Scientific Abstract Presentations: Research & Technology 7 Sunday, October 29 Sun, Oct 29 8:00-9:30 a.m. CDT

Background Traditionally, plastic surgeons have used loupes or operative microscope for visual magnification to aid in tissue dissection and anastomosis of structures. These devices have their own limitations, including fixed or lower magnification, bulkiness, narrow field of view and depth, cost, and set-up time. Current uses of augmented and virtual reality technology in surgery have been limited to pre-operative planning and simulation. We present a proof of concept that utilizes AR and VR, known as mixed reality, to address the limitations of loupes and microscopes to augment visualization.

Methods We first evaluated methods of gaze-based eye tracking to enable digital magnification. Using the Varjo XR-1, an industry-ready head-mounted display (HMD), we compared discrete zoom through a displayed interface versus continuous zoom through eye squinting. Participants completed a survey and interview following the activity. Next we assessed the performance and limitations of MR digital magnification. We utilized an upgraded headset, the Varjo XR-3, to address the hardware limitations of the first study. Participants were asked to complete anastomotic suturing tasks with progressively finer polypropylene suture. Participants completed a similar survey and interview.

Findings All participants felt the discrete zoom was easier to use. Participants had difficulty determining depth and visualizing the suture as it became finer regardless of the magnification level. Using the system usability scale, 9/13 participants rated the second stage user experience as acceptable or above, which was higher than phase 1 (3/6). Wilcoxon rank sum test was used to examine the differences in percentile distribution. We found significant difference in distribution of percentile (p 0.0390). Observing the median and interquartile ranges, phase 2, 77.50 [67.50, 90.00] reported significantly greater percentiles than phase 1, 57.50 [17.50, 72.50].

Conclusion These findings suggest that virtual loupes may be a valuable tool for plastic surgeons, offering potential for variable magnification and advanced visualization. Additionally, improvements in the hardware yielded significantly higher ratings of system usability and user experience. Further development is needed to address the limitations of existing devices.  

Introduction Post-mastectomy implant infections range from 2- 28%,¹⁻² occurring much more frequently than the 1-2% infection rate reported in cosmetic breast augmentation.³ With the evolution of microbiome science, we can now examine and define the unique composition of microorganisms in one's body and how it may play a role in a person's health outcomes. Previous studies have suggested a significant difference in the breast microbiome between cancer and non-cancer patients,⁴⁻⁵ and this may have the potential to influence infection rates. We present our pilot study using 16s rRNA sequencing to characterize the breast microbiome in mastectomy patients both intraoperatively and post-operatively, comparing cancer patients to those undergoing prophylactic risk-reducing mastectomy.

Methods A prospective randomized-controlled trial was designed for mastectomy patients undergoing two-stage implant-based breast reconstruction. Intraoperatively, a 1cm breast tissue specimen was collected, and post-operatively the peri-prosthetic space was sampled via expander aspiration or drain output at two time points (1-2 weeks and 3-4 weeks). Microbial analysis was performed with 16S rRNA microbiome sequencing. The top represented species and relative abundance percentage of various microbial signals in each sample were recorded.

Results Of the 37 enrolled patients with intra-operative breast tissue and post-operative aspirate samples, 23 (62%) patients had invasive cancer, 6 (16%) had carcinoma in situ, and 8 (22%) patients underwent prophylactic risk-reducing mastectomies. The most represented genus in the breast at time of surgery varied significantly between cancer patients, in situ patients, and non-cancer patients(p=0.045), but the peri-prosthetic breast aspirates did not post-operatively (p=0.593). Pseudomonas was the top species in 50% of prophylactic tissue samples, compared to 43% of invasive cancer patients, and 33% of in-situ patients. However post-operatively, Pseudomonas was the top represented species in only 12.5% of prophylactic samples, compared to 43.5% and 66.7% of carcinoma and carcinoma in situ patients respectively. When comparing invasive carcinoma and carcinoma in situ patients to non-cancer patients, the mean relative abundance percentage of each signal in the sample showed no difference for Pseudomonas, Staphyloccocus, Cornyebacterium, Bradyrhizobium and Streptococcus (p>0.05). However, in surgery there was a significantly lower abundance of Acinetobacter in non-cancer patient tissue (1.1% vs 6.0%, p=0.005), and Burkholderia (0.5% vs 3.9%, p=0.037) compared to cancer patients. This changed post-operatively when there was higher Acinetobacter in non-cancer patients at 1-2 weeks (9.2% vs 2.5%, p=0.023).

Conclusion We present the first study to look at the local breast microbiome at time of mastectomy and post-operatively. After surgery, there were different species represented as the top species between prophylactic patients and cancer patients, which may reflect cancer-related immune changes to the balance of the breast microbiome in response to stress and surgery. Further studies are critical to understanding the implications of these differences and how to potentially optimize the balance of microorganisms for improved outcomes.

