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Lucente V, Wright M, Pisan J, Shenoy S, Yedlock R. Single Incision Midurethral Sling Site of Care: Office-based Ambulatory Surgical Unit versus Hosptial-based Ambulatory Surgical Unit Setting. J Minim Invasive Gynecol 2023; 30:665-671. [PMID: 37088282 DOI: 10.1016/j.jmig.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
STUDY OBJECTIVE To compare the economic difference in terms of overall costs between two Ambulatory Surgical Unit (ASU) settings in which a midurethral single incision sling (MSIS) can be performed. DESIGN A retrospective cohort study was carried out, examining the implanting of an MSIS performed at two different ASU settings by a single surgeon. Total cost was determined by assessing differences in charges and subsequent reimbursement associated with the procedure at each ASU setting. Time was measured using an EMR system for tracking both patient entry/exit from the facility as well as intraoperative time. Adverse events commonly associated with the procedure and patient-reported unanticipated adverse events were collected. A validated Surgical Satisfaction Questionnaire was administered postoperatively. SETTING University Health Network Teaching Hospital. PATIENTS A total of 125 women with stress urinary incontinence. INTERVENTION MSIS. MEASUREMENT AND MAIN RESULTS Between January 2016 until August 2020, 125 women underwent an MSIS procedure. The total office-based ASU (O-ASU) charges averaged $4564.00 (reimbursement of $2642.07). The total hospital-based ASU (H-ASU) charges averaged $40 136 (reimbursement of $9000), as well as an anesthesia average charge of $800 (reimbursement of $500). The average O-ASU total patient encounter time was 53.76 minutes versus 344.702 minutes for the H-ASU. There was no difference between commonly associated or unanticipated adverse events nor global patient satisfaction. CONCLUSIONS Based on overall cost, total encounter time, and global patient satisfaction, a certified O-ASU is an optimal site of care for MSIS for surgical management of female stress urinary incontinence.
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Affiliation(s)
- Vincent Lucente
- Institute for Female Pelvic Medicine and Reconstructive Surgery (Drs. Lucente and Wright), Allentown, PA.
| | - Micah Wright
- Institute for Female Pelvic Medicine and Reconstructive Surgery (Drs. Lucente and Wright), Allentown, PA; Department of Minimally Invasive Gynecology (Drs. Wright and Pisan), St. Luke's University Health Network, Bethlehem, PA; Council Oak Comprehensive Health Care (Dr. Wright), Tulsa, OK
| | - John Pisan
- Department of Minimally Invasive Gynecology (Drs. Wright and Pisan), St. Luke's University Health Network, Bethlehem, PA
| | - Sachin Shenoy
- Department of Minimally Invasive Gynecologic Surgery (Dr. Shenoy), University of Alabama, Tuscaloosa, AL
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Abstract
Importance As health care providers are increasingly motivated to perform office procedures, there is marginal training and attention related to crisis management (CM). Objective We review the CM in office gynecology and illustrate the value of applying the STOP (stop, think, observe, plan) mental framework to acute management of office hysteroscopy complications. Evidence Acquisition We performed a literature review on crisis management in gynecology. Results Concepts of team leadership, simulation training, awareness of human error, and panic control are implemented in CM. Conclusions Health care providers need to be cognizant of the importance of CM for optimizing patient safety and quality improvement and consider its application on office-based procedures. Relevance Crisis management has become increasingly relevant in the outpatient setting, seeking to better equip physicians with the skills to manage adverse outcomes while performing office-based procedures.
