Scientific Abstract Presentations: Research & Technology 5 Friday, October 27 Fri, Oct 27 5:00-6:00 p.m. CDT

Background: The COVID-19 pandemic caused shifts in clinician schedules and electronic medical record (EMR) utilization. Ambulatory medicine literature reveals EMR usage dropped during the pandemic then returned to baseline levels with changed utilization patterns. This study aims to investigate how COVID-19 affected plastic surgery resident EMR utilization before, during, and after the pandemic.

Methods: EMR utilization data of 12 plastic surgery residents was extracted via Cerner Analytics at a tertiary academic medical center, encompassing March 15th through June 15th of 2019, 2020, and 2021 representing the pre-pandemic, COVID-19 pandemic, and post-pandemic eras, respectively. On-duty (0600-1759) and off-duty (1800-0559) EMR utilization (chart review, orders, documentation, and patient discovery) was analyzed.

Results: Median minutes per day spent on the EMR decreased significantly during the pandemic, before returning to pre-pandemic levels (64.5 pre-pandemic, 37.2 pandemic, and 65.6 post-pandemic, p-value < 0.001). Residents spent significantly more time on the EMR during off-duty hours during the pandemic (31.9% pre-pandemic versus 38.2% pandemic versus 34.5% post-pandemic, p-value < 0.001). There was no statistical difference in off-duty utilization between eras for senior residents (p-value = 0.58), while junior residents spent more time off-duty during the pandemic which sustained into the post-pandemic era (35.6% pre-pandemic versus 44.9% COVID-19 versus 40.7% post-pandemic, p-value < 0.001). Patient discovery and chart review increased during the pandemic prior to returning to pre-pandemic levels (65% pre-pandemic versus 72% pandemic versus 68% post-pandemic, p-value < 0.001).

Conclusion: Plastic surgery resident EMR utilization decreased during the COVID-19 pandemic with sustained increase in off-duty EMR time spent in the post-pandemic era for junior residents.

Introduction: The main challenge of autologous fat transfer procedures in patients is the requirement of repeat grafting to compensate for the resorbed fat over time. On average about 40-50% of the grafted fat resorb in 3-6 months post grafting requiring repeat graft procedure. Repeat harvest is a painful and expensive procedure exerting a traumatic and financial burden on the patient. In addition, it also led to reduced productivity of the surgeons. The development of strategies that eliminate the requirement of repeat harvest is the need of time. In this direction, we have designed a cryopreservation device and optimized the protocol that enables on-site storage of the excess harvested fat for repeat graft procedures thus eliminating the need for repeat harvest.

Methods: We designed a device that can connect seamlessly to current devices used in fat harvest and grafting. We tested different approaches and methods combinations of cryoprotectant and freezing temperatures, and measured cell viability up to 3 months using viability stains Tryptan blue and Calcin-Am. For in-vivo validation, we used Nu/Nu athymic mice injected with human fat cryopreserved for 7 days, 21 days, 3 months, and 11 months. Each group was compared to a fresh fat graft. We analyzed the graft for weight, volume retention, histology, vacuole formation, and inflammation markers after 9 weeks. Using our method we determined the optimal time range for cryopreserving the fat post-harvest.

Results: In vitro viability analyses showed a combination of 10% DMSO, 2% human serum albumin, and storage temperature of -80˚C demonstrated optimal viability of cryopreserved fat comparable to fresh fat. In vivo, Nude mice studies showed no significant changes in the graft weight and volume retention between the comparison groups up to 11 months. The histological scoring index for inflammation and vacuole formation also showed no significant changes. Our time range analyses showed the best outcome when the fat is cryopreserved within 5 hours post-harvest.

Conclusions: This study shows that the clinical adaptation of our device and protocol can reduce multiple harvest sessions along with the complications of this procedure e.g. ecchymosis, swelling, hematoma, and infections. Fat can be preserved without any morphological, weight, or volume changes for up to 1 year.

