Scientific Abstract Presentations: Practice Management / Surgical Pearls 4 Sunday, October 29 Sun, Oct 29 10:30 a.m.-12:30 p.m. CDT

Background Orbital fractures frequently require operative management by a Plastic and Reconstructive Surgeon. Due to the proximity to the globe and complexity of the reconstruction, orbital fractures and related procedures are not an uncommon source of medical litigation. The aim of the present study was to review orbital fracture malpractice litigation, including case outcomes and compensatory damages. The information is valuable to Plastic and Reconstructive Surgeons as awareness of these cases may serve to reduce the risk of malpractice exposure.

Methods The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to orbital fracture malpractice lawsuits. Cases were included if they were state or federal cases related to both orbital fracture and medical malpractice involving surgical or medical mismanagement or misdiagnosis of orbital fracture. Cases that did not meet inclusion criteria, duplicate cases, and those for which enough information was not available were excluded. The data of interest included motives, legal outcomes, and monetary outcomes of litigations, as well as defendant specialty, location, year, and plaintiff demographics.

Results A total of 49 cases from 1994-2018 met inclusion criteria between the databases. The most common legal complaint was the defendant's failure to make a diagnosis either by not ordering the proper radiological tests or by not interpreting radiological tests correctly, seen in 35% of cases. In 57% of the cases, the defendant was a surgeon, 46% of which involved a plastic surgeon specifically. Cases were resolved in favor of the defendant 49% of the time. Most cases (57%) resulted in a monetary outcome of $0. However, cases that were decided in favor of the plaintiff had significant compensatory damages with the majority being over $100,000 and one case as high as $8 million.

Conclusion Although almost half of the orbital fracture malpractice cases resulted in an outcome favoring the defendant, significant monetary consequences against the defendant were possible in cases when the plaintiff prevailed. As failure to diagnose either by failure to order diagnostic tests or to interpret radiology films was the most common motive for a plaintiff to pursue litigation, Plastic and Reconstructive Surgeons should thoroughly evaluate patients with suspected orbital fractures to avoid litigation.

PURPOSE: Cleft lip with or without cleft palate (CL/P) occurs at higher incidences in Hispanic communities, representing 18.9% of the US population.1 We analyzed the availability and readability of Spanish-written patient education materials (PEM) on CL/P from top-ranking US children's hospitals.

METHODS: This study is a descriptive analysis of online Spanish PEM on CL/P from top-ranked children's hospitals (per 2021-2022 US News & World Report).

Availability was assessed via Google search and authorized hospital websites. For each hospital, a Google search was conducted using the phrase, "labio leporino y/o paladar hendido (translation: CL/P) + name of the children's hospital." Additionally, independently written Spanish text was distinguished from a basic English translation. English PEM readability was assessed using SMOG, a formula that calculates the reading grade level of a text. Spanish PEM readability was assessed using SOL, the SMOG formula converted for the Spanish language. Unpaired two-tailed t-tests were used to compare readability.

RESULTS: 51 children's hospitals met inclusion criteria; five were excluded due to lack of PEM on CL/P. Only 35.3% (n=18) of hospitals had some form of Spanish PEM available: 89% (n=16) available on google search, 78% (n=14) on the official website, and 56% (n=10) on both. Only 10.9% (n=5) were independent Spanish texts. There was a significant difference in reading levels between Spanish and English PEMs; SOL = 9.6 and SMOG = 11.3 (p-value= 0.001).

CONCLUSION: There is a paucity of Spanish PEM for CL/P among the nation's top children's hospitals. Additionally, English and Spanish PEMs are both provided at unacceptably high reading levels.

References: 2020 US Census

Introduction In recent years, there has been a multitude of studies examining the evolving relationship of social media platforms on the practice of plastic surgery. However, there are no studies quantifying how patient-generated content can directly affect a plastic surgeon's practice. Here, we present a report of how one viral patient-generated TikTok video post bilateral breast reduction led to significant changes in a surgeon's referral base and operative volume at an academic institution. The aim of this study is to analyze the impact of one patient-generated viral video on consultation mix and conversion to surgical cases in an academic plastic surgery practice.

Materials and Methods A retrospective review of the senior author's electronic medical record clinic schedule from nine months before and after the viral Tiktok video post-date (January 2021 to September 2022) was performed. All new patient consultations documented by the host institution as consultation for "macromastia consultation," "breast reduction," "breast hypertrophy," "thoracic or lumbar back pain surgical consultation/breast" were recorded and compared between time periods before and after the viral TikTok post. Descriptive statistics and Chi Squared test was used for statistical analysis, (p < 0.05). Google Trends analysis was performed to rule out any potential confounding variables with TikTok usage.

Results A total of 2,275 office visits were included. Consultations for breast reductions doubled after the Tiktok video post-date when comparing time periods (Before: 52 vs After: 110 consultations). Proportion of office visits with new consultations for breast reduction significantly increased (Before: 5.1% vs After: 10.5%; p<0.001). A total of 19 breast reductions were performed by the senior author in period prior to the video post-date, compared to 38 surgeries in the nine months after the viral Tiktok post-date. There was not a significant difference in operations per consultations between the two periods (p=0.80). Google Trends analysis demonstrated no unexplained rise in usage or participation in TikTok at the time of video or geographically.

