Defining the Incidence of the Impostor Phenomenon in Academic Plastic Surgery: A Multi-Institutional Survey Study

BACKGROUND

Impostor phenomenon occurs when high-achieving individuals have persistent self-doubt despite objective measures of competence and success, and has been associated with professional burnout and attenuated career advancement in medical specialties. This study aimed to define the incidence and severity of the impostor phenomenon in academic plastic surgery.

METHODS

A cross-sectional survey containing the Clance Impostor Phenomenon Scale (range, 0 to 100; higher scores indicate greater severity of impostor phenomenon) was distributed to residents and faculty from 12 academic plastic surgery institutions across the United States. Generalized linear regression was used to assess demographic and academic predictors of impostor scores.

RESULTS

From a total of 136 resident and faculty respondents (response rate, 37.5%), the mean impostor score was 64 (SD 14), indicating frequent impostor phenomenon characteristics. On univariate analysis, mean impostor scores varied by gender (67.3 for women versus 62.0 for men; P = 0.03) and academic position (66.5 for residents versus 61.6 for attendings; P = 0.03), but did not vary by race or ethnicity; postgraduate year of training among residents; or academic rank, years in practice, or fellowship training among faculty (all P > 0.05). After multivariable adjustment, female gender was the only factor associated with higher impostor scores among plastic surgery residents and faculty (estimate 2.3; 95% CI, 0.03 to 4.6; P = 0.049).

CONCLUSIONS

The prevalence of the impostor phenomenon may be high among residents and faculty in academic plastic surgery. Impostor characteristics appear to be tied more to intrinsic characteristics, including gender, rather than years in residency or practice. Further research is needed to understand the influence of impostor characteristics on career advancement in plastic surgery.

Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis

BACKGROUND

Various social determinants of health have been described as predictors of clinical outcomes for the craniosynostosis population. However, literature lacks a granular depiction of socioeconomic factors that impact these outcomes, and little is known about the relationship between patients' proximity to the care center and management of the condition.

METHODS/DESIGN

This study retrospectively evaluated patients with craniosynostosis who presented to a tertiary children's hospital between 2000 and 2019. Outcomes of interest included age at presentation for surgery, incidence of reoperation, and length of follow-up. Patient addresses were geocoded and plotted on two separate shapefiles containing block group information within San Diego County. The shapefiles included percent parental educational attainment (bachelor's degree or higher) and median household income from 2010. The year 2010 was chosen for the shapefiles because it is the median year of data collection for this study. Multivariate linear, logistic, and polynomial regression models were used to analyze the relationship between geospatial and socioeconomic predictors and clinical outcomes.

RESULTS

There were 574 patients with craniosynostosis included in this study. The mean ± SD Haversine distance from the patient's home coordinates to the hospital coordinates was 107.2 ± 321.2 miles. After adjusting for the suture fused and insurance coverage, there was a significant positive correlation between distance to the hospital and age at index surgery (P = 0.018). There was no correlation between distance and incidence of reoperation (P = 0.266) or distance and duration of follow-up (P = 0.369). Using the same statistical adjustments, lower parental percent educational attainment and lower median household income correlated with older age at index surgery (P = 0.008 and P = 0.0066, respectively) but were not correlated with reoperation (P = 0.986 and P = 0.813, respectively) or duration of follow-up (P = 0.107 and P = 0.984, respectively).

CONCLUSIONS

The results offer evidence that living a greater distance from the hospital and socioeconomic disparities including parental education and median household income may serve as barriers to prompt recognition of diagnosis and timely care in this population. However, the geospatial and socioeconomic factors studied do not seem to hinder incidence of reoperation or length of follow-up, suggesting that, once care has been initiated, longitudinal outcomes may be less impacted.

Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties

OBJECTIVE

This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties.

BACKGROUND

Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement.

STUDY DESIGN

The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics.

RESULTS

After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001).

CONCLUSIONS

This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

Socioeconomic Disparities in Research Participation: Bias in Plastic Surgery Residency Match

Background

Integrated plastic surgery residency applicants have increased at a rate disproportionate to available positions. Research productivity has become a surrogate marker for competitiveness, and many applicants pursue it to distinguish themselves. To date, no study has investigated socioeconomic disparities in extended research experience (ERE) participation.

Methods

A 35-question cross-sectional survey was distributed to applicants to United States-based integrated plastic surgery residency programs during the 2019-2022 application cycles. Summary tables, student t test, and chi-square tests were used for statistical analysis.

Results

A total of 161 responses (response rate: 20.9%) were recorded. Fifty-nine (40.7%) respondents participated in an ERE. The most common reason for ERE participation was strengthening one's application. The most common reason against participation was avoiding delays in career progression. A greater percentage of respondents from Northeastern medical schools participated in EREs (P = 0.019). There were no significant differences in debt burden between those who did or did not participate in an ERE. A greater percentage of applicants whose parents had advanced degrees participated in EREs (P = 0.053).

Conclusions

There may be geographic and socioeconomic biases present in access to ERE for students interested in plastic surgery. The growing popularity of EREs may have unintended consequences for applicant diversity. As most plastic surgeons ultimately practice in nonacademic settings, applicants and plastic surgeons may consider the financial hardships and possible socioeconomic disparities in research opportunities before participating in or recommending them.

Results of a Pilot Virtual Microsurgery Course for Plastic Surgeons in LMICs

Background

The Plastic Surgery Foundation's Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program seeks to expand surgical capacity worldwide through mentorship and training for local plastic surgeons. This study aims to define the need for microsurgery training among SHARE global fellows and describe results of a pilot course.

Methods

Ten participants of the SHARE Virtual Microsurgical Skills Course were asked to complete an anonymous survey. Pre- and post-course response rates were 100% and 50.0%, respectively.

Results

There was a high incidence of microsurgical problems encountered in the clinical setting. Resource availability was varied, with high access to loupes (100%), yet limited access to microsurgery instruments (50%), medications (40%), operating microscope (20%), skilled nursing (0%) and appropriate peri-operative care settings (0%). Participants identified vessel preparation, instrument selection, and suture handling as priority learning objectives for a microsurgery skills course. Post-course satisfaction with learning objectives was high (60% "very good," 40% "excellent"). Participants reported high levels of improvement in suture handling (Likert 4.60±0.55), end-to-end anastomosis (4.40±0.55), instrument selection (4.20±0.45), vessel preparation (4.20±0.45), and economy of motion (4.20±0.45).

Conclusions

This study demonstrates a high frequency of reconstructive problems encountered by global fellows yet low access to appropriate resources to perform microsurgical procedures. Initial results from a pilot virtual microsurgery course demonstrate very high satisfaction and high self-rated improvement in key microsurgical skills. The virtual course is an effective and accessible format for training surgeons in basic microsurgery skills and can be augmented by providing longitudinal opportunities for remote feedback.

Deconstructing the Excellent Plastic Surgeon: A Survey of Key Attributes

Background

Most plastic surgeons practice in nonacademic settings, leaving a small subset of academic plastic surgeons with the responsibility of selecting the future generation of plastic surgeons without representation from a majority of our field. This raises questions as to whether the academic attributes valued during residency selection are valid predictive markers of who will become an excellent plastic surgeon. A survey was conducted of both academic and nonacademic plastic surgeons, as well as trainees, to determine what traits are considered most essential to being an excellent plastic surgeon.

Methods

An electronic survey was distributed before the American Council of Academic Plastic Surgeons 10th Annual Winter Meeting. Demographics and information regarding the respondents' training and academic status were collected. Respondents were asked to select five traits that they considered most important to be an excellent plastic surgeon from a list of 20 preselected traits. Chi-square and Fisher exact tests were used to perform subgroup analyses.