References 1. Frey JD, Choi M, Salibian AA, Karp NS. Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies. Plast Reconstr Surg. Jun 2017;139(6):1300-1310. doi:10.1097/PRS.0000000000003340 2. Poppler LH, Mundschenk MB, Linkugel A, Zubovic E, Dolen UC, Myckatyn TM. Tissue Expander Complications Do Not Preclude a Second Successful Implant-Based Breast Reconstruction. Plast Reconstr Surg. 01 2019;143(1):24-34. doi:10.1097/PRS.0000000000005131 3. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis. Feb 2005;5(2):94-106. doi:10.1016/S1473-3099(05)01281-8 4. Campbell MJ, McCune E, Johnson B, et al. Breast cancer and the human oral and gut microbiomes [abstract]. Proceedings of the American Association for Cancer Research Annual Meeting 2019; Atlanta, GA Philadelphia (PA): AACR; . Cancer Res 2019;79(13 Suppl):Abstract nr 2830.2019. 5. Tzeng A, Sangwan N, Jia M, et al. Human breast microbiome correlates with prognostic features and immunological signatures in breast cancer. Genome Med. Apr 16 2021;13(1):60. doi:10.1186/s13073-021-00874-2

Introduction: Abstract screening in systematic reviews requires expertise and a considerable amount of time. Machine learning models can learn from examples during the abstract screening and expedite the process. The study aimed to validate a machine learning model in plastic surgery systematic reviews.

Methods: We used the abstracts of two recent plastic surgery systematic reviews that were completely screened by at least two reviewers to build the structure of the model. Then, we applied the model on a new systematic review. We built a recurrent neural network with long short-term memory and tuned the hyperparameters of the network based on the validation subset. We randomly split the data into two equal parts. The first half was further divided into a training subset (60%) and a validation subset (40%), while the second part was used for testing the model for abstracts that were never used in the model training or tuning. The model screened the second half of the abstracts in less than 1 minute. We compared the model predictions with two independent reviewers that were blinded to the model predictions. All the conflicts were resolved by a human reviewer, and all the reasons for mispredictions were explored.

Results: The prospective systematic review had 4628 abstracts. The receiver operatic characteristic curve had an area under the curve of 96%. The sensitivity and specificity of the model were 75% and 98%, respectively. The accuracy was 97%. The model improved the efficiency of abstract screening by 25% (30 hours). The model was used as a validity check to re-evaluate the misclassified abstracts between the model and the reviewers to improve the robustness of the results. The model was correct in 82% of all the conflicts. The most common reason for misprediction by the model was the identification of published protocols from eligible studies.

Conclusion: Deep learning using recurrent neural networks can improve the efficiency and robustness of abstract screening in plastic surgery systematic reviews. Recurrent neural networks are versatile and can be used to improve efficiency, combined with traditional abstract screening to ensure accuracy, and promptly screen new abstracts.

Abstract/Purpose:

ChatGPT is a chatbot paired with powerful artificial intelligence (AI). It was released in November 2022 and within a month had over 100 million users, making it the fastest growing consumer internet application in existence. (1) Within the medical literature, AI has been used in various ways including recognizing the presence of cardiac ischemia and virtual surgical planning. (2,3) However, the utilization of ChatGPT in the field of surgical education has not yet been examined. This study sought to explore the capabilities of ChatGPT in describing the surgical steps of a specialized operation, the Fisher cleft lip repair. In doing so, this allowed testing the expertise and detail of ChatGPT, its ability to coherently write surgical steps, and applications in teaching introductory surgical concepts.

Methods/materials:

A chat log within ChatGPT was created to generate the procedural steps of a cleft lip repair utilizing the Fisher technique. A board certified craniomaxillofacial (CMF) surgeon then wrote the Fisher repair in his own words blinded to the ChatGPT response. Using both responses, a voluntary survey questionnaire was distributed to plastic and reconstructive surgery (PRS), general surgery (GS), internal medicine (IM) residents, and medical students at our institution. Using Likert scales (with 1 being lowest rating and 5 being highest), we collected information on understanding, preference, and identification of the procedural prompts in a blinded study.

Results:

Results show PRS residents were able to detect more inaccuracies of the ChatGPT response as well as prefer the CMF surgeon's prompt in performing the surgery. Residents with less expertise in the procedure not only didn't detect who wrote what procedure, but preferred the ChatGPT response in explaining the concept and chose it to perform the surgery. As responses strayed farther from familiarity with plastic surgery, the surgeon's explanation became more difficult to understand. PRS rated the CMF surgical steps with a comprehension score of 3.3, GS 2.6, IM 2.3, and medical students 2.1. In contrast, the ChatGPT response received a 2.7 rating from PRS in comprehension while all other groups rated it higher than 3.

Conclusions:

In applications to surgical education, ChatGPT was found to be effective in generating easy to understand procedural steps that can be followed by medical personnel of all specialties. However, it does not have expert capabilities to provide the minute detail of measurements and specific anatomy required to perform medical procedures. As the technology advances, further studies should examine methods of implementing artificial intelligence in medical education and practice.

References:

1. Milmo, Dan (February 2, 2023). "ChatGPT reaches 100 million users two months after launch". The Guardian. ISSN 0261-3077. Archived from the original on February 3, 2023. Retrieved February 3, 2023.

