A 4-Year Institutional Experience of Immediate Lymphatic Reconstruction

BACKGROUND

Up to one in three patients may go on to develop breast cancer-related lymphedema (BCRL) after treatment. Immediate lymphatic reconstruction (ILR) has been shown in early studies to reduce the risk of BCRL, but long-term outcomes are limited because of its recent introduction and institutions' differing eligibility requirements. This study evaluated the incidence of BCRL in a cohort that underwent ILR over the long term.

METHODS

A retrospective review of all patients referred for ILR at the authors' institution from September of 2016 through September of 2020 was performed. Patients with preoperative measurements, a minimum of 6 months of follow-up data, and at least one completed lymphovenous bypass were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence.

RESULTS

A total of 186 patients with unilateral node-positive breast cancer underwent axillary nodal surgery and an attempt at ILR over the study period. Ninety patients underwent successful ILR and met all eligibility criteria, with a mean patient age of 54 ± 12.1 years and median body mass index of 26.6 kg/m 2 [interquartile range (IQR), 24.0 to 30.7 kg/m 2 ]. The median number of lymph nodes removed was 14 (IQR, eight to 19). Median follow-up was 17 months (range, 6 to 49 months). Eighty-seven percent of patients underwent adjuvant radiotherapy, and among them, 97% received regional lymph node irradiation. The overall rate of lymphedema was 9% at the end of the study period.

CONCLUSIONS

With the use of strict follow-up guidelines over the long term, the authors' findings support that ILR at the time of axillary lymph node dissection is an effective procedure that reduces the risk of BCRL in a high-risk patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Trends of Autologous Free-Flap Breast Reconstruction and Safety during the Coronavirus Disease 2019 Pandemic

BACKGROUND

 Autologous free-flap breast reconstruction (ABR) is a valuable surgical option for patients following mastectomy. The coronavirus disease 2019 (COVID-19) pandemic has led to a myriad of factors that have affected access to care, hospital logistics, and postoperative outcomes. This study aims to identify differences in patient selection, hospital course and severity, and postoperative outcomes for patients who underwent ABR during and prior to the COVID-19 pandemic.

METHODS

 Patients undergoing ABR from the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database were analyzed to compare sociodemographics, hospital course, and outcomes over the first postoperative month. Multivariable logistic regression was used to identify factors predictive of complications based on the operative year.

RESULTS

 In total, 3,770 breast free flaps were stratified into two groups based on the timing of reconstruction (prepandemic and pandemic groups). Patients with a diagnosis of disseminated cancer were significantly less likely to undergo ABR during the COVID-19 pandemic. On univariate analysis, there were no significant differences in postoperative complications between the two groups. When controlling for potentially confounding sociodemographic and clinical risk factors, the COVID-19 group was significantly more likely to undergo reoperation compared with the prepandemic group (p < 0.05).

CONCLUSION

 When comparing outcomes for patients who underwent ABR prior to and during the COVID-19 pandemic, we found a significant increase in the odds of reoperation for those who had ABR during the pandemic. Debridement procedures and exploration for postoperative hemorrhage, thrombosis, or infection increased in the prepandemic group compared to the COVID-19 group. Notably, operative times decreased.

Identification of genetic variants associated with anterior cruciate ligament rupture and AKC standard coat color in the Labrador Retriever

Canine anterior cruciate ligament (ACL) rupture is a common complex disease. Prevalence of ACL rupture is breed dependent. In an epidemiological study, yellow coat color was associated with increased risk of ACL rupture in the Labrador Retriever. ACL rupture risk variants may be linked to coat color through genetic selection or through linkage with coat color genes. To investigate these associations, Labrador Retrievers were phenotyped as ACL rupture case or controls and for coat color and were single nucleotide polymorphism (SNP) genotyped. After filtering, ~ 697 K SNPs were analyzed using GEMMA and mvBIMBAM for multivariate association. Functional annotation clustering analysis with DAVID was performed on candidate genes. A large 8 Mb region on chromosome 5 that included ACSF3, as well as 32 additional SNPs, met genome-wide significance at P < 6.07E-7 or Log10(BF) = 3.0 for GEMMA and mvBIMBAM, respectively. On chromosome 23, SNPs were located within or near PCCB and MSL2. On chromosome 30, a SNP was located within IGDCC3. SNPs associated with coat color were also located within ADAM9, FAM109B, SULT1C4, RTDR1, BCR, and RGS7. DZIP1L was associated with ACL rupture. Several significant SNPs on chromosomes 2, 3, 7, 24, and 26 were located within uncharacterized regions or long non-coding RNA sequences. This study validates associations with the previous ACL rupture candidate genes ACSF3 and DZIP1L and identifies novel candidate genes. These variants could act as targets for treatment or as factors in disease prediction modeling. The study highlighted the importance of regulatory SNPs in the disease, as several significant SNPs were located within non-coding regions.