Conclusion Tik Tok has become a mainstay in regards to entertainment and educational dissemination, but its use in plastic surgery practice is under investigated. The aforementioned viral Tik Tok video significantly increased the clinical consultation volume and increased the number of surgeries. In this study, we showed that a single, viral TikTok video was associated with a two-fold increase in consultations for reduction mammoplasty, even in the setting of a COVID-19 surge in our area leading to surgical shutdowns. This is the first study to link a patient-generated social media post to a quantifiable change in surgeon clinic consultation referrals and surgical volume.

BACKGROUND: Improving facial aesthetics while maintaining normal function is the goal of an elective rhinoplasty. Neck liposuction is an ideal adjunctive procedure to further improve facial aesthetics and contribute to the overall appreciation of the nasal surgery. METHODS: Neck Liposuction was presented to patients as an associated procedure with an elective rhinoplasty and no additional fee was attached. At the initiation of the rhinoplasty, nasal and neck infiltrations were done with a dilute local anesthetic solution. A 90-cc volume solution (30-cc 1.0% xylocaine with 1/100,000 epinephrine mixed with 60 cc of injectable saline) was prepared. The neck was typically injected with 50 to 60 cc of the solution. Once the nasal surgery, with or without a septoplasty, was completed, the neck area was re-prepped with antiseptic. A small submental incision was made for a short 3 mm-wide canula. Low pressure, 'wall suction' was sufficient for the liposuction, but occasionally traditional liposuction equipment was employed. The canula was passed along the jawline on both sides and lightly across the mid-neck. A single fine absorbable suture closed the incision, and the neck was taped for support with brown-micropore tape or wide steri-strips. No circumferential bindings were placed. After 48 hours, nasal packing and the neck tape were removed. RESULTS: Over a fifteen-year period, fifty-three aesthetic rhinoplasties were performed in combination with neck liposuction. Forty-seven women and six men comprised the group. Eight patients (six women, two men) underwent a sliding genioplasty in combination with their rhinoplasty and neck liposuction. Six separate patients during this period refused to undergo the additional neck procedure with their rhinoplasty. Addition of the neck liposuction prolonged the surgical time by less than fifteen minutes. Complications included two women with transient, unilateral neuropraxia (altered smile) that resolved within a few weeks. No hematomas occurred but steroid injections were often utilized post-operatively to facilitate softening of small subcutaneous collections. Minimal bruising of the neck was observed. Facial aesthetics were subjectively improved with the combined procedures. An objective improvement could be observed even in young, thin patients with minimal neck fullness. Improvement of the profile and neck contour, with a more defined jawline, complemented the rhinoplasty result. Older patients realized more dramatic results. Patients with mandibular hypoplasia and no genioplasty realized an obvious improvement in their chin aesthetics. Patients appreciated the positive changes in their neck profile and no one expressed a regret about undergoing the combined procedures. Addition of neck liposuction as an adjunctive procedure proved a positive inducement for attracting additional rhinoplasty patients.
DISCUSSION: Results define a plastic surgeon within the community. Aesthetic rhinoplasty remains one of the more challenging procedures a surgeon undertakes, and few cosmetic outcomes are as dramatic in improving facial appearance. The addition of neck liposuction to rhinoplasty adds little time or complications, is easy to perform at the completion of nasal surgery, and enhances facial aesthetics. Neck liposuction is an adjunctive procedure that should be considered as a routine addition to aesthetic rhinoplasty.

Purpose: Physician Assistants (PA) and Nurse Practitioners (NP), collectively Advanced Practice Providers (APP), have become an essential part of Plastic Surgery practices who improve access and optimize patient care. The purpose of this study was to evaluate the impact of instituting an APP run body contouring clinic on patient access to care and conversion rate to surgery. Methods: A retrospective chart review was conducted on patients who presented to an APP run body contouring clinic from February 2020 through January 2021. Demographic data, reason for visit, visit type, and conversion rates to surgery were collected. Descriptive statistics were used. Results: A total of 196 patients were evaluated in clinic, including 165 new patient visits. Reasons for visits included consultations for: breast reduction, panniculectomy, brachioplasty, and/or thighplasty consults. Of these patients 110 were appropriate candidates for surgery and subsequently evaluated by a surgeon. At the time of review, 18% (n=20) were pending insurance approval, 57% (n=63) patients were approved, 23% (n=25) received insurance denial of which two percent proceeded to self-pay and go on to have surgery. Fifty-five patients were not optimized for surgery at the time of their 30-minute initial APP consult and were subsequently referred for appropriate medical work-up, smoking cessation, and/or weight loss. This represents roughly 27.5 hours of billable time. Conclusion: This study explored the impact of an APP run body contouring clinic in an academic Plastic and Reconstructive Surgery practice. Academic plastic surgeons are pressured to be clinically productive, prolific in research, and rise in the academic ranks. Independent APP clinics improve patient access to care, generate revenue, both directly and via downstream revenue, and optimize the opportunities for APPs to grow professionally.

