Scientific Abstract Presentations: On-Demand Thursday, October 19 Thu, Oct 19 8:00-10:00 a.m. CDT

Background: Although facial feminizing surgeries (FFS) improve gender dysphoria among male to female transgender (MF) patients, insurance coverage is minimal and underreported. Using a national database, we analyze total charges (TC) and primary payer (PP) distributions in outpatient FFS.

Methods: 2016-2018 data from the National Ambulatory Surgery Sample (NASS) were subset to transgender patients using ICD10 codes. FFS were identified using CPT codes for genioplasty; blepharoplasty; lipectomy; rhytidectomy; brow ptosis; rhinoplasty; osteoplasty; lipectomy; and malar, mandibular, and forehead reconstruction. Demographics, TC, and PP were analyzed using Chi-squared and ANOVA tests.

Results: 20,914 FSS encounters were identified with 69.5% females and mean [range] age of 54 [20, 90] and TC of $24,937 [160, 249,437]. The overall PP distribution for all FFS was 7.3% Medicaid, 33% Medicare, 42% private insurance, and 17% self. TC differed by PP (p<0.001); Medicaid had the highest of $31,601 [1691, 192495], closely followed by self-payers ($31,605 [160, 278415]), while Medicare had the lowest of $17,358 [419, 190810]. TC differed by income (p<0.001), with the highest earners having the highest TC of $26,006 [835, 278415]; and by residence (p<0.001), with patients in large metropolitan areas having the highest of $28,619 [1050, 278415]. Blepharoplasty was the most utilized (15%) and had the lowest overall TC of $12,201 [835, 172403] and the highest proportion of Medicare payment (56%). Rhytidectomy had the most self-payers (73%) and midface reconstruction had the most private insurance payers (81%).

Conclusion: To our knowledge, we are the first to characterize TC and PP distribution in outpatient FFS and we find higher insurance payment rates for FFS compared to previous reports. TC was significantly higher for Medicaid and self-paid procedures compared to Medicare and private insurance. PP also differed between FFS types, with rhytidectomies having the highest proportion of self-payers. These differences in PP based on FFS type and high overall TC underscore the financial burden of gender transition.

Purpose: While there are numerous fellowship pathways for plastic surgery residents to pursue after completion of their training, only two are accredited by the ACGME: hand and craniofacial surgery. However, little is known about the role that these ACGME accredited fellowships have on attaining leadership positions at the institutional and national level in the field of plastic and reconstructive surgery.

Methods: The ABPS Newsletter to Diplomates was used to identify plastic surgeons who received board certification between 2002 and 2013. A web search of all surgeons was performed to identify those who pursued at least one ACGME-accredited fellowship (craniofacial or hand surgery). Further data on these surgeons were collected to include their fellowship training, business education (MBA), and leadership positions held. The leadership positions documented included chair/chief, program director, and national leadership positions within plastic surgery societies. A logistic regression model was used to identify the predictors of holding different leadership positions according to probabilities calculated from expected values.

Results: There were 2190 plastic surgeons identified who received board certification between 2002 and 2013. A total of 551 plastic surgeons pursued a craniofacial (191) and/or hand surgery (332) fellowship after plastic surgery residency. A total of 578 plastic surgeons pursued non-ACGME plastic surgery fellowships. The model found 2 significant factors that increased the probability of surgeons holding a Chair or Chief position in an institution including an MBA degree (37% increase, p = .0006) and craniofacial fellowship (9%, p = .0113). The model found 3 significant factors that increased the probability of surgeons holding a Vice Chair or Vice Chief position in an institution including otolaryngology training (18% increase, p = .0205), an international fellowship (13% increase, p = .0420), and not otherwise specified fellowship (18% increase, p = .0205). The model did not find significant factors that impacted the probability of surgeons holding a Program Director position in an institution. The model found 1 significant factor that increased the probability of surgeons holding plastic-surgery specific positions in an institution including craniofacial fellowship (19% increase, p < .0001). The model found one significant factor that increased the probability of surgeons holding other institutional positions including an MBA degree (11% increase, p = .0195). The model found one significant factor that increased the probability of surgeons holding a plastic surgery national society position including an MBA (6% average increase, p = .0380).

Conclusions: Craniofacial fellowship training is a strong predictor of plastic surgeons holding institutional leadership positions, which may be attributed to craniofacial surgery being performed primarily in academic teaching hospitals, rather than community and private practice settings. Having an MBA degree is the most consistent predictor of plastic surgeons holding leadership positions at both the institutional and national level. This study highlights the factors that may influence leadership roles in plastic surgery, and may serve as a guide for trainees interested in holding these positions in their career.

Purpose: Secure closure of the fascial layers after entry into the peritoneal cavity is essential to prevent an incisional hernia after laparotomy. However, appropriate purchase of the tissue can be challenging because of the proximity of the underlying protuberant bowel which may become punctured by the surgical needle or strangulated by the suture itself. The Glassman Visceral Retainer "FISH" and metal malleable retractor have been used to shield the bowel from such injuries, but do not provide complete coverage and must be removed prior to placement of the final fascial sutures. The need to remove these tools leaves the bowel exposed after removal at the point of poorest visualization and can cause bowel to once again be at risk of inadvertent puncture or strangulation. Thus, we have created a biocompatible, flexible, transparent and rapidly degrading implantable visceral barrier device ("The AbSolute Viscera Barrier") that is resistant to needle puncture and facilitates safe and rapid abdominal closure.

Methods: The implantable AbSolute visceral barrier was fabricated by gradually mixing two common (FDA approved) biocompatible materials and distilled water, vigorously stirring and thermally film-forming into the elastomer by evaporation of water, and eventually resulted in a flexible, clear device. To evaluate the degradation and biocompatibility of the AbSolute barrier, Sprague-Dawley rats underwent laparotomy with subfascial implantation of the device followed by euthanasia at post-operation day 14. To ensure safety of the device's components at supratherapeutic doses, two groups simulating 3X and 5X of the devices were tested for comparison with 4 animals studied per group. Post-operative observation, necropsy, hematological analysis and pathology of visceral organs were assessed.

Results: The devices were placed via laparotomy and the incision closed in standard fashion. All rats stayed active until day 14 postoperatively. At necropsy, all the incisions healed well, and there was no evidence of any remaining material from the implanted devices. There were no signs of toxicity or peritoneal adhesion formation in the device groups. Histology of the adjacent visceral organs reviewed by veterinary pathologists indicated no obvious signs of local organ toxicity, with only some mild foamy macrophages in the spleen in the 3X dose group and a greater extent of foamy macrophages found in spleen, liver and kidney in 5X dose group. Similarly, the hematological analysis demonstrated no changes in erythrocyte or granulocyte counts or assays related to liver, spleen and kidney function, indicating no evidence of systemic toxic effect of the device implantation even at highly supratherapeutic doses.

Conclusions: The AbSolute visceral barrier is a rapidly resorbable (<6 hours) and transparent flexible device that can be left in situ to shield the viscera during peritoneal closure as it exhibits resistance to direct needle puncture and does not promote peritoneal adhesions. These unique characteristics make the biomaterial useful as a physical barrier to prevent inadvertent bowel injury during fascial closure, potentially increase the speed of the surgery, with possible use applications for other medical and surgical procedures as well.

Purpose: Breast aesthetics are an important topic of discussion and analysis within plastic surgery. To those ends, there is a dearth of understanding pertaining to how preferences differ amongst various demographic groups. The objective of this study was to assess how perceptions of the ideal breast differ between respondents stratified by self-identified demographic factors.

Methods: A cohort of 25 patients from the senior surgeons' practices presenting for aesthetic or reconstructive breast surgery was assembled. This cohort was selected with the aim of choosing a sample that maximized diversity based on breast size and shape, skin tone, and nipple-areola complex size and position. Pre-operative anteroposterior photographs were distributed via Qualtrics (Seattle, WA) to a large sample designed to be representative of the demographics of the United States. Survey questions aimed to measure respondents' impressions of "breast attractiveness." Respondents were asked to rate breasts on a Likert scale of 1 to 5, with 1 being not at all attractive and 5 being most attractive. Survey responses were analyzed for differences in breast aesthetic preferences by sex assigned at birth, gender identity, sexual orientation, race, and ethnicity using independent t-tests with a predetermined level of significance of p<0.05.

Results: A total of 1,021 survey responses were collected. Respondents varied in age, gender identity, sexual orientation, and racial and ethnic backgrounds in a way that was representative of the United States population documented in the 2020 census. Considering sex assigned at birth, males rated all breasts higher than females (2.8 vs 2.5, p<0.0001). With respect to gender identity, self-identifying males ascribed higher ratings of breast attractiveness to all breasts than females (2.8 vs 2.4, p<0.0001). Transgender and non-binary cohorts were too small for adequate power of comparison. Considering sexual orientation, individuals attracted to women only provided significantly higher attractiveness ratings to all breasts than individuals attracted to men only (2.8 vs 2.5, p<0.0001). Individuals attracted to both men and women supplied higher breast attractiveness ratings compared to individuals attracted to only men (2.8 vs 2.5, p=0.001) but did not differ from individuals attracted to only women (2.8 vs 2.8, p=0.7). Self-identified White or Caucasian individuals ascribed significantly higher breast attractiveness ratings than self-identified Black or African American individuals (2.7 vs 2.4, p<0.0001) or self-identified Asian individuals (2.7 vs 2.2, p<0.0001). There was no significant difference between self-identified Asians or self-identified Black or African American individuals (2.2 vs 2.4, p=0.147). There was no significant difference in ratings amongst individuals who described themselves as Hispanic or not (2.6 vs 2.6, p=0.23).