Purpose Microsurgery is a specialized surgical area that involves a variety of procedures, commonly used in anastomosis of vessels, flap harvesting, lymphedema, nerve reconstruction, and other advanced techniques. It can be traced back to the 1500s, but significant advances in microsurgery began in the 1900s with the introduction of the triangulation technique of end-to-end anastomosis. The microscope has been the staple of microsurgery, but a new wave of technology, the exoscope, is emerging. This review aims to provide clarity and sufficient evidence to support the use of exoscope systems in Plastic Surgery, which has not been widely used.

Methods A search for full-text articles where the use of an exoscope was compared against a traditional operating microscope was conducted on the databases PubMed, Scopus, Web of Science, and Embase. The following terms were used to guide our search: Microscope AND exoscope AND plastic surgery; Microscope AND exoscope AND microvascular surgery.

Results Our search yielded 69 studies of which 12 were included. Five exoscope systems were used by the authors. All studies reported the exoscope to be a valid alternative to the standard operating microscope. The development of new and improved exoscope systems such as Orbeye, Modus V, VITOM 3D, Zeiss Kinevo 900 microscope, and The Robotic Scope®-system have been able to bridge the gap towards the traditional OM. The exoscope offers several advantages such as comfort, versatility, teaching capabilities, and immersive experience. One drawback is a potentially steep learning curve, but this can be managed with repeated practice. Another disadvantage is a visually bothersome view of the 3D display, nausea, and set-up in some models. However, this may not apply to all systems and users.

Conclusion Based on the evidence collected, we conclude that current exoscope systems are safe and comparable to the traditional OM and should be trialed in Plastic Surgery. In determining which system to implement, one should consider the requirements and specifications of each exoscope and program. Research should be performed on the system's capabilities before acquiring and trialing.

Background: Depression and anxiety have been shown to affect clinical outcomes following surgery, impacting the immune response and lowering the pain threshold.1 As there is a paucity of mental health studies in pediatric surgical patients, the goal of our study is to describe the prevalence of depression and anxiety in this population. Methods: EPIC SlicerDicer was used to facilitate retrospective chart review of all patients seen by a surgical care specialty at Lurie Children's Hospital from January 2012 to December 2022. Percentage of patients within each specialty with concurrent diagnosis of depression, anxiety, and both were identified. Descriptive and statistical analysis was performed for differences in demographics and prevalence of depression and/or anxiety within surgical subspecialties. Results: 494,160 patients were included from 7 surgical subspecialties: Neurosurgery (n = 26,428, 5.35%), Ophthalmology (n = 52,593, 10.64%), Orthopedic Surgery (n = 143,567, 29.05%), Otolaryngology (n = 110,621, 22.39%), Pediatric Surgery (n = 64,620, 12.08%), Plastic Surgery (n = 23,348, 4.72%), and Urology (n = 72,983, 14.77%). Concurrent diagnoses of depression, anxiety, and both occur at significantly higher rates in pediatric patients seen by plastic surgery (0.24%, 0.32%, 0.18%, respectively) than those seen by most other surgical subspecialties (p<0.05). Median age of plastic surgery patients was 17 years (IQR = 15, 19) for those with concurrent anxiety and 18 years (IQR = 17, 20) for concurrent depression. Females made up greater proportions than males for both anxiety (69% vs. 31%) and depression (70% vs. 30%). Those who identified racially as White made up the greatest proportions out of all races for both anxiety (70.3%) and depression (73.2%), and those who identified ethnically as Non-Hispanic/Latino made up greater proportions than those who identified as Hispanic/Latino for both anxiety (75.7% vs 21.6%) and depression (73.2% vs 26.8%). There were no significant differences in rates of anxiety in pediatric plastic surgery (0.32%) compared with pediatric surgery (0.22%, p = 0.561) or neurosurgery (0.27%, p = 0.357). Conclusions: Our single institution study demonstrates that rates of depression, anxiety, and both are higher in pediatric plastic surgery patients compared to patients from most other surgical subspecialties. As depression and anxiety have been associated with greater postoperative morbidity following surgery, pediatric surgical patients should undergo mental health screening using tools such as the PHQ-2/9 and GAD-7 with subsequent mental health resources provided as appropriate. Future studies examining postoperative outcomes in the setting of concurrent mental health diagnosis may better elucidate the relationship between psychosocial factors and surgical outcomes.

