Development of "Explore Plastic Surgery": An Educational Program for Medical Students Without Home Residency Programs

BACKGROUND

Medical students who attend institutions without plastic surgery residency programs are at a disadvantage in the plastic surgery match. We developed an educational program for medical students without home programs called Explore Plastic Surgery to provide an overview of the steps toward a career in plastic surgery. The purpose of this study was to assess the impact, utility, and success of the novel program.

METHODS

Pre- and postevent surveys were distributed to participants. Survey data were analyzed including participant demographics, perceptions of barriers unique to those without home programs, and the overall event utility.

RESULTS

Two hundred seventeen students registered for the program. Ninety-five participants completed the pre-event survey (44%), and of those, 57 participants completed the post-event survey (60%). There was an increase in understanding of the steps toward a career in plastic surgery ( P < 0.001), confidence in overcoming barriers ( P = 0.005), and level of comfort in reaching out to faculty for opportunities ( P = 0.01). There was a decrease in the perceived negative impact that attending medical schools without a home program will have on their abilities to pursue careers in plastic surgery ( P = 0.006).

CONCLUSIONS

After the event, participants demonstrated an increase in their confidence in overcoming barriers and a decrease in their perceptions that attending an institution without a home program would negatively impact their ability to pursue plastic surgery. Initiatives focused on early exposure and recruitment of medical students may be important to promote accessibility and diversity within plastic surgery.

Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review

BACKGROUND

There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients.

METHODS

Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care.

RESULTS

Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting.

CONCLUSIONS

Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.

Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database

BACKGROUND

 Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program database (2010-2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed.

RESULTS

 We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients.

CONCLUSION

 Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

Immediate lymphatic reconstruction: Lessons learned over eight years

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.

The Impact of Health Literacy on Trust in Online Plastic Surgery Content: A Nationwide Analysis

INTRODUCTION

On most online platforms, just about anyone can disseminate plastic surgery (PS) content regardless of their educational or professional background. This study examines the general public's perceptions of the accuracy of online PS content and the factors that contribute to the discernment of credible information.

METHODS

The Amazon Mechanical Turk crowdsourcing platform was used to survey adults in the United States. The survey assessed respondent demographics, health literacy (HL), and perceptions of online PS content accuracy. T-tests, Chi-square tests, and post hoc analyses with Bonferroni corrections assessed differences between HL groups. Multivariate linear regressions assessed associations between sociodemographic variables and perceptions of online content.

RESULTS

In total, 428 (92.0%) of 465 complete responses were analyzed. The median age of respondents was 32 y (interquartile range: 29-40). Online sources were predominantly perceived to have a high degree of accuracy, with mean scores of various platforms ranging from 3.8 to 4.5 (1 = not accurate at all; 5 = extremely accurate). The low HL group perceived social media sites and review sites to be more accurate than the high HL respondents, particularly for Reddit (P = 0.004), Pinterest (P = 0.040), and Snapchat (P = 0.002).

CONCLUSIONS

There is a concerning relationship between low HL and the perceptions of the accuracy of online PS sources. This study underscores the need for education campaigns, the development of trustworthy online resources, and initiatives to improve HL. By fostering a more informed public, individuals seeking PS can make better informed decisions.

A Meta-Analysis of the Mortality and the Prevalence of Burn Complications in Western Populations