Conclusions: In a sample representative of the United States, a difference in breast aesthetic appraisal was observed by various self-identified demographic factors. These distinct differences in numerical ratings that may be reflective of broader, more generalized sentiments and preferences that were not able to be captured by our survey instrument. These findings merit further investigation to understand these trends and observations. Doing so will enable plastic surgeons to have a better understanding of patient preferences and expectations when seeking reconstructive or aesthetic breast surgery.

Purpose: Alveolar bone grafting (ABG) has been the preferred treatment modality for children with alveolar clefts. Historically, patients who undergo ABG are kept inpatient for close postoperative monitoring. However, recent studies have proposed a shift toward outpatient management. The purpose of this study was to compare postoperative outcomes between inpatient and outpatient ABG.

Materials and Methods: A retrospective review of the National Surgical Quality Improvement Program-Pediatric database was conducted on patients who underwent ABG from 2012-2020. Patient demographics, perioperative factors, length of stay (LOS), surgical site infection (SSI) rates, and 30-day outcomes (i.e., readmission, reoperation, postoperative complications) were collected. Entropy balancing was performed to optimally match inpatient and outpatient cohorts based on demographics and comorbidities in a 1:1 ratio. (1,2) Pearson's chi-squared, independent t-tests, and multivariate logistic regressions were used to analyze 30-day outcomes. Costs were derived from Medicaid reimbursement codes. Probabilities were based on outcomes reported by the NSQIP database comparing the two hospital settings. One-way and probabilistic sensitivity analyses tested the robustness of results to model parameters. The associated costs for inpatient and outpatient procedures were calculated and adjusted to 2022 US dollars.

Results: Upon review, 4,924 patients underwent ABG, with 2,467 in each matched hospital setting cohort. Overall, 30-day readmission, reoperation, and complication rates were 0.6%. 0.4%, and 1.2%, respectively with the inpatient cohort presenting with more postoperative complications (1.6% vs. 0.7%; p=0.004). The inpatient cohort had higher rates of superficial incisional SSI (0.5% vs. 0.1%; p=0.007) and organ/space SSI (0.3% vs. 0.0%; p=0.005) compared to outpatient. Upon multivariate analysis, longer LOS following operation (Odds Ratio [OR]: 1.230; p=0.013) and the inpatient setting (OR: 7.248; p=0.011) independently predicted superficial incisional SSI. Based on these clinical outcomes, the total cost of outpatient ABG was estimated to be $11,433 vs. $19,668 for inpatient ABG, resulting in $8,325 cost savings per patient.

Conclusion: ABG is an overall safe procedure for alveolar cleft repair with reported low complication, readmission, and reoperation rates. However, we found that the inpatient setting and extended postoperative stay independently contribute to slightly increased superficial incisional SSI rates. Based on these findings, we recommend shifting towards outpatient ABG procedures as they may confer a lower risk of hospital-acquired infectious complications and cost.

References: 1. Hainmueller J, Xu Y. Ebalance: A Stata Package for Entropy Balancing. Published online September 1, 2013. doi:10.2139/ssrn.1943090 2. Hainmueller J. Entropy Balancing for Causal Effects: A Multivariate Reweighting Method to Produce Balanced Samples in Observational Studies. Polit Anal. 2012;20(1):25-46.

PURPOSE: The pedicled anterolateral thigh (ALT) is a well-described flap for groin reconstruction. Other reconstructive options for groin wounds include tensor fascia lata, sartorius, gracilis, rectus femoris, vastus lateralis, and vertical rectus abdominis myocutaneous (VRAM) flaps. However, significant peripheral vascular disease requiring vascular bypass can preclude the utilization of many reconstructive local and regional options. Our case of a 92 year old female with exposed polytetrafluoroethylene (PTFE) graft of a left iliac to popliteal artery bypass showed scant collateral flow through the profunda femoris artery on angiogram. METHODS: Due to inadequate vascular inflow via the ipsilateral profunda and its branches, a contralateral pedicled ALT flap was used to reconstruct the defect and provide soft tissue coverage over the exposed PTFE graft. The flap was transposed in a subcutaneous tunnel under the mons to the contralateral groin, minimizing the morbidity of an extended incision across the pubis. RESULTS: Only two other cases of pedicled ALT flap for reconstruction of contralateral groin wounds have been reported in the literature.1,2 The patient has had excellent recovery up to 3 months post op and the groin wound was fully healed. CONCLUSION: This case report further supports the use of pedicled ALT flap as a safe, reliable technique for contralateral groin defects in select patient populations when ipsilateral reconstructive options are inadequate.

[1] Ver Halen, J., & Yu, P. (2010). Reconstruction of extensive groin defects with contralateral anterolateral thigh–vastus lateralis muscle flaps. Plastic and Reconstructive Surgery, 125(3). https://doi.org/10.1097/prs.0b013e3181cb67bd

[2] Bharath, S. P., Madhusudan, G., & Manjunath, S. (2010). Pedicled anterolateral thigh flap for contralateral groin composite defect. Indian Journal of Plastic Surgery, 43(1), 103. https://doi.org/10.4103/0970-0358.63960

Introduction: Perinatal brachial plexus palsy (PBPP) is an exceedingly rare condition that poses significant challenges to treating providers. While most cases resolve without surgical intervention, evaluating upper-extremity motor power in infants represents a significant clinical challenge, and it is difficult to predict which patients will improve and which will go on to require surgical management. The Active Movement Scale (AMS) is a validated scale that provides a quantifiable assessment of upper-extremity strength in infants. Our study describes trends in AMS scores over time in PBPP patients. Our goal was to use AMS scores to differentiate between surgical and non-surgical patients in order to better understand the relationship between AMS scores, management, and outcomes in PBPP patients.

Methods: A retrospective review of patients with brachial plexus injury presenting to our institution between 2008 and 2020 was conducted. Patients were included if they had a diagnosis of PBPP and a minimum of three recorded AMS scores. Variables collected included demographic information, birth history, presence of risk factors (e.g., shoulder dystocia, maternal diabetes), AMS scores, management (surgical vs. conservative), and outcomes. Statistical analyses were performed using SPSS statistical software (version 27, SPSS Inc. Chicago, IL).

Results: 173 patients with brachial plexus injury presented to our institution between 2008 and 2020. 57 patients met inclusion criteria; 17 patients required surgery at an average of 7 months old. The average AMS score at initial presentation for patients who did not require surgery was 85.0. On long-term follow up (on average at 17 months), non-surgical patients demonstrated a significant improvement in AMS score, to an average 101.6 (p<0.001). Patients who ultimately required surgery had significantly lower pre-operative AMS scores than non-surgical patients, with an average score of 41.3 at initial presentation (p<0.001). Following surgery, patients' AMS scores increased significantly to an average of 74.6 (p<0.001). Notably, each one-point increase in initial AMS score was associated with a 9.88% reduction in likelihood of surgery (p=0.004). There was no significant difference in the rate of improvement of AMS scores between non-operative and operative patients pre-operatively (p=0.287).

Conclusion: AMS score at time of presentation may predict the likelihood of requiring surgery, with lower initial AMS scores associated with significantly higher risk of requiring operative intervention. However, there was no significant difference in the pre-operative rate of improvement of AMS scores between patients managed surgically compared to non-surgically. This finding suggests that function at initial presentation, rather than rate of improvement over the first year of life, is predictive of future requirement for surgery. These results have important implications on practice management and suggest that a higher index of suspicion for requiring surgical management should be maintained for PBPP patients with low initial AMS scores.