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Miscarriage Treatment-Related Morbidities and Adverse Events in Hospitals, Ambulatory Surgery Centers, and Office-Based Settings. J Patient Saf 2021; 16:e317-e323. [PMID: 30516583 PMCID: PMC7678655 DOI: 10.1097/pts.0000000000000553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of the study was to examine whether miscarriage treatment-related morbidities and adverse events vary across facility types. METHODS A retrospective cohort study compared miscarriage treatment-related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database. The main outcome was miscarriage treatment-related morbidities and adverse events occurring within 6 weeks of miscarriage treatment. Secondary outcomes were major events and infections. RESULTS A total of 97,374 miscarriage treatments met inclusion criteria. Most (75%) were provided in hospitals, 10% ASCs, and 15% office-based settings. A total of 9.3% had miscarriage treatment-related events, 1.0% major events, and 1.5% infections. In adjusted analyses, there were fewer events in ASCs (6.5%) than office-based settings (9.4%) and hospitals (9.6%), but no significant difference between office-based settings and hospitals. There were no significant differences in major events between ASCs (0.7%) and office-based settings (0.8%), but more in hospitals (1.1%) than ASCs and office-based settings. There were fewer infections in ASCs (0.9%) than office-based settings (1.2%) and more in hospitals (1.6%) than ASCs and office-based settings. In analyses stratified by miscarriage treatment type, the difference between ASCs and office-based settings was no longer significant for miscarriages treated with procedures. CONCLUSIONS Although there seem to be slightly more events in hospitals than ASCs or office-based settings, findings do not support limiting miscarriage treatment to particular settings.
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Dunton CJ, Eskander RN, Bullock RG, Pappas T. Low-risk multivariate index assay scores, physician referral and surgical choices in women with adnexal masses. Curr Med Res Opin 2020; 36:2079-2083. [PMID: 33107342 DOI: 10.1080/03007995.2020.1842726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the use of Multivariate Index Assay (MIA OVA1) by gynecologists and determine referral practices and surgical decision making for women with adnexal masses and low-risk MIA OVA1 scores. METHODS Information on patients who received an OVA1 test was collected retrospectively from 22 gynecologic practices through a chart review. Referral patterns were examined for patients with low-risk OVA1 results prior to first surgical intervention. Chart reviews were from a variety of practice and hospital settings representing major geographic regions within the United States. RESULTS A total of 282 independent patient charts were reviewed. Low-risk results were found for 146 patients (52%). Surgery was performed on 82 (56%) patients with low-risk scores. The referral rate to specialty care was 21% (17/82) for low-risk OVA1 patients. Three low-malignant potential tumors were identified in the low-risk patients, with no cases of invasive malignancy. Eighty-six percent of the surgeries performed on low-risk OVA1 patients were minimally invasive. In 44% of the low-risk OVA1 patients, no surgical intervention was performed. CONCLUSIONS A high proportion of low-risk OVA1 patients were not referred to a gynecologic oncologist prior to surgery, indicating gynecologists may use MIA OVA1 along with clinical and radiographic findings to appropriately retain patients for their care. This practice is safe and may be cost-saving, with patient satisfaction implications.
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Affiliation(s)
| | - Ramez N Eskander
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, La Jolla, CA, USA
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Aurshina A, Ostrozhynskyy Y, Alsheekh A, Kibrik P, Chait J, Marks N, Hingorani A, Ascher E. Safety of vascular interventions performed in an office-based laboratory in patients with low/moderate procedural risk. J Vasc Surg 2020; 73:1298-1303. [PMID: 33065244 DOI: 10.1016/j.jvs.2020.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE An exponential increase in number of office-based laboratories (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office-based procedures directed to the objective to assess safety of vascular procedures in OBLs. METHODS A retrospective analysis was performed to include all procedures performed over a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I, venous procedures; group II, arterial; group III, arteriovenous; and group IV, inferior vena cava filter placement procedures. Local anesthesia, analgesics, and conscious sedation were used in all interventions, individualized to the patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. RESULTS Nearly 6201 procedures were performed in 2779 patients from 2011 to 2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852 females (67%) and 928 males (33%). In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group II, 238 arterial procedures (125 femoral/popliteal, 71 infrapopliteal, iliac 42); group III, 129 arteriovenous accesses; and group IV, 51 inferior vena cava filter placements. The majority of procedures belonged to American Society of Anesthesiology class II with venous (61%) and arterial (74%) disease. A total of 5% patients were deemed American Society of Anesthesiology class IV (all on hemodialysis). There was no OBL mortality, major bleed, acute limb ischemia, myocardial infarction, stroke, or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). Thirty-day mortality, unrelated to the procedure, was noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the four groups. CONCLUSIONS Our data suggest that it is safe to use OBL for minimally invasive, noncomplex vascular interventions in patients with a low to moderate cardiovascular procedural risk.
