior maxillary sinus wall (n = 22, 12.9%), nasal bone (n = 20, 11.7%), lateral orbital wall (n = 16, 9.4%), orbital floor (n = 15, 8.8%), and zygomatic bone (13, 7.6%).

Conclusions: Our analysis demonstrates that most patients presenting to our center with craniofacial trauma sustained acute bony fracture, most often to the midface. Our data of common injuries associated with e-scooter trauma could inform implementation in the form of facial safety equipment or safety skills training for e-scooter riders.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314474PMC
June 2020

Discussion: The Impact of Race, Age, Gender, Income, and Level of Education on Motivations to Pursue Cosmetic Surgery and Surgeon Selection at an Academic Institution.

Plast Reconstr Surg 2020 05;145(5):940e-941e

From the Division of Plastic and Reconstructive Surgery, University of California, San Diego.

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May 2020

Diversity in Plastic Surgery: Trends in Female Representation at Plastic Surgery Meetings.

Ann Plast Surg 2020 05;84(5S Suppl 4):S278-S282

From the Division of Plastic and Reconstructive Surgery, University of California San Diego, La Jolla.

Background: Prior studies have shown that roadblocks exist for women to achieve higher career levels in plastic surgery. The authors evaluate female representation as lecturers, panelists, and moderators at national and regional plastic surgery meetings.

Methods: The annual meetings between January 2014 and January 2019 for 12 national and regional plastic surgery societies were included in this study. Data regarding sex of speakers were extracted from meeting programs. Binomial distribution analysis was used to compare female representation at meetings as compared with female representation among plastic surgeons. Analysis of variance with Tukey post hoc analysis was used to evaluate for differences in female representation among regions and subspecialties.

Results: Females comprised 14.8% of speakers, including instructors, moderators, and panelists, at all included plastic surgery meetings. There has not been a significant increase in the representation of females at plastic surgery meetings in the past 5 years (P = 0.08). Five of 12 societies had significantly lower female representation as speakers than expected by the proportion of female plastic surgeons (P < 0.05). American Society for Craniofacial Surgeons had significantly lower representation as compared with other subspecialty meetings (P < 0.01), and Texas Society of Plastic Surgeons had significantly lower representation among regional meetings (P < 0.05).

Conclusions: Female representation among plastic surgery residents and faculty has increased, yet women remain disproportionately underrepresented on the podium at educational meetings. Providing women the opportunity to serve as speakers, moderators, and panelists at meetings will ultimately enhance the diversity of our plastic surgical leadership.
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May 2020

A Comparison of Intracranial Volume Growth in Normal Children and Patients With Metopic Craniosynostosis.

J Craniofac Surg 2020 Jan/Feb;31(1):142-146

Division of Plastic Surgery.

Background: The impact of metopic craniosynostosis on intracranial volume (ICV) and ICV growth is unclear. In addition, the relationship between head circumference (HC) and ICV in these patients is not previously described.

Methods: A retrospective review of 72 patients with metopic craniosynostosis was performed. The ICVs were calculated from manually segmented preoperative computed tomography scans. Magnetic resonance imaging data for 270 healthy children were available. The ICVs were calculated in FreeSurfer.First, a growth curve for metopic patients was generated and a logarithmic best-fit curve was calculated. Second, the impact of metopic craniosynostosis on ICV relative to healthy controls was assessed using multivariate linear regression. Third, the growth curves for metopic patients and healthy children were compared.Pearson's correlation was used to measure the association between HC and ICV.

Results: Mean metopic ICV was significantly lower than normal ICV within the first 3 to 6 months (674.9 versus 813.2 cm; P = 0.002), 6 to 9 months (646.6 versus 903.9 cm; P = 0.005), and 9 to 12 months of life (848.0 versus 956.6 cm; P = 0.038). There was no difference in ICV after 12 months of age (P = 0.916).The ICV growth in patients with metopic craniosynostosis is defined by a significantly different growth curve than in normal children (P = 0.005).The ICV and HC were highly correlated across a broad range of ICVs and patient age (r = 0.98, P < 0.001).