2. Baxt WG, Shofer FS, Sites FD, Hollander JE. A neural network aid for the early diagnosis of cardiac ischemia in patients presenting to the emergency department with chest pain. Ann Emerg Med. 2002;40(6):575-583. doi:10.1067/mem.2002.129171

3. Chim H, Wetjen N, Mardini S. Virtual surgical planning in craniofacial surgery. Semin Plast Surg. 2014;28(3):150-158. doi:10.1055/s-0034-1384811

PURPOSE Microsurgical reconstruction is an indispensable tool in Plastic Surgery. Early detection of microanastomosis failure is critical, but there is a paucity of teaching resources in postoperative monitoring. We recently developed a mobile application (Flap Assessment App; FLAPP), including microsurgery, clinical/Doppler assessments, and flap troubleshooting tutorials, and practice cases. This study tested the usefulness of this app.

METHOD Members of the University of Manitoba Department of Plastic Surgery used the FLAPP teaching app then completed a questionnaire assessing the app sections using a Likert scale. Qualitative analysis was performed. Preliminary results are presented.

RESULTS Participants included residents (43%), nurses (14%), attendings (4%) and physician assistants (PAs) (4%). Of residents, 50% were junior (PGY-1/2) and 50% senior (PGY-3/4/5). 50% of nurses/PAs had >5 years' experience monitoring free flaps, while 33% had <1 year. 100% of participants agreed/strongly agreed that each tutorial section was useful. 100% of participants agreed/strongly agreed that case video quality and variety was acceptable; 86% agreed/strongly agreed that audio quality was acceptable. 100% of participants agreed/strongly agreed the app was useful for teaching and improving confidence/ability in monitoring microanastomoses; 100% agreed/strongly agreed the app should be incorporated into teaching curriculum and would recommend to other trainees. 93% of residents, nurses, and PAs agreed/strongly agreed the app would be beneficial to use prior to clinical assessments and would use the app to practice independently.

CONCLUSION The FLAPP teaching app contains tutorials and practice microsurgical cases useful for learning and improving confidence in post-operative microsurgical monitoring, beneficial for training prior to clinical assessments. Next steps include app updates based on feedback, and additional testing prior to wide release as a free teaching tool.

Background: Access to essential surgical care is an indicator of the strength of a health system, as defined by the Lancet Commission on Global Surgery. Cleft surgery is one of the 44 essential surgical procedures, yet access to cleft care is limited in many low- and middle-income countries.

Aims: 1) To map the number and types of existing cleft care providers in 27 countries where Operation Smile operates. 2) To estimate the proportion of the population within 100km radius of cleft care providers.

Methods: This was a cross-sectional descriptive analysis conducted from April 2020 to October 2020. State (private or public) and NGO cleft care providers in 27 countries where Operation Smile is active were identified through online databases, geocoded, and verified by local Operation Smile staff. Geospatial analyses were performed on ArcGIS. Population density per administrative level 1 (region) was mapped, buffers for 100km radius were used per site. Averages were reported as medians (with ranges).

Results: The average number of cleft care providers per country was 26 (range 11-107) with 0.09 providers per 100,000 population (0.01 - 0.1); 37% of providers (0 – 88%) were state and 61% (13 – 100%) were NGOs. Median percentage of the population that had access to safe surgical care within 100km radius was 37% (range: 13% - 90%).

Conclusion: Nearly two-thirds of the population in countries where Operation Smile works lacked access to cleft surgical care within 100km radius. The majority of care is provided by NGOs. Despite limitations, this is the first study to describe access to cleft surgical care. This research been used by Operation Smile to inform strategic planning of programs to increase access to cleft care in regions where care is limited.

Objectives: Due to the unpredictable and variable nature of scar formation, scarring presents a challenging issue for surgeons. Hypertrophic scarring (HTS) demonstrates increased collagen biosynthesis and deposition compared to normal scar. Circadian rhythms serve to maintain physiological homeostasis, and disruptions to these rhythms may impair wound healing. Neuronal PAS domain 2 (Npas2), a core circadian clock gene, is expressed in dermal fibroblasts and has been shown to play a critical role in wound healing. In previous studies, Npas2 knockout mice showed faster closure of dermal wounds [1], suggesting Npas2 might be a new therapeutic target for wound healing and pathological scarring [2]. As a result of high throughput drug screening followed by in vitro studies, we have identified two FDA-approved compounds (named Dwn1 and Dwn2) that modulate Npas2 expression without cytotoxicity and suppress the excessive collagen synthesis in vitro [3]. Here, we hypothesized that the therapeutic suppression of Npas2 by the hit compounds will result in accelerated wound healing in vivo with minimal HTS.

Methods: Murine dorsal excisional wound model was created according to the previously established procedure [4]. The dorsal skin of the 12-week-old female wild type C57BL/6J mice (Jackson Laboratory) was shaved. Two 5 mm in diameter of full skin thickness excisional wounds were created using skin biopsy punch under general inhalation anesthesia with isoflurane. The open wound margin was tied with silicon splint by nylon stitch to prevent the skin contraction. Dwn1 or Dwn2 dissolved in vehicle solution were applied on the wound as an experimental group. For a negative control group, vehicle solution was applied. Wound healing was monitored every day. Mice were euthanized on 14 days after surgery and the entire full-thickness dorsal dermal tissue including wound were harvested and proceeded histological sections to stain with hematoxylin and eosin (HE) and Masson's Trichrome (MT).