Primary lymphedema is a rare condition affecting 1/100,000 persons. It typically involves the lower extremities. Swelling develops most commonly in males during infancy and females during adolescence. The condition currently is associated with mutations in approximately 30 genes. Prenatal diagnosis rarely occurs. Our Lymphedema Program Database was reviewed for patients who were diagnosed with lymphedema prenatally. Maternal and paternal history, genetic testing, physical examination, and prenatal imaging were recorded. Postnatal infant physical examination, genetic testing, and lymphoscintigram results were studied. Four of 360 (1%) patients with primary lymphedema in our database were diagnosed with swelling by prenatal ultrasound and/or MRI. Three patients did not exhibit lymphedema after birth, two of which had a VEGFC mutation. One patient with a 16p12.2 deletion continued to have bilateral leg edema postnatally. Lymphedema identified prenatally is associated with a VEGFC mutation and can resolve after birth.

Introduction Integrated plastic surgery is one of the most competitive specialties in the National Resident Matching Program, and in recent years has placed an increasing emphasis on student research productivity prior to residency application. Integrated plastic surgery applicants consistently rank among the top applicants in terms of research experiences, including publications, presentations, and abstracts. As a result, plastic surgery program directors have come to rely on research as an important differentiating measure for evaluating prospective trainees. Research acumen is also critical component of professional development and promotion for early career professionals in plastic surgery. Thus, clinical research enterprises organized by young faculty and run by medical student research fellows offer a symbiotic solution to the increasing importance of research productivity to both evaluative processes. However, little has been written by way of guidelines for creating a successful clinical research enterprise (CRE) for those aspiring to establish one at their own institution. The purpose of our study was to present our institution's experience with a successful CRE in craniofacial surgery that is overseen by faculty and managed by an annual research fellow(s). In detailing the history, organization, and operations of our program, we hope it will serve as a model to early career professionals intending to implement plastic surgery clinical research programs at their own institutions.

Methods Since 2018, our institution's Craniofacial Clinic has been home to a successful clinical research enterprise under the supervision of a craniofacial plastic surgeon as principal investigator (PI). Both internal and external applicants, including medical students and residents, are eligible to apply for a single-year research fellowship position in our craniofacial clinical research enterprise. Funding is provided through school of medicine research fellowship programs, the department of plastic surgery, external grants, or by some combination thereof. Research practices and protocols have been developed with an emphasis on data integrity and security, project and database management, collaboration, and research best practices.

Results Our CRE was first established in 2018 and has been host to seven medical student research fellows thus far, comprised of three internal and four external fellows. This structure was enabled through funding from medical school clinical research fellowships, external grants, and departmental funding. As part of this clinical research enterprise, protocols are strictly enforced under the guidance of the Institutional Review Board to maintain data security and comply with HIPAA standards. Project management tools such as Trello and Microsoft Teams are used to monitor, track, and expedite workflow while also ensuring data integrity and proper research best practices. This structure has enabled significant research productivity and facilitated increased collaboration among medical students, residents, fellows, and faculty members.

Conclusion The successful research enterprise, led by an early career faculty member and managed by a medical student research fellow each year, has been consistently productive and beneficial to involved students, residents, clinical fellows, and faculty. This manuscript details the essential characteristics of a successful CRE and offers guidelines for implementing similar programs in plastic surgery departments across the country.

HYPOTHESIS: With the continuous rise of plastic surgical cases, this innovative specialty boasts a strong interrelationship with global health and emissions. Frequent use of operating rooms (ORs) and resources largely contribute to healthcare's waste and emissions; waste quantification can help identify barriers within surgical-centered emissions to aid in the identification of efforts that may reduce it overall.

METHODS: Query of PubMed using terms "plastic surgery AND emissions", "plastic surgery AND economics", and "plastic surgery AND climate" produced minimal articles; this highlights the infancy of this area of study. Applied attention and growth within this area has the potential to positively impact patient care, healthcare economics, and overall climate change.

RESULTS: Literature continues to materialize mitigations to climate change in healthcare, but the unique implications of plastic and reconstructive surgery are minimal. Despite this limitation, conceptualizations can be made based on other surgical specialties that share general overlaps in operation with plastic surgery. Surgery continues to amplify its impact being amongst the most waste-producing enactments. Operating rooms produce 2,000 tons of waste each day and average more than 2 million tons annually; they are also responsible for high energy usage through HVAC systems, lighting, and anesthetic gasses. Greenhouse gas emissions in the United States healthcare system has realized 655 million tons with a drastic 30% increase within the past decade. Surgical emissions have an equal and opposite impact on the specialties themselves. The production of excessive natural disasters from climate change increases the demand for plastic and reconstructive surgeries following trauma. Low economic status and resource limitations increase risk of postoperative complications. Air pollution and contamination of consumptive resources increases risks of cancers that may require surgical intervention. The U.S. healthcare sector itself is responsible for 12% of acid rain, 10% of smog, and 9% of respiratory disease secondary to particulate matter.

CONCLUSION: Worldwide healthcare emissions threaten the well-being of the patients that healthcare workers vow to protect. Plastic and reconstructive surgery provides a unique scope of practice that widens its environmental impact as the field itself grows in both demand and innovations. Simultaneously, impacts on the global climate are a common denominator for all surgical specialties. Education is the strongest pillar of change to reducing the environmental impact by the field of surgery; this could begin as early as the medical student level and continue into each subsequent level of training and practice. Future efforts should be channeled into making the operating theatre a surrogate for environmental advocacy through the development and implementation of reduce and reuse initiatives, as well as full disclosure of economic and emissions expenditure for surgical procedures that can be proactively assessed.