Management of burn injuries is complex, with highly variable outcomes occurring among different populations. This meta-analysis aims to assess the outcomes of burn therapy in North American (NA) and European adults, specifically, mortality and complications, to guide further therapeutic advances. A systematic review of PubMed, Web of Science, and Cochrane was performed. Random-effect meta-analysis of proportions was conducted to assess the overall prevalence of the defined outcomes. Fifty-four studies were included, pooling 60,269 adult patients. A total of 53,896 patients were in North America (NA, 89.4%), and 6,373 were in Europe (10.6%). Both populations experienced similar outcomes. The overall pooled prevalence of mortality was 13% (95% CI 8-19%) for moderate burns and 20% (95% CI 12-29%) for severe burns in the NA region, and 22% (95% CI 16-28%) for severe burns in Europe. Infectious complications were the most common across both regions. European studies showed an infection rate for moderate and severe burn patients at 8% and 76%, respectively, while NA studies had rates of 35% and 54%. Acute kidney injury (39% vs. 37%) and shock (29% vs. 35%), were the next most common complications in European and NA studies, respectively. The length of stay was 27.52 days for severe burn patients in Europe and 31.02 days for severe burn patients in NA. Burn outcomes are similar between Western populations. While outcomes are reasonably good overall, infectious complications remain high. These findings encourage the development of further therapeutic strategies disclosing respective costs to enable cost/efficiency evaluations in burn management.

Preferences and Barriers of Male Patients Seeking Aesthetic Procedures

BACKGROUND

As social attitudes toward plastic surgery continue to evolve, the prevalence of men seeking plastic surgery has been increasing. By delving into the factors that encourage male patients to seek plastic surgery and the obstacles they encounter, this study aims to facilitate the development of more inclusive and effective approaches for this population.

METHOD

An anonymous 41-question survey was conducted among adult men in the USA via the Amazon Mechanical Turk crowdsourcing platform. Questions assessed demographic information and identified factors that influenced males to seek plastic surgery care, the barriers they experienced while seeking care, and their preferences. Multivariate logistic regression was used to assess relationships between demographic variables and likelihood of undergoing cosmetic surgery.

RESULTS

Four hundred and eleven complete responses were analyzed. The median (IQR) age of respondents was 32 (30, 40) years old. Of the respondents, 60% had undergone cosmetic surgery. Functional improvement (40%), personal aspiration (32%), and partners' opinions (22%) were the most commonly cited reasons for undergoing procedures. The most common barriers faced by this population were recovery time following a procedure (52%), perceived risk of complications (48%), cost (43%), fear of being identified as having had plastic surgery (32%), and surgeons not being able to meet expectations (31%). Eighty-nine percent of respondents who underwent plastic surgery procedures reported facing at least one barrier. Multivariate regression demonstrated that higher education levels were strongly associated with a likelihood of undergoing cosmetic surgery (p < 0.001). Income (p = 0.44) and region (p = 0.23) did not significantly affect the likelihood of undergoing plastic surgery.

CONCLUSION

Despite improving societal stigma, many male patients continue to face barriers when obtaining plastic surgery care. Efforts may be made to alleviate these barriers and surgeons looking to expand their practice may benefit from increased outreach to male patients. This may be compounded with improved education targeting stigma and risks of procedures, increasing male-specific marketing communications to make them feel welcome in an industry predominantly focused on female patients, and offering male-tailored procedures.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND

The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes.

METHODS

A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases.

RESULTS

Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04).

CONCLUSIONS

Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Racial and ethnic representation in united states plastic surgery clinical trials: A systematic review and meta-analysis

In 1993, the National Institutes of Health Revitalization Act mandated increasing minority and women enrollment in clinical trials (CTs). This study aimed to investigate trends in race and ethnicity enrollment and reporting in US plastic and reconstructive surgery (PRS) CT.

METHODS

A comprehensive systematic review was performed. All CTs in PRS from 2012 to 2022 were included. To assess racial and ethnic representation within CTs, a random-effects meta-analysis of proportion was conducted to pool the prevalence of the binomial data.

RESULTS

A total of 3609 studies were initially identified in the search strategy, with 154 later classified as CTs in PRS. Only 36 met the eligibility criteria for reporting race and ethnicity and were included in the analysis. A total of 7281 participants were included: 446 (6.1%) males and 6835 (93.9%) females. From CTs that correctly reported race, the pooled prevalence of races were as follows: Whites 78% (95% confidence interval [CI] 73-82%), Black or African Americans 8% (95% CI 5-11%), Asians 1% (95% CI <1-2%), American Indians <1% (95% CI <1-<1%), and Pacific Islanders <1% (95% CI <1-<1%). From the studies that reported ethnicity correctly, the pooled prevalence of Hispanics was 7% (95% CI 5-9%), and Non-Hispanics was 12% (<1-38%).