Conclusion: Patients with metopic craniosynostosis have significantly reduced ICVs compared to healthy children, yet greater than normal ICV growth, which allows them to achieve normal volumes by 1 year of age. The HC is a reliable metric for ICV in these patients.
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April 2020

Reply: Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents.

Plast Reconstr Surg 2020 01;145(1):221e-224e

Division of Plastic and Reconstructive Surgery, University of California, San Diego, La Jolla, Calif.

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January 2020

A Study to Evaluate Change in Ventricular Volume Obtained by Cranial Distraction for Craniosynostosis.

Ann Plast Surg 2019 05;82(5S Suppl 4):S301-S305

From the Plastic Surgery Division, Department of Surgery, and.

Background: The aims of the current analysis were to study the change in ventricular volume (VV) obtained with cranial distraction in patients with craniosynostosis and compare it with the change in total intracranial volume (ICV) and brain volume.

Methods: After institutional review board approval, a retrospective review was performed on patients undergoing cranial distraction over a 5-year period. GE Healthcare AdW 4.3 volume assessment software was utilized to calculate preoperative and postdistraction ICV, VV, and whole-brain volume. Data were also collected on patient demographics, age at the time of distraction, time spent in distraction and consolidation, and length of stay. t Tests were used for comparison.

Results: Twenty-three patients met our inclusion criteria. Forty-eight percent of patients (n = 11) had right-sided cranial distraction, 30% (n = 7) had bilateral distraction, and 22% of patients (n = 5) had left-sided distraction. At the preoperative stage, mean head circumference was 42.5 ± 4.7 cm, mean ICV was 810.1 ± 27 cm, mean non-VV (NVV) was 796.2 ± 268 cm, and mean VV was 13.9 ± 9 cm. After a mean of 27.4 mm of distraction, occurring over a mean of 26 days and consolidation period of 149 days, a second computed tomography scan was obtained. Mean postdistraction head circumference was 49.1 ± 3.9 cm, mean ICV was 1074.1 ± 203 cm, mean NVV was 1053.5 ± 197 cm, and VV was 20.6 ± 14 cm. Mean % increase in ICV at this stage was 47.4%; mean % NVV increase was 48.5% as opposed to 60.3% increase in VV.

Conclusions: Cranial distraction is known to effectively increase ICV. Our study suggests that the effect of this volumetric increase is much more pronounced on the VV compared with the brain volume. Further studies are underway to investigate whether this short-term marked increase in VV is sustained over a long-term period.
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May 2019

Can Head Circumference Be Used as a Proxy for Intracranial Volume in Patients With Craniosynostosis?

Ann Plast Surg 2019 05;82(5S Suppl 4):S295-S300

Department of Neurosurgery, University of California San Diego, Rady Children's Hospital, San Diego, CA.

Background: Calculation of intracranial volume from neuroimaging can be complex and time consuming. In the adult population, there is evidence suggesting that owing to its strong correlation, head circumference (HC) may be used as a surrogate for intracranial volume (ICV). We were interested in studying the correlation between HC and ICV in patients with craniosynostosis.

Methods: After institutional review board approval, a retrospective review was performed on patients with craniosynostosis. GE Healthcare AdW 4.3 volume assessment software was used to calculate ICV and HC based on preoperative computed tomographic scans. Pearson correlation was used to estimate correlation coefficients between ICV and HC for this patient population, with 0 to 0.3 considered a weak correlation, 0.4 to 0.6 considered a moderate correlation, 0.7 to 1 considered a strong correlation, and P < 0.05 was considered statistically significant.

Results: A total of 196 craniosynostosis patients were included in this study. There were 121 male and 75 female patients. Seventy-nine patients had metopic, 45 had coronal, 64 had sagittal, and 8 had lambdoid synostosis. Mean age was 8.2 months. Mean HC and ICV were 42.9 cm and 829 cm, respectively. Overall, there was a strong correlation between HC and ICV (r = 0.81). Patients were further categorized by craniosynostosis type. Very strong correlation was obtained for patients with coronal (0.89), metopic (0.98), and lambdoid craniosynostosis (0.97). Strong correlation was obtained for patients with sagittal synostosis (0.73). When categorized by sex, a stronger correlation was obtained for female patients (0.84) compared with male patients (0.80). Statistical significance was reached for all reported correlations.

