Scientific Abstract Presentations: Practice Management / Surgical Pearls 2 Friday, October 27 Fri, Oct 27 2:00-3:30 p.m. CDT

Purpose: Bibliometrics is the field in which statistical analyses are used to quantify the impact of published data within a specific field. In plastic surgery academia, research output is heavily used as a metric of accreditation, from assessing residency applicants to evaluating faculty for promotion. Currently, the application of bibliometrics in plastic surgery remains relatively new and is heavily dependent on the use of the h index as a benchmark metric for academic productivity. The h-index is defined as an author's h papers with at least h citations. While the h-index is simple and intuitive, it also has nonnegligible limitations; it disfavors junior researchers, favors publication quantity, and discounts highly cited works as they are only counted towards the h-index once. Given the importance of bibliometrics within plastic surgery, there is a paramount need to adopt additional metrics to measure research productivity. The authors sought to validate the use of time-independent bibliometrics to complement the h-index in measuring citation impact and use these metrics to generate research profiles and rank for academic plastic surgeons and their departments.

Methods: The gender and academic roles of plastic surgeons at integrated residency programs were recorded. Author publications were retrieved from Scopus. Bibliometrics software was used to calculate the following metrics: h-index; e-index, which accounts for the excess citations "missed" by the h-index; and the g-index, which prioritizes an author's most cited works. Time-corrected versions of these indices (m-quotient, ec- and gc-index) were used to correct for years since the first publication. Departmental ranks were determined using the cumulative sum of faculty time-corrected indices. Two-sided tests were used to examine gender differences in bibliometrics. Kruskal-Wallis tests assessed for bibliometric differences between academic roles (i.e., professor, chairs, and associate and assistant professors). Kendall tau correlation coefficients (t) were used to assess for congruency between calculated research rankings and Doximity rankings. P-values ≤0.05 were deemed significant.

Results: A total of 850 academic plastic surgeons across 81 departments were identified. Men had statistically greater h-indices than women (median 13.0 [IQR: 7.0–21.0] vs. 6.0 [3.0–13.0]; p<0.001); a similar pattern was observed for e- and g-indices. Professors had the highest median h- (21.0 [14.0–31.0]), e- (28.65 [18.37–41.49]), and g-indices (38.0 [24.0–54.5]) across all academic roles. When correcting for time, there were no significant differences in m-quotient and ec-index between genders. Departmental chairs had significantly higher indices than all other roles after correcting for time, and this difference was less pronounced compared to uncorrected indices. Compared to Doximity rankings, the calculated research ranks were low-to-moderately correlated (t = 0.495 [95% CI: 0.345–0.646; p<0.001]).

Conclusions: This comprehensive study represents the largest publication analysis and comparison of academic plastic surgeons and their programs. The use of time-corrected indices indicates that there are no statistical differences in publication quality between men and women. Furthermore, the absolute differences in citation impact between academic roles are less pronounced when correcting for time. The use of h-index is a valid citation metric but should be complemented by analyses that encompass an author's greater impact.

Background: In Plastic Surgery, social media is widely used for patient outreach, disseminating research findings, and providing education regarding plastic surgery procedures. Over 80% of plastic surgeons have social media accounts, with 67% utilizing these media platforms for posting patient photos.[1] Despite the prevalence of social media use among plastic surgeons, patient attitudes toward image medium preference and level of patient identifiability remains unknown. This investigation aims to assess patient attitudes toward the type of media used for dissemination as well as how identifiable patients are within photos.

Methods: Participants were eligible for the study if they were over the age of 18 and previously had an elective aesthetic procedure. Participants were recruited via email using the marketing research company Dynata in 2022 and given a web-based Likert-type ad-hoc survey evaluating their comfort with hypothetical scenarios regarding the use of their images (Face/Neck, Breast/Chest and Abdomen) in various advertising mediums (website, social media, and magazine/television) and how identifiable they were within those images. Descriptive statistics and bivariate analysis was performed.