References 1. Ghoneim, M.M., O'Hara, M.W. Depression and postoperative complications: an overview. BMC Surg 16, 5 (2016). https://doi.org/10.1186/s12893-016-0120-y

Introduction Pectoralis major muscle flaps (PMMF) are versatile and reliable procedures utilized in the reconstructive surgery for a variety of defects involving the head, neck, and chest. Acquiring and mastering an understanding of the anatomy and operative steps of complex procedures such as myocutaneous flaps by plastic surgery residents and fellows takes years. Surgical education and training is constantly evolving and is shifting towards advanced technology to deliver learning experiences. In this work, we demonstrate the potential for immersive virtual reality first-person video from the operative surgeon's perspective for teaching and learning plastic and reconstructive surgery.

Methods & Materials The case is a 53-year-old male with a history of squamous cell carcinoma of the larynx status post total laryngectomy with simultaneous PMMF two years prior who had now developed a left sided pharyngocutaneous fistula. Contralateral PMMF was offered to reconstruct his defect. The full length of the procedure was captured in the surgeon's first-person perspective using our novel head-mounted gimbal stabilized stereoscopic camera system.1

Results From incision to skin closure, 207 minutes of 5.7K stereoscopic first-person video was recorded which was then edited down to a 14-minute immersive virtual reality video. The critical steps of the procedure including exposure and elevation of pectoralis major muscle, identification of the thoracoacromial vessels, and creation of the supraclavicular subcutaneous tunnel are highlighted during the video.

Conclusion Pharyngocutaneous fistulas are not uncommon complications following total laryngectomy, and simultaneous PMMF reconstruction is used to mitigate risk.2 Further reconstructive efforts using the contralateral PMMF increases the challenges of this procedure. Learning how to perform difficult visuospatial techniques, especially in plastic and reconstructive procedures, often demands the visual perspective of the operating surgeon. Modern surgeons-in-training go beyond the conventional textbooks and atlases and seek out intraoperative videos in order to learn the craft. While there have been increasing reports of first-person surgical video in both the scientific and public domains, our camera system elevates this perspective into a novel, immersive experience by using stereoscopy and advanced stabilization to achieve unparalleled depth into the open operative field.

Surgical training models in residency and fellowship programs are competency-based and yet assessing operative competency is driven by subjective assessment by supervising surgeons. Limitations on training due to increasing competing demands on the surgical resident in the context of strict duty hours requires innovative educational solutions. By enabling trainees to visually embody the master surgeons' visual perspectives, the conveyance of operative skills is facilitated. This video represents the first in a series of complex myocutaneous flap procedures captured using this technology at our institution. Further research is being conducted on the comparative impact of immersive video to conventional video.

References 1. A head-mounted gimbal-stabilized stereoscopic camera setup for creating immersive open surgical video. Quaranto BR, Hu J, Raine B, Lamb M, Schwaitzberg SD. Surgical Innovation 2023, In Press. 2. Guimarães AV, Aires FT, Dedivitis RA, et al. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: A systematic review. Head Neck. 2016;38 Suppl 1:E2317-E2321. doi:10.1002/hed.24248

Background: Over 750,000 people in the United States suffer from end-stage renal disease (ESRD) with upwards of 65% of these patients utilizing an arteriovenous fistula (AVF) for hemodialysis.1,2 Within this population, there is a growing incidence of co-morbid ESRD and obesity (BMI >35kg/m2), which precludes many patients from kidney transplantation and underscores significant need for long-term access.3,4 Compared to traditional superficialization techniques for overlying adiposity, liposuction is minimally invasive and well tolerated, allowing for earlier fistula use with a lower complication profile. We present a practical solution to deep hemodialysis access, highlighting the process of patient selection and pre-operative planning, surgical technique, and follow-up in 14 patients undergoing liposuction for AVF superficialization.

