The Facilitator,

Temporary Migration for Training: A Special Case Background Against a background of globalization and medical migration, issues have been raised regarding training outside the clinician's own context. Objective There is a dearth of published literature on these issues and we aimed to explore these. Methods Taking Chang Gung Memorial Hospital fellowships in microfacial and craniofacial surgery as our case study, we developed an online survey to look at the circumstances leading junior doctors to seek specific, high-level training outside their country of intended practice and how effective this was for their future career, the service they provide, and their institutions. Results Fellows come to the Chang Gung Memorial Hospital predominantly from Europe, North America, and Asia, rather than specifically from developing countries. The predominant reasons were professional, personal, and to gain training that was not available at home, followed by career development. The fellowship was not commonly used as a career step or a means of migration. Our results showed that most fellows received training that enabled them to provide a service for complex cases on returning to their home country. Implementing newly acquired skills at home did not present any consistent challenges for fellows. Conclusions This study addressed a new phenomenon for the literature on medical migration: temporary migration from developed countries for the purposes of training and not permanent migration. The motivation for seeking these fellowships was to make up for training opportunities that were not available in highly planned health economies. To develop their practice in their home institutions, fellows often had to make adjustments to ensure effective transfer of skills and, in doing so, contribute to service development.

Book Review: Special Types of Finger Replantation No abstract available

Book Review: Dermatologic Complications With Body Art: Tattoos, Piercings and Permanent Make-up No abstract available

Course Review: Newcastle Surgical Training Centre Cadaveric Speech and Palate Surgery Course The Newcastle Surgical Training Centre Cadaveric Speech and Palate Surgery Course is an interactive and practical 1-day course for plastic surgery, ear, nose and throat surgery, and maxillofacial surgery trainees wishing to develop skills in cleft palate and speech surgery. The course is delivered by an expert faculty with delegates attending from the United Kingdom and abroad and costs £495 (US $650) to attend. This review provides information and an evaluation of the course.

A Modification of the Posterior Perichondrio-Adipo-Dermal Flap for Protruding Ear Correction: A Customized Technique Prominent ear deformity is a common congenital deformity of the external ear affecting 5% of the general population. Because of the deformity's displeasing nature, corrective prominent ear surgery is widely common and performed as a prophylactic surgery. More than 200 surgical techniques for the correction of prominent ear deformity have been described to improve the cosmetic outcome and decrease complication rates. The aim of the study was to present a modified post auricular flap technique that increases the control of reshaping the ear cartilages, decreases the operation time, and provides a symmetrical long-lasting cosmetic outcome. One hundred sixty-two patients (141 male and 21 female) had ear correction surgeries performed by the same surgeon using the described technique between January 2015 and January 2018. One hundred sixty patients were gone through bilateral ear correction, whereas only 2 patients had unilateral ear correction procedures. A modified posterior perichondrio-adipo-dermal flap technique for protruding ear correction was applied to all patients. The patients' ages ranged from 18 to 40 years, with a median of 28.3 years. The mean follow-up time was 22.5 months (6–36 months). Total operation time was 35 minutes on average (25–45 minutes). As more experience was gained in flap harvesting, operation time became shorter. The mean preoperative upper third ear proportion-scalp distance was 33.1 mm and the middle third ear proportion—scalp distance was 29.8 mm. At the sixth month of the surgery, the measurements were 9.8 and 11.6 mm. Measuring and adjusting flap's width provided to achieve symmetry in initial technique. Locating the postoperative scar along the posterior surface of the helical groove also provides a natural view. Different from traditional posterior fascial flap, the width of the flap was narrowed to 8 to 10 mm. In the traditional technique, the flap was dissected along the incision margins. Narrowing the width of the flap decreased the operation time. The preserved skin between the helix and the mastoid bone has the same width with perichondrio-adipo-dermal flap. That increases the control over the helix-mastoid distance and posterior auricular fold not to mention provides permanent results. The previously mentioned method can be a simple, useful, and practical technique for protruding ear deformity.

A Comparison of Outcomes and Resource Utilization Between Plastic Surgeons and General Surgeons in Implant-Based Breast Reconstruction Background Because of lack of patient education on the importance of surgeon certification and barriers to access a plastic surgeon (PS), non–PSs are becoming more involved in providing implant-based breast reconstruction procedures. We aim to clarify differences in outcomes and resource utilization by surgical specialty for implant-based breast reconstruction. Methods Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2014. Patients undergoing immediate implant-based reconstruction or immediate/delayed tissue expander–based reconstruction were identified (Current Procedural Terminology codes 19340 and 19357, respectively). Outcomes studied were major and wound-based 30-day complications, operation time, unplanned readmission or reoperation, and length of hospital stay. Results We identified 9264 patients who underwent prosthesis or tissue expander–based breast reconstruction, 8362 (90.3%) by PSs and 902 (9.7%) by general surgeons (GSs). There were significant differences in major complications between specialty (1.2% PS vs 2.8% GS; P < 0.001). There were no significant differences in unplanned reoperation (5.3% PS vs 4.9% GS; P = 0.592), unplanned readmissions (4.3% PS vs 3.8% GS; P = 0.555), wound dehiscence (0.7% PS vs 0.6% GS; P = 0.602), or wound-based infection rates (2.9% PS vs 2.8% GS; P = 0.866). As it pertains to resource utilization, the GS patients had a significantly longer length of stay (1.02 ± 4.41 days PS vs 1.62 ± 4.07 days GS; P < 0.001) and operative time (164.3 ± 97.6 minutes PS vs 185.4 ± 126.5 minutes; P = 0.001) than PS patients. Conclusions This current assessment demonstrates that patients who undergo breast implant reconstruction by a GS have significantly more major complications. It is beneficial for the health care system for PSs to be the primary providers of breast reconstruction services. Measures should be taken to ensure that PSs are available and encouraged to provide this service.