Results: A total of 271 participants were eligible respondents. 83 participants completed the study and successfully met the inclusion criteria for analysis (successfully answered 2 attention questions). The response rate was 30.6%. Approximately 49% of participants were age 65 and older, 95% identified as women and 53% underwent face and neck aesthetic procedures. Patients were more comfortable with de-identified photos than identified photos across all three modalities (website: 27% de-identified vs 22% identified; p=0.002, social media:23% de-identified vs 19%; identified; p<0.001 and magazine or television ads 26% de-identified vs 16% identified; p<0.001). Patients were more comfortable with their surgeon disseminating de-identified photos via websites than social media, magazine or television ads (26% versus 23% and 25%; p<0.001).

Conclusion: Patients who underwent elective aesthetic surgery were significantly more comfortable with surgeons sharing de-identified rather than identifiable clinical photographs. Compared with social media, magazines, or television, patients were more comfortable with their photos being posted on a website. While market forces determine what forms of social media are most effective, understanding patient attitudes and comfort with the use of their clinical images is imperative for maintaining a respectful surgeon-patient relationship.

1. Landeen KC, Smetak MR, Keah NM, Davis SJ, Shastri K, Patel P, Stephan SJ, Yang SF. Professional Social Media in Facial Plastic and Reconstructive Surgery: Usage, Resources, and Barriers. Ann Otol Rhinol Laryngol. 2022 Nov 3:34894221133746. doi: 10.1177/00034894221133746. Epub ahead of print. PMID: 36330593.

Introduction: The Women's Health and Cancer Rights Act of 1998 codified access to reconstructive surgery to breast cancer patients. Correspondingly, fat grafting when used for oncologic breast reconstruction is routinely covered by insurance providers. However, we suspect that fat grafting applications for other reconstructive goals, particularly to the face, , is not as widely covered or reimbursed.

Methods: Policies of private medical insurance companies were examined for information regarding coverage or reimbursement of fat grafting after breast or head and neck reconstruction. Keywords including "fat grafting," "lipofilling," "facial fat graft," "reconstructive surgery," "cosmetic surgery," "breast reconstruction," and "facial reconstruction" were used on each company's website.

Results: The 25 largest private insurance companies based on dollars collected in premiums were included in this study. Eight companies deemed fat grafting for breast reconstruction to be medically necessary, 12 regard it to be experimental, 1 considers it to be cosmetic and 1 leaves the necessity of fat grafting to the discretion of the surgeon. For facial reconstruction, only 3 companies report fat grafting for facial reconstruction as medically necessary, 11 deem it as experimental, 5 consider it cosmetic, and 3 rely on the discretion of the surgeon. Eleven companies report covering fat grafting for breast reconstruction while only 5 private companies include coverage for facial fat grafting.

Conclusions: While fat grafting is widely used for reconstruction of the breast and face, there exists significant variability in insurance coverage for this procedure among the largest insurers in the United States. Moving forward, we aim to compare policies from commercial insurance companies with state-level Medicare and Medicaid guidelines regarding fat grafting.

PURPOSE: Craniofacial Intraosseous Lipomas (CIOLs) account for about 4% of all intraosseous lipoma diagnoses. Fewer than 50 cases of pediatric CIOLs (PCIOLs) have been reported in literature to date and thus, there is no effective diagnostic approach and standardized treatment for this patient population. This study aims to formulate a multidisciplinary approach to the diagnosis and treatment of PCIOL and review the potential reconstructive options. METHODS: We conducted a literature review on diagnostics and current surgical techniques for PCIOL. RESULTS: The proposed diagnostic procedure includes MRI, CT and CT venogram to delineate the sinus anatomy in relation to the mass, and an initial biopsy. The multidisciplinary treatment team should include a pediatric craniofacial surgeon, pediatric neurosurgeon, and medical oncology. Virtual surgical planning (VSP) is an indispensable to plan the resection of the mass and the reconstruction. Reconstructive options include autologous bone grafts or an alloplast (Medpor or PEEK implants). The unpredictable bone resorption as well as large cranial defects that may require reconstruction are critical limitations for autologous cranioplasties. Medpor provides adequate cerebral neuroprotection, allows for vascular tissue ingrowth and incorporation, and is easy to modify intraoperatively. These features render it to be a useful reconstructive option for patients with PCIOL. CONCLUSION: This influences the diagnosis and surgical treatment of PCIOL to emphasize a multidisciplinary approach that takes advantage of VSP and tailored implant options.