CONCLUSIONS

Disparities in minority representation were present among PRS CTs. This suggests clear limitations in generalizing PRS CT results to the population. Efforts to decrease the gap in minority enrollment and accurately report race and ethnicity are needed in all fields, including plastic surgery.

The impact of race and ethnicity in outpatient breast reconstruction decision-making and postoperative outcomes: A propensity score-matched NSQIP analysis

BACKGROUND

Recent literature has established outpatient breast reconstruction (BR) to be a safe alternative to inpatient BR. However, the impact of race and ethnicity on BR patient decision-making and postsurgical outcomes remains unexplored. This study aims to assess the impact of race and ethnicity on outpatient BR timing and postoperative complication rates.

METHODS

The 2013-2020 ACS-NSQIP database was utilized to identify women undergoing outpatient BR. Propensity score-matched analysis was conducted to generate balanced cohorts based on race and ethnicity. t-tests and Fisher's exact tests were used to assess group differences. Logistic regressions were modeled to evaluate differences in complications between groups.

RESULTS

A total of 63,526 patients underwent outpatient BR. After propensity score matching, 7664 patients and 3948 patients were included in the race and ethnicity-based analysis, respectively. There were statistically significant differences in the timing of BR patients received across cohorts. NW patients had lower rates of immediate BR (IBR) compared with White patients (47% vs. 53%, p < 0.001), and this also was seen in Hispanic patients (97% vs. 3%, p = 0.018). Subsequently, there were higher rates of delayed BR (DBR) in the NW cohort (55% vs. 45%, p < 0.001) and in the Hispanic cohort (95% vs. 5%, p = 0.018). There were no significant differences in the rates of 30-day postoperative complications across cohorts.

CONCLUSIONS

Ultimately, our findings suggest that minority patients are more likely to undergo DBR than nonminority patients. However, there were no differences in 30-day postoperative outcomes across race or ethnicity. Future studies to elucidate patients' decision-making process in choosing optimal BR types and timing are necessary to better understand the impact of the observed differences in patient care.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents

BACKGROUND

This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements.

METHOD

Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05).

RESULTS

Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively).

CONCLUSIONS

Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.

Utilization of patient-reported outcome measures in plastic surgery clinical trials: A systematic review

BACKGROUND

Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs).

METHODS

A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis.

RESULTS

Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade.

CONCLUSIONS

The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.

Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature

BACKGROUND

 There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction.

METHODS

 A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis.

RESULTS

 A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort.

CONCLUSION

 There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

 Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

RESULTS

 In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05).

CONCLUSION

 While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis

BACKGROUND

Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates.

METHODS

The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups.

RESULTS

A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups.

CONCLUSIONS

Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.

Beyond Accreditation Council for Graduate Medical Education Required Scholarship: The Academic Journey of Plastic Surgery Residents

INTRODUCTION

Research productivity is an important part of required Accreditation Council for Graduate Medical Education scholarship during residency training and critical to trainees who intend to pursue careers in academia. This study aims to determine plastic surgery residents' experiences with and attitudes toward research.

METHODS

Accredited independent (52) and integrated (86) plastic surgery program websites were manually searched for currently active residents' names and email addresses. Identified residents were emailed a survey consisting of 25 questions through Research Electronic Data Capture.

RESULTS

A total of 45 plastic surgery residents responded to the survey request (14.6% response rate). Respondents were 57% female and 43% male, with an average age of 30.7 y. At the time of survey participation, 95% of surgery residents were involved in research endeavors, voluntarily or as part of their residency training. Of the respondents, 13 (32%) previously participated in a research fellowship compared to 28 (68%) respondents who did not. Interestingly, respondents who completed fellowships were 2.84 times (95% confidence interval: 0.52-15.38, P = 0.2269) more likely to intend continuing research endeavors after residency. Participants were most in agreement with statements suggesting their research fellowship benefitted their application in the plastic surgery match process (4 [interquartile range (IQR): 4, 4]), improved their ability to conduct research (4 [IQR: 4, 4]), and helped to better understand medical literature (4 [IQR: 3, 4]).