Results: Daily observations confirmed that wound healing was significantly accelerated in the Dwn1 or Dwn2 compared to the vehicle control group. In the HE observation, hyperkeratosis and residual clots were not observed in the Dwn1 or Dwn2-treated wounds. Furthermore, the edge of dermis connective tissue with hair follicles moved toward the center of wounds by Day 14. The epithelial layer at the wound area appeared to be similar to the intact skin epithelium, and the immune response had declined. In the MT observation, wounds treated with Dwn1 or Dwn2 showed histological evidence of less HTS phenotype in the wounded tissue.

Conclusion: This study suggests that the hit compounds may be novel therapeutic agents for accelerated wound healing with minimal HTS.

[1] Sasaki H, Hokugo A, Wang L, et al. Anat Rec 303(6):1630-1641.2020 [2] Shibuya Y, Hokugo A, Okawa H, et al. Elife. 11:e76207.2022 [3] Clements A, Shibuya Y, Hokugo A, et al. Front Med 9:1014763. 2023 [4] Wang X, Ge J, Tredget EE, et al. Nat Protoc 8(2):302-9.2013

Introduction: Skin necrosis is a pervasive challenge in the realm of plastic surgery, particularly for breast cancer patients who undergo reconstruction, with estimates suggesting that skin necrosis affects between 5% to 30% of mastectomy flaps.1 This complication is driven by various etiologies, including tissue hypoxia, ischemia, and venous and lymphatic congestion culminating in tissue edema and ultimately arterial insufficiency. Tacrolimus, a calcineurin inhibitor with demonstrated potential to enhance the growth of lymphatic collateral vessels and mitigate lymphedema, was posited as a possible solution to necrosis.2,3 Topical minoxidil is a vasoactive agent that has also been shown to improve perfusion and angiogenesis in cutaneous skin flaps.4 Previously, we found that topical tacrolimus can reduce full-thickness necrosis in rat pedicled dorsal flaps by an average of 33.8% compared to petroleum jelly, and that preoperative and postoperative applications of the agent led to increased tissue viability compared to postoperative treatments alone. The aim of this study is to further investigate the effects of topical minoxidil, tacrolimus, and petroleum jelly on skin perfusion after an ischemic challenge.

Methods: 24 Sprague-Dawley rats were randomized to two treatment arms (0.1% topical tacrolimus, 5% minoxidil) and 2 were used as control (petroleum jelly). The rats are treated for seven days preoperatively, after which a cranially based dorsal skin flap measuring 3 x 10 cm was raised. The topical agents are applied for seven more days after the surgery. On POD 8, the rats are sacrificed. One blinded reviewer measured the total skin flap surface area, and demarcated regions of full perfusion (viable tissue), partial necrosis (reversible ischemia), and full thickness necrosis. Percentages were calculated using Fiji and statistical analyses were performed in Prism: GraphPad.

Results: The average full perfusion (viable) areas for topical minoxidil, tacrolimus, and control were 41.4%, 50.9%, and 41.4%, respectively. The average partial necrosis (reversible ischemia) areas for topical minoxidil, tacrolimus, and control were 39.7%, 39.2%, and 40.4%, respectively. The average full thickness necrosis areas for topical minoxidil, tacrolimus, and control were 18.9%, 9.9%, and 18.3%, respectively. Tacrolimus led to the lowest area of compromised (ischemic and necrotic) tissue compared to minoxidil and petroleum jelly treatments (49.1% vs. 55.6% and 58.6%).

Conclusion: Skin necrosis following breast reconstruction surgery can result in delayed wound healing, increased infection risk, prolonged hospitalization, and negatively impact aesthetic outcomes. Pre- and post-surgical treatment with topical tacrolimus resulted in notably less necrosis than minoxidil, which was similar to control. Further immunohistochemistry evaluations are needed to characterize their effects on angiogenesis.

References 1. Robertson SA, Jeevaratnam JA, Agrawal A, Cutress RI. Mastectomy skin flap necrosis: challenges and solutions. Breast Cancer (Dove Med Press). 2017 Mar 13;9:141-152. doi: 10.2147/BCTT.S81712. PMID: 28331365; PMCID: PMC5357072. 2. Gardenier JC, Kataru RP, Hespe GE, et al. Topical tacrolimus for the treatment of secondary lymphedema. Nat Commun. 2017;8:14345. 3. Jung WF, Van YR, Huang H, Otterburn DM. The Effect of Presurgical and Postsurgical Topical Tacrolimus on Pedicled Flap Survival in Rats: A Pilot Study. Ann Plast Surg. 2022 May 1;88(3 Suppl 3):S235-S238. doi: 10.1097/SAP.0000000000003205. PMID: 35513326. 4. Gümüş N, Odemiş Y, Tuncer E, Yılmaz S. The effect of topical minoxidil pretreatment on nonsurgical delay of rat cutaneous flaps: further studies. Aesthetic Plast Surg. 2013 Aug;37(4):809-15. doi: 10.1007/s00266-013-0161-x. Epub 2013 Jun 14. PMID: 23764964.