Background: Department of surgery (DOS) chairs play a significant role in determining the direction of their program and their field. We sought to determine the characteristics that distinguish DOS versus plastic and reconstructive surgery (PRS) chairs and chiefs.

Methods: We queried the Scopus Author Identifier and Database for all current 2023 PRS department/division chairs of integrated PRS programs along with their respective DOS chairs. Multivariable logistic regression analysis was used to determine the association of chairs' and chiefs' characteristics with the outcome of being a DOS chair.

Results: PRS chairs (N=80) and DOS chairs (N=80) were evaluated for 80 programs. Compared with PRS chairs, DOS chairs had a statistically significant higher median [IQR] h-index (21 [13, 29] PRS vs. 43 [26, 59] DOS, P<0.001), M-quotient (0.82 [0.54, 1.13] PRS vs. 1.34 [0.94, 1.94] DOS, P<0.001), total publications (72 [33, 148] PRS vs. 169 [95, 242] DOS, P<0.001), and first (11 [5, 19] PRS vs. 23 [13, 38] DOS, P<0.001) and last authorships (26 [11, 56] PRS vs. 39 [22, 71] DOS, P=0.008). DOS chairs also had a longer time since publication of their first senior authored paper (P=0.001) and a higher number of advanced degrees compared to PRS chairs (17 PRS vs. 22 DOS, P>0.05). DOS chairs were mostly surgical oncologists (n=18), followed by general surgeons (n=13) and vascular surgeons (n=11). Three department of surgery chairs practiced PRS. PRS and DOS chairs did not differ statistically by sex or race. When controlling for other demographics and characteristics of academic productivity, a higher h-index was found to be significantly associated with the outcome of being DOS chair (OR 1.07, 95% CI 1.01-1.15, P=0.033).

Conclusion: There were three PRS DOS chairs, which is a stark contrast in comparison to other specialties. A higher h-index was associated with the outcome of being DOS chair when controlling for other factors. Residents and fellows from PRS and other surgical specialties should keep academic productivity in mind throughout their training to increase their prospects of becoming chair.

Background: Custom helmet therapy is a common treatment for plagiocephaly and other skull deformities seen in the postnatal period. Unfortunately, these helmets can create a significant financial burden on families, especially when not covered through insurance. GoFundMe (GFM), the largest online medical fundraising platform, reports raising over $650 million annually across 250,000 campaigns. To date, no studies have evaluated the use and results of US-based GFM campaigns for this therapy.

Methods: GFM campaign data were collected querying terms "plagiocephaly", "brachycephaly", "flat head syndrome", and "helmet therapy". Campaigns that were duplicates, for animals, not directly raising funds for helmets, covering post-surgical helmets, and foreign campaigns were excluded. These data, including demographics, story themes, and unique characteristics, were analyzed by two independent reviewers. Logistic regression was used to determine each variable's impact on success, defined as attaining ≥75% of a campaign's goal. Statistical significance was set at p≤0.05.

Results: Overall, 413 campaigns from 2011 to 2022 were analyzed with an average raised of 71% (range: 0%-206%), donated of $2,005 (range: $0-$7,799) and requested of $3,151 (range: $160- $30,000). In all, 228 (54%) achieved success, 167 (40%) met their goal, and 35 (8%) raised no funds. The mean reported age was 6 months (range: 2-17m). In total, campaigns raised $828,256 of a requested $1,301,317.

Factors associated with positively influencing success were military affiliation (OR=2.480, p=0.008), providing multiple images (OR= 1.764, p=0.005), including a quoted cost (OR=2.090, p<.001), providing campaign updates (OR=1.070, p=0.042), indicating a sense of urgency (OR=1.540, p=0.036), indicating a torticollis diagnosis (OR=1.560, p=0.043), mentioning possible complications without treatment (OR=1.803, p=0.004), and were created during the months of CARES Act stimulus check distribution and the subsequent two months (OR=2.580,p=0.034).

Factors associated with negatively influencing success were raising additional funds for therapy (OR=0.359, p=0.029), unrelated medical costs (OR=0.339, p=0.009) and for multiple helmets for one patient (OR=0.0233, p=0.029).

Race impacted success with Black (OR=0.306, p=0.012) and Hispanic (OR=0.485, p=0.003) campaigns performing worse compared to White campaigns, while Asian and racially anonymous campaigns had no statistical significance compared to White campaigns. No other racial comparisons yielded significance.

Regionally, 220 (53.3%) resided in the South, 76 (18.4%) in the West, 52 (12.6%) were of unknown origin or territory-based, and 42 (10.2%) in the Midwest. Campaigns in the Midwest (OR=2.356, p=0.017) and Northeast (OR=5.016, p=0.004) performed better compared to Southern campaigns. Northeastern campaigns also performed better compared to Western campaigns (OR=3.272, p=0.047) and unknown origin or territory-based campaigns (4.071, p=0.023).

There was no significance in success based upon the relationship of the patient to the crowdfunder (i.e., friend, family), the age of the patient, or between male and female patients.

Conclusion: As the cost of helmet therapy may not be covered by insurance, many families turn to crowdfunding to alleviate this financial burden. While this study explored many factors associated with success, further studies are necessary to identify other variables that may influence campaign success.