Results

A total of 187 responses were received from meeting attendees, representing an 89.0% response rate. Overall, the five values endorsed as most important for a plastic surgeon were being technically sound (53%), collaborative (48%), ethical (44%), compassionate (37%), and emotionally intelligent (33%). However, the emphasis placed on these different attributes differed significantly amongst different demographic groups.

Conclusion

It is important that we use methods such as holistic review when evaluating plastic surgery applicants to ensure our selection process is congruent with the traits we value.

Strength in Numbers: A SWOT Analysis of Plastic Surgery

Background

Plastic surgeons comprise the minority of practicing surgeons, with an even smaller minority practicing in an academic setting. As the practice of medicine and the systems in which we operate continue to evolve, it is essential that plastic surgeons have a say in the changing landscape. This study conducted a strengths, weaknesses, opportunities, and threats (SWOT) analysis of plastic surgery to identify unifying strengths and common threats.

Methods

An electronic survey was distributed to American Council of Academic Plastic Surgeons' Winter Meeting attendees on three separate occasions preceding the meeting. Respondents were asked to provide demographic information and to identify the top three strengths, weaknesses, opportunities, and threats (SWOT analysis) for the specialty. Subgroup analyses were performed based on demographic characteristics.

Results

A total of 187 responses were received from meeting attendees, representing an 89.0% response rate. Most respondents were non-Hispanic (78.6%), White (66.8%), women (59.5%), and faculty/independent physicians (65.8%). The most identified strength in plastic surgery was our problem-solving abilities (62.0%). The most identified weakness was poor public perception of plastic surgery (54.0%). The most identified opportunity was demonstration of value to health systems (67.9%), and the most identified threat was scope of practice creep by other specialties (78.1%). The SWOT analysis identified lack of surgeon diversity as a key weakness, improvement of surgeon diversity as a key opportunity, and lack of diversity among plastic surgeons as a key threat to the specialty.

Conclusion

Only through a diverse but united front can we effectively use our strengths to face our threats and employ opportunities to overcome our weaknesses.

A Practical Guide to Implementing Holistic Review during Surgery Resident Selection

Provider workforce diversity is a key component of improving healthcare quality and addressing healthcare disparities. Furthermore, the traditional approach of "score-centered" application metrics do not consistently correlate with meeting milestones in surgery, nor do they adequately predict a surgical resident's clinical strength and operative abilities. We present here an adaptable process by which surgical residency programs can identify their values and incorporate holistic review into their resident selection process to improve resident selection and physician workforce diversity.

A SWOT Analysis of Hot Topics in Plastic Surgery Resident Education: Consensus From the ACAPS 10th Annual Winter Meeting

Background

With the aim of facilitating a critical self-reflection on how to align plastic surgery education with making excellent plastic surgeons, a rotating small-group session followed by live interactive audience polling was used to perform a SWOT (strengths, weaknesses, opportunities, and threats) analysis at the 10th Annual American Council of Academic Plastic Surgeons Winter Meeting.

Methods

The final day of the conference included a 3-hour session of rotating small groups followed by live interactive audience polls discussing the following six relevant educational topics: the Plastic Surgery Common Application and resident selection, aesthetic surgery education, leadership development and business education, embedded fellowships and focused training, mentorship, and faculty retention.

Results

A total of 60 individuals participated in the activity. A SWOT analysis was successfully performed for each educational topic, and a minimum of four opportunities were identified per topic to help guide future endeavors. Examples of opportunities include releasing recommendations for the implementation of holistic review; developing formal guidelines for aesthetic surgery education in residency via collaboration between ACAPS, American Society of Plastic Surgeons, and The Aesthetic Society; creating extended focused elective rotations; integrating business education into formal curricula for all training levels; enforcing transparency regarding position expectations and offerings including salary, call schedule, and current challenges; and more.

Conclusion

The results of this study will help guide future initiatives by the ACAPS to improve resident education and academic retention.

The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties

BACKGROUND

The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery.

METHODS

A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20.

RESULTS

Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction.

CONCLUSIONS

Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

Management of Craniosynostosis in Lethal Perinatal Hypophosphatasia

Although perinatal lethal hypophosphatasia (HPP) was once a disease with a universally poor prognosis, it has now become a rare but treatable condition with the advent of enzyme replacement therapy with asfotase alfa. As a result, a greater population of patients with perinatal HPP are presenting with abnormal head shape and craniosynostosis. The authors present here 3 cases of perinatal lethal HPP, 1 treated with traditional open cranial vault remodeling and 2 treated utilizing distraction osteogenesis techniques. All patients demonstrated outcomes comparable to those previously reported with traditional observation or open cranial vault repair. Thorough consideration and discussion between the surgical team and patient's family is needed to determine a treatment plan that best addresses the goals of patient and family in light of recent advances in medical treatment in this rare patient population in which surgical interventions were previously nearly impossible. This article further supports the safety and efficacy of surgical intervention and explores the utility of distraction osteogenesis to address craniosynostosis in this patient population.

Custom 3D-Printed External Cranial Orthotic for Prevention and Treatment of Syndrome of the Trephined

Syndrome of the Trephined (SoT) is a frequently misunderstood and underdiagnosed outcome of decompressive craniectomy, especially in cases of trauma. The pressure gradient between atmospheric pressure and the sub-atmospheric intracranial pressure results in a sinking of the scalp overlying the craniectomy site. This gradually compresses the underlying brain parenchyma. This parenchymal compression can disrupt normal autoregulation and subsequent metabolism, yielding symptoms ranging from headaches, dizziness, altered behavior to changes in sensation, and difficulty with ambulation, coordination, and activities of daily living. We present a case of SoT treated with a 3D-printed custom polycarbonate external cranial orthotic that allowed us to re-establish this pressure gradient by returning the cranium to a closed system. The patient demonstrated subjective improvement in quality of life and his symptoms. This was consistent with the re-expanded brain parenchyma on CT imaging.

Racial and Ethnic Disparities in Selected Speakers at Plastic Surgery Conferences

Disparities in representation amongst academic physicians continue to persist at multiple levels, including the resident selection process and faculty career advancement. This study aimed to evaluate the racial and ethnic representation amongst plastic surgeons who are selected to speak at national and regional plastic surgery conferences.

Methods

The researchers evaluated selected speakers at 12 plastic surgery annual meetings over 7 years (2014-2020). Racial and ethnic distribution in selected speakers at conferences were compared with those of medical school graduates, plastic surgery residents, and practicing plastic surgeons.

Results

There were a total of 79 meetings, with 8931 total speaking opportunities and 1276 unique speakers. The percentage of individuals underrepresented in medicine (UIM) is 15.2% in matriculating medical students, 8.9% in active PRS residents, 8.3% in practicing PRS physicians, and 4.7% in invited conference speakers. Within racial/ethnic groups of invited speakers, there was no significant difference in either the average number of fellowships completed or average number of plastic surgery publications (P = 0.44 and 0.39, respectively). No individual UIM speaker had more than 20 speaking opportunities over these 7 years, compared with 17.0% in non-UIM speakers.

Conclusion

Given the results of the study, the researchers conclude that racial minorities are disproportionately underrepresented as selected speakers at plastic surgery conferences, despite similarities in qualifications such as fellowship training, publication number, and years since board certification.

Autologous Fat Grafting: an Emerging Treatment Option for Complex Anal Fistulas

BACKGROUND

Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas.