Impact of financial well-being on gender affirmation surgery access and hospital course

BACKGROUND

Although gender affirmation surgery (GAS) can effectively treat gender dysphoria, it remains one of the most expensive components of gender affirming care. This study aims to identify the impact of financial well-being on GAS access and hospital course in the United States.

METHODS

The National Inpatient Sample database was queried from 2012 to 2019. US transgender patients undergoing GAS were identified. Predictors included patient sociodemographic variables. Outcomes included hospitalization course variables. Regression modeling was used to assess the relationship between predictor and outcome variables. Significance was set at α = 0.05.

RESULTS

A total of 5620 weighted GAS encounters were identified (genital surgery 92.3%, chest surgery 16.6%). 1825 (32.5%) patients were in the highest income bracket, compared with 1120 (19.9%) patients in the lowest bracket. Higher income was associated with younger age at the time of GAS. Patients in the highest income quartile were also 3.7 times more likely to be funded by private insurance and self-pay options than those in the lowest income quartile (95% confidence interval [CI]: 3.1-4.4, p < 0.0001). Additionally, patients in the lowest income quartile were 4.2 times more likely to require either home healthcare or transfer to a nursing facility post discharge than those in the highest income quartile (95% CI: 3.1-5.8, p < 0.001).

CONCLUSIONS

To promote equitable care to transgender patients, efforts to reduce financial barriers to healthcare access are much needed, particularly through broader insurance coverage of GAS procedures. Broadly, our results highlight the impact of socioeconomic variables on healthcare access and outcomes.

Sources of Facial Injury Across Age Groups: A Nationwide Overview Using the National Electronic Injury Surveillance System Database

BACKGROUND

Facial trauma comprises a significant portion of injuries that occur each year in the United States, with injuries ranging from lacerations to complex facial fractures. This study aims to provide a broad epidemiologic overview of facial trauma in the United States to direct preventative safety measures.

METHODS

A cross-sectional study was conducted utilizing the National Electronic Injury Surveillance System database to identify the weighted national incidence of facial injuries from 2017 to 2021. Descriptive and inferential statistical analysis was used to compare the demographics of patients, the settings where the injury occurred, and the products resulting in the injury.

RESULTS

A total of 8,465,538 out of 64,312,132 weighted encounters involved facial injuries. Less than 10 years was the highest-represented age group (36.8%). The most frequent disposition was treated and released (91.1%), with increasing age associated with higher rates of hospitalization (odds ratio: 1.04, P < 0.001). Cases predominantly occurred at home (49.0%), and the most common type of injury was laceration (36.5%). At-home injuries increased with age, comprising 39.2% of facial injuries for 21 to 40 years, 52.0% for 41 to 64 years, and 58.0% for older than 65 years. Building structures (21.4%) were the most prevalent source of injury, composed predominantly of floors (58.3%) and ceilings and walls (10.4%).

CONCLUSIONS

There is an understated burden of at-home facial injuries across all age groups, beyond the pediatric and geriatric population. Fall prevention and home environmental hazards education could benefit all ages, reducing the incidence of facial trauma.

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer-Related Lymphedema

BACKGROUND

The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo.

METHODS

Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data.

RESULTS

Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant.

CONCLUSION

Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, V.