PURPOSE: Plastic surgery residents complete thousands of procedures during their training. Differences between the procedures residents perform during residency, evaluation metrics and the broader practice of plastic surgery have not been formally studied. We aim to examine how the distribution of graduating resident case log procedures compares to ACGME minimum procedure count requirements residents are subject to, content on the annual in-service examinations they sit for, and programming at two major annual meetings. METHODS: Nine procedural categories were identified based on ACGME and in-service training examination categories. Six categories of reconstructive plastic surgery procedures (head & neck, breast, trunk, hand & upper extremity, lower extremity, and integument) and three categories of aesthetic plastic surgery procedures (head & neck, breast, and trunk & extremity) were defined. Three-year averages for the number of procedures completed in each category by plastic surgery residents graduating in 2019-2021 were calculated from ACGME national case log data. The titles and durations of medical programming sessions scheduled for PSTM 2022 and abstract presentations at the PSRC Annual Meeting 2022 were abstracted from online data. Meeting content percentages were determined by dividing presentation duration by total meeting time. Finally, test items from the 2020-2022 administrations of the ASPS Plastic Surgery In-training Exam (PSITE) available on the ACAPS website were abstracted and similarly assigned to a single procedure category when possible. Meeting content and test items that were unable to be readily placed into distinct categories were excluded. A percentage difference test was used for comparison. RESULTS: Overall, ACGME requirements had the lowest percent differences with case logs; reconstructive trunk (59.2% difference) and reconstructive integument procedures (55.4% difference) were overrepresented on case logs relative to ACGME requirements. Meeting content at PSTM 2022 and PSRC 2022 had the highest percent differences. PSTM 2022 skewed significantly towards aesthetic procedures overall, with aesthetic head & neck (69.3% difference) and aesthetic trunk & extremity procedures (100.4% difference) overrepresented and reconstructive breast procedures (116.8% difference) underrepresented relative to case logs. PSRC 2022 skewed significantly towards reconstructive procedures overall, with aesthetic breast (71.1% difference) and aesthetic trunk & extremity procedures (136.2% difference) underrepresented relative to case logs and reconstructive head & neck procedures (65.0% difference) overrepresented relative to case logs. Finally, there was reasonable concordance between case log procedures and in-service examination content; reconstructive breast (64.8% difference) and aesthetic breast procedures (57.2% difference) were underrepresented on the PSITE relative to case logs and aesthetic head & neck procedures (51.5% difference) were overrepresented on the PSITE relative to case logs. CONCLUSION: The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures residents actually complete during their training. We hypothesize that this is partially reflective of the heterogeneity of the specialty as well as possible vendor sponsor bias. Following these comparisons over time will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of practice settings and further training they pursue.

Purpose: Tissue expanders are commonly used in staged breast reconstruction. They are often placed at the time of mastectomy; complication rates following such immediate breast reconstruction are high and range widely in the literature. We wanted to investigate whether the placement of tissue expanders in a delayed-immediate fashion, at least one week postmastectomy, can reduce complication rates. We present a case series of patients who underwent delayed-immediate placement of tissue expanders and compare their outcomes to patients with expander placement at the time of mastectomy.

Methods: We conducted a retrospective review of patients undergoing staged breast reconstruction between 2017 and 2020 performed by the senior author at a single institution. Six breast oncologic surgeons performed the mastectomies. Perioperative complications were compared between those who underwent immediate placement of tissue expanders at the time of mastectomy versus those who had them placed at least a week later.

Results: Between 2017 and 2020, 74 patients underwent 120 mastectomies followed by two-staged breast reconstruction, either with implant or autologous tissue as the final reconstruction. The mean age was 48 years (range 24-76). Fifty-three patients (72%) had immediate placement of tissue expanders, and twenty-one (28%) had delayed-immediate placement, usually about one week postmastectomy. About half of all patients (47%) experienced a complication during their reconstructive course, most commonly infection (32%). Among the 120 tissue expander placements, 38% had a complication. There was at least one complication in 47% of the expanders in the immediate group and 18% in the delayed-immediate group. In multivariable logistic regression analyses, delayed-immediate reconstruction was associated with 82% reduced odds of a complication (p = 0.04) and 78% reduced odds of an infection (p = 0.02). Furthermore, post hoc analyses suggested that delayed-immediate tissue expander placement was associated with lower healthcare costs.

Conclusion: If plastic surgeons have identified high complication rates among their patients undergoing staged breast reconstruction using tissue expanders, delayed-immediate placement is a potential strategy to reduce complications. As we continue to offer it as an option for our patients, we are prospectively examining whether it improves the patient experience and decreases overall healthcare costs.

Background: Gender disparities exist in surgery amongst current leadership and the lack of females in high ranking positions play a significant role in the diversity of institutions and the field at large. Reasons for not reaching gender parity are multifactorial, with current literature attributing lack of exposure to mentorship, disproportionate opportunities, and the surgical culture as some of the reasons females have not ascended to leadership positions at the same rate as their male counterparts.1 This study explores the scholarly metrics and characteristics that may distinguish females and males who serve as surgery department and plastic surgery department or division leadership.