METHODS

This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment.

RESULTS

In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion.

CONCLUSION

AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.

Perioperative Comparison Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis

There are multiple treatment options for unilateral lambdoid craniosynostosis (ULS) including open posterior cranial vault remodeling (OCVR) and distraction osteogenesis (DO). There is a paucity of data comparing these techniques in the treatment of ULS. This study compared the perioperative characteristics of these interventions for patients with ULS. An IRB-approved chart review was performed from January 1999 to November 2018 at a single institution. Inclusion criteria included the diagnosis of ULS, treatment with either OCVR or DO using a posterior rotational flap technique, and a minimum 1-year follow-up. Seventeen patients met the inclusion criteria (12 OCVR and 5 DO). Patients in each cohort were found to have a similar distribution in sex, age at the time of surgery, synostosis laterality, weight, and length of follow-up. There was no significant difference in mean estimated blood loss/kg, surgical time, or transfusion requirements between cohorts. Distraction osteogenesis patients had a longer mean hospital length of stay (3.4 +/- 0.6 d versus 2.0 +/- 0.6 d, P = 0.0004). All patients were admitted to the surgical ward postoperatively. In the OCVR cohort, complications included 1 dural tear, 1 surgical site infection, and 2 reoperations. In the DO cohort, 1 patient had a distraction site infection, treated with antibiotics. There was no significant difference in estimated blood loss, volume of blood transfusion, or surgical time between OCVR and DO. Patients who underwent OCVR had a higher incidence of postoperative complications and the need for reoperation. This data provides insight into the perioperative differences between OCVR and DO in patients with ULS.

To Operate or Not to Operate? Reconstructive Surgical Burden and Quality of Life of Pediatric Patients with Facial Differences

OBJECTIVE

The Craniofacial Condition Quality of Life Scale (CFC-QoL) was used to evaluate the relationship between surgical burden and quality of life (QoL).

DESIGN

Patient-parent dyads completed the CFC-QoL which queries the following QoL domains: Bullying, Peer Problems, Psychological Impact, Family Support, Appearance Satisfaction, and Desire for Appearance Change. Stepwise multivariate linear regressions were performed for each QoL domain.

SETTING

Urban tertiary care center.

PATIENTS, PARTICIPANTS

Pediatric patients with facial differences, and their parents.

INTERVENTION

Survey study.

MAIN OUTCOME MEASURE(S)

Demographic, diagnostic, and surgical characteristics were collected. Surgical burden was calculated as the standard deviation from the mean number of surgeries per diagnostic cohort.

RESULT

Patients (N  =  168) were majority female (57.1%) and Hispanic (64.3%). Diagnoses were cleft lip and/or palate (CLP,n  =  99) or other craniofacial conditions (CFC,n  =  69). Average patient age was 2.3  ±  5.6 years at first reconstructive surgery and 12.3  ±  3.4 years at study enrollment. Patients received an average of 4.3  ±  4.1 reconstructive surgeries.Worse Bullying was associated with higher surgical burden. Worse Peer Problems was associated with higher surgical burden, but only for children with non-CLP CFCs. Worse Family Support was associated with CFC diagnosis, female sex, and higher surgical burden. Worse Psychological Impact was associated with higher surgical burden. Worse Appearance Satisfaction was associated with younger age and with lower surgical burden. Greater Desire for Appearance Change was associated with older age, higher surgical burden, CLP diagnosis, female sex, and non-Hispanic ethnicity. Socioeconomic status did not predict QoL per patient self- or parent-proxy report.

CONCLUSIONS

Higher surgical burden was associated with worse QoL outcomes in multiple domains.

Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties"

BACKGROUND

Over the past decade across multiple surgical specialties, Medicare reimbursement rates have remained stagnant failing to keep pace with inflation. An internal comparison of subspecialties within plastic surgery has not yet been attempted. The goal of this study is to investigate the trends in reimbursement from 2010 to 2020 and compare across the subspecialties of plastic surgery.

METHODS

The Physician/Supplier Procedure Summary (PSPS) was used to extract the annual case volume for the top 80% most-billed CPT codes within plastic surgery. Codes were defined into the following subspecialties: microsurgery, craniofacial surgery, breast surgery, hand surgery, and general plastic surgery. The Medicare physician reimbursement was weighted by case volume. The growth rate and compound annual growth rate (CAGR) were calculated and compared against an inflation-adjusted reimbursement value.

RESULTS

On average, inflation-adjusted growth in reimbursement for the procedures analyzed in this study was (-13.5%). The largest decrease in growth rate was within the field of Microsurgery (-19.2%), followed by Craniofacial surgery (-17.6%). These subspecialties also had the lowest CAGR (-2.11% and -1.91%, respectively). For case volumes, Microsurgery increased case volumes by an average of 3% per year, while craniofacial surgery increased case volumes by an average of 5% per year.

CONCLUSION

After adjusting for inflation, all subspecialties had a decrease in growth rate. This was particularly evident in the fields of craniofacial surgery and microsurgery. Consequently, practice patterns and patient access may be negatively affected. Further advocacy and physician participation in reimbursement rate negotiation may be essential to adjust for variance and inflation.

Psychosocial Burden of Pediatric and Adult Patients With Congenital Versus Traumatic Facial Differences: Assessment of Psychiatric Distress and Healthcare Utilization in the United States From 2004 to 2012

BACKGROUND

Psychiatric distress and its effects on healthcare utilization in pediatric patients with congenital and traumatic facial differences remain poorly understood. This study analyzes the psychosocial burden along with mental health and reconstructive surgery services utilization of this patient population in comparison with adult patients with such facial differences.

METHODS

The 2004-2012 Medical Expenditures Panel Survey was queried for all patients with facial differences. Socioeconomic variables, Patient Health Questionnaire 2 and Kessler 6 scores, responses from validated screening surveys, and utilization of mental health and reconstructive surgery (ie, plastic surgery and otolaryngology) services were compared between pediatric and adult patients with congenital and traumatic facial differences.

RESULTS

Children ages 5 to 12 years were more likely to be affected by facial trauma, whereas adolescents aged 13 to 17 years were more affected by congenital facial conditions. Pediatric patients with congenital facial conditions had higher rates of medical care, education, and special therapy utilization ( P < 0.0001), although their facial trauma counterparts used mental health services more often ( P < 0.0001). In adults, more facial trauma patients reported poorer perceived mental health status ( P = 0.01). Among patients with any facial difference, distressed adult patients were less likely to see a reconstructive surgeon even when controlling for socioeconomic variables (0.55 [0.31-0.97], P = 0.04).

CONCLUSIONS

In the pediatric population, psychosocial considerations should include both age and etiology of facial differences to best optimize care. Among adults with facial trauma, poor mental health may contribute to lower rates of surgical follow-up, highlighting a potential benefit for provision of mental health services earlier for these patient populations.

Virtual and In-Person Day Camps for the Craniofacial Community

ABSTRACT

Children with congenital craniofacial conditions (CFCs) and their families may stand to benefit from day camps offering tailored psychosocial support and resources. Nonprofit ConnectMed International has held virtual and in-person day camps in San Diego for this community since 2018. We administered surveys before and after a series of day camps to understand the needs of this community and benefits perceived programming offered. Although studies have reported the psychosocial benefits of camps for children with rare diseases, few have examined the specific benefit for children with CFCs and their parents. Herein, we present the findings of our survey study as the first article to report a needs assessments and psychosocial benefits of day camps for children with CFCs and their parents.