A National Analysis of Socioeconomic Variables of Access to Inpatient Body Contouring Procedures After Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS

NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS

A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS

There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

Edematous Dermal Thickening on Magnetic Resonance Imaging as a Biomarker for Lymphatic Surgical Outcomes

Background and Objectives: One of the surgical treatments for breast cancer-related lymphedema (BCRL) is debulking lipectomy. The aim of this study is to investigate whether dermal thickness could be utilized as an objective indicator of post-operative changes following debulking. Materials and Methods: A retrospective review of BCRL patients who underwent debulking lipectomy was conducted. MRI-based dermal thickness was measured by two separate trained readers at 16 regions of the upper extremity. Pre- and post-operative reduction in dermal thickness was compared across the affected and unaffected (control) arms for each patient. The Wilcoxon rank sum test was used to assess for significant change. Univariate linear regression was used to assess the relationship between dermal thickness reduction and changes to LYMPH-Q scores, L-Dex scores, and relative volume change. Results: Seventeen patients were included in our analysis. There was significant reduction in dermal thickness at 5/16 regions in the affected arm. Dermal thickness change was significantly correlated with LYMPH-Q scores, L-Dex scores, and relative volume change in 2/16 limb compartments. There was predominant dermal thickening in the dorsal compartment of the upper arm and in the ventral and ulnar compartments of the forearm. Conclusions: Dermal thickness shows promising utility in tracking post-operative debulking procedures for breast cancer-related lymphedema. Further studies with larger patient populations and a variety of imaging modalities are required to continue to develop a clinically objective and reproducible method of post-surgical lymphedema staging and monitoring.

Non-Linear Lymphatic Anatomy in Breast Cancer Patients Prior to Axillary Lymph Node Dissection: A Risk Factor For Lymphedema Development

Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has become increasingly utilized for the prevention of breast cancer related lymphedema. Preoperative indocyanine green (ICG) lymphography is routinely performed prior to an ILR procedure to characterize baseline lymphatic anatomy of the upper extremity. While most patients have linear lymphatic channels visualized on ICG, representing a non-diseased state, some patients demonstrate non-linear patterns. This study aims to determine potential inciting factors that help explain why some patients have non-linear patterns, and what these patterns represent regarding the relative risk of developing postoperative breast cancer related lymphedema in this population. A retrospective review was conducted to identify breast cancer patients who underwent successful ILR with preoperative ICG at our institution from November 2017-June 2022. Among the 248 patients who were identified, 13 (5%) had preoperative non-linear lymphatic anatomy. A history of trauma or surgery of the affected limb and an increasing number of sentinel lymph nodes removed prior to ALND appeared to be risk factors for non-linear lymphatic anatomy. Furthermore, non-linear anatomy in the limb of interest was associated with an increased risk of postoperative lymphedema development. Overall, non-linear lymphatic anatomy on pre-operative ICG lymphography appears to be a risk factor for developing ipsilateral breast cancer-related lymphedema. Guided by the study's findings, when breast cancer patients present with baseline non-linear lymphatic anatomy, our institution has implemented a protocol of prophylactically prescribing compression sleeves immediately following ALND.

The use of abdominal wall tissue expansion prior to herniorrhaphy in massive ventral hernia defects

BACKGROUND

Massive ventral hernias pose a challenging reconstructive problem. In comparison to bridging mesh repair, the primary fascial repair is associated with significantly reduced rates of hernia recurrence. This study will review our experience with massive ventral hernia repairs using tissue expansion and anterior component separation as well as present the largest case series to date.

METHODS

A retrospective review was conducted of 61 patients who underwent abdominal wall tissue expansion prior to herniorrhaphy at a single institution between 2011 and 2017. Demographics, perioperative co-variates, and outcomes were recorded. Univariate and subgroup analysis was performed. Kaplan-Meier survival analysis was used to assess the time to recurrence.

RESULTS

Sixty-one patients underwent abdominal wall expansion via tissue expanders (TE). Of these, 56 subsequently underwent staged anterior component separation for attempted closure of large ventral hernia. Major complications of TE placement included TE replacement (4,6.6%), TE leak (2,3.3%), and unplanned readmission (3,4.9%). Higher BMI groups were significantly associated with comorbid hypertension (BMI<30 kg/m², 22.7%; BMI 30-35 kg/m², 68.7%; BMI>35 kg/m², 64.7%; P = 0.004). 15 patients (32.6%) had hernia recurrence and 21 patients (34.4%) still required bridging mesh during herniorrhaphy after tissue expansion.