Purpose: Some burn injuries may benefit from microsurgical and free flap reconstruction. Despite functional benefits, surgeons cite increased morbidity in burn survivors. We conducted a systematic review to summarize complications in microsurgical and free flap burn reconstruction in the literature. We hypothesized complication rates improved in studies published after year 2000. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, five databases were searched for observational studies in English on postburn free flap reconstruction in acute (≤ 6 week) or secondary (> 6 week) phases. Studies with over three patients ≥ 18 years at time of reconstruction were included. Studies with animals, cadaver, and locoregional/pedicled flaps without use of the operating microscope were excluded. Patient demographics, burn information, flap data, and complications were extracted. Complications included death and cause of death, flap failure and causes of flap failure, arteriovenous thromboses, skin/flap necrosis, hematoma/seromas, surgical site infections, wound disruption (i.e. wound dehiscence or epidermolysis). Fisher's exact test was used to assess for differences in complication rates from studies pre- and post-year 2000. Significance was set at p<0.05. All statistical analyses were conducted in RStudio 4.1.2. Results: Of 1,071 studies obtained, 18 were included spanning 39 years (1982-2021). Studies were published from 16 institutions across 13 countries. Of 238 patients included (75.2% male), median age was 40 [IQR 36.1, 47] years. For 256 recipient sites, there were 269 free flaps encompassing 105 acute (43.7%) and 130 secondary (54.2 %) reconstructions. Most free flaps were anterolateral thigh (ALT, n=64, 23.8%) for upper extremity reconstruction after thermal injury (n=14 flaps, 21.9% of ALT flaps). By type of injury, 68.8% of flaps after caustic injury were free jejunum flaps (n=11 flaps) to the esophagus, 11.9% of flaps after electric injury were ALT flaps (n=8 flaps) to the upper extremity, and 16.7% of flaps after thermal injury were ALT flaps (n=14 flaps) to the upper extremity. Of 85 complications (35.7% of all patients), 52 (49.5%) occurred in patients undergoing acute reconstructions and 3 (2.3%) undergoing secondary reconstructions. The most common complication was flap necrosis (n=9, 3.8% of flaps) and venous/arterial thromboses (n=9, 3.8% of flaps). There was one postoperative death 66 days after thermal burn injury. There were 32 reoperations (13.4% of all patients) with the majority for hematoma evacuation (n=5, 15.6% of reoperations) followed by a tie between flap salvage procedures and anastomotic revisions (n=4, 12.5% of take-backs). There were 19 flap failures (7.1% of flaps) mostly occurring after electric injury (n=10 failures, 52.6% of failures) and upper extremity reconstructions (n=8 failures, 42.1% of failures). There was no difference in complication rates between articles published pre- and post-year 2000 (p=0.196). Conclusions: Our systematic review of the literature identified a pooled, complication rate of 35.7% for post-burn free flap reconstruction in patients 18 years and older. Additionally, there were no differences in complication rates before and after year 2000. Optimizing postoperative management with an interdisciplinary burn and reconstructive team may be a solution to reducing complications.

Purpose: Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI care in the setting of biceps function recovery within 3 months, but lack of shoulder function recovery, or 2) BPBI that was never treated, even nonoperatively. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of 6 patients who underwent shoulder reanimation.

Methods: The surgical technique is as follows: First, a deltopectoral incision is made. Often, the pectoralis minor, pectoralis major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. To prepare for a bipolar latissimus transfer, an interval in the axilla is developed. The latissimus, lower trapezius, scapula, infraspinatus, and posterior deltoid are then exposed. The latissimus is released from its origin, its tendon on the humerus is released, and the latissimus is pedicled on its neurovascular bundle. The latissimus is passed anteriorly to reanimate abduction and forward flexion (FF). For ER, the lower trapezius or teres major can be used with an Achilles tendon allograft extension. The posterior deltoid is split, and the infraspinatus is followed to its insertion. The proximal humerus is identified, and two suture anchors are placed. The distal end of the allograft is parachuted using anchors and the allograft is split into two limbs, which are passed and woven through the donor muscle. The latissimus is rotated anteriorly and fanned across the shoulder, recapitulating the deltoid. Finally, the muscle is secured to the clavicle, acromion, scapula, and humerus and inset into the deltoid. Oftentimes, further scapular stabilization is necessary. This is achieved through rhomboid muscle advancement and contralateral trapezius transfer.

Results: Six patients (14+-4.3 years) were included. All patients participated in our postoperative rehabilitation protocol involving a custom orthotic to position the operative shoulder in ER and abduction (0-6 weeks), protected active/passive movement emphasizing activation of transferred muscles (7-12 weeks), full active movement and initiation of functional activities (12-18 weeks), and strengthening and return to full function (19 weeks onward). Preoperatively, patients generally lacked ER and were at -80°. Postoperatively, patients generally achieved 90° abduction and 20-40° ER. In maximum abduction, patients achieved 60-80° ER. Preoperatively, patients generally had 0-20° abduction, which they achieved through scapulothoracic motion. Postoperatively, patients achieved 60-100° abduction. Scapular winging was controlled through dynamic stabilization. Preoperatively, patients had 0-20° FF that was mediated through scapulothoracic motion. Postoperatively, patients' FF increased to 40-70° through glenohumeral motion only.

Conclusions: This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rigorous postoperative rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

Background: Shortcomings of macrotextured anatomical implants, together with their safety concerns, include the preimposed aesthetic limitations of the acceptable breast shape considered solely in the body standing position, with the operated breasts still stiff and inflexible. Therefore, Motiva Ergonomix nanotextured breast implants were designed for more natural aesthetic outcomes in breast surgery and to increase safety profile. Objectives: The aim of this retrospective study was to examine the potential of reproducing natural aesthetic outcomes in breast aesthetic surgery, considered as satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with Ergonomix nanotextured breast implants, as well as to analyze the safety profile defined as incidence of complications. Results: The revision rate was 0,7% percent with a demonstrated very low device-related complications (0,5%): 3 implant ruptures, 2 implant malpositioning at 12 months, 2 hematoma evacuation. There were no late complications and no cases of primary capsular contracture. At 3 months, 99% of the patients were "extremely satisfied or very satisfied" with the aesthetic results in general as well as in relation to shape, touch and dynamics exclusively, together with the outcome analyzed by the surgeon as "excellent or very good" in 97% of cases. Conclusions: The extended potential of enhanced aesthetic and safety profile is re-defined by the implant ergonomy and observed by patients, with the resulting breast shape adapting to the body position, together with pliability perceived as softness in touch and extensive dynamics imitating naturalness.

Purpose: With the shift towards integrated plastic surgery residencies, fellowship training for plastic and reconstructive surgeons has become increasingly popular1. The field of aesthetic surgery has grown tremendously, and literature analyzing otolaryngology fellowships found that facial plastic surgery was the most popular fellowship pursued2. However, the popularity of aesthetic fellowship training across other disciplines remains unknown. The goal of the present study was to analyze fellowship match trends after Plastic and Reconstructive Surgery residency and compare these to other residency programs with aesthetic training fellowships (otolaryngology, ophthalmology and dermatology) to determine trends and differences in aesthetic fellowship training across fields.

Materials & Methods: The present retrospective review used data from The San Francisco Match, National Resident Matching Program, American Society for Dermatologic Surgery, and The Accreditation Council for Graduate Medical Education (ACGME) to collect information about the fellowship match for residency programs with an aesthetic fellowship option (plastic and reconstructive surgery, ENT, dermatology, and ophthalmology). Information including the year, number of graduating seniors, number of total applicants and matched applicants for each respective residency and fellowship options were collected. Ratios were created between the number of graduating seniors and number of residents applying and matching into each respective fellowship were created. For each residency, these ratios were compared to determine the distribution of residents seeking aesthetic fellowships as compared to other fellowship options.

Results: Otolaryngology had the highest percentage of residents pursuing aesthetic fellowship training via facial plastic surgery compared to other fellowships (rhinology, neurotology, and pediatrics) in both applicants and number matched (ANOVA p<0.001). Plastic and reconstructive surgery had the most applicants pursuing microsurgery fellowship. Although this was historically followed by craniofacial fellowship, since 2020, the number of aesthetic plastic surgery applicants surpassed those applying to craniofacial surgery (ANOVA p<0.001). In Dermatology, Mohs surgery fellowship has predominated as the most popular fellowship option, followed by aesthetic dermatology since 2016, although there was not a significant difference between pediatric vs cosmetic dermatology (ANOVA p<0.001, t-test p=0.925). Oculofacial plastic surgery after ophthalmology was less commonly pursued than retina, cornea, glaucoma, and pediatric fellowships but more common than neuroophthalmology, uveitis, anterior segment and other fellowships (ANOVA p<0.001).

Conclusions: The percent of graduating residents pursuing fellowship training continues to rise yearly, reflecting the increased desire for specialization in the medical field across time. Aesthetic fellowship training continues to be an increasingly popular field among surgeons, representing the most common otolaryngology fellowship and the second most common plastic and reconstructive surgery fellowship and dermatology fellowships pursued compared to other fellowship options.

References: 1. Bovill JD, Haffner ZK, Huffman SS, Sayyed AA, Shan HD, Abu El Hawa AA, Slamin RP, Evans KK, Song DH. Trends in Fellowship Training across United States Plastic and Reconstructive Surgery Academic Faculty. Plast Reconstr Surg Glob Open. 2022 Oct 17;10(10):e4611. doi: 10.1097/GOX.0000000000004611. PMID: 36262681; PMCID: PMC9575958. 2. Miller RH, McCrary HC, Gurgel RK. Assessing Trends in Fellowship Training Among Otolaryngology Residents: A National Survey Study. Otolaryngol Head Neck Surg. 2021 Nov;165(5):655-661. doi: 10.1177/0194599821994477. Epub 2021 Feb 23. PMID: 33618575.