Differences in Applicant Perceptions of Virtual Interviews Between Integrated Plastic Surgery and Subspecialty Fellowship Applicants

OBJECTIVE

We aim to survey and compare integrated plastic surgery and plastic surgery subspecialty fellowship applicants on their experiences with virtual interviews and to determine if there are differences between them.

DESIGN

An IRB-approved survey study was conducted using the Qualtrics platform.

SETTING

The study was conducted at the Johns Hopkins University and the R Adams Cowley Shock Trauma Center in Baltimore Maryland.

PARTICIPANTS

Applicants that applied to 1) the Johns Hopkins/University of Maryland or the University of California San Diego integrated plastic surgery residency programs, 2) craniofacial surgery fellowship, and 3) microsurgery, hand surgery, or burn surgery fellowship at the Johns Hopkins University were selected to participate in the survey.

RESULTS

A total of 94 surveys were completed by residency applicants and 55 by fellowship applicants. After the interview season, 80% of fellowship applicants recommended virtual interviews compared to 61.7% of residency applicants (p = 0.03). Fellowship applicants reported significantly less issues with self-advocacy and did not view the virtual interview process as significant of a detriment when meeting program residents/staff, viewing the hospital/surrounding area, and learning about the program (p < 0.05). A higher percentage of fellowship applicants interviewed at multiple programs during a single day compared to residency applicants (56.4% vs 27.7%; p < 0.001).

CONCLUSIONS

A higher proportion of fellowship applicants prefer virtual interviews, which associated with key differences in perceptions, expectations, and priorities. Our data supports that fellowship programs may wish to continue virtual interviews even after COVID-related restrictions are lifted, because fellows are equally able to self-advocate in a virtual format while benefiting from cost and time savings; fellowship programs would also gain the cost and time savings from this model as well.

Reduction of Work-Related Musculoskeletal Disorders in Plastic Surgeons by Introduction of a Posture Training Device

BACKGROUND

Plastic surgeons have an increased risk for the development of musculoskeletal disorders because of frequent poor ergonomics of the operating room. This study characterizes selected plastic surgery procedures, with an attempt to identify high-risk procedures and procedural components as well as the impact of biofeedback on surgical ergonomics.

METHODS

A commercially available posture training device was used to initially record neck and spine positioning and later to send biofeedback to prompt surgeons to correct posture. Device data were correlated with in-person observations to characterize factors associated with more time spent in the slouched/nonneutral cervical and thoracic spine posture.

RESULTS

The proportion of time spent in the upright position during surgery was significantly different among male and female participants, level of training, participant height, in the sitting versus nonsitting positioning (P < 0.001), with loupes use, and if there was more than an 8-inch height difference between 2 participants (mean, 0.70 ± 0.285). Using the device intervention, all participants spent a larger proportion of operating time upright. Half of these improvements in posture were statistically significant. While in feedback mode, participants experienced shorter and more frequent periods of slouching/nonneutral posture. When comparing the same participant performing the same procedure with and without device biofeedback, 72.2% of participants spent more time in the upright/neutral posture during the surgery when the device was sending feedback.

CONCLUSIONS

Biofeedback devices used in the operating room can lead to improved surgical posture, which may translate to reduction of workplace injuries, and overall physician health. This study found that a commercially available posture training device and sitting stools in the operating room could significantly improve physician cervical and thoracic spine posture.

Analysis of Readmission and Complications After Repair of Orbital Fractures Using California's Office of Statewide Health Planning and Development Database

BACKGROUND

Orbital fractures represent one of the most common trauma-related facial fractures and may present with a variety of concomitant injuries. Many factors including age, associated diagnoses, and fracture complications are important in determining surgical candidacy. We used a statewide database to determine the prevalence of orbital fractures, rates of surgical repair during initial admission, and early patient outcomes.

METHODS

A longitudinal analysis of patients with orbital fracture was performed using California's Office of Statewide Health Planning and Development patient discharge database for admissions occurring between January 2015 and December 2018.Patients were identified using International Classification of Diseases, Tenth Revision codes. The primary risk factor was surgical management of orbital fractures. The primary outcomes of interest were readmission requiring surgical management and complications of the fracture. Survival models were developed to evaluate the risk of a repair at readmission adjusting for relevant covariates.

RESULTS

Of the 67,408 facial fractures included in our study, 8.7% (n = 5872) were diagnosed with orbital fractures. Among this population, 18.4% (n = 1082) underwent surgical repair during their initial admission. Patients were primarily male (71.1%; n = 4,173) and presented in a nonurgent fashion (93.7%; n = 5501). Less than half (42.8%) of patients with an urgent presentation and 16.8% of patients with a nonurgent presentation underwent repair. Centers of Medicaid & Medicare Services guidelines dictated presentation classification. Repair was associated with a significantly higher survival outcome. Orbital fractures were more frequently repaired in the setting of concomitant zygomatic, nasal, and LeFort I-III fractures. Increased risk in complications was observed in all concomitant fracture groups, and there existed a decreased risk of postsurgical complications in these same cohorts.

CONCLUSIONS

Although most orbital fractures were managed nonoperatively, our analysis found that rates of repair for orbital floor, maxillary, and zygomatic fractures were greater than for other facial fractures. Concomitant fractures were associated with an increased hazard ratio for complications. Although low in prevalence overall, the most often observed postoperative complications in this population were diplopia, glaucoma, and blindness/low vision.

Tissue Expander-Assisted Component Separation for Pediatric Abdominal Wall Reconstruction

BACKGROUND

Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population.

METHODS

A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure.

RESULTS

The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%.

CONCLUSIONS

Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.

Using the Disruptive Score to Identify Publications That Changed Plastic Surgery Practice

PURPOSE

The impact of academic publications is often characterized by the total number of future citations. However, this metric does not adequately characterize the true impact in terms of changing practices or paradigms. A new metric called the "disruption score" (DS) has been developed and validated in nonsurgical publications. This study aims to use the DS to identify the most disruptive publications in plastic surgery.The DS, a ratio of 2 numbers, varies between -1 and +1. Scores closer to -1 are developing papers that summarize the known literature while papers closer to +1 are disruptive-they result in a paradigm shift in the field of study.

METHODS

A search was performed for all articles from 1954 to 2014 in the following journals: Plastic and Reconstructive Surgery; Aesthetic Surgery Journal; Journal of Plastic, Reconstructive, and Aesthetic Surgery; Annals of Plastic Surgery; Aesthetic Plastic Surgery; Clinics in Plastic Surgery; and Plastic Surgery. The disruptive score was calculated for each article.The top 100 papers ranked by DS were examined and any editorials/viewpoints, publications with less than 26 citations, or less than 3 references were excluded because of their subjective nature and smaller academic contribution. The remaining 64 publications were analyzed for topic, study type, and citation count.

RESULTS

A total of 32,622 articles were found with a DS range from 0.385 to 0.923. The mean score of the top 64 articles was 0.539 with an average citation count of 195 and 9 references. Plastic and Reconstructive Surgery had the most disruptive papers with 50. There were no randomized controlled trials with a majority of the studies being technical descriptions or case series.

CONCLUSIONS

There are many ways to measure academic success, but there are fewer ways to measure the impact of academic contributions. The DS is a novel measurement that can demonstrate when an article results in a paradigm shift as opposed to just total citation count. When applied to the plastic surgery literature, the DS demonstrates that technical innovation and creativity are the most academically impactful. Future evaluations of academic success should include the DS to measure the quality of academic contributions.