CONCLUSIONS

Plastic surgery programs' robust research emphasis has a favorable translation into residents' self-perceived understanding of medical literature and clinical knowledge.

Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization

PURPOSE

The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS.

METHODS

This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians.

RESULTS

A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively).

CONCLUSIONS

There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.

Outcomes of patients in rural communities undergoing autologous breast reconstruction: A comparison of cost and patient demographics with implications for rural health policy

BACKGROUND

Patients with breast cancer living in rural areas are less likely to undergo breast reconstruction. Further, given the additional training and resources required for autologous reconstruction, it is likely that rural patients face barriers to accessing these surgical options. Therefore, the purpose of this study is to determine if there are disparities in autologous breast reconstruction care among rural patients on the national level.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database was queried from 2012 to 2019 using ICD9/10 codes for breast cancer diagnoses and autologous breast reconstruction. The resulting data set was analyzed for patient, hospital, and complication-specific information with counties comprised of less than 10,000 inhabitants classified as rural.

RESULTS

From 2012 to 2019, 89,700 weighted encounters for autologous breast reconstruction involved patients who lived in non-rural areas, while 3605 involved patients from rural counties. The majority of rural patients underwent reconstruction at urban teaching hospitals. However, rural patients were more likely than non-rural patients to have their surgery at a rural hospital (6.8% vs. 0.7%). Rural-county residing patients had lower odds of receiving a deep inferior epigastric perforator (DIEP) flap compared to non-rural-county residing patients (OR 0.51 CI: 0.48-0.55, p < .0001). Further, rural patients were more likely to experience infection and wound disruption than urban patients (p < .05), regardless of where they underwent surgery. Complication rates were similar among rural patients who received care at rural hospitals versus urban hospitals (p > .05). Meanwhile, the cost of autologous breast reconstruction was higher (p = .011) for rural patients at an urban hospital ($30,066.2, SD19,965.5) than at a rural hospital ($25,049.5, SD12,397.2).

CONCLUSION

Patients living in rural areas face disparities in health care, including lower odds of being potentially offered gold-standard breast reconstruction treatments. Increased microsurgical option availability and patient education in rural areas may help alleviate current disparities in breast reconstruction.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery

BACKGROUND

Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO).

OBJECTIVES

The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery.

METHODS

Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed.

RESULTS

Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups.

CONCLUSIONS

Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

LEVEL OF EVIDENCE: 4

A 4-Year Institutional Experience of Immediate Lymphatic Reconstruction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, V.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Plastic Surgery Residency Applicants' Perceptions of a Virtual Interview Cycle

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

A single-cell atlas of human and mouse white adipose tissue

White adipose tissue, once regarded as morphologically and functionally bland, is now recognized to be dynamic, plastic and heterogenous, and is involved in a wide array of biological processes including energy homeostasis, glucose and lipid handling, blood pressure control and host defence1. High-fat feeding and other metabolic stressors cause marked changes in adipose morphology, physiology and cellular composition1, and alterations in adiposity are associated with insulin resistance, dyslipidemia and type 2 diabetes2. Here we provide detailed cellular atlases of human and mouse subcutaneous and visceral white fat at single-cell resolution across a range of body weight. We identify subpopulations of adipocytes, adipose stem and progenitor cells, vascular and immune cells and demonstrate commonalities and differences across species and dietary conditions. We link specific cell types to increased risk of metabolic disease and provide an initial blueprint for a comprehensive set of interactions between individual cell types in the adipose niche in leanness and obesity. These data comprise an extensive resource for the exploration of genes, traits and cell types in the function of white adipose tissue across species, depots and nutritional conditions.

Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps

Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.

Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.

Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.

Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.