Introduction: ChatGPT is an innovative artificial intelligence (AI) language model developed and released by OpenAI in late 2022. Recent studies have assessed the use of ChatGPT in the medical field including for note writing, diagnostic purposes, and on medical licensing examinations. Given the expert knowledge and complexity of the context-dependent medical decision-making required to answer the Plastic Surgery In-Service Exam, we aimed to evaluate the performance of ChatGPT in answering these questions as compared with the average scores of plastic surgery residents.

Methods: We used the Plastic Surgery In-Service exams from 2018 to 2022 as the question source for this study. For each question, the stem and all multiple-choice options were imported into the ChatGPT interface. Questions that were not scored on the in-Service exam were excluded from the study. Since ChatGPT only accepts text input, any questions that included an image or tables were also excluded. Categorical data were presented using counts and frequency analyzed using the Chi-squared test and Fisher's exact test. The 2022 exam was used to compare the performance of ChatGPT to plastic surgery residents nationally.

Results: We reviewed the questions of 5 years of the Plastic Surgery In-Service exams, for a total of 1250 questions. A total of 18 questions were inconclusive according to the ChatGPT For these questions, ChatGPT either stated that more information was required to answer the question or that there were multiple correct answers from the choices given. After excluding inconclusive questions and questions with photographs and tables, a total of 1129 questions were included in the final analysis. ChatGPT was able to answer 630 (55.8%) of these correctly. ChatGPT scored the highest on the 2018 exam (58.1%) and on the comprehensive section (58.7%). There were no significant differences in regard to questions answered correctly among exam years or among the different exam sections. ChatGPT answered 57% of questions correctly on the 2022 In-Service exam. When compared to the performance of plastic surgery residents in 2022, ChatGPT would rank in the 49th percentile for first-year integrated plastic surgery residents, 13th percentile for second-year residents, and 0th percentile for 5th and 6th-year residents. ChatGPT's performance on this exam was in the 24th, 7th, and 10th percentile when looking at the first, second, and third-year independent track plastic surgery residents, respectively.

Conclusion: ChatGPT was able to answer the vast majority of questions that were on the exam, with less than 2% of questions being inconclusive. In terms of accuracy, ChatGPT is able to perform at the level of a first-year resident on the Plastic Surgery In-Service examination. However, it performed poorly when compared to residents in more advanced years of training. While ChatGPT has many undeniable benefits and potential uses in the field of healthcare and medical education, it will require additional research to assess its accuracy.

Introduction: Facial Plastic Surgery fellowship is a post-graduate program available to residents in an Accreditation Council for Graduate Medical Education accredited otolaryngology or plastic surgery program. Fellowship program directors (PDs) play an essential role in the onboarding of new fellows. Because these PDs train the next generation of facial surgeons, there has been a widespread interest in characterizing the qualities and qualifications of these leaders. However, there is a lack of literature on the characteristics of facial plastic surgery fellowship PDs. To bridge this gap, we investigated the demographic, educational, and scholarly attributes of the American Academy of Facial Plastic and Reconstructive Surgery accredited facial plastic surgery fellowship PDs.

Methods: Facial plastic and reconstructive fellowships were identified from the AAFPRS database. Demographic, educational, and scholarly characteristics of PDs were collected using publicly accessible resources such as institutional websites, physician databases (Healthgrades, Doximity, LinkedIn), and CMS Open Payments website. Clinical experience was calculated using the number of years since completion of medical school. Fisher's exact test, Chi-square test, and Student's t-test were used for comparisons of PD characteristics.

Results: 98 PDs were identified, with a mean age of 54.7 ± 10.9 years. 87 PDs were men, and 11 PDs were women, with men significantly older than women (p = 0.002). All PDs completed their medical degree and residency in the US or Canada, exclusively in otolaryngology. Most programs had an academic affiliation (84.7%). Of PDs with an academic rank (74.5%), the majority were professors (41.1%). Overall, the mean h-index was 14.4 ± 9.9, the mean five-year h-index was 3.6 ± 3.0, and the mean m-quotient (a measure of average research productivity) was 0.6 ± 0.3. A majority (92.9%) of PDs received industry payments in 2021, totaling a mean of $14,144.1 ± $55,525.8 per physician. No differences in academic metrics were observed between men and women (p > 0.05). PDs of programs with an academic affiliation had a higher h-index, five-year h-index, and m-quotient relative to colleagues in programs without an academic affiliation (p < 0.05).

Conclusion: This study demonstrates that facial plastic surgery PDs are predominantly men and all were otolaryngology-trained. This training history may reflect the relative novelty of integrated plastic surgery residency programs and a preponderance of otolaryngology graduates within the subspecialty. There is a lack of plastic surgeons serving as PDs in facial plastic surgery fellowships. This may present a potential selection bias, favoring otolaryngology-trained candidates for fellowship positions compared to plastic surgery-trained individuals. Plastic surgeons who aim to achieve a PD position in this subspecialty may be presented with obstacles due to this current landscape. Moreover, although there were significantly more male PDs, there was no significant difference in academic productivity between gender. While these results suggest relative gender parity among those who reach this leadership position, there remain relatively few women in these leadership positions. These findings can serve as a baseline to study the contemporary state of facial plastic surgery leadership and monitor its evolution.

