Scientific Abstract Presentations: Research & Technology 3 Thursday, October 26 Thu, Oct 26 5:00-6:00 p.m. CDT

Introduction

Understanding key drivers of opioid use after surgery is crucial as opioid misuse continues to increase.1 Past studies have shown that opioid use in children has been linked to a 33% increase in opioid misuse in adulthood.2 Therefore, the present study aims to identify patient-specific features that are associated with post-operative opioid prescription at discharge in pediatric plastic surgery patients.

Methods

Using patient data from a single pediatric plastic surgeon, demographic, clinical, intraoperative, and medication characteristics were collected for each patient < 18 years old at time of procedure who underwent pediatric surgery between January 2020 and November 2022. These characteristics included the Child Opportunity Index, language spoken, patient race, procedure type, sex, age at surgery, Body Mass Index (BMI), insurance type, length of stay, intraoperative time, surgical history, and opioid prescription in the inpatient setting. The outcome analyzed was active opioid prescription at hospital discharge. Patient-specific characteristics were inputted into a backwards-elimination logistic regression model to identify key patient features associated with opioid prescription at this time point. Sub-analyses were conducted for two groups: cleft palate/alveolar graft surgeries and cutaneous procedures.

Results

A total of 516 patients were analyzed in the overall cohort (70 patients underwent a cleft palate procedure/alveolar graft and 212 patients underwent a cutaneous procedure). After adjusting for covariates in the overall cohort, opioid use in the inpatient setting (OR: 5.71, p=0.009), private insurance status (OR: 1.87, p=0.018), cleft palate/alveolar graft procedure (OR: 2.38, p=0.015), increased age (OR: 1.15, p<0.001), and greater intraoperative time (OR: 1.01, p<0.001) were significantly associated with higher odds of opioid use at discharge. Conversely, cutaneous procedures were associated with lower odds of opioid use at discharge (OR: 0.32, p=0.003). However, when analyzing sub-cohorts of cleft palate/alveolar bone graft patients and cutaneous procedure patients, there were no predictive characteristics identified with logistic regression.

Conclusion

Patient-specific characteristics, including increased age, intraoperative time, and cleft palate/alveolar bone graft procedure were identified as independent predictors of opioid use at discharge in this pediatric plastic surgery patient population. These findings highlight the critical importance of early identification of these risk factors during the surgical planning stage. Armed with this information, healthcare professionals can provide families with valuable education and counseling regarding opioid use, empowering them to make informed decisions about pain management after discharge.

1. Jalali MS, Botticelli M, Hwang RC, Koh HK, McHugh RK. The opioid crisis: a contextual, social-ecological framework. Health research policy and systems. 2020;18(1):87-87. doi:10.1186/s12961-020-00596-8

2. Meza BC, Swarup I, Woodard T, Cazzulino A, Talwar D, Shah AS. Refilling Opioid Prescriptions After Pediatric Orthopaedic Surgery: An Analysis of Incidence and Risk Factors. Journal of pediatric orthopaedics. 2021;41(3):e291-e295. doi:10.1097/BPO.0000000000001736

Purpose: Increasing the diversity of plastic surgery trainees is an important step in providing better care for our increasingly diverse patient populations. However, many barriers exist in recruiting candidates who are underrepresented in medicine (URiM) to plastic surgery. Prior research suggests that URiM applicants place significant emphasis on institutional and program diversity when choosing residency programs. Given that information presented on residency programs' websites can strongly influence applicants' decisions to apply to or rank a program, demonstrating a commitment to diversity, equity, and inclusion (DEI) on program websites may aid in recruiting applicants with URiM backgrounds. Previous studies have evaluated the presence of DEI-related information on the program websites of surgical subspecialties. However, to our knowledge, no such studies have evaluated the presence of similar information on plastic surgery websites.

Methods and Materials: Using eight DEI-related criteria, we evaluated the websites of 103 plastic surgery residency programs for the presence of DEI-related content during the month of June 2022. Programs were included for analysis if they were listed in the FREIDA AMA residency database. Each program was evaluated by two individual graders. We analyzed the data using confirmatory factor analysis in R, using the Lavaan package.