Purpose Artificial Intelligence (AI) is a computational science that aims to simulate and expand human intelligence. The concept of AI was first introduced by Alan Turing, who developed the Turing test to evaluate a machine's ability to exhibit intelligent behavior compared to a human being. AI has seen significant growth and development since the 1980s, with techniques such as Bayesian networks, artificial neural networks, fuzzy systems, and hybrid systems being utilized in various settings within the healthcare system. AI in healthcare can be divided into two broad categories: physical and virtual. Virtual applications range from electronic patient records to neural network-guided treatment, while physical applications include robotic assistance to surgical procedures and disabled and elderly patients. Machine learning is currently the most applicable form of AI in healthcare, with ever-growing data sets. In plastic surgery, AI is increasingly being used in big data, machine learning, deep learning, natural language processing, and facial recognition. This review aims to search for current applications of AI in patients undergoing facial lifting procedures and smile reanimation surgery to increase the reach of this technology to other surgeons.

Methods A search for full-text articles where the use of artificial intelligence was used in surgical procedures pertaining to facial lifting or smile reanimation was performed on PubMed, Scopus, Web of Science, and Embase. The following terms were used to guide our search: Artificial Intelligence AND Facial Lifting OR Facial Lift; Artificial Intelligence AND Smile Reanimation. Reports had to state the use of these technologies in surgeries within a plastic surgeon's scope. Only studies that were original works were included.

Results The use of artificial intelligence (AI) in smile reanimation surgery has been explored in several studies. Dusseldorp et al. found that patients with non-flaccid facial palsy had a higher chance of perceiving joy after surgery using a Gracilis-free muscle flap, and that patients with flaccid facial palsy had an increase in joy and a decrease in the perception of negative emotions after surgery. Boonipat et al. used a commercially available AI system to detect an increase in happiness in patient smile videos post-surgery. Dusseldorp et al. also utilized AI to analyze spontaneous smiling and found an increase in the probability of perceiving joy during spontaneous smiling after surgery. Kollar et al. used AI-driven video analyzing software to measure changes in facial expression post-surgery, finding significant increases in perceived happiness and changes in action/emotional units.

Conclusion AI has been implemented in facial reanimation surgery to measure and quantify patient outcomes, with AI-driven video analysis specifically showing improvements in joy and emotion for patients with facial palsy. AI has also been used to measure perceived age, patient satisfaction, and emotion in patients undergoing other facial surgeries, demonstrating its value as an objective tool in analyzing facial expressions and emotions.

INTRODUCTION: A key feature of Peripheral Arterial Disease (PAD) is compromised ambulation, which consequently is associated with decreased quality of life, increased falls, and need for reconstructive surgical intervention. Existing literature on how PAD impairs gait remains sparse and inconsistent. We aim to assess the kinematic gait parameters of patients with Peripheral Artery Disease (PAD) compared to age-and-gender-matched controls.

METHODS: Adults with PAD, as defined by existing history in shared patient charts, presenting to a tertiary wound care center who could ambulate unassisted and without pain were offered participation. Patients without PAD presenting to the same single tertiary wound center were matched to age (±5 years) and gender. To reproducibly evaluate gait, participants completed a standardized protocol with wearable Opal sensors (ADPM, Portland Oregon) and completed a 120-second walk test which was analyzed by Motility Lab software (Hamilton Thorne). Demographic and clinical variables across groups were analyzed by One Way Analysis of Variance (ANOVA) and Chi-2 tests for independence; group differences in gait were analyzed using independent sample t-test using STATA VSN 7.0 with significance defined as p < 0.05.

RESULTS: A total of 39 patients with PAD were included with 39 controls. There was no difference in demographics with an average age of 66 years and BMI of 30 kg/m2; both cohorts had comparable rates of smoking (41.02 vs. 48.71%, p=0.5), type II diabetes (48.71 vs. 69.23%, p=0.08), chronic kidney disease (15.38 vs. 28.21, p=0.2), and depression (15.38 vs. 7.69%, p=0.20 (Table 2). PAD patients walked with a slower pace (0.78 ± 0.20 vs. 0.89 ± 0.23 m/s, p=0.03), greater step duration (0.63± 0.079 vs. 0.60 ± 0.08 seconds, p=0.04), decreased cadence (95.79 ± 10.10 vs. 100.38 ± 11.23 steps/minute, p=0.03), and decreased step length (0.98 ± 0.21 vs. 1.06 ± 0.20 m, p=0.05).

CONCLUSION: Our cohort of patients with high co-morbidities found that the addition of PAD may influence more advanced ambulatory dysfunction. Vascular monitoring and surgical intervention may be warranted in patients who have complications in wound healing and a diagnosis of PAD. Clinicians may consider incorporating quantitative gait analysis in the risk stratification in patients with PAD in the setting of wound care and reconstructive surgery.

Background: Autism spectrum disorder (ASD) patients are a unique subtype of pediatric patients. These patients, while at an increased risk for craniofacial fractures, remain understudied and injuries in this population are poorly characterized. The goal of this study is to present demographic, diagnostic, and treatment data on pediatric facial fracture patients with an ASD diagnosis.

Methods: We performed a retrospective review of patients under 18 years of age who were evaluated at a pediatric level I trauma center from 2006 to 2021 for facial fractures. Data included demographics, etiology, types of facial fracture, associated injuries, management and outcomes. Patients who presented with an existing diagnosis of ASD were compared to patients without a diagnosis of ASD.

Results: Facial fractures were diagnosed in 3334 patients, of whom 30 met inclusion criteria and had a diagnosis of ASD. The average age was 12.0 ± 4.8 years. The majority were white (90.0%) and male (93.3%). Eleven patients had a concomitant ADHD diagnosis (36.7%). Twelve patients had previous neurological disorder diagnoses (40.0%). The most common mechanisms of injury were violence (n = 9, 30.0%) and activities of daily living (n = 8, 26.7%). Nasal fracture was the most common fracture (n = 24, 77.4%). There was no difference in rates of maxillary, nasal, or mandibular fractures in patients with ASD compared to controls. Patients with ASD were significantly less likely to present with orbital fractures (9.7% vs 26.2%, p <0.037). Logistic regression analysis demonstrated the odds of receiving operative treatment were lower in patients on the autism spectrum (odds ratio, 0.4; CI 95%, 0.2-0.8). Within those who did receive surgical intervention, closed nasal fracture reduction was the most common procedure (19.2%). Univariate analysis demonstrated that there was no difference in rates of admission between ASD patients and controls (25.8% vs 32.5%, p = 0.431).

Conclusions: Pediatric facial fractures in ASD patients are poorly characterized. Our study describes the unique characteristics of this understudied population. In this study, we found that despite a similar pattern of facial fractures sustained compared to controls, patients with ASD were significantly less likely to receive operative treatment.

Background: Socioeconomic status (SES), income and insurance type have been shown to be associated with disparities in surgical outcomes for reduction mammoplasty and breast reconstruction. However, it is unknown if a similar association exists between SES factors and outcomes for body-contouring after massive weight-loss. Complications have the potential to mitigate otherwise reliable improvements in quality-of-life outcomes. This investigation sought to examine SES factors and association with poor surgical outcomes after panniculectomy.

Methods: A retrospective chart review was conducted for patients who underwent panniculectomy from 2018 to 2022. Data included demographics, co-morbidities, insurance type, and any complications. US Census data was used to determine median income for each patient zip-code. Income levels were defined by 175% and 275% of the Federal Poverty level (FPL) for a family of four. Those who lived in zip-codes with median incomes <175% FPL were designated 'low-income', and those in zip-codes >275% FPL were designated 'high-income.' Zip-codes between 175% and 275% FPL were 'average-income.' Comparisons of continuous variables used Welch's t-tests assuming unequal variance. Categorical comparisons utilized Odds Ratios, 95% Confidence Intervals and Pearson Chi-Squared analysis.

Results: 266 patients were identified via CPT code audit, with 204 remaining after exclusion of cosmetic abdominoplasty. Average age at surgery was 46.1±12.0 years, and average BMI was 31.2±6.6. Average resection weight was 3978.2±7114.6 grams, and no difference in resection weight was demonstrated across income groups (p=0.8303). Income groups had similar distributions of age, resection weight, BMI, and DM, but Black patients were disproportionately represented in the low-income group (p<0.001). 72 patients had complications (35%). Complication rates varied between the three income levels (p=0.0164) of low-income (50.0%), average-income (30.1%) and high-income (26.1%). Patients designated low-income were 2.83 (1.33, 6.01) times as likely to have complications compared to those designated high-income (p=0.0067), and 2.32 (1.15, 4.68) times as likely as patients who were average-income (p=0.0192). Patients designated as low-income were 4.21 (1.42, 12.5) times as likely to have a complex non-healing wound compared to the high-income group (p=0.0095), with no difference seen between low-income and average-income groups. Patients with at least one complication had an average zip-code designated income of $64,415, significantly lower than $73,576 for patients without complications (p=0.0027). This investigation is limited by use of US Census Data, which provides an estimate of socioeconomic factors and median income in each zip-code but may not be entirely representative of individual income or SES.

Conclusions: SES, insurance type, and income have been previously shown to present significant barriers to accessibility of body-contouring procedures after massive weight loss. We demonstrate that SES factors may have a detrimental impact beyond initial access barriers due to increased complication rates. Complications are typically multifactorial, though income groups demonstrated similar profiles overall apart from income and race. Further regression-based analysis will be pursued with this dataset to elucidate factors which may contribute to inequity in body-contouring outcomes.