Methods: Patients with well-matured fistulas with difficult access due to adiposity were selected. Pre-operative ultrasound mapped fistulas and their depths in 2cm intervals along their length, applying minimal skin pressure with the probe to preserve true fistula depth. Adiposity superficial and lateral to the fistula were marked and infiltrated with Klein tumescent solution to generate a 5cm-wide rectangular treatment zone longitudinally oriented over the fistula.5 The zone was first pre-tunneled with basket-tipped cannulas off suction before changing to Mercedes and spatula-tipped cannulas for completion liposuction. Liposuction was conducted in a cross-hatched fashion through stab incisions on one end of the target area at each corner. Intra-operative ultrasound and digital compression of the skin over the cannulas confirmed cannula positioning superficial and lateral to the fistula, ensured guided liposuction in the treatment zone, and recorded fistula depth. A palpable thrill remained present throughout superficialization. The newly superficialized AVF was then dressed in gentle ACE wrap compression. Cannulation began 4-weeks post-operatively.

Results: Mean BMI was 37kg/m2 (22-53kg/m2). Mean access depth pre-operatively was 10.9mm (8-15mm), immediately post-operative was 7mm (6-9mm), and at 4-weeks was 5.3mm (4-8mm). Thirteen fistulas were successfully accessed following liposuction superficialization. Average usable access length was 12.7cm (10-15cm) following surgery. All patients discharged home following surgery. There were no post-operative infections or hemorrhage.

Conclusion: Early experience with liposuction for superficialization of deep hemodialysis access is promising. It offers an innovative solution to an ever-growing problem, and the possibility of improved outcomes and quality of life for patients living with ESRD and obesity. Given poor graft survival when renal transplantation is pursued and often suboptimal long-term AVF patency in obese patients, ensuring durable access is warranted.4 Current approaches involve meticulous AVF dissection, fistula manipulation, and longer operative times. Our experience shows liposuction is a safe and effective superficialization technique to increase patient eligibility and enable successful and early cannulation, all the while decreasing recovery time.

References: 1. Dahlerus C, Kim S, Chen S, Segal JH. Arteriovenous Fistula Use in the United States and Dialysis Facility-Level Comorbidity Burden. Am J Kidney Dis. 2020;75(6):879-886. doi:10.1053/J.AJKD.2019.08.023 2. Kidney Disease Statistics for the United States - NIDDK. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease. Accessed March 7, 2023. 3. Kramer HJ, Saranathan A, Luke A, et al. Increasing body mass index and obesity in the incident ESRD population. J Am Soc Nephrol. 2006;17(5):1453-1459. doi:10.1681/ASN.2005111241 4. Maliska CM, Jennings W, Mallios A. When Arteriovenous Fistulas Are Too Deep: Options in Obese Individuals. J Am Coll Surg. 2015;221(6):1067-1072. doi:10.1016/J.JAMCOLLSURG.2015.09.004 5. Klein JA. The Tumescent Technique: Anesthesia and Modified Liposuction Technique. Dermatol Clin. 1990;8(3):425-437. doi:10.1016/S0733-8635(18)30474-1

Background:  Racial diversity in clinical trials (CTs) serves as a metric of equality of access to health care, but unfortunately, trials frequently lack or misreport representation of the population they are intended to emulate. In 1993, the National Institutes of Health Revitalization Act mandated an increase in minority and women enrollment in CTs. Further, in 2016 the Food and Drug Administration released guidelines on collecting and reporting race and ethnicity in an effort to achieve meaningful diversity in racial and ethnic representation. The purpose of this study was to investigate trends in race and ethnicity enrollment and reporting in US plastic and reconstructive surgery (PRS) clinical trials and compare representation in clinical trials to the US population census.