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Affiliation(s)
- Afsha Aurshina
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY.
| | - Yuriy Ostrozhynskyy
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Ahmad Alsheekh
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Pavel Kibrik
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Jesse Chait
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Natalie Marks
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Anil Hingorani
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Enrico Ascher
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
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Schimberg AS, Wellenstein DJ, van den Broek EM, Honings J, van den Hoogen FJA, Marres HAM, Takes RP, van den Broek GB. Office-based vs. operating room-performed laryngopharyngeal surgery: a review of cost differences. Eur Arch Otorhinolaryngol 2019; 276:2963-2973. [PMID: 31486936 PMCID: PMC6811667 DOI: 10.1007/s00405-019-05617-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/24/2019] [Indexed: 02/07/2023]
Abstract
Purpose Office-based transnasal flexible endoscopic surgery under topical anesthesia has recently been developed as an alternative for transoral laryngopharyngeal surgery under general anesthesia. The aim of this study was to evaluate differences in health care costs between the two surgical settings. Methods PubMed, EMBASE and Cochrane Library were searched for studies reporting on costs of laryngopharyngeal procedures that could either be performed in the office or operating room (i.e., laser surgery, biopsies, vocal fold injection, or hypopharyngeal or esophageal dilation). Quality assessment of the included references was performed. Results Of 2953 identified studies, 13 were included. Quality assessment revealed that methodology differed significantly among the included studies. All studies reported lower costs for procedures performed in the office compared to those performed in the operating room. The variation within reported hospital and physician charges was substantial. Conclusion Office-based laryngopharyngeal procedures under topical anesthesia result in lower costs compared to similar procedures performed under general anesthesia. Electronic supplementary material The online version of this article (10.1007/s00405-019-05617-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anouk S Schimberg
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.
| | - David J Wellenstein
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Eline M van den Broek
- Center for Health Services Research, Larner College of Medicine, University of Vermont, Burlington, USA
| | - Jimmie Honings
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Henri A M Marres
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Robert P Takes
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Guido B van den Broek
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
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Percutaneous Vertebral Augmentation for Vertebral Compression Fractures: National Trends in the Medicare Population (2005-2015). Spine (Phila Pa 1976) 2019; 44:123-133. [PMID: 30562331 DOI: 10.1097/brs.0000000000002893] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of Medicare data OBJECTIVE.: To analyze trends of vertebral augmentation in the elderly Medicare population in the context of evolving evidence and varied medical society opinions. SUMMARY OF BACKGROUND DATA Percutaneous vertebral augmentation offers a minimally invasive therapy for vertebral compression fractures. Numerous trials have been published on this topic with mixed results. The impact of these studies and societal recommendations on physician practice patterns is not well understood. METHODS The Centers for Medicare and Medicaid Services annual Medicare Physician Supplier Procedure Summary database was examined for kyphoplasty and vertebroplasty procedures from 2005 through 2015. Top provider specialties were determined based on annual procedural volume, and grouped into the three broad categories of radiology, surgery, and anesthesia/pain medicine. Data entries were independently analyzed by provider type, site of service, submitted charges, and reimbursement rates for interventions during the study period. RESULTS Between 2005 and 2015 total annual claims for vertebral augmentation procedures in the Medicare population increased from 108.11% (37,133-77,276) peaking in 2008 and declining by 15.56% in 2009. Radiology is the largest provider of vertebral augmentation by specialty with declining market shares from 71% in 2005 to 43% in 2015. The frequency of vertebroplasty declined by 61.7% (35,409-13,478) from 2005 to 2015 with reduction in Medicare reimbursement. Annual volume of kyphoplasty grew by 18.3% (48,725-57,646) with significant increase in reimbursement for office-based procedures ($728.50/yr, P < 0.001, R = 0.69). CONCLUSION The annual volume of vertebral augmentation declined in 2009 following two negative trials on vertebroplasty. Although these publications had a persistent negative impact on practice of vertebroplasty, the overall frequency of vertebral augmentation in the Medicare population has not changed significantly between 2005 and 2015. Instead, there has been a significant shift in provider practice patterns in favor of kyphoplasty in increasingly outpatient and office-based settings. LEVEL OF EVIDENCE 3.