CONCLUSION

The use of tissue expansion prior to herniorrhaphy can be effective in achieving durable closure for most massive abdominal wall defects - especially those associated with musculofascial, soft tissue, or skin deficiencies. In this proof-of-concept analysis, we found that the efficacy and safety profile of this technique compares favorably to other methods for massive hernia repair in the literature.

Which Groups of Plastic Surgery Patients are Impacted by Social Media Use: An In-Depth Review of Social Media Engagement

BACKGROUND

Empowerment is the process in which patients gain greater control of their health through active and informed decision making. Greater patient empowerment has shown to be positively correlated with improved healthcare outcomes and experiences. It is unclear how social media impacts plastic and reconstructive surgery (PRS) patients' healthcare decision making. This study aims to help quantify how social media sites influence levels of PRS patient empowerment.

METHODS

In this cross-sectional study, a modified Cyber Info-Decisional Empowerment Scale (CIDES)survey was distributed through Amazon Mechanical Turk (mTurk) to U.S. adults. Sociodemographics, PRS history, social media usage and data collected. Wilcoxon signed-rank test and Kruskal-Wallis tests were used to assess for heterogeneity for categorical variables. ANOVA and t-tests were used to evaluate differences in means for Likert scale-based responses.

RESULTS

473 survey responses were included. The participants were grouped based on their surgical history: cosmetic (187, 39.5%), reconstructive (107, 22.6%), both cosmetic and reconstructive (36, 7.6%), and non-PRS (143, 30.2%). There was increased empowerment depending on the online resources used. Specifically, social media was associated with significantly greater empowerment in six of seven CIDES categories. Of the social media platforms, Facebook was associated with higher empowerment in three of seven CIDES categories.

CONCLUSION

Social media use appears to positively impact PRS patients' empowerment, which may reflect better patient decision making and autonomy when consulting with their plastic surgeon.

Correlation of Scholarly Activity and Departmental Clinical Productivity in a Surgical Subspecialty

INTRODUCTION

Promotion within academic surgery involves demonstrated excellence in administrative, clinical, and scholarly activities. The present study analyzes the relationship between scholarly and clinical productivity in the field of reconstructive microsurgery.

METHODS

This is a retrospective cohort study of microsurgery fellowship directors (MFDs). Data on clinical productivity were obtained from the American Society for Reconstructive Microsurgery and scholarly productivity from Scopus. Outcomes were department annual free flap volume, number of publications, and h-index. Descriptive statistics were calculated, and nonparametric tests were used to compare continuous variables.

RESULTS

Thirty-nine MFDs were included in this study. All were plastic surgery residency trained and 38% trained under the independent training pathway. Most underwent formal fellowship training in reconstructive microsurgery (89%). The top three microsurgery fellowships trained 37% of all MFDs. Twenty-five percent of MFDs trained at the institution where they ultimately became program director. Twenty percent of MFDs had an additional degree (4 MS, 2 PhD, and 1 MBA). The median number of annual free flaps performed per institution was 175 (interquartile range [IQR] 122). The median h-index was 17 (IQR 13) resulting from 48 (IQR 99) publications. There was a correlation between department annual free flap volume and h-index (r = 0.333, P = 0.038).

CONCLUSIONS

There is a correlation between academic productivity of MFDs and the clinical productivity of their department. This study provides a benchmark for aspiring reconstructive microsurgeons.

Post-Mastectomy Tissue Expander Placement Followed by Radiation Therapy: A Cost-Effectiveness Analysis of Staged Autologous Versus Implant-Based Unilateral Reconstruction

BACKGROUND

There is no preferred approach to breast reconstruction for patients with locally advanced breast cancer (LABC) who require post-mastectomy radiation therapy (PMRT). Staged implant and autologous reconstruction both have unique risks and benefits. No previous study has compared their cost-effectiveness with utility scores.