Methods: We queried the Scopus Author Identifier and Database for current 2023 PRS department/division chairs of integrated plastic and reconstructive surgery (PRS) programs along with their respective department of surgery (DOS) chairs. Statistical analyses were performed with R (version 4.1.0) and RStudio (version 1.4.1717) software. Descriptive analysis was performed to determine any differences in characteristics of DOS and plastic surgery leadership.

Results: PRS chairs (N=80) and DOS chairs (N=80) were evaluated for 80 programs. In total, 12/80 (15%) of PRS chairs and 12/80 (15%) of DOS chairs were female. Compared with female PRS chairs, male PRS chairs had a longer time since publication of their first senior authored paper (15.1 [7.7, 20.5] female PRS vs. 21.4 [14.3, 26.8] male PRS, p<0.001). However, there were no significant differences between male and female PRS chairs in terms of h-index, M-quotient, total publications, last author publications, or years since first manuscript. Compared with female PRS chairs, female DOS chairs had a statistically significant higher median h-index (16.5 [12, 28] female PRS vs. 42 [29, 50] female DOS, p=0.009), M-quotient (0.82 [0.71, 1.06] female PRS vs. 1.41 [1.18, 1.65] female DOS, p=0.033), total publications (72 [28, 100] female PRS vs. 171 [108, 217] female DOS, p=0.017), and first (6 [1, 18] female PRS vs. 21 [13, 27] female DOS, p=0.03) and last authorships (22 [7, 35] female PRS vs. 58 [40, 78] female DOS, p=0.026).

Conclusion: Females constitute just 15% of PRS chairs and chiefs. However, when compared with their male counterparts, our data did not reveal significant differences other than duration in the field. Gender based leadership and promotion disparities exist on all levels of academic plastic surgery. To address the gender gap, interventions targeted at recruitment, retention, and advancement of female plastic surgeons must be implemented.

References: 1. Keane AM, Larson EL, Santosa KB, et al. Women in Leadership and Their Influence on the Gender Diversity of Academic Plastic Surgery Programs. Plast Reconstr Surg. 2021;147(3):516-526. doi:10.1097/PRS.0000000000007681

Purpose: Many benefit from the use of social media, including healthcare businesses, specifically surgery where a service based practice model can exist. More specifically, social media has been demonstrated to serve as a critical tool for plastic surgeons, facilitating patient engagement, peer-to-peer education and learning, and outreach to the broader public community. This study aims to perform a meta-analysis of data to determine the most valuable and useful social media platforms for practicing plastic surgeons developing their practice by assessing the perceived value to the practice and quantifying return on investment.

Methods/Materials: A systematic review was performed using PubMed. The initial search yielded 3,592 articles. 16 articles met inclusion and exclusion criteria.

Results: The general theme for content recommendations found in this study include focusing on aesthetic attributes, displaying professionalism, and making sure the surgeon was the person delivering the content. One study found that patients are more likely to engage with aesthetic content rather than scientific content. Preferred platform for social media marketing varied, and may be dependent on age. Younger generations are more likely to utilize Instagram, Snapchat, and TikTok, while older generations may be more likely to utilize Facebook and YouTube. Age specific recommendations include utilizing Instagram, Snapchat, and TikTok with emphasis on breast augmentation for patients aged 17-35 given this is the most common procedure performed for this age group. Patients between the ages of 36-70 are most likely to be engaged on facebook, instagram, and Facebook with liposuction being the most common procedure in this age group. For ages 70+, patients are most likely to utilize facebook with the most common procedure performed as blepharoplasty.

Conclusion: Effective social media marketing for the plastic surgeon considers delivering the right content and choosing the right platform. The right content and platform is critically dependent on the specific age of the audience.

Background: Artificial intelligence (AI) has been rapidly evolving and is awaiting integration into healthcare. With ChatGPT continuing to captivate public attention, greater consideration of its potential impact on plastic surgery is warranted. As a natural language processing software, ChatGPT is inherently dialogistic. Given this property, our aim was to determine if this AI function can be used as a patient directed self-service tool whereby patients can have their clinical questions directly answered by AI. The goal of this research is to determine the functionality of incorporating AI as a clinical tool to help manage patient questions and clinical concerns in the perioperative period. While such tools introduce complex medico-legal questions, which are beyond the scope of this initial pilot study, our objective was to assess the content, accuracy, and accessibility of AI generated content regarding common perioperative questions and complications for reduction mammaplasty.

Methods: AI interface ChatGPT (OpenAI, February Version, San Francisco, CA) which is publicly accessible was utilized to query 20 common patient questions or complications that arise in the perioperative period of a reduction mammaplasty. Searches were performed in duplicate, where a query was performed for a general term ("breast reduction bleeding") and repeated with a specific clinical question ("I had a breast reduction yesterday and now I have bleeding. What should I do?"). Query outputs were analyzed both objectively for metrics including output length, sentence structure, and readability scores and subjectively for tone, content, and accuracy. Microsoft Excel (Version 7, Seattle, WA) was used for performing descriptive statistics, t-tests, and chi-square tests where appropriate with a predetermined level of significance of p<0.05.