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Scott GM, Diamond C, Micomonaco DC. Assessment of a Lateral Nasal Wall Block Technique for Endoscopic Sinus Surgery Under Local Anesthesia. Am J Rhinol Allergy 2018; 32:318-322. [PMID: 29683003 DOI: 10.1177/1945892418770263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction With increasingly limited operative resources and patient desires for minimally invasive procedures, there is a trend toward local endoscopic procedures being performed in the outpatient clinic setting. However, there remain limited data supporting a technique to adequately anesthetize the lateral nasal wall and provide patient comfort during these procedures. The objective of this study is to assess the efficacy of a novel lateral nasal wall block for use in office-based endoscopic sinus surgery. Methods A prospective cohort study assessing consecutive patients undergoing office-based endoscopic sinus surgery using our described lateral nasal wall block anesthesia technique. Procedural patient comfort was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS), completed by participants immediately following an office-based endoscopic procedure and prior to discharge from clinic. Postoperative analgesic use was assessed at the first postoperative visit. Results Thirty-five consecutive patients undergoing office-based outpatient endoscopic sinus surgery for chronic rhinosinusitis (with and without polyps) were assessed. The mean ISAS score was 2.83 (95% confidence interval: [2.69, 2.97]). All participants (100%) agree or strongly agree that they were satisfied with their anesthesia care and would want the same anesthetic again. No participant required narcotic analgesia, and 80% used no oral analgesia following the procedure. Conclusions Recent advances in office-based endonasal surgical procedures must be accompanied by the assessment and validation of local anesthetic techniques. The described novel lateral nasal wall block is well tolerated, provides patient satisfaction, and allows for limited use of postprocedure oral analgesics.
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Affiliation(s)
- Grace M Scott
- 1 Department of Otolaryngology-Head & Neck Surgery, Algoma District Medical Group, Northern Ontario School of Medicine, Sault Ste. Marie, Ontario, Canada
| | - Chris Diamond
- 2 Division of Otolaryngology-Head & Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Damian C Micomonaco
- 1 Department of Otolaryngology-Head & Neck Surgery, Algoma District Medical Group, Northern Ontario School of Medicine, Sault Ste. Marie, Ontario, Canada
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Rogers JD, Sanders P, Piorkowski C, Sohail MR, Anand R, Crossen K, Khairallah FS, Kaplon RE, Stromberg K, Kowal RC. In-office insertion of a miniaturized insertable cardiac monitor: Results from the Reveal LINQ In-Office 2 randomized study. Heart Rhythm 2017; 14:218-224. [DOI: 10.1016/j.hrthm.2016.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gupta V, Parikh R, Nguyen L, Afshari A, Shack RB, Grotting JC, Higdon KK. Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities. Aesthet Surg J 2017; 37:226-235. [PMID: 27553613 DOI: 10.1093/asj/sjw138] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned. OBJECTIVES This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals. METHODS A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed. RESULTS Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01). CONCLUSIONS Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Varun Gupta
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - Rikesh Parikh
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - Lyly Nguyen
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - Ashkan Afshari
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - R Bruce Shack
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - James C Grotting
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
| | - K Kye Higdon
- Drs Gupta and Higdon are Assistant Professors, Drs Nguyen and Afshari are Research Fellows, and Dr Shack is a Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Dr Nguyen is also a General Surgey Resident, Department of Surgery, Morristown Medical Center, Morristown, NJ, and Dr Afshari is also a General Surgery Resident, Department of General Surgery, University of South Carolina, Columbia, SC. Dr Parikh is a plastic surgeon in private practice in Bellevue, WA. Dr Grotting is a Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, AL; and CME/MOC Section Editor for Aesthetic Surgery Journal
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