Delayed Presentation of Sagittal Suture Craniosynostosis

BACKGROUND

Sagittal craniosynostosis typically presents as dolichocephaly or less frequently as clinocephaly, a "saddle-shaped" phenotype. This project aimed to characterize clinically relevant differences between sagittal synostosis phenotypes and examine the etiology of the delay in presentation.

METHODS

An institutional review board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Analyses examined correlations between subphenotype, time of presentation, minor suture fusion, developmental delay, and operative technique.

RESULTS

One hundred sixty patients diagnosed with single-suture sagittal craniosynostosis were identified. A total of 30.6% had a saddle phenotype (n = 49) and 69.4% had dolichocephaly (n = 111). Patients with the saddle phenotype were more likely to present with a developmental delay and to have at least 1 minor suture fused than patients with dolichocephaly were. Patients with the saddle phenotype presented for surgery at an older age and were more likely to undergo open cranial vault repair, with increased blood loss, higher transfusion volume, and longer time.

CONCLUSIONS

This study highlights clinical differences in sagittal craniosynostosis phenotypes and shows that developmental delay is an initial presentation of the saddle phenotype. The saddle phenotype also correlated with fusion of the minor squamous and sphenoid sutures. The link between developmental delay and minor suture fusion was notable and should be explored with a larger sample size. Patients with saddle synostosis present for surgery at an older age than patients with dolichocephaly and therefore are more likely to receive open cranial vault repair, with a taxing intraoperative experience characterized by increased blood loss, increased transfusions, and longer operation time.

Treatment of Unicoronal Craniosynostosis by Rotational Flap Technique Preserves Blood Supply to the Frontal Bone Flap

BACKGROUND

Surgical correction of unicoronal craniosynostosis (UCS) remains a challenging problem. Long-term results are often unsatisfactory secondary to recurrence of the original deformity, requiring secondary operations such as fat grafting or complete revision of the calvarial remodeling. Distraction osteogenesis (DO) has recently emerged as a new modality for treatment of UCS, with promising results and decreased rates of reoperation compared with open cranial vault remodeling. A theoretical benefit of DO is preservation of blood supply to the frontal bone following osteotomy, as the frontal bone can be retained in situ compared with the complete removal and reshaping of the frontal bone during traditional fronto-orbital advancement. Preservation of blood supply to the frontal bone may allow for more robust bony healing and preservation of long-term growth potential; however, the vascularity of the frontal bone flap in DO has not previously been demonstrated. Here, we demonstrate unequivocally that blood supply to the frontal bone is preserved after creation of a rotational bone flap in DO management of UCS.

METHODS

Frontal bone flap creation via osteotomy for DO treatment of UCS was performed via previously reported technique. Indocyanine green was injected intravenously, and bone perfusion was assessed with a fluorescence imaging system.

RESULTS

Four patients underwent three cranial remodeling and three distractor removal procedures. After frontal bone flap creation via osteotomy for DO, perfusion to the osteotomized portion of the frontal bone flap is preserved. Blood flow is seen crossing the midline of the frontal bone. After removal of the distractor, perfusion in the osteoid consolidate is also observed.

CONCLUSIONS

Preservation of blood supply has not been previously demonstrated empirically in the setting of DO treatment of UCS. We show for the first time that during frontal bone flap creation, blood flow to the osteotomized portion of the frontal bone flap is maintained. Robust blood flow to the osteoid consolidate is also demonstrated. These data support the use of DO in treatment of UCS, as preserved blood supply to the bone is more likely to support improved healing and long-term results.

Ethical Dilemmas in Global Plastic Surgery: Divergent Perspectives of Local and Visiting Surgeons

BACKGROUND

As more of the world's resources are directed toward improving patient access to safe surgical and anesthesia care, there is a growing concern that volunteer surgeons' "desire to help" has numerous unintended consequences. The purpose of this study was to ask in-country, local surgeons and visiting volunteer plastic surgeons about the frequency of ethical dilemmas for different types of global surgery collaborations and to assess their perception of compliance with the concepts of autonomy, beneficence, nonmaleficence, and justice.

METHODS

A cross-sectional email survey tool was sent to a representative sample of domestic American Society of Plastic Surgeons members, all international members of the American Society of Plastic Surgeons, and international partners of the Volunteers in Plastic Surgery committee of the Plastic Surgery Foundation. The survey response rate was 7.7 percent, with 356 respondents from 65 countries.

RESULTS

This survey data showed a statistically significant divergence of perspectives between local and visiting surgeons in regard to scope of practice, quality of patient care, impact on local health care systems, perception of the quality of care by local providers, the integrity of the informed consent process, and photography in global plastic surgery collaborations. Though the short-term mission trip model was particularly polarizing when comparing the responses of local and visiting surgeons, educational and research exchanges may also significantly interrupt local health care and incite ethical lapses.

CONCLUSION

This survey provides quantitative insight into the impact of current global plastic surgery collaborations and highlights ethical areas of disagreement between local and visiting surgeons.

Prevalence of Workforce Diversity Research Among Surgical Specialties in the United States: How Does Plastic Surgery Compare?

BACKGROUND

Plastic surgeons are not as diverse as expected in relation to the increasingly diverse patient and medical student population. The authors assess the state of diversity in 8 primary surgical specialties in the United States and evaluate trends in research interest in diversity over the past 30 years.

METHODS

Articles regarding diversity in surgery from 1990 to 2020 were systematically reviewed. The Association of American Medical Colleges Physician Specialty Data Reports and the Accreditation Council for Graduate Medical Education Data Resource Books provided resident/fellow and faculty data from 2011 to 2016. Trends were analyzed over time per specialty.

RESULTS

From 1990 to 2020, a total of 199 publications related to diversity were identified among the various surgical specialties. Orthopedic surgery had significantly more publications per year compared with other specialties (P < 0.05). Every specialty demonstrated a significant increase in publications about diversity over time (P < 0.05). A majority of publications were related to sex rather than underrepresented in medicine topics. The proportion of female surgeons was significantly higher for plastic surgery than for orthopedic surgery and neurosurgery (P < 0.001). Plastic surgery exhibited the highest growth rate in female residents (+1.6% per year, P < 0.001). The proportion of underrepresented minorities composing surgical trainees has not significantly increased in any surgical specialty between 2011 and 2016 (P > 0.05).

CONCLUSIONS

Although diversity representation in surgery has somewhat improved, the rate is too slow to match the growing diversity of the US population. Outcomes have been disparate between specialties and demonstrate greater increases in sex equality relative to ethnic/racial equality. Evidence-based interventions need to be developed and implemented.

The Influence of Academic Pedigree on Integrated Plastic Surgery Resident Training Location

INTRODUCTION

Plastic surgery residencies are among the most competitive programs for graduate medical education. While board scores and research output are well-studied indicators of match success, no studies describe the association between an applicant's medical school ranking and subsequent residency ranking.

METHODS

A cross-sectional study of integrated plastic surgery residents for the 2019 to 2020 academic year was performed. Integrated plastic surgery residency programs were ranked according to 2020 Doximity Residency Navigator. AAMC-affiliated allopathic medical schools were ranked according to US News & World Report 2020 Best Medical Schools. Multiple regression analysis was used to determine if academic pedigree predicted placement at highly competitive plastic surgery residency programs.