Introduction: Over the past two decades, non-surgical treatments for facial aging with botulinum toxin and dermal fillers have become a mainstay in plastic surgical practices.1,2 Two practice models exist, one in which the plastic surgeon provides both the non-surgical and surgical treatments and the other in which an advanced practice provider (APP) performs the non-surgical treatments. This study aims to provide objective data regarding the model in which APPs perform the non-surgical treatments and determine the model's effectiveness by assessing the conversion rate of non-surgical to surgical procedures.

Methods: A retrospective chart review was conducted on patients treated with either botulinum toxin or dermal fillers at our division between 2015 and 2021. Patients who had cosmetic surgery at our division before non-surgical treatments were excluded. Patient demographics, number of botulinum toxin and filler visits, age at the first botulinum toxin and filler visit, prior cosmetic surgeries, and cosmetic surgeries at UF were recorded. Collected data was compared between patients with and without prior cosmetic surgery, and between patients undergoing cosmetic surgery at UF and those who did not. Statistical tests included Fisher's exact tests and chi-square tests.

Results: Of the 737 patients included, 39 underwent surgical treatment, with an overall conversion rate of 5.3%. Patients with a history of cosmetic surgery had a higher conversion rate than those without prior cosmetic surgery (12.5% vs. 4.1%, p<0.01). Patients undergoing surgical treatment were more likely to have had prior cosmetic surgery (p<0.01), received fillers (p<0.01) and were older at the time of the first filler visit (p<0.01). Overall, patients underwent a total of 49 facial cosmetic surgeries and 33 body cosmetic surgeries, for an average of 2 surgical procedures per patient. The most common surgical procedures were facelifts and body liposuction.

Conclusions: These findings demonstrate that patients who are older, have had cosmetic surgery in the past, and are treated with fillers are more likely to have surgical procedures, indicating a potential provider focus on treatment counseling and optimization of outcomes. Although most surgeries were performed on the face, the two most common procedures were facelifts and body liposuction. These findings also indicate that non-surgical aesthetic treatments remain a mainstay in the plastic surgery practice. Further studies should compare the two practice models to provide objective data that could support either model as being preferred.

References: 1. Aesthetic Plastic Surgery National Databank Statistics 2020–2021. (2022). Aesthetic Surgery Journal, 42 (1 SUPPL.), 1–18. 2. Richards, B. G., Schleicher, W. F., D'Souza, G. F., Isakov, R., & Zins, J. E. (2017). The Role of Injectables in Aesthetic Surgery: Financial Implications. Aesthetic Surgery Journal, 37(9), 1039–1043.

BACKGROUND: Impostor syndrome occurs when high-achieving individuals have persistent self-doubt despite objective measures of competence and success, and has been associated with professional burnout and attenuated career advancement in medical specialties. This study aimed to define the incidence and severity of impostor syndrome in academic plastic surgery. METHODS: A cross-sectional survey containing the Clance Impostor Phenomenon Scale (0-100; higher scores indicating greater severity of impostor syndrome) was distributed to residents and faculty from 12 academic plastic surgery institutions across the United States. Generalized linear regression was used to assess demographic and academic predictors of impostor scores. RESULTS: From a total of 136 resident and faculty respondents (response rate, 37.5%), the mean impostor score was 64 (SD 14), indicating frequent impostor syndrome characteristics. On univariate analysis, mean impostor scores varied by gender (Female: 67.3 vs. Male: 62.0; p=0.03) and academic position (Residents: 66.5 vs. Attendings: 61.6; p=0.03), but did not vary by race/ethnicity, post-graduate year of training among residents, or academic rank, years in practice, or fellowship training among faculty (all p>0.05), Figures 1, 2. Among faculty, the highest impostor scores were seen among those 0-5 years in practice or 11-15 years in practice and were higher among Assistant Professors or full Professors compared to Associate Professors, though these differences were not statistically significant (all p>0.05), Figure 3. After multivariate adjustment, female gender was the only factor associated with higher impostor scores among plastic surgery residents and faculty (Estimate 2.3; 95% Confidence Interval 0.03-4.6; p=0.049). CONCLUSION: The prevalence of impostor syndrome may be high among residents and faculty in academic plastic surgery. Impostor characteristics appear to be tied more to intrinsic characteristics, including gender, rather than years in residency or practice. Further research is needed to understand the influence of impostor characteristics on career advancement in plastic surgery.