Methods: A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. Inclusion criteria encompassed all clinical trials in PRS from 2012 to 2022. A two-stage screening process was conducted to select articles that met the inclusion criteria. To assess racial and ethnic representation within CTs, a random-effects meta-analysis of proportion was performed to pool the prevalence of the binomial data.

Results: A total of 3,609 studies were initially identified in the search strategy with 154 of them later classified as clinical trials in PRS. Overall, 118 (76%) of the CTs did not report race or ethnicity. 36 met eligibility criteria of reporting race and ethnicity and were included in the analysis. From those, 29 (80.6%) and 27 (75%) of included CTs correctly reported race and ethnicity, respectively. A total of 7281 participants were present in the included studies, 446 (6.1%) males and 6835 (93.9%) females. Geographically, 28.5% of all CTs were done in the West, followed by the Midwest with 25%. Further, 38.9% of the CTs were in the field of reconstruction, while 33.3% were cosmetic. From CTs that correctly reported race, the pooled prevalence of races were as follows: Whites 78% (95% 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 the representation of minorities were present among PRS clinical trials. This suggests clear limitations in the generalization of PRS clinical trials' results to the general population. Efforts to decrease the gap in minority enrollment and correctly report race and ethnicity are much needed within the field.

Recent advancements in robotics and biomedical engineering have outpaced the capability of man-machine interfaces to decipher and transfer biological signals to prosthetic devices according to the demands of the human body. Here, we hypothesized that muscles can serve as an ultimate interface for amplifying neural input from the spinal cord. We emulated a clinical scenario where high- or low-neural capacity donor nerves (facial and ulnar nerves) were surgically rewired to a skeletal muscle controlled by a minimum of motor neural input (sternomastoid muscle). We found that the sternomastoid muscle successfully underwent functional reinnervation after nerve transfer using either facial or ulnar nerves as the donor of neuronal sources. Using retrograde neural tracing and electrophysiological tests, the reinnervated muscle showed almost a 15-fold hyper-reinnervation after the high-capacity nerve transfer (facial nerve), indicating its capability of incorporating a multifold of neural signals. Additionally, the surgically redirected neuronal sources redefined the physiological properties of the reinnervated muscle by altering the expression of myosin-heavy chain types according to the donor nerve (Figure 1). These findings suggest that skeletal muscles can serve as a biological amplifier of neural information from the spinal cord for controlling bionic prostheses.

Background: Surgical drains, used in a variety of procedures, are placed prior to closing an operative wound and allow for drainage of bodily fluids that would otherwise accumulate in potential spaces created by operations.1 To prevent premature drain removal, drain tubing is secured to the patient at the exit point by tying suture in a "Roman garter" technique.2 Suture-based drain securement is known to cause discomfort, particularly at the site of skin fixation as drain tubing movement is transmitted to a focal point. Patients may experience skin irritation, pain, skin tugging, loosening, and unintended loss of the drain. A novel, sutureless drain securement device (SDSD) was created to address these factors which impact patient experience while maintaining the functionality and purpose of surgical drains.

Methods: An IRB-approved randomized control trial enrolled 21 patients of 7 different surgeons. Patients 18 years or older who underwent placement of 2 or more drains as part of either breast reconstruction, breast reduction, abdominoplasty, or body contour surgery were included. Patients under the age of 18 and/or those with an allergy to skin adhesives or Tegaderm dressing and unilateral drain placement were excluded. Subjects were then randomized to receive a right or left SDSD with the contralateral site undergoing traditional suture-based drain securement. Outcomes evaluated included: time taken to secure and dress SDSD versus traditional suture-based technique, surgeon assessment of SDSD usability, adverse outcomes, patient satisfaction, and a blinded evaluation of each skin site at the time of drain removal. Analysis was performed using paired t-tests.