Background: Body Dysmorphic Disorder (BDD) is a neuropsychiatric disorder involving debilitating preoccupation with one's own external appearance. Individuals with this somatoform disorder often seek resolution of self-perceived defects through cosmetic surgery, usually resulting in poor post-operative patient satisfaction. Establishing routine BDD pre-screening techniques for those desiring such physical modifications is vital prior to surgical intervention. Despite growing awareness of BDD in the cosmetic setting, diagnosis during preoperative consultation remains challenging and uncommon. This systematic review offers insight into current methods for the identification of BDD using validated screening tools for plastic surgeons.

Methods: We conducted our review in accordance with PRISMA guidelines and utilized 4 databases to ensure comprehensive results: PubMed (NLM), Embase (Elsevier), Web of Science Core Collection, and PsycInfo (EBSCOhost) to identify and characterize all screening instruments utilized for BDD employed before cosmetic surgical intervention described in literature from January 2010 to search date. All resulting articles were screened and extracted by two independent reviewers for relevance. A health sciences librarian established search terms for each database on February 2nd, 2023.

Results: 92 studies were included for data collection and met the inclusion criteria after a full-text review. Reviewers recorded the number of occurrences in which a screening tool was used in a study, excluding mentions of the same study in a systematic review or book chapter to avoid duplication. In total, 96 occurrences of BDD tool employment were recorded, with some studies utilizing more than one of the 26 different BDD screening tools identified. 23 different procedure types were specifically mentioned in the studies in varying quantities (n=76). The Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) accounted for the majority (n=16,16.7%) of screening questionnaire types applied by surgeons, followed by the Body Dysmorphic Disorder Questionnaire (BDDQ) (n=10,10.4%), Dysmorphic Concern Questionnaire (DCQ) (n=8,8.3%) and the Body Dysmorphic Disorder Questionnaire- Dermatology Version (BDDQ-DV) (n=8,8.3%). Screening tools were used and validated in 12 different languages. The most popular procedure type sought by patients was rhinoplasty (n=29,38.2%) and then injectables (neuromodulators and fillers) (n=13,17.1%). 89 studies reported country, with the United States producing the greatest number of studies (n=17,19.1%), followed by Iran (n=12,13.5%), and Brazil (n=11,12.4%). In total, studies on BDD prescreening measures were produced by 20 countries.

Conclusions: Though multiple BDD screening instruments have been applied in the cosmetic surgery setting worldwide, there is no established 'gold standard'. Our data suggest that screening tools have been greater utilized and validated for certain procedures such as rhinoplasty, and minorly invasive procedures (injectables), whereas other procedures including abdominoplasty, aesthetic genital surgery, and breast procedures have not been as extensively employed or validated. This finding suggests that more studies are potentially warranted to test the validity of BDD screening tools in patients seeking certain cosmetic and reconstructive procedures to improve patient care. Additionally, further analysis of the comparative sensitivity and specificity of current BDD screening tools could be justified to near the development of a standardized tool to be utilized effectively in practice.

Background Velopharyngeal dysfunction (VPD) is a common sequela following primary repair of cleft palate. It is classically diagnosed and repaired between ages 3-6 following perceptual speech evaluation. While studies commonly use this age group to report VPD rates and speech outcomes, the continued risk of VPD requiring intervention later than age 6 has not been described. Here we examine age at VPD intervention over a 40-year period at our institution, to inform optimal screening points for VPD in patients with cleft palate. Methods Patients with cleft palate with follow-up visits at age 14 or older in our multidisciplinary cleft palate/craniofacial team clinic from 1997-2017 were included. We collected Veau class, date of first and last team clinic visits, and dates and types of surgical interventions for VPD from the following list: pharyngeal flap, sphincter pharyngoplasty, and palatal re-repair. Kaplan-Meier survival analysis was used to examine patients' risk of VPD intervention through age 18. We also examined differences in repair type by Veau Class and used survival analysis to examine differences in age at repair between repair types, and between the first (1980-2001) and second (2001-2022) halves of the repair period. Results 129 patients qualified, of whom 94 (72.9%) received a surgical intervention for VPD. The median age at VPD repair was 6.1 years. Kaplan-Meier survival analysis revealed that despite a steep decline in the percentage of patients with operation-free survival between ages 3-6, when perceptual speech examination to identify VPD commonly takes place, 51% (48/94) of VPD repairs occurred after age 6. Repair type had a significant effect on age at surgery (p<0.01) with median age at palatal re-repair around 12 years of age, compared to a median age of pharyngeal flap or sphincter pharyngoplasty around 5 years of age. The relative proportions of each repair type differed between the first and second halves of the study period (p<0.01). On pairwise analysis, there was a significant reduction in sphincter pharyngoplasty (82.1% to 18.4%, p<0.01), and a significant increase in palatal re-repair procedures (0% to 71.1%, p<0.01) between the first and second halves of the study period. This change in procedure prevalence also impacted age at repair, with a later median repair-free survival of 10 years in the second half of the study period, compared to a median of 5 years in the first half of the study period (p<0.01). Veau class was not associated with significant differences in the types of surgery received, with more than 50% of patients in each Veau class receiving sphincter pharyngoplasty (p=0.94). Conclusions A significant proportion of patients with cleft palate will go on to develop VPD at ages later than 6. As timing of repair differs based on repair type, there may be differences in the size of the involved gap based on patient age, with younger patients presenting with large velopharyngeal gaps and older patients presenting with a small gap during growth and adenoid involution. These findings highlight the importance of interval perceptual speech evaluations into adolescence to promote optimal velopharyngeal outcomes.

Purpose: Severe craniofacial fractures pose occult threats to critical nearby structures, particularly the intracranial space, cervical spine (C-spine), or airway patency(1). As technology and safety evolve in sectors such as transportation and manufacturing, it is imperative to reevaluate patterns of injury caused by related mechanisms. Studies investigating common craniofacial fracture patterns have frequently been limited by sample size, lacked details on the mechanism of injury (MOI), or are relatively antiquated. Our aim is to characterize modern combinations of craniofacial fractures across a variety of MOIs, providing data useful in informing clinical heuristics and preventing the delayed identification of underlying injuries.

Methods: Patients from the National Trauma Data Bank (NTDB) for the years of 2010-2019 with fractures to the craniofacial skeleton, skull vault, and C-spine were included. Fractures and corresponding severities were determined by Abbreviated Injury Scale (AIS) predot codes and AIS severity scores. Mechanisms of injury were identified by external cause-of-injury codes and were categorized as fall, machinery, struck by/against, motor vehicle accident (MVA), cyclist, and pedestrian. Descriptive statistics and data visualization was performed in R.

Results: A total of 425,625 patients satisfied inclusion criteria. Patients who sustained a fall, cyclists, and pedestrians most commonly suffered simple, closed vault fractures (31.0%, 28.3%, 28.9%, respectively). Patients injured in machines or MVAs most often sustained C-spine fractures with minor/no compression and/or no neurologic deficits (20.4%, 42.6%, respectively). As expected, patients that were struck by/against an object most commonly fractured the orbital floor (24.6%). Multiple concomitant craniofacial fractures accounted for 6.2%, 16.2%, 7.6%, 13.1%, 10.9%, and 15.1% of patients in the categories of fall, machinery, struck by/against, MVA, cyclist, and pedestrian, respectively. The frequencies of these combination fractures varied statistically across MOIs (p < 0.001). Furthermore, the top 10 fracture patterns for each MOI significantly differed as well (p < 0.001). Concomitant vault and C-spine fractures were most prevalent in all mechanisms except struck by/against, which most commonly resulted in mandibular and orbital floor fractures. Alluvial plots demonstrated that machinery injuries produced relatively heterogeneous craniofacial injuries, while most other MOIs were dominated by a few common fracture patterns. Importantly among all patients with craniofacial fractures, 6.4% also had C-spine fractures.

Conclusions: Analyzing one of the largest modern cohorts of craniofacial trauma patients, this study characterizes patterns in craniofacial fractures and uniquely integrates details of MOI and implications for C-spine injury. The incidence of fracture patterns differed significantly across MOIs. Interestingly, machinery-related fracture patterns are fairly heterogenous compared to other mechanisms. Moreover, C-spine injuries are commonly coincident with craniofacial fractures agnostic of MOI, representing a major morbidity and warranting continued judicious evaluation.

References: (1) Mithani SK, St. -Hilaire H, Brooke BS, et al. Predictable Patterns of Intracranial and Cervical Spine Injury in Craniomaxillofacial Trauma: Analysis of 4786 Patients. Plastic and Reconstructive Surgery. 2009;123(4):1293. doi:10.1097/PRS.0b013e31819e26f2

Purpose: Mainstream avenues for tissue decellularization possess disadvantages to the recipient with the utilization of harmful substances that ultimately decrease the viability of the extracellular matrix (ECM) scaffold. Moreover, mainstream sterilization agents possess effects that are damaging to the environment. Supercritical carbon dioxide (scCO2) has emerged as an environmentally sustainable agent to simultaneously sterilize and decellularize tissue for reconstructive purposes. We have previously validated the efficacy of scCO2 in performing these functions in human and ovine costal cartilage with histological and spectrophotometric methods. We now investigate the in-vivo response to cartilage implants prepared with this eco-friendly alternative to assess the viability and biocompatibility of these materials for cartilaginous reconstruction.