Results: On average, programs fulfilled 2.1±1.6 of the metrics with a range of 0-7 fulfilled per program. Our model revealed that the criteria were a high quality (p<0.0001) measure of DEI-related metrics. Criterion 5, the presence of a diversity page or section (25%), was most achieved, followed by criterion 2, the presence of a diversity mission statement (22%), and criterion 4, mention of diversity initiatives (19%). Factor analysis demonstrated that criteria 1-5 were significant (1-5, loading between 0.41-0.92, all p<0.01), including the CFI of 0.89, RMSEA of 0.06 and SRMR of 0.07, with 90% CI [0.022, 0.096]. Criteria 7 and 8 were not significant and were fulfilled by only 5% and 6% of program websites, respectively. There is a significant association between program size and the presence of DEI-related criteria (linear 0.039; quadratic -0.005; both p<0.01), such that mid-sized programs (16-18 residents) had the highest quality of DEI advertising compared to both small and large programs. Programs associated with USWN Top 20 Hospitals published significantly fewer DEI-related criteria on their residency websites than other programs (p<0.0001). Program region had no association with the presence of DEI-related criteria (p=0.41).

Conclusion: Mid-size programs had greater DEI quality on their websites, while smaller and larger programs similarly had poorer assessed quality. There is room for all programs to improve the presence of DEI-related material on their websites, especially related to care of transgender patients and populations.

Background: Following the integration of the electronic medical record (EMR) into the healthcare system, concern has grown regarding EMR use on physician well-being. For surgical residents, time spent on the EMR increases the burden of a demanding, hourly-restricted schedule and detracts from time spent honing surgical skills.
Objective: To characterize these burdens, we sought to describe EMR utilization patterns for plastic surgery residents. Methods: Integrated plastic surgery resident EMR utilization from March 2019 to March 2020 was extracted via Cerner Analytics at a tertiary academic medical center. Time spent in the EMR on-duty (0600-1759) and off-duty (1800-0559), including chart review, orders, documentation, and patient discovery, was analyzed. Statistical analysis was performed through independent T-tests and ANOVA. Results: Twelve plastic surgery residents spent an average of 94 ± 86 minutes/day on the EMR, one third of which was spent off-duty. Juniors (PGY 1-3) spent 123 ± 99 minutes/day versus seniors (PGY 4-6) who spent 61 ± 49 minutes/day (p-value < 0.01). Seniors spent 23% of time on the EMR off-duty, compared with 40% for juniors (p-value < 0.01). Chart review comprised the majority (42%) of EMR usage, followed by patient discovery (22%), orders (14%), documentation (12%), other (6%), and messaging (1%). Seniors spent more time on patient discovery (25% versus 21%, p-value < 0.001), while juniors spent more time performing chart review (48% versus 36%, p-value = 0.19). Conclusion: Integrated plastic surgery residents average 1.5 hours on the EMR daily. Junior residents spend one hour more per day on the EMR, including more time off-duty and more time performing chart review.

Background: On November 20, 2022, ChatGPT was made available to the general public free of charge. As a large language model (LLM), the software was able to process inquiries by users and generate text based on compiled datasets in a humanist manner. Due to the importance of research in the Plastic Surgery community, we set out to determine if ChatGPT could be utilized to produce novel systematic review ideas relevant to Plastic Surgery.

Methods: ChatGPT was given commands to "give novel systematic review ideas" for 4 unique topics: cosmetic, craniofacial, microsurgery, and hand. For each topic, the open AI model was told to give 10 general systematic reviews and 10 systematic review topics focusing on 2 specific areas within that topic for a total of 80 systematic review topics. To assess for ChatGPT's accuracy to devise unpublished systematic review ideas, a literature search was conducted by the authors in PubMed, CINAHL, EMBASE, and Cochrane to account for general literature and the number of systematic review papers that had been published on each topic.