Background: The importance of healthy lifestyle choices is well understood for long-term success in plastic surgery procedures, for example, body contouring procedures.[1] While studies emphasize this importance, there is a lack of literature examining the fundamental knowledge base of medical practitioners at different levels of their training who are encouraging these healthy lifestyle choices. This study aimed to evaluate a top 25 NIH-funded school's medical students' self-reported assessment of their nutrition and exercise knowledge base and preparedness for counseling patients on the topics.

Methods: A short survey was constructed to assess participants' confidence in counseling patients on specific evidence-based nutrition and exercise practices, views on preclinical training, and background knowledge regarding common nutrition and exercise misconceptions. The online survey was distributed to a top 25 NIH-funded medical school classes of 2022-2025. Responses from 119 medical students were collected.

Results: Out of 119 respondents, 49 (43.8%), 35 (31.3%), 24 (21.4%), and 4 (3.6%) were from the class of 2025, 2024, 2023, and 2022 respectively, with 2024-2022 completing or have completed clerkships. Among respondents, 83 (70.3%) students felt either poorly prepared or unprepared to answer questions regarding nutrition and weight loss and exercise specifics as treatment. Only three students (2.5%) felt very prepared to counsel patients on these modalities, and 92% (110) demonstrated the presence of at least one common misconception regarding nutrition and/or exercise. There was no difference in preparedness or misconceptions when comparing clinical vs. preclinical students on Fisher exact test (p=.1346).

Conclusions: This survey examined medical students' beliefs regarding their training in evidence-based nutrition and exercise topics. We found them ill-equipped in these topics, revealing the need to reevaluate the current curriculum in medical schools and plastic residency programs, especially with the growing demand for cosmetic plastic surgery procedures and the increasing prevalence of obesity.[2,3] To ensure the best post-operative and long-term outcomes for plastic surgery patients, we must ensure practitioners are adequately prepared to, at minimum, briefly counsel patients on the foundations of nutrition and fitness topics.

1. Rohrich RJ, Broughton G 2nd, Horton B, et al. The key to long-term success in liposuction: a guide for plastic surgeons and patients. Plast Reconstr Surg. 2004;114(7):1945-1953. doi:10.1097/01.prs.0000143002.01231.3d

2. Aesthetic Plastic Surgery National Databank Statistics 2020–2021, Aesthetic Surgery Journal, Volume 42, Issue Supplement_1, July 2022, Pages 1–18, https://doi.org/10.1093/asj/sjac116

3. Bryan Stierman, M.D., M.P.H., Joseph Afful, M.S., Margaret D. Carroll, M.S.P.H, et al. (2020). National Health and Nutrition Examination Survey 2017–March 2020 Prepandemic Data Files Development of Files and Prevalence Estimates for Selected Health Outcomes. National Health Statistics Reports. http://dx.doi.org/10.15620/cdc:106273 

Purpose Increasing the gender and racial diversity of the medical workforce is an important driving force for improving healthcare quality and access in underserved communities.[1] While improvements have been made, such diversity still lags at the physician level in plastic surgery.[2] This could be due in part to relatively less exposure to the field during medical school for underrepresented minority (URM) and female students. We hypothesized that there are fewer opportunities for plastic and reconstructive surgery exposure during medical school for URM and female students than their White/Asian and male counterparts, respectively.