Methods: To prepare ovine cartilage samples, floating lamb ribs were either minced into 1 mm3 cubes or zested into 1 mm2 flakes. Human costal cartilage was obtained from tissue donor banks and minced to 8 mm3 cubes. All samples were first decellularized with two iterations of NovaSterilis™ scCO2 exposure in a 1.25L NovaGenesis™ unit (35°C at 2,300 psi for 4 hours/cycle) submerged in dilute ethanol and NovaKill™ additive. Samples were then sterilized with scCO2 in a NovaSterilis™ Nova2210 unit for 3 hours (35°C and 1,436 psi) submerged in water with peracetic acid-based NovaKill™ additive. PLA scaffolds were designed for optimal porosity and subcutaneous surface area exposure, printed on a 3D printer (Prusa i3 MK3S) and sterilized. Decellularized ovine (minced and zested) and human costal cartilage (minced) was packed into the scaffolds with empty cages serving as a control. Samples were implanted subcutaneously on the dorsa of immunocompetent Sprague-Dawley rats, such that each rat had 2 implants of each group. After 1 and 3 months in-vivo, the constructs were explanted for volumetric (microCT) and histologic (H/E, Safranin-O, DAPI) analyses.

Results: At explanation, all PLA scaffolds were encased in a fibrous capsule. Masses of each group of constructs (minced ovine, zested ovine, minced human, and empty) were similar between 1 and 3 months. MicroCT scans revealed 1 and 3 month explant volumes of 1060.8±82.5 mm3 to 1218±101.1 mm3, 1121.1±76.8 mm3 to 1034.2±137.6 mm3, 1303.6±431.5 mm3 to 1267.0±151.7 mm3, and 817.1±316.7 mm3 to 911.6±147.2 mm3, for zested ovine, minced ovine, minced human, and empty control groups respectively. H&E staining revealed a mild inflammatory infiltrate composed of mononuclear and lymphocytic cells, no polymorphonuclear phenotypes were observed. Cartilage architecture was also preserved with intact lacunae that were devoid of nuclei alongside a fibrovascular tissue ingrowth loosely surrounding cartilage pieces. Safranin-O staining revealed the expected depletion of glycosaminoglycans due to scCO2 decellularization. DAPI revealed no nuclear staining within cartilage pieces.

Conclusions: Decellularization of ovine and human cartilage with a more environmentally-conscious and biocompatible agent such as scCO2 has proven to be an efficacious material for cartilaginous reconstruction. Constructs containing scCO2-decellularized cartilage facilitated fibrovascular cartilaginous ingrowth of native tissue that displayed less of an immunogenic reaction witnessed among currently available prosthetic devices. Ongoing explantation of 6 month constructs as well as future biochemical testing will further elucidate the long term immuno-compatibility of these newly developed materials.

Background The deep inferior epigastric perforator (DIEP) flap remains the accepted gold standard breast reconstruction. A secondary benefit may be improving the abdominal contour, however poor scaring can lead to aesthetic dissatisfaction and complications. While studies have demonstrated favorable aesthetic results and decreased operative time using dermal stapling, no reports exist regarding epidermal stapling. The aim of this study is to compare the aesthetic scar outcomes and postoperative complications of abdominally based breast reconstruction patients who have undergone suture closure versus epidermal staple closure.

Methods A total of 217 patients who underwent abdominal-based autologous breast reconstruction from 2011 to 2022 were included and retrospectively analyzed (staples= 41, suture= 176). Twenty-four patients' postoperative abdominal scar photographs were randomly chosen (staples = 12, sutures = 12). Anteroposterior and bilateral oblique photographs of the abdomen were chosen at least four months after surgery and were cropped consistently from the lower breast border to the upper mons. The photographs were randomly displayed in a consistent order. Three board-certified plastic surgeons independently reviewed the abdominal scars using a modified Patient and Observer Scar Assessment Scale (POSAS) and Visual Analogue Scale (VAS). The reviewers did not participate in the procedures and were blinded to the type of abdominal incision closure. Postoperative complication P-values are the results of Mann-Whitney tests for continuous variables or Fisher's exact tests for categorical variables. VAS and POSAS scores were analyzed using t-tests. Interrater reliability was expressed by the Intraclass Correlation Coefficient (ICC). For all analyses, statistical significance was defined as p ≤ 0.05.

Results Assessment of abdominal scars closed by epidermal staples revealed significant improvements in thickness (p=0.033), relief (p=0.033), surface area (p=0.017), overall opinion (p=0.033), POSAS score (p=0.034), and VAS scar score (p=0.023) in comparison to scars closed by sutures. Surface area (ICC=0.637), overall opinion (ICC=0.744), POSAS (ICC=0.671), VAS (ICC=0.700), pigmentation (ICC=0.535), and thickness (ICC=0.526) ratings showed moderate interrater reliability, while relief (ICC=0.256) rating showed poor interrater reliability. Staple and suture closure of abdominal incisions had similar abdominal overall complication rate (p=0.43), skin necrosis (p=0.43), seroma (p=1.00), hematoma (p=1.00), infection (p=0.49), and dehiscence (p=0.65).

Conclusions Abdominal donor site scar quality was superior using the epidermal staple compared to traditional suture closure.

Background: Autologous breast reconstruction confers favorable patient reports of satisfaction and quality of life compared to implant-based reconstruction over a lifetime. The latissimus dorsi with immediate fat transfer (LIFT) is an alternative approach to abdominally based free flaps (Ab-FF) which expands fully autologous reconstruction to non-microsurgeons. This study aims to compare the two procedures with respect to their clinical and patient-reported outcomes one year postoperatively.

Methods: We conducted a retrospective review of LIFTs and Ab-FFs performed between March 2017 and August 2022. The primary outcomes were postoperative complications, reoperations, and longitudinal BREAST-Q scores. BREAST-Q modules included Satisfaction with Breasts, Abdomen, Back, Psychosocial Well-being, Physical Well-being: Chest, Abdomen, Back, and Sexual Well-being.

Results: Of the 281 included patients (408 breasts), 211 received Ab-FF and 70 received LIFT. One-year follow-up (12.0, IQR: 12.8 months) demonstrated that Ab-FF independently predicted dehiscence, secondary procedures, and breast revision surgery. Elevated BMI and comorbidities predicted dehiscence, while laterality of reconstruction and comorbidities predicted revisional surgery. Radiation predicted postoperative fat grafting. BREAST-Q scores fluctuated over time but were similar across all measured domains by one year postoperatively.

Conclusions: Although Ab-FF is the current gold-standard approach for fully autologous reconstruction, LIFT procedures may be associated with a less complicated postoperative course while eliciting similar patient-reported outcomes. LIFT may subsequently be preferred in patients with elevated BMI and comorbidity burdens to limit postoperative complications. LIFT also can be utilized by more plastic surgeons who are either not microsurgically trained or do not have an environment that fosters Ab-FF.

Introduction With the transition to smooth tissue expanders (TE), differences between TE subtypes have not been fully elucidated. We aimed to evaluate the differences in TE characteristics and complications between two commonly used Mentor smooth tissue expander models, Artoura and CPX4.

Methods A retrospective review of patients who received Smooth Artoura or CPX4 TEs from 2012 to 2022 was conducted. Demographic, peri-operative information, pain scores, TE variables, cancer characteristics and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure.

Results During the study period, 62 Artoura TEs and 79 CPX4 TEs were used. Patients who received CPX4 tended to be older (51.09 vs 46.18 years old, p=0.02) and have a larger BMI (28.66 vs 23.50 kg/m2, p<0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 mL vs 348.07 mL, p=0.01) and had a greater drain duration (16.91 vs 14.33 days, p=0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contractions. When controlling for BMI, diabetes, TE plane placement, acellular dermal matrix use, radiation and chemotherapy exposure, there was no association between TE subtype and each complication.

Conclusions Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have adequate and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Purpose: Facial feminization surgery (FFS) is a key part of gender-affirming surgery to help patients live according to their gender identity. Although the differences between masculine and feminine facial structures have been explored, there is little literature on standardizing facial angles, width, and height within the most commonly manipulated craniofacial regions. The frontal nasal angle and bossing angle are used to measure changes to the orbit and forehead region through forehead contouring. The bigonial width, chin height, and chin width are used to assess changes from mandibular contouring and genioplasty. Identifying standardized measurements and how they relate to patient satisfaction can influence postoperative outcomes. We aim to measure the craniofacial changes from FFS and its relationship to patient satisfaction.