Results: Overall, we determined that our study had a 61.3% accuracy rate in forming novel systematic review ideas. When stratified by general and specific topics within Plastic Surgery, we found that ChatGPT was 60% accurate for general topics and 62.5% accurate for specific topics. There were 8 topics (16.3%) of novel systematic review ideas that had no previously published literature. Taking into account the inability to write systematic reviews on those topics, our updated accuracy of ChatGPT was determined to be 58.6% (41/70). Overall, the majority of systematic review ideas that were derived from ChatGPT were novel.

Conclusion: Particularly in Plastic Surgery, ChatGPT can be used in research and development to analyze large amounts of medical data, identify trends, and provide insights into best practices in plastic surgery. Our study demonstrates that the software can reliably come up with novel systematic review ideas to help providers institute evidence-based research into their practices. Plastic Surgery is a field that relies heavily on research to improve the care of patients and utilizing technology to our advantage may be a method to optimize patient outcomes.

Background: Recent studies have shown a declining percentage of Underrepresented Racial Minority (URM) plastic surgery residents despite the rising number of URM medical students. This study aims to identify reasons behind the persistence and exacerbation of this disparity despite awareness of the barriers and efforts made toward diversity and inclusion.

Methods: Results from a systematic literature search of the PubMed/MEDLINE, ASPS publications, and Embase databases were uploaded to Ryyan and reviewed for inclusion by two independent reviewers in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Results: 18 articles and one database report published between May 1996 and May 2022 were reviewed and analyzed, identifying implicit bias in scores, evaluations, and mentorship disproportionately affecting minority medical students. 58% of these studies were published between 2020 and 2022. Of the studies included, 37% examined diversity trends of medical students/applicants, 47% analyzed diversity amongst residents and faculty, and 72% argued the necessity for diversity in healthcare. Every included article addressed race and ethnicity.

Conclusion: Despite identifying several barriers and efforts made towards alleviating them, the exacerbating lack of racial diversity amongst plastic surgery residents proves that there is a hole in studies around barriers preventing URM medical students from joining plastic surgery programs. Many reports focus on obstacles URM medical students face within the medical education system and fail to account for the disadvantages of being a racial minority individual as it pertains to life outside medical education. Overlooked psycho-socio-economic barriers marginally faced by URM students may reveal additional obligations and challenges outside of medicine that impact their interest and ability to pursue competitive specialties. Therefore, we have developed a survey targeting medical students nationwide to identify these overlooked barriers.

Background: Organoids are best characterized as three-dimensional, scalable representations of in-vivo structures in which the morphological and molecular features of the tissue are preserved ex-vivo at the cellular level. Incorporating these constructs in studies of pathophysiological abnormalities has led to enhanced disease modeling in translational research and improvements in cell-based therapies in plastic and reconstructive surgery. Additionally, organoids have served as a valuable asset for assessing mechanical aspects of regeneration derived from in-vivo observation, as well as the signaling pathways that mediate lineage-dependent differentiation and collective cellular plasticity. This systematic review seeks to highlight key developments in the generation and application of organoids that, in the future, may pave a way forward for enhancing patient treatment and care in plastic surgery.

Methods: This review was carried out in accordance with PRISMA guidelines and included 3 databases: PubMed (NLM), Embase (Elsevier), and Web of Science Core Collection (Clarivate). Terms queried in these databases consisted of organoids, organoid constructs, and organoid models combined with plastic surgery, cosmetic surgery, aesthetic surgery, and reconstructive surgery to explicitly gauge relevant applications of organoids within the specialty. All database searches were completed on February 17th, 2023. Two reviewers simultaneously screened full articles for inclusion and exclusion factors. Articles were excluded if they (1) solely mentioned organoids from the standpoint of experimental research in fields other than plastic and reconstructive surgery, (2) did not discuss models for the purpose of regenerative research or development of regenerative models, and (3) did not mention the term organoid at all. Studies were included if they (1) alluded to organoid models as an intermediate or end product in studies related to aesthetic, cosmetic, reconstructive, or plastic surgery, (2) incorporated organoid models in translational and basic science research in Departments of Plastic Surgery, or (3) concentrated on organoid models in the last 10 years in relation to regenerative medicine and the development of research- and transplant- grade synthetic human or animal structures.