Methods Allopathic medical schools in the US were assessed for presence of an ACGME-accredited integrated plastic surgery residency, ACGME-accredited fellowship (hand and/or craniofacial), and plastics advisory infrastructure (plastic surgery interest group and/or ASPS regional ambassador affiliation). The demographic proportions for each exposure type were calculated by aggregating AAMC medical student race/ethnicity and gender enrollment data stratified by allopathic medical schools for the 2021-2022 academic year and cross-referencing with presence of each exposure type.[3]

Results URM students made up a lower percentage of medical students in schools with a plastic surgery residency (20.07%) than those enrolled in medical schools without one (24.56%). This trend persisted when broken down by URM subgroups. In contrast, White and Asian students made up higher percentages of medical students in schools with a plastic surgery residency (56.52% and 27.57%, respectively) than in those without (53.88% and 25.73%, respectively). Women made up a higher percentage of medical students in schools with a plastic surgery residency (53.02%) than in those without (52.28%). URM students made up a lower percentage of medical students in schools with an ACGME-accredited plastics fellowship (21.63%) than in those without (21.97%). URM students also constituted a lower percentage of medical students in schools with a plastics advisory infrastructure (21.14%) than in those without (23.42%).

Conclusions URM medical students are less likely to have exposure opportunities to plastic surgery contrary to their Asian, White, and female counterparts who made up a higher proportion of students enrolled in medical schools with an integrated plastic surgery residency than in those without. Our findings indicate that better distribution of specialty-specific resources and mentorship opportunities may help bridge racial gaps in plastic surgeon demographics, while other barriers may exist in the educational pipeline that hinder female surgeon representation in the field.

References 1. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273(19):1515-1520. 2. Lane M, Sears ED, Waljee JF. Confronting Leaky Pipelines: Diversity in Plastic Surgery. Curr Surg Rep. 2022;10:63-69. 3. 2022 FACTS: Enrollment, Graduates, and MD-PhD Data. Association of American Medical Colleges. (n.d.). Accessed January 10, 2023. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-enrollment-graduates-and-md-phd-data

Purpose: Prior research into female representation in leadership positions, has not comprehensively analyzed gender diversity within residency class as well as faculty by academic title, including society and journal board within the past 5 years. This study sought to examine gender distributions within plastic surgery leadership positions in journal editorial boards, society boards and within academic faculty.

Methods: A cross-sectional study was performed to evaluate gender in plastic surgery among academic faculty, journal editorial boards, and professional societies' leadership positions. Our sample included 1918 subjects across 879 plastic surgery journal editorial board members, 872 plastic surgery academic faculty members, and 167 plastic surgery association board members. The following journals were studied: Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Reconstructive Microsurgery, Journal of Craniofacial Surgery, Journal of Reconstructive Microsurgery, and The Cleft Palate-Craniofacial Journal. Similarly, the names and gender of board members were obtained for the following societies: American Society of Plastic Surgeons, American Association of Plastic Surgeons, The Plastic Surgery Foundation, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Cleft Palate Craniofacial Association, American Society for Reconstructive Microsurgery, American Association for Hand Surgery, and the American Board of Plastic Surgery. The name, gender, position, and year of graduation from residency for all faculty members were obtained.