Conclusion: Our preliminary data suggest that a very strong correlation exists between HC and ICV for male and female patients with all types of craniosynostosis, making HC a useful surrogate for ICV in this patient population.
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May 2019

Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents.

Plast Reconstr Surg 2019 03;143(3):940-949

From the School of Medicine and the Division of Plastic Surgery, University of California, San Diego.

Background: Prior studies have shown a lack of diversity among plastic surgery trainees. The authors evaluate trends in minority representation among applicants to plastic surgery and the correlation with practicing residents, compared to other specialties.

Methods: The Association of American Medical Colleges Electronic Residency Application Service provided applicant data for integrated, independent plastic surgery, and other select specialties from 2010 to 2016. Journal of the American Medical Association Graduate Medical Education annual reports and Association of American Medical Colleges graduate student questionnaires provided resident and medical student data. Binomial distribution analysis was used to assess differences in Black, Hispanic, and female proportions of applicants and residents. Best-fit trend lines were compared among groups and specialties.

Results: Women have seen an increase in integrated and independent resident representation (+2.23 percent and +0.7 percent per year, respectively) over the past 7 years, despite a relative decrease in applicants. The proportion of female applicants and residents correlated yearly for all specialties (p > 0.05). Conversely, for all years and all specialties, the Black proportion of applicants was significantly higher than the resident representation of the same year (p < 0.05). Hispanic applicant and resident representation have seen a minimal change.

Conclusions: Female representation among trainees has increased greatly, but there has been a decline in Black representation of integrated plastic surgery residents despite increases in medical school graduates and applicants. The data highlight a discrepancy between the population of applicants and residents suggesting that barriers starting from medical school may contribute to the lack of diversity in plastic surgery.
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March 2019

Distraction Osteogenesis for Unicoronal Craniosynostosis: Rotational Flap Technique and Case Series.

Plast Reconstr Surg 2018 12;142(6):904e-908e

From the School of Medicine, the Division of Plastic Surgery, Department of Surgery, and the Department of Neurosurgery, University of California, San Diego; and the Fresh Start Center for Craniofacial Anomalies, Rady Children's Hospital San Diego.

Background: The limitations of the soft-tissue envelope, devascularized bone grafts, and relapse of the deformity are important considerations in the surgical treatment of unicoronal craniosynostosis. The authors report their technique evolution of distraction osteogenesis for treatment of patients with unicoronal craniosynostosis.

Methods: Open anterior cranial vault reconstruction combined with internal distraction was used, with the aid of virtual surgical planning. Technique evolution included maximizing bone flap perfusion by means of limited rotational flap osteotomies, and preservation of dural attachments. Clinical and procedural characteristics including distraction protocol, intracranial volume change, efficiency of distraction, transfusion, operative time, length of hospitalization, complications, and postoperative outcomes were analyzed.

Results: Sixteen patients with nonsyndromic unicoronal craniosynostosis underwent repair between August of 2013 and December of 2016. Mean age was 9.0 months. Distractors were advanced a mean of 27.1 mm and achieved a cranial volume change of 29.5 percent, with a mean efficiency of 1.3 percent increase per millimeter of distraction. Mean operating time was 169.3 minutes. Complications were predominately related to infections at the distractor site. At most recent follow-up, all patients had a Whitaker grade I result.

Conclusions: Distraction osteogenesis can be a safe and effective method of achieving satisfactory aesthetic outcomes and volume expansion for patients with unicoronal craniosynostosis. The technique presented is proposed to maximize bone flap viability and limit relapse of deformity. Further long-term follow-up is needed for definitive comparison with traditional anterior cranial vault reconstruction.

Clinical Question/level Of Evidence: Therapeutic, IV.
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December 2018

Discussion: The Ethical and Professional Use of Social Media in Surgery: A Systematic Review of the Literature.

Authors:
Amanda A Gosman

Plast Reconstr Surg 2018 09;142(3):403e-404e

From the Division of Plastic Surgery, University of California, San Diego.

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September 2018
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