Results: A total of 40 AI generated outputs were analyzed. Mean word length was 191.8 words with 998.9 characters. Mean Fresh-Kincaid Grade Level was the 13th Grade and Mean Flesh Reading Ease was 39.7 (1-100 where 100 is most readable). Regarding content, out of all query outputs 97.5% were on the appropriate topic. Medical advice was deemed to be reasonable in 100% of cases. General queries more frequently (16/20) reported overarching background information whereas specific queries more frequently reported prescriptive information (18/20) (p<0.0001). Specific queries recommended discussion with the surgeon in 100% of cases, while general queries recommended the same in 95% of cases. AI outputs specifically recommended following surgeon provided postoperative instructions in 86.8% of instances. Notable interesting responses included instances of a congratulations and an apology.

Conclusions: Currently available AI tools, in their nascent form, are capable of providing recommendations for common perioperative questions and concerns for reduction mammaplasty. While the reading level of these outputs are higher than ideal, this represents a first step in developing a plastic surgery specific AI application that can serve as the first resource for patients undergoing surgery. Limitations include a potential delay in patients seeking urgently needed medical care. With further calibration, AI interfaces may serve as a tool for fielding patient queries in the future, however patients must always retain the ability to bypass technology and be able to contact their surgeon.

Introduction: Pre-market notification, also known as 510K, is a cost-effective pathway for FDA medical device approval that bolsters physician innovation in small-to-medium enterprises. Pre-market authorization (PMA) requires pre-approval clinical trials that are cost prohibitive for physician-led enterprises. This investigation aims to examine trends of 510K and PMA device approvals in the field of topical advanced wound care associated with increased regulatory burden.

Methods: FDA device databases were searched for approvals in wound care. Devices with 510K eligibility or PMA requirements were included if they were dressings with integrated antimicrobials, collagen, or biologics, or constituted a dermal substitute or topical integrative scaffold. Data collection included device classification, date of approval, applicant entity, and applicant annual revenue. Chi-squared analysis, regression models, and t-tests were used in statistical analysis.

Results: 341 PMA approvals and 1093 pre-market notification 510K approvals were identified from 1990-2022, for 1434 approvals in topical advanced wound care. Obtaining pre-market approval was more likely for entities with over 500 employees (p < 0.0001) and annual revenues of $100 to 500 million (p < 0.0001). Only five unique companies acquired all 341 PMA approvals over the studied three decades. There was a linear decrease in 510K approvals over time (p <0.0001), while PMA approvals were not impacted. There was an overall decline in small device enterprises obtaining device approval through the 510K pathway (p=0.0017).

Conclusions: Decline of 510K approvals over time demonstrates opportunity loss for device enterprises rooted in physician innovation. Small enterprises are primarily physician-led and historically most impacted by regulatory burden. Cost-prohibitive approval pathways likely stifle physician innovation in device development and may prevent potentially market-disrupting products designed by physicians from improving patient quality-of-life.

Introduction: Gender-affirming surgery (GAS) is a life-affirming treatment for gender dysphoria. Patients undergoing GAS may turn to crowdfunding to offset the cost of care. Previous studies(1) have examined how word count, social media shares, goal amounts, and number of donors predict crowdfunding success. Other studies(2,3) have focused on top surgery campaigns alone. Currently, no studies investigate how social determinants of health, including insurance, employment, or hidden costs of care, impact campaign success. This study identifies specific crowdfunding trends among patients seeking GAS in the United States (US), as well as potential barriers to care and predictive factors of successful campaigns.

Methods: GoFundMe (GFM) searches for GAS-specific campaigns from 2018-2022 were conducted. For inclusion, campaigns raised funds for patients in the US seeking GAS with or without associated costs. Five independent reviewers screened campaigns and extracted the data. Using SPSS, a chi-square analysis determined likelihood ratios of success for demographics, cover image themes, and narrative elements.

Results: Out of 1174 total results, 917 eligible campaigns raised $2,083,539 ($0-$75,353) from 39,176 donors out of $13,994,022 ($1-$160,400) requested. On average, successful campaigns (≥75% of goal) raised $8889 and requested $8971, while unsuccessful campaigns (≤25%) raised $643.29 (p<0.001) and requested $11,906 (p<0.001). The most represented states were California (n=113), New York (n=85), and Texas (n=63). Patients were typically transfeminine (n=362), white (n=515) and self-employed or independent contractors (n=125). The vast majority raised funds on their own behalf (n=830). Top surgery (n=458) was the most common procedure. Time off work (n=210) was the most commonly cited ancillary cost. Gender identity, race, medical comorbidities, non-dysphoria psychiatric diagnoses, sexual orientation, or cover image did not influence success (p=0.076-0.721). Full or partial insurance coverage was the strongest predictor of success (p<0.001), while facial feminization (p=0.002) and body contouring (p=0.004) predicted unsuccessful campaigns.

Discussion: As GAS becomes an increasingly accepted treatment for gender dysphoria by society and medical professionals, hidden and conspicuous financial barriers still exist for patients. Those with adequate insurance coverage requested lower amounts allocated primarily toward associated costs including time off work (p<0.001), whereas patients undergoing procedures deemed "cosmetic" by insurance, such as body contouring, requested higher amounts (p<0.05) and were less successful. Freelance work serving young LGBTQ+ populations may also increase the likelihood of success. Additional obstacles cited in patient stories include state Medicaid limitations, surgeons not accepting insurance, and the need to travel for their procedures. Surgeons should strive to identify, and help their patients overcome, these obstacles on their gender journeys. Additional crowdfunding campaign analyses can improve access to this life-saving care.