Results: No drain securement failure was encountered. The average duration of drain placement was 8.24 days (range = 5-14 days). Securement of the SDSD was significantly faster (p= 0.0008) when compared to traditional suture. Blinded skin site evaluations concluded no significant difference in erythema and blistering, (p=0.655) and (p=0.8936) respectively. Patients significantly favored the SDSD in all survey categories including activities of daily living, irritation, itching, tugging, and pain.

Conclusions: The novel SDSD enhances the overall patient experience with surgical drains. The SDSD offers a reliable, standardized, patient-friendly alternative to traditional suture-based drain securement. Utilization of the SDSD reduces the time to secure drains and has the potential to reduce the risk of sharps injury. Implementation of the SDSD technology may be adapted to other suture-secured medical devices.

References: 1. Khansa, Ibrahim M.D.; Khansa, Lara Ph.D.; Meyerson, Joseph M.D.; Janis, Jeffrey E. M.D.. Optimal Use of Surgical Drains: Evidence-Based Strategies. Plastic and Reconstructive Surgery 141(6):p 1542-1549, June 2018. | DOI: 10.1097/PRS.0000000000004413 2. Heskin L, Cahill V, Filobbos G, Regan P, O'Sullivan ST, Bryan K. A new adaptation for a secure surgical drain placement and a comparison with four common drain fixation methods. Ann R Coll Surg Engl. 2019;101(1):60-68. doi:10.1308/rcsann.2018.0177

Background: Prior research has shown that low Non-Technical Skills (NTS) among surgical teams is linked to surgical adverse events, and formal training in NTS can significantly reduce these.1-3 To gauge the level of NTS knowledge and training among US academic plastic surgeons, we conducted a national survey study. We hypothesized that most respondents would not have received formal NTS training but would favor providing such training to residents. Methods: A 29-question survey was distributed to academic plastic surgeons via email with the support of the American Council of Academic Plastic Surgeons. The survey inquired about demographics, knowledge and training in NTS, NTS importance and assessment tools, and NTS training in plastic surgery residency programs. Outcomes were analyzed with descriptive statistics and for associations between co-variables (region, sex, years since completing residency/fellowship). Results: One-hundred ninety-three responses were obtained. Only 43.5% knew the definition of NTS. Most respondents (60.1%) thought a plastic surgery NTS assessment tool would lead to a lower rate of adverse surgical events in the operating room. Respondents that had received NTS training in the past (61.6%, p=0.003) and felt more experienced in NTS (60.6%, p=0.001) were significantly more likely to formally teach NTS. Professionalism was considered the most important NTS (42.0% ranked it highest). Leadership was considered the least important (69.1% ranked it lowest). Of the 74.1% of respondents that thought NTS teaching should be standardized nationally, most (55.5%) thought the format should be online lectures. Conclusions: NTS knowledge and training among academic plastic surgeons could be improved. There is a preference for increased training and assessment for residents. The development of formal training and/or assessment programs could improve surgeons' NTS with the potential to improve patient outcomes.

References 1. Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events. JAMA Netw open. 2019;2(7):e198067. doi:10.1001/jamanetworkopen.2019.8067 2. Zegers M, de Bruijne MC, de Keizer B, et al. The incidence, root-causes, and outcomes of adverse events in surgical units: Implication for potential prevention strategies. Patient Saf Surg. 2011;5(1):13. doi:10.1186/1754-9493-5-13 3. Hernandez-Boussard T, McDonald KM, Rhoads KF, Curtin CM. Patient Safety in Plastic Surgery: Identifying Areas for Quality Improvement Efforts. In: Annals of Plastic Surgery. Vol 74. Lippincott Williams and Wilkins; 2015:597-602. Doi: 1097/SAP.0b013e318297791e