RESULTS

A total of 914 residents across 69 integrated plastic surgery residency programs were included. Ten medical schools accounted for 169 (18.4%) of all trainees. 159 (16.5%) matched at their home program for residency. Medical school ranking and medical school-affiliated integrated plastic surgery program ranking were significant predictors of match success and future residency competitiveness. The presence of an affiliated plastic surgery residency program predicted total number of medical school graduates who matriculated into plastic surgery residency (p < 0.0005). Graduates of top-ranked schools represented a disproportionate number of current plastic surgery residents (Top 10 program: 12.5%, Top 20: 24.1%, Top 40: 40.9%, Top 50: 49.1%).

CONCLUSIONS

Both medical school ranking and home plastic surgery program ranking appeared to influence match success and future residency training program competitiveness. This is the first study to demonstrate these associations.

Applicant Preferences for Virtual Interviews: Insights from the 2020-21 Integrated Plastic Surgery Application Cycle

Background:

The COVID-19 pandemic created an unprecedented residency application cycle that required the use of virtual interviews. The inaugural class of applicants participating in virtual interviews were surveyed concerning their preferences and suggestions for future application cycles.

Methods:

A survey was distributed to 349 individuals who applied for an integrated plastic surgery residency position at three institutions during the 2020–21 application cycle. Responses were analyzed to determine the most popular attributes of virtual interviews.

Results:

Response rate was 44%. Eighty-six percent of applicants valued having time to consider their interview offers before scheduling; however, nearly one-third felt the instructions provided by programs lacked clarity and did not abide by the American Council of Academic Plastic Surgeons guidelines. Eighty-two percent of applicants valued having a preinterview social, and most preferred smaller breakout rooms organized by themes. A short interview day (less than three hours) was associated with less applicant familiarity with the program, its people, and its location when compared with medium (three to seven hours) and long (more than seven hours) interview days (P < 0.001 for all). Eighty percent of applicants preferred an interview day where they were placed into interview rooms by a program coordinator.

Conclusions:

The virtual interview format can be optimized in many ways to benefit both applicants and programs. The data presented in this article provide suggestions for future iterations of virtual interviews.

Analysis of Actual Versus Predicated Intracranial Volume Changes for Distraction Osteogenesis Using Virtual Surgical Planning in Patients With Craniosynostosis

INTRODUCTION

The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management.

METHODS

All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests.

RESULTS

Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012).

CONCLUSIONS

Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients.

Improving the Standardized Letter of Recommendation in the Plastic Surgery Resident Selection Process

OBJECTIVE

The American Council of Academic Plastic Surgeons (ACAPS) Plastic Surgery Recommendation Form is a standardized letter of recommendation (SLOR) used in the plastic surgery resident selection process since 2012. This study aims to evaluate this form and use a multistep survey to optimize this SLOR.

DESIGN

A 16 question survey was sent via Survey Monkey to 510 ACAPS faculty. The results of this survey were followed up with a live-response survey at the ACAPS Spring Retreat. Consensus was used to modify and create a more optimal SLOR.

SETTING

This study was performed by the Division of Plastic and Reconstructive Surgery at the University of California, San Diego.

PARTICIPANTS

Survey respondents represented over five hundred plastic surgery faculty from a variety of subspecialties and academic programs nation-wide.

RESULTS

The response rate to the online survey was 36%. On a scale of 1 (not useful) to 5 (very useful), letter readers and letter writers found the SLOR 3.88 and 3.90 respectively. Most respondents believed that the SLOR should be used as an adjunct to the narrative LOR. Forty-two faculties participated as respondents to the live audience questions, although over a 100 faculty were present for the discussion. Most participants agreed that independent program applicants should have a separate SLOR form, with at least 1 filled out by the Program Director of the residents' primary board. The majority (61%) of respondents supported the addition of 1-line characteristics to each applicant quality, and the change to a percentile format for assessment.

CONCLUSIONS

Letters of recommendation are vital to the resident selection process, and thus it is incumbent upon fields of medicine to consciously work on improving how these letters are written. This study outlines a 2-step process by which a SLOR was evaluated and optimized for faculty in the field of plastic surgery.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair

PURPOSE

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

METHODS

A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

RESULTS

A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

CONCLUSIONS

There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

Analysis of Narcotic Use in Isolated Facial Fractures: Potential Targets for a Narcotic Reduction Protocol

ABSTRACT

Anecdotal evidence suggests that patients with isolated traumatic facial fractures have high narcotic usage, yet there is a lack of literature delineating this relationship. This study aimed to characterize total amount and factors predictive of narcotic usage following isolated traumatic facial fracture. Study participants (n = 35) were predominantly male (91.4%), mean age 40.5, Caucasian (34.3%), suffered some form of assault (62.9%), and remained hospitalized for an average of 3.0 days. Average morphine milligram equivalent (MME) use in the inpatient setting was 967.6 for operative (n = 30) and 37.5 for nonoperative (n = 5) patients. Average total narcotic use across inpatient and outpatient settings was 1256.6 MME for operative and 105 MME for nonoperative patients. Operative intervention predicted a significant difference in total inpatient narcotic usage (P = 0.009). For patients who underwent surgical intervention, significant variations in narcotic usage were found based on mechanism of injury (24-hour postoperative, P = 0.030), but not injury severity or number of procedures. Specifically, individuals suffering highly traumatic fractures (eg, gunshot wound) demonstrated increased total postoperative narcotic usage of 1194.1 MME (P = 0.004). Interestingly, non-narcotic analgesic use including acetaminophen and lidocaine-epinephrine resulted in significantly lower narcotic usage in the postoperative setting. These findings suggest a role for narcotic-reducing enhanced recovery after surgery protocols in the setting of isolated facial trauma.

Orbital Volumetric Analysis in Patients With Unicoronal Craniosynostosis: A Comparison Between Distraction Osteogenesis and Fronto-Orbital Advancement

BACKGROUND

Unicoronal craniosynostosis is associated with orbital restriction and asymmetry. Surgical treatment aims to both correct the aesthetic deformity and prevent the development of ocular dysfunction. We used orbital quadrant and hemispheric volumetric analysis to assess orbital restriction and compare the effectiveness of distraction osteogenesis with anterior rotational cranial flap (DO) and bilateral fronto-orbital advancement and cranial vault remodeling (FOAR) with respect to the correction of orbital restriction in patients with unicoronal craniosynostosis.

METHODS

A retrospective review of all patients with a diagnosis of unicoronal craniosynostosis and treated with either DO or FOAR from 2000 to 2019 was performed. Preoperative and postoperative total orbital volumes, as well as quadrant and hemispheric volume ratios, were calculated from 3-dimensional head computed tomography scans. Selected preoperative and postoperative orbital measurements, including the maxillary length of the orbit (MLO; zygomaticofrontal suture to the top of zygomatic arch) and the sphenoid length of the orbit (SLO; the top of sphenoid suture to the top of zygomatic arch), were also obtained.

RESULTS

Data were available for 28 patients with unicoronal craniosynostosis. Mean preoperative total orbital volume was significantly smaller on the synostotic side compared with the nonsynostotic side (10.94 vs 12.20 cm3, P = 0.04). Preoperative MLO and SLO were significantly longer on the synostotic side compared with the nonsynostotic side (MLO: 20.26 vs 17.75 mm, P < 0.001; SLO: 26.91 vs 24.93 mm, P = 0.01). Distraction osteogenesis and FOAR produced significantly different changes in orbital quadrant and/or hemispheric volume ratios on the nonsynostotic side but not on the synostotic side.

CONCLUSIONS

Before correction, patients with unicoronal craniosynostosis have significantly smaller total orbital volumes on the synostotic side compared with the nonsynostotic side and significantly greater MLO and SLO on the synostotic side compared with the nonsynostotic side. There is no significant difference between DO and FOAR with regard to correcting the observed orbital restriction in these patients.