References: 1. Akiki RK, Borrelli MR, Kwan D. Online Crowdfunding Enables Patients' Access to Gender-Affirming Surgery. Transgend Health. 2021 Oct 4;6(5):240-243. doi: 10.1089/trgh.2020.0128. PMID: 34993296; PMCID: PMC8664102. 2. Barcelos CA, Budge SL. Inequalities in Crowdfunding for Transgender Health Care. Transgend Health. 2019 Mar 6;4(1):81-88. doi: 10.1089/trgh.2018.0044. PMID: 31032423; PMCID: PMC6484344. 3. Faletsky A, Han JJ, Lee KJ, et. al. Crowdfunding for Gender-Affirming Mastectomy: Balancing Fundraising With Loss of Privacy. Ann Plast Surg. 2022 Apr 1;88(4):372-374. doi: 10.1097/SAP.0000000000002953. PMID: 34270468.

Purpose: The CLEFT-Q is a patient-reported outcome measure which assesses outcomes of children and young adults with cleft lip and/or palate (CL/P) aged 8-29 years. There is a gap in measurement of younger children's perspectives as they may be unable to complete the scales themselves, but many interventions occur before age 8. The objective of this study was to determine the age that parents can act as a proxy report for children under 8 years of age with CL/P in order to develop a parent-proxy version of the CLEFT-Q.

Methods and Materials: Parents of children with CL/P under 8 years of age were recruited from the Plastic Surgery Clinic to participate in cognitive debriefing interviews to determine if the items in the scales were comprehensible, relevant, age-appropriate, and adaptable to parent-proxy. Interviews continued until saturation was achieved. Scales were adapted based on interview results.

Results: 11 interviews were completed. Parents' ability to report on behalf of their children as a parent-proxy depended on the concept being tested. Parents expressed ability to act as a proxy starting at age 3 for the Speech scales, when their child began school/daycare for the School scales, and when their child began feeding for the Eating/Drinking scale. Parents' ability to proxy report for the Appearance, Psychosocial, and Social Function scales varied depending on their child's awareness of their appearance and their self-awareness, in some cases as young as age 3. Adapted scales will be field tested based on the earliest age that parents were able to act as a parent-proxy.

Conclusions: The Parent-Proxy CLEFT-Q will allow for better understanding of the perspectives of younger children with CL/P. We have defined age parameters for parent-proxy report. Field-testing the revised scales will further confirm when parents can provide valid proxy report in order to finalize the Parent-Proxy CLEFT-Q scales for clinical use.

BACKGROUND: Surgeons have stressful lifestyles. Yoga and meditation have a 3,000+ year-old history in Eastern Medicine, however only in the last 40 years have Westerners begun to utilize these practices. A reliable method for maintaining physical and mental wellbeing of surgeons has yet to be investigated. Here we aim to analyze which aspects of surgery contribute to poor physical wellbeing and if/how much yoga or meditation is required to see improvements in overall health of surgeons.

METHODS: Willing surgeons at a single-center institution were randomly assigned groups. IRB approval was granted. Treatment group performed yoga or meditation for a minimum of 5 minutes every 2 weeks over a 6 month period; the control group was asked not to perform either. A pre- and post-study survey was sent using RedCaps software to both groups. Data collected and analyzed included demographic information, specialty, surgical instruments, positioning of surgeon, location/severity/duration of pain, mood, sleep, flexibility, balance, posture, and work efficiency. Each individual's post-study responses were analyzed against their pre-responses and treatment group was compared against control group for statistical analysis. Authors were blinded to the participants in each group for the duration of the study.

RESULTS: Surgeon participants included multiple subspecialties. 52 surgeons responded to the pre-survey and 30 of these responded to the post-survey. Of those who responded to both, 15 were in the treatment group and the other 15 were in the control group. Participants included PGY2-PGY9 residents/fellows as well as attendings in practice ranging from 0-20+ years. 63.5% of those reported acute pains and 30.7% reported chronic pains of various degrees and locations. All in the treatment group reported improved posture, flexibility, sleep, stress, anxiety, feelings of overworked, work performance, and mood compared to their pre-study survey. Those who performed yoga/meditation more often were shown to have greater improvements in pain scores than those who performed inconsistently. The treatment group reported higher average scores than control group for posture in the OR, general posture, flexibility, coordination, balance, and work performance. Sleep quality and stress in the OR were rated as nearly equivalent between groups; those in the treatment group reported decreased rates of stress at home. The treatment group reported average scores at less than half of that reported by control for feelings of overworked, sadness, apathy, fatigue, and anxiety and these were significant.

CONCLUSION: Surgeons dedicate substantial time and energy, often at the cost of physical/mental health. Yoga and meditation have long been utilized to combat these in the general population. This knowledge was extrapolated to a group of surgeons and though our data is limited by power we were able to show significant improvements in work efficiency, mood, stress/anxiety/depression levels, and pain scores both longitudinally amongst individuals as well as in comparison of those individuals against surgeons who did not perform yoga/meditation. Future directions include actigraphy and biofeedback devices to measure degrees of change in posture and flexibility as well as obtain objective data in regards to sleep and vital sign derangements.