Results: A total of 36 studies met inclusion criteria, 35 of which were published within the last 5 years, and 15 of which were published in the last 12 months. Of significance, 11 articles pursued studies involving mammary organoid models. At the cellular level, such models primarily examined cellular differentiation, aging, senescence, immortalization, tumorigenesis, and disease heterogeneity. At the molecular level, these studies documented breast cancer risk factors, generalized gene expression, protumorigenic modifications as a result of exogenous exposures, alternative splicing mechanisms in gene mutations, endogenous gene induction, influence of lipid or fibroblast co-culture, estrogen and androgen receptor-positive modeling, drug screening with corresponding clinical response, and ductal elongation remodeling.

Conclusions: Organoids epitomize a novel approach for investigating the cell-cell and cell-matrix interactions in plastic and reconstructive surgery research. Characterizing how these constructs are used elucidates areas where these tools have been and can be most impactful. Ultimately, the accelerated usage of organoid models over time demonstrates significant purpose in goals related to enhancing regenerative medicine and bio-technical approaches in plastic, cosmetic, aesthetic, and reconstructive surgery.

ABSTRACT (466/500) Background: Negative pressure wound therapy (NPWT) has been shown to improve wound healing via macro- and micro-deformational forces, altered wound microenvironment, and modulated local fluid balance in part via enhanced lymphatic function. This systematic review captures basic science findings, clinical outcomes, physiologic studies, and mathematical models describing the effects of NPWT on lymphangiogenesis and lymphatic regeneration.

Methods: This systematic review was conducted per PRISMA guidelines. PUBMED, OVID, and Web of Science were searched. All studies published before March 2023 were assessed for eligibility. Inclusion criteria were prospective or retrospective studies in English that reported novel basic science or clinical data, physiologic mechanisms, or computational and mathematical theorems on the effects of NPWT and altered pressure systems on lymphatics. Reviews, opinions, case reports, and zoologic studies were excluded.

Results: 29 studies met inclusion criteria. All manuscripts were published between 1989 and 2023. The distribution of study types was basic science (n=7), clinical (n=12), physiologic (n=6), and computational or mathematical models (n=4).

From a basic science standpoint, histological analysis of animal and human tissue samples after NPWT using lymphatic markers D2-40 podoplanin stain and LYVE-1 have demonstrated morphologic improvement in lymphatic vessels including increased vessel diameter, open lumens, and orientation of regeneration in the direction of subatmospheric pressure. On longer timescales, NPWT was shown to increase lymphatic vessel counts and density, though effect modulated by patient comorbidities. Microdeformational forces are suggested to compress lymphatic capillaries at the wound-sponge interface, decreasing lymph fluid exudation and potentially explaining observed increased intraluminal B-cell concentrations with decreased macrophage penetrance into surrounding tissue.

Clinically, incisional wound vacuums (VAC) under continuous suction -80 to -125mmHg were most frequently used (incisional VAC n=7; traditional VAC n=2; external negative pressure therapy (NPT) n=3). Positive clinical outcomes included effective prophylaxis against lymphedema and lymphorrhagia after inguinal lymph node dissection and lower extremity vein harvest for vascular intervention, as well as managing such complications. NPT was used for lymphedema treatment and orthopedic perioperative edema management.

From a physiologic standpoint, interstitial edema, central venous pressure (CVP), and contraction of collecting lymphatics against one-way valves modulate lymph flow. NPWT primarily affects initial lymphatics and interstitial pressure; this contrasts with NPT reduction of CVP and increased lymph flow into the venous system. Existing computational models modify Starling's equation with novel parameters for lymphatic resistance, tissue compliance, vessel permeability, and colloid transport via lymph. However, the clinical utility of these models is limited by assumptions necessary to generate a cohesive system.

Conclusion: The positive effects of NPWT on lymphatic function and regeneration are supported by basic science and clinical literature, with explanatory mechanisms presented in physiological studies and computational models. We propose a clinically relevant mathematical model to synthesize cell signalling pathways, mechanotransduction, and fluid dynamic principles to elucidate lymphangiogenesis and improved wound healing to inform clinical use of NPWT.