Purpose: SWOT (strengths, weaknesses, opportunities, and threats) analyses are a business strategy tool that assess how an organization compares its competition. To facilitate a critical self-reflection on how to align plastic surgery education with making excellent plastic surgeons, a rotating small-group session followed by live interactive audience polling was used to perform a SWOT analysis at the 10th Annual American Council of Academic Plastic Surgeons (ACAPS) Winter Meeting. Participants analyzed 6 different domains of plastic surgery training and academic retention and voted on the most promising opportunities for growth in each respective domain.

Methods: The 10th Annual ACAPS Winter Meeting took place in New Orleans on February 24-26, 2023. The theme of this meeting was "Deconstructing the Excellent Plastic Surgeon." The final day of the conference included a 3-hour session of rotating small groups followed by live interactive audience polls discussing the following 6 relevant educational topics: Plastic Surgery Common Application & Resident Selection, Aesthetic Surgery Education, Leadership Development & Business Education, Imbedded Fellowships & Focused Training, Mentorship, and Faculty Retention. A total of 6 groups consisting of approximately 8 attendees and 2 moderators rotated through each topic and conducted a SWOT analysis. A group scribe documented the most common recurring ideas. A live response poll was conducted to determine which opportunity for each group most warranted further investment. The results are presented here.

Results: A total of 60 individuals participated in the small group activity and 35 to 40 individuals participated in the live response activity. The majority of participants were academic faculty surgeons. A SWOT analysis was successfully performed for each educational topic, and at minimum 4 opportunities were identified per topic to help guide future endeavors. The highest rated opportunities are presented here; if there is no true majority in voting percentage, the top two choices are presented. (1) Resident Selection: Program statements regarding their values and what they are looking for in a prospective applicant (45%), and ACAPS releasing recommendations for the implementation of holistic review (25%). (2) Aesthetic surgery: Developing formal guidelines for aesthetic surgery education in residency via collaboration between ACAPS, American Society of Plastic Surgeons (ASPS), and the Aesthetic Society (56%). (3) Leadership Development and Business Education: Integrating business education into formal curricula for all training levels (65%). (4) Imbedded Fellowships/ Focused Training: Creating extended focused elective rotations in a given specialty (33%) and keeping training as is without shortened training options (33%). (5) Mentorship: Creating structured resources for how to be a good mentor and mentee (45%) and aligning mentorship opportunities to streamline access to these opportunities (29%). (6) Faculty Recruitment/ Retention: Enforcing transparency regarding position expectations and offerings including salary, call schedule, and current challenges (49%) and offering improve family/person support, childcare, and maternity/paternity leave (34%).

Conclusion: There is opportunity for improvement in multiple facets of training. The results of this study will help guide future initiatives by the American Council of Academic Plastic Surgeons to improve resident education and academic retention.

Purpose: Iodine Deficiency Disorder (IDD) is an important and actual public health problem throughout the world and particularly in Armenia.1 Armenia has high IDD prevalence and is an endemic zone for goiter.2 Autologous fat grafting (AFG) is quite a trendy and demanded intervention in modern regenerative and aesthetic medicine. AFG is a secure and successively applied method of soft tissue augmentation for both reconstructive and cosmetic indications.3 Main objective of our prospective study was to evaluate the potential effect of a Vitamin D supplement on AFG survival in patients with endemic goiter and to compare the results with a relatively healthy population undergone AFG.4 Methods And Materials: A prospective study was conducted among 100 patients, who were hospitalized in the Department of Plastic and Reconstructive Surgery, Heratsi Hospital Complex from September 2022 to November 2022, whose average age was 35,24. According to the analysis of the received data 78% (n= 39) are female, 28.2% (n=11) of whom suffer from endemic goiter. Patients suffering with endemic goiter were examined in order to detect the effect of Vitamin D supplement on the outcome of AFG. Thyroid functional tests, the 25-hydroxy vitamin D test were performed to measure the level of TSH, FT3, FT4 and vitamin D among the participants of the study.5 Results: As stated in research data, 30% (n=30) of patients suffer from endemic goiter (average age 32.8, average BMI 29,924). On the report of the functional analysis of the thyroid gland, 40% (n=6) of the latter had normal indicators (average level of TSH= 1.8±0.9mu/I, FT3= 1.5±0.6nmol/L, FT4= 90±13nmol/L), and the remaining 60% (n=9) had insignificant changes from the normal ranges (average level of TSH= 5.5±0.5mu/I, FT3= 2.8±0.4nmol/L, FT4= 60±10nmol/L). Studying the results of laboratory tests, 53.33% (n=8) of patients suffering from endemic goiter and 57.14% (n=20) of the healthy population have vitamin D deficiency (the average level of 25-hydroxy vitamin D is 8±3 ng/mL and 9±4 ng/mL respectively). Analyzing the long-term outcomes of post-operative vitamin D administration in the target population (those suffering from both vitamin deficiency and endemic goitre), we concluded that the latter increased fat graft volume retention compared to the endemic goiter-only and vitamin-D-deficient-only patients. Conclusion: Based on our study vitamin D administration seems to be an effective drug for improving long-term AFG outcomes among patients suffering with endemic goiter and vitamin D deficiency. We suggest to conduct more detailed research among patients suffering from thyroid disorders to assess the effectiveness of vitamin D depending on the methods of fat procurement/placement and recipient zone and to study its influence on ADSC in a laboratory manner.