Methods: We analyzed pre-and post-operative CT scans among 19 patients who underwent facial feminization surgery in Mimics V25.0 software by Materialise. Two angles were measured to assess changes in forehead contouring: the bossing angle (BA: glabella-nasion-anterior table) and the frontal nasal angle (FNA: glabella-nasion-sella). The bigonial width was assessed as the distance between the bilateral inferior gonions. The chin height was measured from the menton to the root of the central incisors and the chin width was assessed as the distance between the mental tubercles. Patients were surveyed postoperatively for satisfaction using the FACE-Q module. Paired t-tests were utilized to assess the degree of pre-and post-operative changes, and the degree of change in FACE-Q satisfaction. Pearson correlation was utilized to assess associations between post-operative angles and FACE-Q satisfaction scores.

Results: The average postoperative facial satisfaction score was 73 out of 100 among all patients. Among patients that completed pre and postoperative FACE-Q surveys, there was a significant increase in overall face satisfaction from 28 to 72 (p=0.051). There was no significant change in pre to postoperative satisfaction in the areas of the face including the chin, jaw, and forehead. All measurements decreased significantly postoperatively. The bigonial width decreased by an average of 6% (p<0.001). The FNA had an average 14% decrease (p=0.028), and the BA had an average 58% decrease (p<0.001). The chin width had an average 38% decrease (p<0.001) while the chin height had an average 11% decrease (p<0.001). There was no correlation between the percent change in any specific facial region and FACE-Q assessed satisfaction.

Conclusion: The overall FACE-Q satisfaction score among FFS patients was high postoperatively. While there were significant changes in each region of the face analyzed, the lack of correlation to FACE-Q satisfaction suggests multiple factors that contribute to patients' postoperative satisfaction beyond bony changes such as the alleviation of gender incongruence or positive surgical experience. Further studies are needed to assess components affecting FFS patients' satisfaction following surgery.

Introduction

Burn injuries are a global health problem, and non-fatal burn injuries are a leading cause of morbidity. With new materials and technologies becoming available in recent years, there are a variety of burn treatment options to choose from. However, among these options, there is no established current standard of care for the conservative management of burns that do not require excision and skin grafting. We aimed to identify the most used agents for non-operative burns among burn surgeons in the US.

Methods

An 8-question survey related to non-operative burns management was sent to 64 directors of American Burn Association (ABA)-verified burn centers. The survey investigated the preferred agents to treat non-operative superficial, superficial partial thickness, deep partial thickness, and full thickness burns. Results were tabulated and expressed as percentages of the total number of answers for each question.

Results

Burn unit directors reported an estimated mean number of 533 ± 201 burn inpatients and a mean number of 1338 ± 1370 outpatients per year. For superficial burns, the top choice agents identified were Eucerin (47.1%), Aquaphor (35.3%), and antimicrobial ointment such as bacitracin, neomycin, or polymyxin (17.7%). For superficial partial thickness burns, antimicrobial ointment (26.1%) and Mepilex Ag (26.1%) were the preferred agents, followed by Aquaphor (13.0%). The preferred agents for deep partial thickness burns were Mepilex Ag (22.2%), antimicrobial ointment (16.6%), and chemical debridement by agents such as Santyl, Xenaderm, or Granulex (16.7%). Other agents used for both superficial and deep partial thickness burns included Mepilex alone (4.4%, 5.6%), silicone dressing (4.4%, 5.6%), and other silver dressings including Acticoat (4.4%, 5.6%), Aquacel Ag (4.4%, 5.6%), Silverlon (4.4%, 5.6%), and Exsalt (4.4%, 5.6%). The preferred agents for full thickness burns were silver sulfadiazine cream 1% (41.7%), antimicrobial ointment (8.3%), chemical debridement (16.7%), Silverlon (8.3%), Exsalt (8.3%), and Sulfamylon (8.3%).

Conclusion

The standard method of treatment for non-operative burns differed by burn depth, with humectants being favored for superficial burns and antimicrobial agents being preferred for partial thickness and full thickness burns. Overall, burn surgeons are willing to consider newer treatments such as the highly favored Mepilex Ag in addition to well-established methods. Thus, it is important to conduct follow-up studies and randomized clinical trials to ensure that our understanding of the standard of care for burn management remains current.

Skin-sparing mastectomy (SSM) remains the most commonly performed mastectomy technique with the goal of preserving native breast skin to be utilized for breast reconstruction. Incision patterns employed for SSM may be classified into the traditional transverse elliptical incision or skin reducing patterns. The transverse incision is centered around the nipple areolar complex (NAC) whereas skin reducing patterns employ vertical and/or low transverse incisions along the inframammary fold similar to those utilized in breast reduction/ mastopexy procedures.1 Advancements in both oncologic and reconstructive breast surgery have made postoperative cosmesis and patient satisfaction critical outcome measures. We aim to identify if there is a preference among the public regarding aesthetic outcomes between the traditional transverse and skin reducing incision patterns following implant-based breast reconstruction (IBBR). A review of patients who underwent SSM and IBBR was completed. Twelve patients were included, 6 with a transverse elliptical incision pattern and 6 with skin reducing mastectomy (SRM) patterns, of multiple oncologic breast surgeons and plastic surgeons. Patients were matched regarding to demographic data and preoperative breast cup/ ptosis grade. Descriptive statistics were performed to characterize the patient sample. A survey of de-identified postoperative patient photos was created via RedCap to assess aesthetic outcomes in seven breast-related categories: Symmetry, Volume, Projection, Shape, Skin Quality, Scar Pattern, and Overall Aesthetic Rating.2 Survey respondents were also categorized based on the presence or absence of healthcare work experience. The survey was distributed via social media and the Amazon MTurk crowdsourcing platform. Once survey responses were recorded, the sample was stratified by the incision pattern employed and respondent aesthetic evaluation was calculated using logistic regression. Student's t-tests, Pearson chi-square tests, or Fisher exact tests were used to determine associations between dependent and independent variables. Wald test and the likelihood ratio test were used to test the significance of individual predictive variables, and the model χ2 statistic was applied to test the overall significance of the model. A p-value of less than 0.05 was considered statistically significant. 1,192 survey responses were recorded and analyzed. Respondents tended to be female, less than 40 years of age, and similarly distributed in terms of those with healthcare experience and those without it. In every breast-related category, the SRM was rated higher compared to the transverse pattern. When comparing aesthetic preference of results between incision patterns with NAC reconstruction, SRM patterns were preferred. This study represents a crowdsourced survey of aesthetic results of patients following SSM with traditional transverse versus SRM patterns and IBBR. The SRM patterns were more aesthetically pleasing to the general public regardless of respondent age, gender, or healthcare experience. In patients where SRM incision patterns are feasible, their use may improve patient satisfaction with their mastectomy/ reconstruction aesthetic outcome.

1. van Paridon, M. W., Kamali, P., Paul, M. A., Wu, W., Ibrahim, A. M. S., Kansal, K. J., Houlihan, M. J., Morris, D. J., Lee, B. T., Lin, S. J., & Sharma, R. (2017). Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes. Journal of Surgical Oncology, 116(2), 195–202. https://doi.org/10.1002/JSO.24634

Introduction: Unicoronal craniosynostosis (UCC) is described most classically by facial abnormality in conjunction with anterior calvarial asymmetry. While facial abnormalities such as the harlequin eye deformity are unique to the diagnosis, cranial dysmorphology mimics that of other causes such as positional plagiocephaly. Currently, physicians are without tools to measure the anterior asymmetry leading to impaired diagnosis and surgical evaluation.

Methods: The Wake Forest Cranial Imaging Database, a multicenter imaging database, was used to identify individuals with unicoronal craniosynostosis (n=102). A control group was established using 200 consecutive patients with positional plagiocephaly. A single preoperative CT or 3D-photograph was used to create a cranial surface model of each individual which was then mirrored as needed so that the side of greatest anterior growth was on the right. Cartesian grids were created on the scalp's surface based on the head's length, width, and height. To control for head size, length, width, and height at each point were measured relative to an individual's total cranial length, width, or height. Trends in growth restriction and compensation were evaluated using population averages at each point. Regional trends could be evaluated between the two populations. These trends were used to create a tool able to differentiate between the two groups. Diagnostic performance was evaluated using Area Under the Curve Analysis (AUC). The clinical relevance of this tool was evaluated using individuals who were recommended CT imaging by craniofacial surgeons for rule out of UCC which found no suture fusion between 2018 and 2022. This was used to evaluate if the prior application of the metric could have predicted their low risk of craniosynostosis.

Results: As classically described, growth contralateral to the fused suture increased resulting in asymmetric frontal bossing. Notably, the largest growth restriction was seen in the posterior rather than anterior cranium where both sides remain shorter than those with positional plagiocephaly. This occurs to a greater degree on the side of suture fusion. While in positional plagiocephaly, the head maintains a typical pattern of width with the eryuon located superiorly and posteriorly, those with UCC have an anterior and inferiorly located euryon and, unlike those with positional plagiocephaly, anterior width that is greater than posterior width. Similarly, an abnormal pattern of greater anterior than posterior height is seen. Overall, these patterns can be summarized as impaired posterior growth which results in compensatory increases in anterior growth. Growth restriction is more severe on the side ipsilateral to suture fusion while compensatory growth is greater contralateral. By measuring the contralateral frontal bossing, an effective diagnostic tool is created with an AUC of 0.985. A metric cutoff of 0.977 maximizes sensitivity and specificity at 93% and 96% respectively. 25 individuals were identified between 2018 and 2022 as having obtained unneeded CT imaging, and threshold of 0.929 was evaluated as it would have perfect (100%) sensitivity relative to UCC. An index cutoff of 0.929 would have identified 24/25 as having low risk of craniosynostosis.