Results: A total of 872 plastic surgery academic faculty were reviewed from 86 plastic surgery programs, 23.7% were male. Among the 180 faculty members from the Midwest region, 26.1% were female. A total of 307 faculty members were identified from the Northeast region, of whom 20.9% were female The Northwest region had a total of 17 faculty members; 35.3% were female. In the South, 210 faculty members were identified and included 23.8% females. In the Southwest, 11.1% were females Finally, for the West, 140 faculty members were identified and included 24.3% females. Faculty members were further subdivided by academic rank. A significant difference was found between the number of male and female faculty members at all academic positions. Of 245 full professors, 7.8% were female. There were 226 associate professors queried with 22.1% identified as female. 401 assistant professors were identified with 33.4% identified as female. Years in practice after completing terminal training were analyzed across the academic faculty. Among faculty with less than 10 years since completion of terminal training, 34.9 % were female. For faculty with 10 to 20 years post-terminal training, 23.5% were female. For those with 20 to 30 years of experience, 13.6% were female. For faculty with over 30 years since graduation, 7.6% were female. There was a significant difference between the number of male and female members across all six journals with over 80% being male. Among the analyzed editorial boards, only 27% were female.

Conclusion: Our results show that representation of women in plastic surgery trails behind recently reported numbers for other specialties. Difficulty finding mentors, family responsibilities, and institutional biases have been cited as barriers to women reaching faculty and leadership roles in plastic surgery.

References: 1. Linscheid LJ, Holliday EB, Ahmed A, et al. Women in academic surgery over the last four decades. Plos One. Dec 16 2020;15(12)doi:ARTN e0243308 10.1371/journal.pone.0243308 2. Danko D, Cheng, Losken A. Gender Diversity in Plastic Surgery: Is the Pipeline Leaky or Plugged? Plastic and Reconstructive Surgery. Jun 2021;147(6):1480-1485. doi:10.1097/Prs.0000000000008002 3. Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. Oct 2016;212(4):566-+. doi:10.1016/j.amjsurg.2016.06.012 4. Oseni TO, Kelly BN, Pei K, et al. Diversity efforts in surgery: Are we there yet? Am J Surg. Jul 2022;224(1 Pt B):259-263. doi:10.1016/j.amjsurg.2022.01.014 5. Brisbin AK, Chen W, Goldschmidt E, Smith BT, Bourne DA. Gender Diversity in Hand Surgery Leadership. Hand (N Y). Mar 10 2022:15589447211038679. doi:10.1177/15589447211038679

Purpose Characterize and identify gaps in the plastic surgery workforce.

Background Studies demonstrate a lack of diversity in plastic surgery.1,2 Despite policy shifts to reverse inequalities, there has been no significant change in integrated plastic surgery applicants demographics between 2010-2014 and 2015-2020.3 These disparities are pronounced in academic plastic surgery, with less Black and Hispanic representation compared to the U.S. population.4 This trend is also seen in fellowships, demonstrating female racial/ethnic minorities' disproportionate underrepresentation.5

Methods and Materials Surgeon demographics were extracted from the Centers for Medicare and Medicaid Services(CMS) open database. Urban/rural classification and academic affiliation were crosslinked from the Inpatient Prospective System database. Sole proprietorship status was cross-linked from the NPI Registry. Data was analyzed using STATA/BE 17.

Results We analyzed 15,352 general and plastic surgeons in the US. Plastic surgeons were less likely to be females(P<0.05) and more likely to be sole proprietors(P<0.05) and affiliated with a teaching hospital(P<0.05) than general surgeons. There was no difference in rural-practicing surgeons(P=0.860). Plastic surgeons graduating in the last 20 years were more likely to be affiliated with an academic hospital than those graduating more than 20 years ago(P<0.5). Although there has been an increase in female plastic surgeons, there was a decline in female plastic surgeon proportion who graduated after 1999. Finally, DO graduates make a smaller proportion of plastic compared to general surgeons(1.7% vs 5.2%, p<0.0001).

Conclusions Although the plastic surgery workforce is gaining female representation and shifting to academia, significant progress in serving rural communities has not been made. Moreover, the decline in practicing female surgeons warrants further investigation along with the potential shift from graduates to academia rather than private practice.