1. WHO, UNICEF, ICCIDD. Progress Towards Elimination of IDD. Geneva, WHO; 1999.
2. ICCIDD. About ICCIDD, ICCIDD Mandate. Middle East / Eastern Mediterranean Region. Southeast Asia Region. West / Central Europe. 20 Aug 2002. Available at: http:/www.people.virginia.edu/~jtd/ iccidd/abouticciddhome.htm. Accessed August 21, 2003.
3. Rohrich RJ. The American Society of Plastic Surgeons' procedural statistics: what they really mean. Plast Reconstr Surg. 2003;112:1389–92.
4. Loder S, Wang S, Amurgis C, DeSanto M, Stavros AG, Patadji S, Olevian D, Lee P, Guerrero D, Gusenoff JA, Rubin JP, Kokai LE. Active Vitamin D3 (Calcitriol) Increases Adipose Graft Retention in a Xenograft Model. Aesthet Surg J. 2023 Jan 6:sjad001. doi: 10.1093/asj/sjad001. Epub ahead of print. PMID: 36611261.
5. Laboratory Procedure Manual. Available: http://www.cdc.gov/nchs/data/nha nes/nhanes0708/THYRODemetThyroidStimulating_Hormone.pdf. Accessed on March 08, 2021.

Background & Aims: Our tertiary skin cancer service had to adapt rapidly to limited availability of 99Tc radionuclide and evaluate the use of indocyanine green (ICG) with near-infrared fluorescence as an alternative. ICG has several advantages over other tracers used in SLN localisation, including its rapid uptake by lymphatic vessels and its low risk of allergic reactions. The tracer is routinely used in SLN localisation in other cancers such as breast cancer and gastrointestinal tumours. This study aims to evaluate the feasibility of ICG for SLN localisation in melanoma patients at a tertiary skin cancer unit.

Methods Prospective case series of melanoma patients undergoing SLN biopsy with either triple localisation technique (99Tc + blue dye + ICG) or dual localisation technique (patent V blue dye + ICG) were reviewed for accuracy in sentinel lymph node (SLN) detection. All patients received a single intradermal injection of 2.5mg (1ml) ICG dye.

Results 34 patients were included in this prospective case series: 23 patients had triple localisation technique (99Tc + blue dye + ICG), 11 patients had dual dye localisation technique (blue dye + ICG).

In the triple localisation group, primary melanoma sites were mostly in the head and neck region (n=15); followed by truncal (n=4) and the extremities (n=4), respectively. 45 SLNs were visualised via lymphoscintigraphy, 3 of which were echelons. 62 tissue samples were obtained for histopathological analysis. Sixty-three SLNs were identified from these samples but 5 tissue samples harvested were found to be non-lymph nodes. Only 2 SLNs were melanoma positive and were localised by all three tracers (99Tc + blue dye +ICG). 43 lymph nodes were identified by all 3 tracers. 13 lymph nodes were positive for 99Tc + ICG dye; 2 lymph nodes were only positive for 99Tc and 5 lymph nodes were negative for all three techniques. Of the 5 non-lymph node samples: 1 stained for ICG, 2 were identified via gamma probe and 2 were positive for both blue dye + ICG.

In the dual localisation group (blue dye + ICG), all primary melanoma sites were situated in the extremities. Twenty-one individual samples were collected of which 15 were lymph nodes. Six lymph nodes stained positive for both dyes with the remaining 9 stained positive for ICG only. Two lymph nodes tested positive for melanoma and both stained for ICG only. Of the 6 non-lymph node specimens 50% of samples stained of both dyes and the remaining stained of ICG only. There were no intra- or postoperative complications in both study groups.

Conclusions There is a clear learning curve when utilising ICG for SLN localisation. In the dual dye localization group, melanoma positive SLNs were detected by ICG dye but not patent V blue dye. The finding correlates with previous studies that directly compared both dyes with ICG being more sensitive than patent V blue dye in SLN detection. Although dual tracer technique with lymphoscintigraphy and blue dye is the gold standard, clinicians should learn alternative techniques in order to maintain service resilience.

Background Vascularized composite allograft (VCA) transfers multiple tissue types, such as skin, muscle, and blood vessels, to reconstruct body parts missing that autologous surgery cannot be addressed. VCA transplantation has been achieved with penile, hand, and facial tissues. However, the need for life-long immunosuppressive therapy is a major contributor to recipient morbidity and mortality. Decellularization and recellularization of the composite allografts is one method to circumvent the recipient's immune response. Decellularization protocols remove all cellular material from the grafts, leaving only the extracellular matrix (ECM). Decellularized composite allografts (DCAs) can then be recellularized with the recipient's cells, resulting in non-immunogenic biologic grafts Methods: In this study, we have decellularized five whole human digits, which had been in cold storage for four months. In brief, digits were thawed and continuously perfused with PBS (1 hour), 0.2% SDS (120 hours), Distilled Water (24 hours), 1% Triton 100-x (24 hours), and PBS (48 hours). Flow rates were adjusted to maintain pressures of 50-60mmHg. Three human digits taken from cold storage served as controls. Results: There was a visible decrease in digit opaqueness. X-ray of the digits with contrast agent showed an intact vascular network. Additionally, the intrinsic function of the extensor and flexor tendons was preserved. DNA quantification of the digits showed significantly lower DNA content in DCA skin (101.99±99 vs. 28.53±16.26, p<0.01), muscle(74.65±44.79 vs. 26.55±18.04, p<0.01), bone (42.00±49.66 vs. 5.28±2.96, p<0.01), vessels (83.46±39.88 vs. 21.84±14.27, p<0.0001), and nerves (49.32±39.51 vs. 18.82±16.06, p<0.05). Notably, tissue is accepted as decellularized with DNA content of less than 50ng/mg. Discussion: Our results indicate that decellularization of whole digits from long-term freezer storage is feasible and represents an essential step in developing non-immunogenic VCA transplantation. Future work will focus on histologic and microscopic analysis of DCAs, comparison of ECM-bound growth factors to native tissue, and recellularization with primary human cells.