Purpose: Clinical trial research in plastic surgery is growing but to a lesser degree than in medical specialities and certain other surgical specialties. Within plastic surgery and the major subspecialties, the amount of research varies. This study aimed to establish the current state of plastic surgery research globally by analyzing recent trends in clinical trial research.

Methods: The ClinicalTrials.gov database was used to collect data on registered trials including study status, country, sponsor, study phase, and primary purpose. The following search terms were used: "plastic surgery", "craniofacial surgery", "hand surgery", "microsurgery", "aesthetic plastic surgery", "aesthetic breast surgery", and "breast reconstruction". Descriptive statistics were performed, and Chi-square tests using adjusted residuals were conducted to compare trial characteristics between subspecialties.

Results: There were 257 registered trials found for "plastic surgery". Top three countries included the US (142), Canada (13), and France (10). Academic institutions/hospitals sponsored 51% of trials while industry sponsored 36%. Primary purposes included 79% for treatment, 10% for prevention, and 4% for supportive care. Distribution of study phases included 27% for phase 2 and 4 each and 22% for phase 3. Among the subspecialties, there were significant differences for the trial sponsor type (p = .002), study purpose (p = .002), and study phase (p = .001). For sponsor type, "microsurgery" trials were significantly more likely to be funded by industry (33% of those funded by industry) and less likely to be funded by academic institutions and hospitals (7% of those funded by institutions/hospitals). "Hand surgery" trials were significantly more likely to be funded by institutions/hospitals (61%) and less likely to be funded by industry (31%). "Craniofacial surgery" studies were significantly more likely to be funded by foundations/societies (34% of those funded by foundations/societies) and less likely to be funded by institutions/hospitals (5%). "Aesthetic plastic surgery" trials were significantly more likely to be funded by industry (15%) and less likely to be funded by institutions/hospitals (2%). For study purpose, "breast reconstruction" trials were significantly more likely to be supportive care trials (47%) and less likely to be treatment trials (18%). For study phase, "microsurgery" trials were significantly more likely to be phase 3 studies (22%). "Hand surgery" trials were significantly more likely to be phase 4 studies (62%) and less likely to be phase 2 (46%) and phase 3 (46%).

Conclusion: Plastic surgery research has grown over the years, but inconsistently across subspecialties. It will become increasingly important to recognize research needs and potential sources of funding for such research. This is a first step to better understand the current state of research around the world and to facilitate identification of areas requiring further development.

Background: Mixed Reality Head Mounted Displays (MR-HMDs) can superimpose virtual elements like digital models of patient anatomy (skulls, muscles, organs) onto the real world, allowing users to visualize and interact with them similarly to physical objects. This technology presents an exciting path forward for surgical planning; Superimposing surgical guides and medical imaging directly on patients enriches surgical procedures, and previous studies by our team have shown that the use of 3D modelling for craniofacial reconstructive surgery is both cost-effective and time-efficient. With these benefits in mind, we developed a novel MR program for the Microsoft HoloLens 2 which can accurately position digital models and potentially any virtual element in real space using non-proprietary QR codes. This approach is unique even among current industry-leading MR surgical tools, and we believe that playing to the strengths of MR while also being clinically useful through high accuracy will pave the next step in the expansion of MR in surgery.

Objective: We aim to evaluate the utility of our in-house developed Mixed Reality HoloLens 2 program for use in virtual surgical planning.

Methods: Currently, our program works by reading a QR code and then placing a virtual element a certain distance from a scanned QR code. The virtual element can be any 3D object, and the distance is determined by integrating user-defined parameters and a formula that we developed which converts the HoloLens's QR positioning data into a real-life position. To test the utility of our project, we created a virtual model of a patient's skull with 8 "landmark points" on the face of the skull. We then used our program to superimpose the virtual model on an anatomically accurate 3D-printed version of the patient's skull using a QR code placed near the anterior fontanelle as a reference point. The position of QR code reference point is adjustable and can be modified to fit the procedure with simple adjustments. With the virtual model superimposed, the physical markings on the skull were made on top of the landmark points. The distances between the physical markings and the landmark points were measured with calipers twice.

