The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, EMBASE and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared to the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0% vs. 10.4%) but less donor-site complications (20.2% vs. 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps (P = 0.0006) but no statistical difference in speech and swallowing function following reconstruction (P = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

Oncological scoring systems in surgery are used as evidence-based decision aids to best support management through assessing prognosis, effectiveness and recurrence. Currently, the use of scoring systems in the hepato-pancreato-biliary (HPB) field is limited as concerns over precision and applicability prevent their widespread clinical implementation. The aim of this review was to discuss clinically useful oncological scoring systems for surgical management of HPB patients. A narrative review was conducted to appraise oncological HPB scoring systems. Original research articles of established and novel scoring systems were searched using Google Scholar, PubMed, Cochrane, and Ovid Medline. Selected models were determined by authors. This review discusses nine scoring systems in cancers of the liver (CLIP, BCLC, ALBI Grade, RETREAT, Fong’s score), pancreas (Genç’s score, mGPS), and biliary tract (TMHSS, MEGNA). Eight models used exclusively objective measurements to compute their scores while one used a mixture of both subjective and objective inputs. Seven models evaluated their scoring performance in external populations, with reported discriminatory c-statistic ranging from 0.58 to 0.82. Selection of model variables was most frequently determined using a combination of univariate and multivariate analysis. Calibration, another determinant of model accuracy, was poorly reported amongst nine scoring systems. A diverse range of HPB surgical scoring systems may facilitate evidence-based decisions on patient management and treatment. Future scoring systems need to be developed using heterogenous patient cohorts with improved stratification, with future trends integrating machine learning and genetics to improve outcome prediction.

Background Virtual supervisory relationships provide an infrastructure for flexible learning, global accessibility, and outreach, connecting individuals worldwide. The surge in web-based educational activities in recent years provides an opportunity to understand the attributes of an effective supervisor-student or mentor-student relationship. Objective The aim of this study is to compare the published literature (through a critical review) with our collective experiences (using small-scale appreciative inquiry [AI]) in an effort to structure and identify the dilemmas and opportunities for virtual supervisory and mentoring relationships, both in terms of stakeholder attributes and skills as well as providing instructional recommendations to enhance virtual learning. Methods A critical review of the literature was conducted followed by an AI of reflections by the authors. The AI questions were derived from the 4D AI framework. Results Despite the multitude of differences between face-to-face and web-based supervision and mentoring, four key dilemmas seem to influence the experiences of stakeholders involved in virtual learning: informal discourses and approachability of mentors; effective virtual communication strategies; authenticity, trust, and work ethics; and sense of self and cultural considerations. Conclusions Virtual mentorship or supervision can be as equally rewarding as an in-person relationship. However, its successful implementation requires active acknowledgment of learners’ needs and careful consideration to develop effective and mutually beneficial student-educator relationships.

Innovation: Is It Possible to Speed the Introduction of New Technology While Simultaneously Improving Patient Safety?'' 1 In his submitted Letter to the Editor, he emphasizes the need to keep the patient at the center of the innovation process, for both surgery and medicine. Certainly, we would agree with this concept. In our publication, we outlined the vetting process for each new innovation under consideration, noting, in particular, that one of the core components of the process was specific scrutiny regarding three attributes of each proposed innovation: feasibility, safety, and efficacy. In effect, this component of the evaluation directly challenged the surgical innovator to define exactly what aspect of patient care would be improved by the innovation (eg, faster recovery, improved function, quality of life). When an innovation fails to address the quality of care, 2 then there is only innovation for innovations sake.Our publication describes a governance structure that facilitated safe introduction of novel procedures, device applications, and devices themselves to clinical care. Out of scope of this process, and therefore not included in this report, was the important corollary concepts of human-centered design in the development of novel products. Surgeons would do well to learn more about these ideation concepts, most particularly, the value of deep knowledge of patient experience that can only come from close observation and ''walking in their shoes,'' where innovations are created intentionally to solve specific problems that impact our patients. 3 Too often, our innovations are the result of serendipity. The scope and scale of our innovations could be accelerated by the combination of adherence to design principles that focus on product-market fit and by committees like the CQIT which bring these concepts from idea to bedside efficiently and without harm.