Introduction

Syndrome of the Trephined (SoT) is an underdiagnosed and misunderstood result of decompressive craniectomy. After undergoing decompressive craniectomy, patients can display symptoms ranging from headaches, dizziness, altered behavior to changes in sensation, difficulty with ambulation, coordination, and activities of daily living. These are frequently misattributed to sequelae of traumatic brain injury. Currently, the only treatment for SoT is cranioplasty. However, there is no method for prevention or treatment for patients in the months between craniectomy and definitive cranioplasty. We present the case of a patient with SoT whose symptoms were treated with a custom, 3D printed external orthotic to re-establish the pressure gradient between his intracranial contents and the atmosphere. Methods

Digital Surface imaging (DSi TM) technology is utilized to obtain a preliminary imaging to craft a mold. This imaging is applied in CAD/CAM to craft the custom polycarbonate orthotic. 
Informed consent was obtained, including provisional IRB approval, and adherence to all 

FDA expanded access protocols.

Results A 49-year-old man underwent decompressive craniectomy for a traumatic subdural hematoma. He had a lengthy inpatient hospitalization after leaving the ICU due to debilitating headaches, difficulty with ambulation/coordination, and intermittent behavioral issues which inhibited his safe discharge to a long-term acute care facility.
The device was applied with patient in Trendelenburg position to re-expand the scalp flap. The device was then applied achieving a water-tight seal using a hydrocolloid paste at the edge of the craniectomy defect. Any slight imperfections in contour of device to scalp were corrected using a heat gun. The device maintained seal and was removed at the time of cranioplasty. Pre-operative/post-device application CT demonstrated an achievement of 3% brain re-expansion on analysis using Brain Lab (Munich, Germany). The patient reported improvements in his headache consistent with decreased pain medication requirements specifically during Valsalva maneuvers.

Discussion
By placing the patient in the Trendelenburg position, his scalp flap was able to be passively re-expanded, which was maintained through an air-tight seal of the device. This expansion can protect the scalp soft tissue itself, by counteracting the tension and relative ischemia at the skin superficial to the edges of the craniectomy defect. Patients with sunken scalp flaps are at increased risk for serious post-cranioplasty complications including hematoma and fluid collection due to increased dead space creation. We propose that if scalp skin and intracranial volume can be maintained near their pre-surgical volumes through external tissue expansion, less dead space will be created at the time of cranioplasty and improved surgical outcomes will result. Ideally, the device would be placed about 2 weeks post-craniectomy to establish a seal prior to onset of sinking of the scalp flap and maintain scalp expansion. We hypothesize that placement of an external cranial orthotic at this time would mitigate symptoms associated with SoT.
This demonstrates a proof-of-concept study of the potential utility for a 3D-printed external cranial orthotic to treat and ideally prevent SoT in post-craniectomy patients. Further study is required to better understand ideal patient selection, timing, safety, and impact on neurocognitive recovery.

Background: In graduate medical education, mentorship has been correlated with improved career satisfaction and reduced burnout. Women and underrepresented minorities (URM) commonly report difficulty in developing and maintaining successful mentorship relationships. We sought to identify factors associated with successful mentorship.

Methods: We conducted an electronic survey of graduate medical education trainees at a single academic institution, including demographic factors [age, gender, race /ethnicity, language, sexual orientation, and family history of professional education] and mentorship factors [number of mentors, satisfaction, attributes, and perceptions of strengths and barriers]. Open-ended comments were collected for thematic analysis.

Results: 108 responses were received for 22.9% response rate. 55% were from surgical residents (including 8 integrated Plastic Surgery trainees). 57% were from female residents; 45.7% of non-responders were female. 23.1% were from URM compared to 14.3% of non-responders. 70% are the first physician in their family. 81% had at least one mentor with an average of 2.6 mentors per respondent. Males were more likely to strongly value professional characteristics in their mentors (p <0.05). Female respondents were less likely to strongly identify with mentors (p<0.05). URM were more likely to strongly value personal and relational characteristics (p<0.05). Both URM and non-URM residents valued professional and demographic characteristics similarly.

Conclusion: Gender, race, and ethnicity may help identify trainees at risk for poorly perceived mentorship. Targeted mentorship programs may improve perceived mentorship quality in at-risk groups and improve the academic trajectory of residents.