References: [1] Butler PD, Britt LD, Longaker MT. Ethnic Diversity Remains Scarce in Academic Plastic and Reconstructive Surgery. Plastic and Reconstructive Surgery. 2009;123(5):1618-1627. doi:https://doi.org/10.1097/prs.0b013e3181a07610

[2] Silvestre J, Serletti JM, Chang B. Racial and Ethnic Diversity of U.S. Plastic Surgery Trainees. Journal of Surgical Education. 2017;74(1):117-123. doi:https://doi.org/10.1016/j.jsurg.2016.07.014 ‌ [3] Hernandez JA, Kloer CI, Porras Fimbres D, Phillips BT, Cendales LC. Plastic Surgery Diversity through the Decade: Where We Stand and How We Can Improve. Plastic and reconstructive surgery Global open. 2022;10(2):e4134. doi:https://doi.org/10.1097/GOX.0000000000004134

[4] Smith BT, Egro FM, Murphy CP, Stavros AG, Nguyen VT. An Evaluation of Race Disparities in Academic Plastic Surgery. Plastic and Reconstructive Surgery. 2020;145(1):268-277. doi:https://doi.org/10.1097/prs.0000000000006376

[5] Oberoi MK, Reghunathan M, Aref Y, Dinis JJ, Balumuka D, Gosman A. Racial/Ethnic and Gender Disparities Over the Last Decade Within Microsurgery and Craniofacial Fellowship Training. Annals of Plastic Surgery. 2023;Publish Ahead of Print. doi:https://doi.org/10.1097/sap.0000000000003403

PURPOSE: Specialized burn centers are critical in minimizing burn-associated morbidity and mortality. However, American Burn Association (ABA)-verified burn centers are unequally distributed across the U.S., and fewer verified centers are available for pediatric patients relative to adults. The economic burden of transport to verified centers represents a significant proportion of the already high cost of burn-associated care. The present study aims to quantify inequitable burn care access in the contiguous U.S. due to age group and locality as a function of physical proximity and transportation cost.

METHODS: County-level distances (n=3,108) to the nearest ABA-verified adult or pediatric burn center were determined and mapped. Distances were then analyzed separately for rural (n = 1441) and urban (n = 1667) counties for both adult and pediatric burn centers. Distance calculations for each population were combined with transport cost data (2022 CMS Ambulance Fee Schedules) to determine the average cost of transport for each patient population (adult versus pediatric, urban versus rural).

RESULTS: 59 adult and 43 pediatric ABA-verified centers were identified from the ABA burn center directory. Pediatric patients reside 30.57 miles (p < 0.001) further than adults from the nearest center, accounting for a 10.53% - 15.79% transport cost increase. Transport costs increased dramatically between urban and rural counties, with rural patients facing a cost increase of 33.97% and 81.85% for ground and air transportation, respectively.

CONCLUSIONS: Physical proximity to burn care may appear to differ only modestly across age and region. However, the seemingly marginal increase in distance significantly impacts the cost of patient transport. The present study highlights physical and economic barriers to burn care access faced by rural and pediatric patients. Increasing ABA burn center certification in targeted areas across the U.S. may decrease the disparities in access to burn care faced by these groups. Future studies should be conducted to expand on this report's findings and more completely characterize additional costs associated with inequitable burn care access.

INTRODUCTION: In the current landscape, women are entering medicine at the same rate as men. Subsequently, the number of women pursuing a career in surgery is increasing. However, the increase in women has not yet translated to equal representation in leadership positions. Previous studies have commented on women in academic and leadership positions and the specific challenges often faced to obtain these positions. While this information is vital to foster change, recognizing the pathway, perspectives and commonalities of women who have become leaders in the field is also crucial to inspire future leaders. The purpose of this study is to take a constructive look at success in leadership and identify the key characteristics women in leadership positions hold, as well as the institutional initiatives to encourage future women leaders.

METHODS: A cross-sectional study was conducted in 2022-2023 evaluating the gender representation of U.S. academic plastic surgery faculty leaders. Websites of plastic surgery residency programs, medical journals, non-profit organizations, and national societies were accessed for demographic information. Leadership roles included Chair/Chief, Program Director (PD), Principal Investigators (PI) and positions held in professional, research, editorial board, healthcare facility, non-profit, political/advocacy, and industry organizations. Residency program websites were searched for Diversity, Equity, and Inclusion (DEI) elements, including dedicated webpages and targeted vocabulary. Self-identification and profiles were used to categorize gender. A survey through the American Society of Plastic Surgeons was distributed evaluating the pathway of leadership.