Upper Lip Reconstruction With Modification for Creating a Philtrum With Single-Stage Full-Thickness Skin Graft in Burned Face Injury Background The philtrum plays an important role in determining the shape and form of the upper lip and creates individual identity. Postburn scar contracture in this area often leads to severe functional and aesthetic disfigurement. In this report, we present a novel method of philtrum reconstruction using full-thickness skin grafts (FTSGs) after burn injury. Methods Between August 2011 and October 2017, 8 patients with postburn philtrum deformity who underwent FTSG for replacement of the whole upper lip unit with a silastic tube for creation of the philtral dimple were included. A review of photographic documentation was used to evaluate the aesthetic results. Results The size of FTSG ranged from 4 × 9 to 6 × 17 cm. No patient had immediate postoperative complications, such as hematoma, infection, or necrosis. The crests of the ridges preserved their height and length, and the dimple remained visible after an average follow-up of 30.4 months (range, 3–69 months). All patients were satisfied with both functional and aesthetic results. Conclusions This technique of single-stage reconstruction of the upper lip and philtrum with FTSG and silastic tube produced favorable results in the formation of the philtral ridges and the dimple. Through thoughtful preoperative design, meticulous scar release, and skin grafting, satisfactory functional and aesthetic results are achievable.

Marjolin Ulcer: An Observational Epidemiological Study From a Tertiary Care Centre in India Introduction Marjolin ulcer is a rare skin malignancy. Marjolin ulcer arises in zones of long-standing scars, inflammation, or chronic wounds. Material and methods The present study was conducted to assess the demographic profile and identify the predictors of recurrence in 55 patients with Marjolin ulcer admitted over 10 years. Patients underwent either wide local excision with 2-cm peripheral margin or amputation if clinically indicated due to joint involvement. Lymph nodes were dissected if found positive. Patients received adjuvant radiotherapy if tumor clearance was less than 4 mm or the draining lymph nodes were positive. Results Of the total 55 cases (mean age, 48.75 years; range, 24–74 years), 34 were men and 21 were women (male/female, 1.6:1). The most common cause of injury was flame burn (n = 32, 58%) followed by trauma (n = 10, 18%). The lower limb was frequently affected (n = 38, 69.1%). Twenty-six patients with resection margins less than 4 mm had received adjuvant radiotherapy. Among the 55 patients, 6 (11%) had undergone lymph node dissection. Local recurrence was noted within 18 months in 9 (16.35%) patients, of which 5 patients had a tumor-free margin of less than 4 mm. We found 2 predictors for local recurrence. First, moderately differentiated squamous cell carcinoma (P = 0.04) and, second, patients with lymph node involvement (P = 0.001). Conclusion Marjolin ulcer is a high-risk skin tumor. Patients with positive lymph node or with moderately differentiated squamous cell carcinoma have high chances of recurrence. Frequent and intense follow-up is required for at least 2 years.

Risk Factors Associated With Postoperative Recurrence in Patients With Tenosynovial Giant Cell Tumor of the Hand: A Retrospective Cohort Study Identification of risk factors for recurrence of tenosynovial giant cell tumors of the hand is crucial to provide adequate preoperative counseling and tailor surgical treatment. However, the risk factors are still controversial, which are the subject of this research. Recently, we conducted a retrospective cohort study of 135 consecutive patients with giant cell tumors of the tendon sheath of the hand from January 2010 to July 2016. All patients underwent surgical excision, received necessary imaging examinations, and had routine follow-up and thus were identified as those who had recurrence by confirmation of reoperation, and the duration ranged from 24 to 103 months (mean, 53.5 ± 21.4 months). There were 14 local recurrences (10.4%) within 6 to 24 months, respectively, after surgery. Data pertaining to sex, age, tumor sites, tumor size, tumor number, course of disease, bone erosion, tumor growth patterns, anesthesia mode, and the surgeon's experience were all extracted, and Cox regression models were used to estimate recurrence rate with adjustment for potential confounders. According to the Cox regression analysis, the recurrence rate after surgery was significantly higher in patients with a diffused form than in those with a localized one (P = 0.001); in addition, patients with 2 or more tumors had a much higher postoperative recurrence rate than did those with only 1 tumor (P = 0.023). This study suggested that the recurrence rate of tenosynovial giant cell tumors of the hand was closely related to the tumor number and tumor growth patterns.