METHODS

A literature review determined the probabilities and outcomes for mastectomy and staged implant or autologous reconstruction. Utility scores were used to calculate the quality-adjusted life years (QALYs) associated with successful surgery and postoperative complications. Medicare billing codes were used to assess costs. A decision analysis tree was constructed with rollback and incremental cost-effectiveness ratio (ICER) analyses. Sensitivity analyses were performed to validate results and account for uncertainty.

RESULTS

Mastectomy with staged deep inferior epigastric perforator (DIEP) flap reconstruction is costlier ($14,104.80 vs $3216.93), but more effective (QALYs, 29.96 vs 24.87). This resulted in an ICER of 2141.00, favoring autologous reconstruction. One-way sensitivity analysis showed that autologous reconstruction was more cost-effective if less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective.

CONCLUSIONS

For patients with LABC who require PMRT, staged autologous reconstruction is significantly more cost-effective than reconstruction with implants. Despite the decreased morbidity, staged implant reconstruction has greater rates of complication.

Outpatient Prosthetic Based Reconstruction During COVID-19 Pandemic Possible in Selected Patients Without Increased Complications

BACKGROUND

Following the reopening of elective surgery, our division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential COVID-19 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction.

METHODS

A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient surgeries. Odds ratios were calculated to determine whether any pre-operative factors increased odds of 30-day complications.

RESULTS

A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR: 0.275, 95% CI: 0.047-1.618, p = 0.153). Patients with complications had significantly longer median operating times (5.0, IQR 4.0 - 6.0 vs. 4.0, IQR 3.0 - 5.0, p = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR: 1.596, 95% CI: 1.039-2.451, p = 0.033). Age was independently associated with increased risk of 30-day complication (OR: 1.062, 95% CI: 1.010-1.117, p = 0.020).

CONCLUSIONS

Our findings support a continuation of same-day discharge strategy which could decrease costs for patients and hospitals without increasing complications.

Underreporting and Underrepresentation of Racial and Ethnic Minority Patients in Lymphedema Clinical Trials: A Systematic Review

The generalizability of findings from Clinical Trials (CTs) investigating lymphedema treatment modalities requires an accurate representation of the target population. This study aims to evaluate racial and ethnic reporting and representation in lymphedema CTs. A comprehensive systematic literature search was conducted during May 2023 using multiple databases, following the PRISMA guidelines. All CTs published from 2018 to 2023 were included. A total of 84 articles were included in this review, from which 6,546 participants were included in the analysis. Seventy-four (88.1%) articles addressed secondary lymphedema, of which 60 (81.1%) were related to breast cancer. Only 12 (13%) of CTs reported at some extend race or ethnicity. Of these, five (41.6%) reported race and two (16.6%) reported ethnicity according to FDA guidelines. White race had the highest pooled prevalence (80%; 95% CI 72-86%; I2=90%), followed by Black (7%; 95% CI 2- 15%; I2= 94.3%) and Asian (4%; 95% CI 1-8%; I2= 89.9%). In studies reporting ethnicity, participants were predominantly non-Hispanic (92.1%; 95% CI 90 - 94%). There is an underreporting and underrepresentation of racial and ethnic minorities among lymphedema CTs, limiting their generalizability. It is imperative to future development of strategies to enhance diversity in the study sample.

Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery

BACKGROUND

In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery.

METHODS

A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement.

RESULTS

Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90^o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments.

CONCLUSION

ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Readability, Understandability, Usability, and Cultural Sensitivity of Online Patient Educational Materials (PEMs) for Lower Extremity Reconstruction: A Cross-Sectional Study