RESULTS: A total of 85 plastic surgery programs were identified, including 1209 residents, 108 fellows and 1011 faculty, and 83 PIs. 44% of the residents, 35% of the fellows, 25% of the faculty and 39% of the PIs were women. Of the PIs identified, 25% of the women PIs had a PhD and 13% had both MD and PhD. There were 9 women Chair/Chief of plastic surgery and 16 women Program Directors. Among these, 28% held additional degrees (MBA, MS, ect) and 76% completed a fellowship after residency. Of the women faculty identified, 26% held leadership positions in other organizations, averaging 1-2 positions each, with a major focus in educational leadership. Residency programs with a woman Chair/Chief and/or PD had an affiliated DEI committee. Less than half (40%) of all residency programs had dedicated DEI efforts clearly mentioned on their webpage, and of those a majority had a woman Chair/Chief or PD.

CONCLUSION: Plastic surgery has almost equal percentage of women and men residents, suggesting that there is no shortage of qualified women to fill leadership roles in the specialty. The trajectory to a leadership role may however look different between genders, especially when we expand our definition to include all types of leaders and academic roles. Women are holding a variety of leadership positions that equally impact the field of plastic surgery, and those roadmaps are important. The keys to success identified here are not only applicable to women, but all future leaders, and can be used to develop more initiatives and pathways for trainees pursing leadership positions in plastic surgery.

Background With United States Medical Licensing Examination (USMLE) Step 1 becoming pass/fail, clerkships grades are projected to serve a more critical role in assessing plastic surgery applicants' academic performance. However, there is considerable variation in clinical clerkship grading scales among medical schools. This lack of standardization may be disadvantageous towards Plastic and Reconstructive Surgery (PRS) applicants from institutions that grade more competitively. The variation of grading scales in relationship of institutions and the outcomes of matching PRS applicants has yet to be thoroughly explored leading to a lack of consensus opinion on the best way institutions can elevate students in their academic pursuits. As such, the aim of this study was to evaluate the percentage of clerkship honors awarded at medical schools and determine whether grade distributions correlated with matching in PRS residency.

Methods We identified 300 matched plastic surgery residents that attended 58 US-accredited medical schools from September 2020 to September 2022. Grade distribution, and percentage of clerkship honors awarded was extracted from Medical Student Performance Evaluations (MSPE) from publicly available data or from the ERAS system obtained from The Ohio State University Department of Plastic and Reconstructive Surgery. PRS applicants' home institution and matched institution were extracted from a self-reported Google Docs spreadsheet. US News and World Report (USNWR) ranking of each applicant's home institution was collected and Doximity Residency Navigator was used to idenify the ranking to the respective plastic surgery residency programs. Bivariate linear regression and student t-test was used to determine the significance of scores.

Results Fifty-two institutions reported grade distributions and six did not. Clerkship honors were awarded to students ranging from 5% to 68% and three institutions operated on a pass/fail system. There were a higher number of matched applicants (n=172) from schools where honors were awarded to over 40% of students (p=0.0016). USNWR top 25 schools were more likely to award more students with clerkship honors whereas institutions ranked below 25 were less likely to award honors (44% vs. 30%, p =0.0037). Further, applicants coming from schools who awarded more clerkship honors matched at plastic surgery residency programs with higher Doximity Residency Navigator ranking (55% v 32%, p=0.041).

Conclusion Although the match process is multifactorial, grades are a critical component of the application. PRS programs should be astute in understanding the differences in medical school grading systems and recognize that top 25 institutions award honors more often, despite similar absolute grades. Although medical schools are allowed to decide on their own grading system and distribution. We call to action that a more standardized approach to clerkship grades is needed to fairly compare the academic performance of PRS applicants more objectively from all institutions.