The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures

Aesthetic training concept during plastic surgery residency - Opportunity or risk?

Background

Aesthetic surgery training renders to be challenging to acquire sufficient hands-on experience during residency. To resolve this problem, the "Munich Model" was established in our clinic: Senior residents perform aesthetic surgeries, supervised by an experienced plastic surgeon while patients benefit from reduced surgery costs. With this model, we hypothesize no significant differences in the postoperative outcome between procedures performed by residents and plastic surgeons.

Methods

Between August 2012 and December 2017, 481 aesthetic surgeries were included in this retrospective single-center study, of which 283 were performed by residents and 198 by plastic surgeons. Procedures included mastopexy, abdominoplasty, extremity lift, breast reduction, breast augmentation, facial surgery, aesthetic liposuction and lipedema liposuction. Postoperative outcomes were compared regarding surgery time, time of drain removal, inpatient length of stay, duration of wound healing, perioperative blood loss and occurrence of major (surgical revision needed) and minor complications (no surgery needed).

Results

We found no significant differences in aesthetic surgical procedures between residents and board-certified plastic surgeons in the outcome measures of surgery duration, time of drain removal, inpatient length of stay, perioperative blood loss and complication rate, including major and minor complications. Only the inpatient stay was prolonged in aesthetic liposuctions performed by residents.

Conclusion

This study demonstrates comparatively that supervised aesthetic surgeries at a university hospital utilizing the "Munich Model" widely meet the specialist surgeons' standards.

Evaluating the Impact of ACGME Resident Duty Hour Restrictions on Patient Outcomes for Bilateral Breast Reductions

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions limiting residents to 80 hours per week in 2003 and further extended restrictions in 2011 to improve resident and patient well-being. Numerous studies have examined the effects of these restrictions on patient outcomes with inconclusive results. Few efforts have been made to examine the impact of this reform on the safety of common plastic surgery procedures. This study seeks to assess the influence of ACGME duty-hour restrictions on patient outcomes, using bilateral breast reduction mammoplasty as a marker for resident involvement and operative autonomy.

Methods

Bilateral breast reductions performed in the 3 years before and after each reform were collected from the National Inpatient Sample database: pre-duty hours (2000-2002), duty hours (2006-2008), and extended duty hours (2012-2014). Multivariable logistic regression models were constructed to investigate the association between ACGME duty hour restrictions on medical and surgical complications.

Results

Overall, 19,423 bilateral breast reductions were identified. Medical and surgical complication rates in these patients increased with each successive iteration of duty hour restrictions (P < 0.001). The 2003 duty-hour restriction independently associated with increased surgical (OR = 1.51, P < 0.001) and medical complications (OR = 1.85, P < 0.001). The 2011 extended duty-hour restriction was independently associated with increased surgical complications (OR = 1.39, P < 0.001).

Conclusions

ACGME duty-hour restrictions do not seem associated with better patient outcomes for bilateral breast reduction although there are multiple factors involved. These considerations and consequences should be considered in decisions that affect resident quality of life, education, and patient safety.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes

BACKGROUND

 Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis.

METHODS

 Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels.

RESULTS

 Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%).

CONCLUSION

 With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy

BACKGROUND

Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited.

METHODS

Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time.

RESULTS

Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41).

CONCLUSION

While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.

Mastopexy: Current Trends in Private Practice and Academic Practice and the Impact on Resident Training

INTRODUCTION

Training residents for cosmetic surgery is challenging. This study's goal is to identify the mastopexy spectrum, comparing private and academic practice, and determine the impact on resident training and readiness.

METHODS

An institutional review board-approved retrospective analysis of the senior author's mastopexy practice was performed: 5 years private; 5 years academics consecutively. Indications for surgery, type of surgery, and complications (return to operating room, hospital readmission, prosthesis loss, nonoperative hematoma, seroma, wound dehiscence, infection) were recorded. Surveys were sent to all graduated, board-certified plastic surgeons (all in private practice) who trained in performing mastopexy with the lead surgeon in our apprenticeship model.

RESULTS

A total of 246 mastopexies were reviewed (155 in private practice and 91 in academic setting). There were 7 main indications for mastopexy identified: ptosis, postpartum atrophy, nonsurgical weight loss, surgical weight loss, asymmetry, reconstruction/balancing, revision from previous augmentation. Fisher exact test was performed. Primary mastopexy alone was significantly more prevalent in private practice (P = 0.0184). Revisional mastopexy/augmentation was significantly more prevalent in academic practice (P = 0.0047). There was no statistical difference in major or minor complications between private and academic setting (P = 0.077 and P = 0.219, respectively). All graduated trainees reported being "comfortable" or "very comfortable" performing mastopexies.

DISCUSSION

Primary mastopexy is more commonly performed in a private practice setting. Mastopexy, in academics, is more likely in conjunction with reconstruction/balancing. Despite lesser representation of pure cosmetic mastopexy, trainees are well prepared for mastopexy. This indicates that principles and techniques of aesthetic surgery are adequately taught.

Impact of Residents on Operative Time in Aesthetic Surgery at an Academic Institution

Background

Duration of surgery is a known risk factor for increased complication rates. Longer operations may lead to increased cost to the patient and institution. While previous studies have looked at the safety of aesthetic surgery with resident involvement, little research has examined whether resident involvement increases operative time of aesthetic procedures.

Objectives

We hypothesized that resident involvement would potentially lead to an increase in operative time as attending physicians teach trainees during aesthetic operations.

Methods

A retrospective cohort analysis was performed from aesthetic surgery cases of two surgeons at an academic institution over a 4-year period. Breast augmentation and abdominoplasty with liposuction were examined as index cases for this study. Demographics, operative time, and resident involvement were assessed. Resident involvement was defined as participating in critical portions of the cases including exposure, dissection, and closure.

Results

A total of 180 cases fit the inclusion criteria with 105 breast augmentation cases and 75 cases of abdominoplasty with liposuction. Patient demographics were similar for both procedures. Resident involvement did not statistically affect operative duration in breast augmentation (41.8 ± 9.6 min vs 44.7 ± 12.4 min, P = 0.103) or cases for abdominoplasty with liposuction (107.3 ± 20.5 min vs 122.2 ± 36.3 min, P = 0.105).

Conclusions

There was a trend toward longer operative times that did not reach statistical significance with resident involvement in two aesthetic surgery cases at an academic institution. This study adds to the growing literature on the effect resident training has in aesthetic surgery.

Level of Evidence: 2