Rotation flap distraction osteogenesis for unicoronal synostosis

Unicoronal craniosynostosis is notoriously difficult to treat, with long-term studies demonstrating high rates of relapse and the need for reoperation using open fronto-orbital advancement. Applying the principles of distraction osteogenesis to cranial vault remodeling has demonstrated promising short-term results that compare favorably with traditional methods, with simultaneous correction of both frontofacial and endocranial morphology, along with significant increases in intracranial volume. Here, the authors demonstrate their technique for rotation flap distraction osteogenesis in the treatment of unicoronal synostosis and provide case examples.

The video can be found here: https://vimeo.com/519505008.

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review

BACKGROUND

Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice.

PRIMARY AIM

To provide a qualitative systematic review analysis of long-term outcomes after PABG.

MATERIALS AND METHODS

A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings.

RESULTS

After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice.

CONCLUSION

The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction

INTRODUCTION

In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction.

METHODS

The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant.

RESULTS

There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01).

DISCUSSION

A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.

Electric scooter craniofacial trauma

OBJECTIVE

The use of standing electronic scooters associated with micromobility applications (e-scooters) has risen nationally. The aim of this study was to obtain a detailed view of soft tissue and bony craniofacial injury associated with e-scooter-related trauma.

METHODS

Single-institution retrospective case series of patients presenting to a level 1 trauma center emergency department or trauma unit with documented e-scooter-related craniofacial injury.

RESULTS

Of 203 included patients, 188 (92.6%) patients sustained craniofacial injury. One hundred thirty-one (64.5%) had exclusively soft tissue injury, 3 (1.5%) exclusively bony injury, 51 (25.1%) both soft and bony injuries, and twenty-five (12.3%) patients sustained dental injury. Aesthetic units most frequently sustaining acute soft tissue injury were the forehead (n = 106, 34.6%), scalp (n = 36, 11.8%), chin (n = 34, 11.1%), upper lip (n = 32, 10.5%), and cheek (n = 31, 10.1%). Aesthetic subunits most often sustaining acute soft tissue injury included the brow (42, 13.7%), central forehead (39, 12.7%), lateral forehead (n = 25, 8.2%), and upper lip vermillion (n = 23, 7.5%). Craniofacial osseous fracture most often occurred in the orbit (n = 42, 24.6%) and maxilla (n = 40, 23.4%). Individual osseous segments most frequently sustaining acute fracture included the anterior maxillary sinus wall (n = 22, 12.9%), nasal bone (n = 20, 11.7%), lateral orbital wall (n = 16, 9.4%), orbital floor (n = 15, 8.8%), and zygomatic bone (13, 7.6%).

CONCLUSIONS

Our analysis demonstrates that most patients presenting to our center with craniofacial trauma sustained acute bony fracture, most often to the midface. Our data of common injuries associated with e-scooter trauma could inform implementation in the form of facial safety equipment or safety skills training for e-scooter riders.

LEVEL OF EVIDENCE

4.

Endoscopic surgery for nonsyndromic craniosynostosis: a 16-year single-center experience

OBJECTIVE

In this paper the authors review their 16-year single-institution consecutive patient experience in the endoscopic treatment of nonsyndromic craniosynostosis with an emphasis on careful review of any associated treatment-related complications and methods of complication avoidance, including preoperative planning, intraoperative management, and postoperative care and follow-up.

METHODS

A retrospective chart review was conducted on all patients undergoing endoscopic, minimally invasive surgery for nonsyndromic craniosynostosis at Rady Children's Hospital from 2000 to 2015. All patients were operated on by a single neurosurgeon in collaboration with two plastic and reconstructive surgeons as part of the institution's craniofacial team.

RESULTS

Two hundred thirty-five patients underwent minimally invasive endoscopic surgery for nonsyndromic craniosynostosis from 2000 to 2015. The median age at surgery was 3.8 months. The median operative and anesthesia times were 55 and 105 minutes, respectively. The median estimated blood loss (EBL) was 25 ml (median percentage EBL 4.2%). There were no identified episodes of air embolism or operative deaths. One patient suffered an intraoperative sagittal sinus injury, 2 patients underwent intraoperative conversion of planned endoscopic to open procedures, 1 patient experienced a dural tear, and 1 patient had an immediate reexploration for a developing subgaleal hematoma. Two hundred twenty-five patients (96%) were admitted directly to the standard surgical ward where the median length of stay was 1 day. Eight patients were admitted to the intensive care unit (ICU) postoperatively, 7 of whom had preexisting medical conditions that the team had identified preoperatively as necessitating a planned ICU admission. The 30-day readmission rate was 1.7% (4 patients), only 1 of whom had a diagnosis (surgical site infection) related to their initial admission. Average length of follow-up was 2.8 years (range < 1 year to 13.4 years). Six children (< 3%) had subsequent open procedures for perceived suboptimal aesthetic results, 4 of whom (> 66%) had either coronal or metopic craniosynostosis. No patient in this series either presented with or subsequently developed signs or symptoms of intracranial hypertension.

CONCLUSIONS

In this large single-center consecutive patient series in the endoscopic treatment of nonsyndromic craniosynostosis, significant complications were avoided, allowing for postoperative care for the vast majority of infants on a standard surgical ward. No deaths, catastrophic postoperative morbidity, or evidence of the development of symptomatic intracranial hypertension was observed.

Evaluation of Information Sources in Plastic Surgery Decision-making

Background

Today, patients can access a myriad of information sources regarding plastic surgery procedures prior to meeting with a surgeon. Despite their widespread use, the role of these sources in a patient’s decision-making remains undefined. We hypothesized that the physician remains the key information source for patients making surgical decisions in plastic surgery, but that other sources may deliver important insights and prove helpful to varying degrees. We also explored motivations for this outside information search and any differences in perceived value among patients.

Methods

We administered a survey regarding various information sources to our breast reconstruction, reduction, and abdominoplasty patients. Responses were compared between surgery groups and demographic groups. Ordinal logistic regression analysis was used to determine the impact of patient characteristics on helpfulness rank of different sources.

Results

Survey results were obtained from 58 patients, of whom 10 (17.2%) had abdominoplasty, 35 (60.3%) breast reconstruction, and 13 (22.4%) breast reduction. The most popular information sources prior to the first surgical appointment were Internet searches (56.9%) and family/friends/other patients (39.7%). After the initial appointment, the most useful sources were plastic surgeons (84.5%), and the Internet (36.2%). Most patients (73.5%) still sought outside information after their appointment.

On a Likert-type scale of helpfulness, plastic surgeons ranked 4.28/5, followed by the web-based patient education platform, 3.73 and the Internet, 3.6. A total of 63% of participants listed plastic surgeons as their single most important source of information.

In ordinal logistic regression analysis, non-white race was significantly associated with higher rank of surgeon helpfulness (p < 0.05). Relative to low-income patients, income $50-100k (p < 0.05) and $100k+ (p < 0.05) were associated with lower rank of surgeon helpfulness.

Conclusions

Most patients seek outside information prior to visiting with a surgeon from the Internet, social media, or family and friends. Patients consider plastic surgeons their most valuable information source overall, though still in need of supplementation for varying reasons. Additionally, certain demographic differences affect patient perception of information sources, and this is an important factor for surgeons to consider as they approach educating patients.