Results: Overall, the average distance between the points drawn on the physical skull and the landmark points was 1.95mm (SD 2.56mm). The first measurements had a mean difference of 1.95mm (SD 2.65mm) and the second attempt had a mean of 1.84mm (SD 2.39mm). The average discrepancy between attempt measurements were only 0.63mm.

Conclusion: The high difference and variance between the "ideal" positions indicated by the landmark points and the drawn-on points indicates the need for further adjustments before this program can be used as a surgical guidance tool. Since most of the points deviated in a similar direction (as indicated by the low discrepancy between measurements), an ideal fix could be simply adding a linear transformation into the formula. This, when combined with the overall benefits and flexibility of using QR codes, demonstrates that this guidance tool still has a high degree of utility for virtual surgical planning.

Background:A long-standing challenge of utilizing murine models of infected recalcitrant wounds is lack of a penetrating polymicrobial, antimicrobial resistant, biofilm infection within the deep wound bed that recapitulates clinical pathogenic phenotypes of chronic wounds. In mice, acute wounds inoculated with planktonic or pre-formed biofilms have insufficient maturation time due to inherent differences in native wound healing mechanisms, whereby mice heal through rapid contracture, and the bulk of bacterial contamination remains in the eschar rather than directly growing on wound surface. We hypothesize that this limitation can be overcome by surgically eradicating re-epithelialization with wound edge inversion prior to biofilm grafting to allow granulation tissue synthesis and biofilm maturation to occur simultaneously and unimpeded. In this study, we will report the reproducibility of robust, polymicrobial biofilm persistence in deep granulation tissue of a diabetic wound mouse model and test resistance to oral antibiotics.

Methods:In a previous study, we showed that wound edge inversion, mimicking an epibole structure, significantly inhibited re-epithelialization, increased wound inflammation and delayed wound closure for 7 weeks compared to controls . We conducted a pilot study in which preformed biofilms were grafted directly onto 7-day old wounds and determined that 44% of wounds remained open and infected for 14-days , with two wounds maintaining infection for 6-weeks. To generate biofilms, monocultures of P.aeruginosa, P.mirabilis, E.coli, S.Aureus, and E.faecalis were combined in a 1:1 ratio and cultured using the "Lubbock" method. The culture timeframe for which species representation in the biofilms remained relevant was verified over 21 days utilizing CHROMagar Orientation plates and CFU counting. In this study, 25 severely diabetic female C57BLKS/J-(BKS.Cg-Dock7m+/+Leprdb/J)-000642 mice received bilateral edge inverted wounds which were inoculated after 7-days with polymicrobial biofilms. To determine biofilm penetration depth, wounds were sharply debrided weekly for 10 weeks post-inoculation, with specimens collected for PCR. Immediately following debridement, wounds were blotted and stained with Alcian blue to detect microbial presence. Following three weeks of positive Alcian blue staining, one group of 5 mice received oral ciprofloxacin, vancomycin, and metronidazole . Impact of antibiotic administration on biofilm presence, wound architecture, and overall survival was assessed. Finally, cohorts were sacrificed biweekly for wound bed histology.

Results:The current pilot study is underway and results from wound bed RNA analysis, biofilm persistence over time, culture swab characterization of biofilm components, histological analysis, and impact of antibiotic administration are pending .

Conclusions:Over 90% of chronic wounds contain bacterial biofilms and adequate therapeutics that are safe, cost effective and robust remain an urgent clinical need. To study biofilm effects on wound healing and test treatment modalities, mouse models of infected wounds have been developed since the late 1990's and have utilized both mono- and polymicrobial planktonic inoculations as well as grafted pre-formed polymicrobial biofilms but which lack clinically relevant biofilm distribution on chronic wounds. In this study, we have longitudinally characterized biofilm maturation and penetration into granulation tissue of a chronic diabetic wound. This new model will be invaluable for assessing therapeutics targeting contamination of the base and perimeter of the recalcitrant diabetic wounds.