Background: Lower extremity reconstructive surgery is an evolving field wherein patients rely on accessible online materials to engage with their perioperative care. This study furthers existing research in this area by evaluating the readability, understandability, actionability, and cultural sensitivity of online health materials for lower extremity reconstruction. Methods: We identified the 10 first-appearing, educational sites found by searching the phrases “leg saving surgery”, “limb salvage surgery,” and “leg reconstruction surgery”. Readability analysis was conducted with validated tools, including Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed with Patient Education and Materials Assessment Tool (PEMAT), while cultural sensitivity was measured with Cultural Sensitivity Assessment Tool (CSAT). A Cohen's κ value was calculated (PEMAT and CSAT analyses) for inter-rater agreement. Results: The mean SMOG reading level for websites was 13.12 (college-freshman reading level). The mean PEMAT understandability score was 61.8% and actionability score was 26.0% (κ = 0.8022), both below the 70% acceptability threshold. The mean CSAT score was 2.6 (κ = 0.73), exceeding the 2.5 threshold for cultural appropriateness. Conclusion: Online PEM for lower extremity reconstruction continue to fall below standards of readability, understandability, and actionability; however, they meet standards of cultural appropriateness. As patients rely on these materials, creators can use validated tools and positive examples from existing PEM for greater patient accessibility.

Plastic Surgery Residency Applicants' Perceptions of a Virtual Interview Cycle

BACKGROUND

The 2020-2021 residency application cycle marked the first year of fully virtual integrated plastic surgery interviews. The virtual format was a double-edged sword for applicants with several advantages such as reduced costs and time lost from travel and disadvantages as the novel format introduced new stressors on top of an already demanding process. Concerns included unfair interview invitation (II) distribution, interview "hoarding," and assessing "fit" virtually. In this study, we aimed to understand applicants' experiences of the 2020-2021 virtual plastic surgery interview cycle.

METHODS

A survey was sent to 330 applicants in the 2020-2021 integrated plastic surgery application cycle. The survey included questions about participant demographics, pre-interview preparation, virtual interview experiences, and post-interview process. Statistical comparisons were performed on responses using SPSS.

RESULTS

Eighty-nine participants responded to the survey, representing a 27.0% response rate. Applicants received an average of 13.3 IIs (range 0-45) and attended an average of 11.4 interviews (range 0-30). Almost half (48.2%) did not feel IIs were distributed equitably and more than half (68.2%) reported that there should be a limit on the number of IIs an applicant can accept. The majority of respondents (88.1%) reported spending $500 or less on virtual interviews. Half (50.6%) participated in virtual sub-internships, of which 30.4% became significantly less interested in a program afterwards.

CONCLUSIONS

The inaugural virtual interview cycle had several advantages and disadvantages. Lessons learned from this year could be utilized towards building a more equitable, fair, and effective potential virtual cycle in years to come.

Misconceptions, myths, and mystery: A Cross-Sectional Survey Study on Public Knowledge and Values of Microsurgery

BACKGROUND

Microsurgery is a foundational plastic surgery principle. However, public unawareness of microsurgery and its associated rigorous training in the USA, may contribute to current misconceptions and undervaluing of plastic and reconstructive surgeons (PRS). This study aims to characterize public knowledge of microsurgery.

METHODS

A cross-sectional survey was conducted from August to September 2021 using Amazon Mechanical Turk to assess baseline public knowledge of microsurgery. A multivariable logistic regression model was constructed to evaluate the association between baseline knowledge and demographic characteristics. Significance was set to a p<0.05.

RESULTS

A total of 516 responses were analyzed. The mean age was 36.7 SD 16.04 years (White 84%, and non-Hispanic 70%). Of those surveyed, 52% agreed that general surgeons perform microsurgery, while only 28% agreed that PRS perform microsurgery. When asked if head and neck reconstruction, breast reconstruction, and finger replantation required microsurgery, only 28%, 41%, and 41% of respondents agreed, respectively. When controlled for sociodemographic factors, Hispanics had significantly more odds to mistake that head and neck reconstruction did not require microsurgery (OR 0.49, 0.30-0.80, p 0.004) and less odds to consider PRS for reconstruction (OR 0.51, 0.32-0.84, p 0.008). Females had 1.63 more odds of considering PRS for reconstruction (1.09-2.43 p 0.017). Low-educated subjects had significantly more odds to consider general surgeons as those who performed reconstructive microsurgery (OR 8.70, 1.09-69.40, p 0.041) Conclusions: Misconceptions of microsurgery as a foundational principle of plastic surgery persist and correlate with undervaluing the specialty. Knowledge differs by ethnicity, level of education, and gender. Therefore, patient counseling should use culturally appropriate elements to demystify microsurgery, build value, and better inform risks and benefits.