Efficacy of a Procedure-Specific Education Module on Informed Consent in Plastic Surgery

INTRODUCTION

Truly informed consent is an elusive goal, seldom attained in medical or surgical practice. Patients often do not fully understand procedures and therapies they undergo or the associated sequelae. Historically, informed consent and patient education have been limited to physician discussions, sometimes with the addition of simple visual aids. More recently, there is a growing body of decision aids available, including interactive multimedia patient educational modules that review preoperative through postoperative care, risks, benefits, alternatives, different surgical options, as well as commonly asked questions. We hypothesized that the addition of a Web-based educational tool would positively impact attainment of informed consent and satisfaction in plastic surgery patients.

METHODS

We performed a prospective randomized controlled study comparing patients who presented in consultation for breast reconstruction, breast reduction, and abdominoplasty. Patients received standard patient education along with a procedure-specific (study) or general patient safety (control) Web-based educational module. Informed consent was measured using a surgical-focused, modified version of the Shared Decision-making 25 index tool. Patient demographic information as well as surrogate markers of familiarity with technology were recorded preoperatively and postoperatively. Comparisons were made between study and control groups, procedure subgroups, and preoperative and postoperative time points. Demographic factors and consent variables were compared among experimental and procedure groups.

RESULTS

Data were collected from 65 patients preoperatively and 48 patients postoperatively. Thirty patients competed both surveys. Overall, no differences in patient characteristics or familiarity with technology were observed between experimental groups. Demographic characteristics were also similar between groups. No meaningful differences were identified in comparisons between experimental groups on either cross-sectional or longitudinal analyses. Nearly all patient responses were consistent with being well informed and satisfied with the educational process.

CONCLUSIONS

Overall, patients undergoing plastic surgery procedures are adequately informed and have a high degree of satisfaction regarding their patient education. The addition of a Web-based informed consent tool did not make a demonstrable difference in informed consent.

Evaluation of Ventilation Tube Placement and Long-term Audiologic Outcome in Children with Cleft Palate

Objective

The purpose of this study was to assess the effect of ventilation tube (VT) placement on long-term hearing outcomes in children with cleft palate.

Study Design

Case series with chart review.

Setting

Genetic and dysmorphology database at Rady Children's Hospital–San Diego (RCHSD).

Patients

Children with cleft palate diagnosis who underwent surgery at RCHSD between 1995 and 2002.

Main Outcome Measure

The primary outcome studied was hearing acuity at 10 years of age. Independent variables studied included gender, age at palate repair and first VT placement, total number of VTs, number of complications, and presence of tympanic membrane perforation.

Results

An increased number of tubes was associated with a greater incidence of hearing loss at age 10, even after adjusting for total number of otologic complications. The timing of initial tube placement did not have a significant effect on long-term hearing outcome in this study.

Conclusions

While children with worse middle ear disease are more likely to receive more tubes and have long-term conductive hearing loss as a result of ear disease, the results of this study suggest that multiple tube placements may not contribute to improved long-term hearing outcomes. Further research focusing on long-term outcomes is needed to establish patient-centered criteria guiding decision making for ventilation tube placement in children with cleft palate.

Abstract P3-14-02: Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons

Purpose/Objective

In the United States over 40% of incident breast cancer diagnoses are in women over 65 years of age. Effective breast cancer treatments allow elderly patients to live long, healthy lives; questions regarding long-term quality of life are increasingly important. In women over 65, post-mastectomy breast reconstruction (PMBR) is uncommon with reported rates of 6-30%. The goal of this study is to report complication rates in elderly PMBR patients and to evaluate the impact of individual surgeons on PMBR in elderly patients.

Material/methods

We identified 19,417 Medicare beneficiaries diagnosed with localized breast cancer between 2005 and 2011 who underwent mastectomy. Medicare claims were used to identify PMBR, post-operative complications after PMBR (within 30 days of surgery), and long-term complications related to reconstruction (within three years following surgery). Mastectomy surgeon was identified from Medicare claims with surgeon characteristics identified through linkage to the American Medical Association (AMA) Masterfile.

Multi-level, multivariable logistic models clustered by surgeon and geographic area were used to determine the impact of surgeons on the likelihood of reconstruction. The intraclass correlation coefficient (ICC) and median odds ratio (MOR) were used to describe the relative impact of the individual surgeon. The ICC estimates the proportion of variability explained by the surgeon on PMBR rates. The MOR quantifies the likelihood of a patient having a different PMBR outcome if the patient were to change surgeons (or geographic area); it is directly comparable to odds ratios. Odds ratios (OR) were used to describe the impact of fixed demographic and clinical covariates.

Results

Among the entire cohort, 1,234 (6.4%) patients underwent PMBR. The post-operative complication rate was 8.4% and the long-term complication rate was 19.9%. Eighteen percent of the variability in PMBR use was attributed to the individual surgeon (ICC 0.181). The MOR for surgeon was found to be 1.85 (95% CI [1.70,1.99]), indicating that a patient had an 85% chance of having a different outcome (receiving or not receiving PMBR) if the patient saw a different mastectomy surgeon. The MOR for geographic area indicated that a patient had a 32% chance of having a different outcome if the patient saw a surgeon in a different geographic area (1.32, 95% CI [1.17, 1.47]). Patients who were Asian, single, older, of lower socioeconomic status, and underwent radiation therapy were less likely to undergo PMBR. Patients who had pre-operative MRI or received chemotherapy were more likely to undergo PMBR. Patients who were treated by female surgeons or plastic surgeons were significantly more likely to undergo PMBR. Overall, the individual surgeon was the most predictive of PMBR, except for the use of pre-operative MRI and mastectomy surgeon's specialty being plastic surgery.

Conclusion

A small minority of older women undergo PMBR despite having low post-operative and long-term complication rates. The individual surgeon and geographic area significantly influences whether older breast cancer patients will undergo PMBR. Future research should focus on surgeon characteristics that may influence a patient's decision to undergo PMBR.

Citation Format: Schoenbrunner AR, Fero KE, Boero IJ, Matsuno R, Kronstadt N, Lance S, Reid C, Wallace AM, Gosman AA, Murphy JD. Post mastectomy breast reconstruction in elderly women: Complications and the impact of individual surgeons [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-02.

Streamlining the management of patients with problematic wounds: must a multidisciplinary team formulate all patient management plans?

 The importance of the management of patients with problem wounds by multidisciplinary teams (MDTs) is uniformly emphasized. The aim of this study was to examine the impact of the review of individual cases by MDT on the management plan proposed by the Surgical Wound Care Specialist (SWCS).

METHODS

Trained "field" nurse specialists assessed problem wound patients in ambulatory care settings followed by the evaluation by the SWCS. The initial management plan (IMP), including a statement regarding the probability of the plan change by the MDT, was formulated by a SWCS based on evaluation of electronically transmitted patient record (including photographs) by a "field" nurse, followed by direct face-to-face evaluation by the same SWCS. Subsequently, the MDT reviewed individual cases formulating the final management plan (FMP). Over a 24-month period (2005-2006) the MDT reviewed clinical data for 124 new patients and a collective decision about the FMP was made.

RESULTS

As the result of the MDT discussion, 3 of the 124 cases had clinical management changes (clinically important disagreement) and 5 trivial assessment changes. All cases were identified (among 4 others) by SWCS as potential "change cases" before the MDT meeting.

CONCLUSION

The MDT review made no difference in the case management plan in 93.6%, with significant changes recommended only in 2.4% of cases. In consideration of a potential management plan change the SWCS correctly identified cases requiring discussion, which indicates that a selective rather than blanket approach would be effective. This has the potential to expedite patient care and to reduce costs without affecting patient care.