Conclusion: Unicoronal craniosynostosis is classically described as an anterior pathology, however, here we find that the growth restriction leads to a significantly shortened posterior cranium. Diagnostically, applying these nuanced trends in the context of physical examination of facial abnormality can accurately identify UCC near the level of CT imaging. With regard to operative evaluation, future work evaluating posterior cranial growth postoperatively is needed to evaluate this region's outcomes.

Introduction: The induction of normal cells into having a neoplastic growth has a chain of a perpetual cascade of signaling that promotes the cell to be unorganized, and unregulated and starts the proliferation of monoclonal cells, with the help of a supportive stroma that provides nutrition through blood vessels and adjacent structures. Our novel perfusion tissue model was injected with oncogenic cell lines that promote the growth of neoplasia to recreate this signaling and to fully understand the mechanism in which a normal cell loses uniformity in size and shape and causes irreversible neoplasia, invasion of basement membrane and invades adipose tissue promoting angiogenesis in adjacent tissue. This study shows the pathways in which tumor cells act insidiously activating or decreasing signaling to proliferate and invade.

Methods: Cancer cell lines (Breast, melanoma, and prostate) were injected into our perfusion model that uses human abdominal tissue recovered from an abdominoplasty. We canulate the superficial inferior epigastric artery and vein and perfuse it with our special culture media containing amino acids, antibiotics, and hydrocortisone. We injected cancer cell lines and then proceed to administer an enhancer to promote growth within each cell line. After 10 days we performed an excisional biopsy to remove the tumor, afterwards we stain the samples for H&E and immunochemistry for DAPI and Ki-67.

Results: The tumor cell lines grew, and it was palpable in the physical examination of our human tissue. The H&E stain showed a rapid proliferation of atypical cells that invaded the dermis within 10 days after injection. There is evidence these tissue immune cells were activated and accumulated in the pleomorphic cells to contain the spread of the tumor. This experiment also shows invading cells in the stroma all the way to adipose tissue, there were visible metastatic cells in distant parts of our tissue. Immunochemistry of KI-67 and DAPI shows increase mitotic activity and visible nuclei spreading to adipose tissue and blood vessels.

Conclusions: Our perfusion model using human skin has shown promising results to cultivate and proliferating cancer cells to fully understand the behavior of tumor growth and the mechanism by which immune cells respond to atypical cells. We can begin testing new chemotherapeutics and monoclonal antibodies in our model and stop using animal models that do not have the same behavior as a human.

Background: Exosomes are extracellular vesicles, which play an important role in intercellular communication due to their specific bioactive cargo and are postulated to overcome limitations associated with current cell-based therapy. The ideal concentration of Purified Exosome Product (PEP), an off-the-shelf product, to enhance nerve regeneration has not been adequately investigated. The aim of this study was to determine the optimal concentration of PEP for nerve regeneration in vitro using a dose-response analysis.

Materials and methods: Neonatal dorsal root ganglia (DRG) were incubated with (i) 5%, (ii) 10%, (iii) 15% and (iv) 20% PEP solution (N=6/group). After 72 hours, samples were stained against Neurafilament-160 to determine the average neurite outgrowth as a measure of nerve regeneration. Each group was compared to all PEP concentrations and negative controls. Live cell imaging (Incucyte) was used to visualize neurite outgrowth every three hours until the end of incubation.

Results: The macroscopic appearance of neurites, stained against Neurofilament-160, was most evident in the 5% PEP group. Compared to untreated DRGs, neurite outgrowth was found superior in the 5% PEP group (P=0.03). DRGs treated with 10%, 15% and 20% PEP concentration were found comparable to controls and demonstrated no statistical difference between each other (respectively P=0.59, P=0.74, P=0.99). Moreover, no decreasing or increasing trend in neurite length was identified after administration of higher concentrations of PEP. Migration of PEP was found towards the DRG in live cell imaging.

Conclusion: 5% PEP was found to be optimal for nerve regeneration based on this in vitro dose-response analysis. This optimal concentration of PEP will be applied in future in vivo peripheral nerve basic science research.

Background: Patients seeking aesthetic surgery have access to a diverse range of healthcare providers who can perform their procedures, including both plastic and non-plastic surgeons. A prior survey distributed in 2017 aimed to better understand general misperceptions of the titles "plastic surgeon" and "general surgeon", and found that there were high levels of confusion amongst the general public.1 This study aims to determine how public knowledge surrounding this topic has changed by evaluating perceptions of cosmetic versus plastic surgeons.

Methods: Amazon's Mechanical Turk crowdsourcing service and REDCap's survey manager were used to recruit survey participants and collect responses. An anonymous 14-question survey gauged perception of the differences between cosmetic versus plastic surgeons. Participants were then shown descriptions of each and asked how their opinions changed after acquiring this information. Comparisons were made using Chi-square and Fisher exact tests depending on sample size and underlying distributions. A verification question was included to ensure participants were paying adequate attention to each survey question.

Results: A total of 443 verified responses were collected. The average age of participants was 34.1 years. Initially, 161 participants (36%) believed that there were no differences between plastic and cosmetic surgeons. However, 268 respondents (60%) believed that the two types of surgeons underwent different training programs but ultimately learned the same skills. The average length of training expected in a provider performing aesthetic surgery was 4.9 years. Before being shown the difference between the two titles, 216 (49%) of participants stated they would intentionally only reach out to a cosmetic surgeon for an aesthetic surgery, while 139 participants (31%) would intentionally only reach out to a plastic surgeon. The remaining 20% showed no preference between the two types of surgeons. After being given the definitions of cosmetic and plastic surgeons, almost all participants (93%) reported having changed their opinion about at least one of the surgeon types. Additionally, significantly fewer patients would choose a cosmetic surgeon (p = 0.0102) and significantly more patients would choose a plastic surgeon after learning the difference (p < 0.00001).

Conclusion: While there are numerous healthcare providers who perform aesthetic surgery, the length of training can be dramatically different and often falls below what patients expect when consulting a surgeon. Patients should be aware of the differences in credentials and training among them to make informed decisions about the surgeons they choose to seek out. Our study revealed that simple targeted education helped correct misunderstandings and significantly changed public preferences on who to seek out for aesthetic care. Therefore, greater efforts should be made to improve transparency and optimize patient autonomy in aesthetic surgery through public education campaigns distinguishing between plastic surgeons and cosmetic surgeons.

1. Shah A, Patel A, Smetona J, Rohrich RJ. Public Perception of Cosmetic Surgeons versus Plastic Surgeons: Increasing Transparency to Educate Patients. Plast Reconstr Surg. 2017;139(2):544e-557e. doi:10.1097/PRS.0000000000003020

Background: The field of Plastic and Reconstructive Surgery (PRS) is becoming increasingly competitive as a residency choice for medical students. Our program aimed to evaluate if students who participated in a Plastic and Reconstructive Surgery (PRS) Summer Research Program have a better understanding and an increased career interest in the field of Plastic and Reconstructive Surgery. Methods: We proposed a six-week summer research program and didactic teaching series aimed to introduce students to the field of plastic and reconstructive surgery, basic research skills, and a structure for project development. To evaluate the program's efficacy, we used two identical surveys collected before the course and after completion. In addition, a post-course survey was employed to assess the effectiveness of the weekly lecture series, knowledge of the field and research process, and the benefit of our mentorship model. Results: Confidence in performing a literature search increased from 78% to 94% (p < 0.05). Confidence in creating an annotated bibliography had a 32% increase (p < 0.05). Additionally, students' confidence in writing a manuscript increased from 22% to 74% following the course (p < 0.05). Overall, there was a general improvement in post-course competencies across all areas. Conclusions: Our data showed improved student understanding of the field, comfort in the research process, and ability to find and work with a mentor. We believe this program can be broadly applied, is simple to implement, cost-effective, and easily reproducible for institutions interested in providing early exposure and mentorship to preclinical students.

Background Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique.

Methods We queried the PubMed electronic database from its inception until December 2022 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate.

Results 42 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in BCT patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p=0.014) and in 41/517 BCT patients (p=0.301)

Conclusion Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients.

Purpose: Sports and recreation related maxillofacial injuries are one of the most common etiologies of facial fractures and dental injuries, and these types of injuries are becoming increasingly common as participation in sports and other physical activities grows. There is no prior study on the distribution of such injuries among various types of recreational activities in large, demographically diverse groups in the United States. As such, the objective of the present study is to offer a detailed analysis of recreation-related facial fractures and dental injuries taking into account age, gender, race and etiology using a national sample. This information can enable the identification of high-risk activities as well as groups most prone to injury, leading to tailored intervention effort towards decreasing orofacial injuries.

Methods: A cross-sectional study of patients reported to the National Electronic Injury Surveillance System (NEISS) from 2019 to 2021 was performed. The NEISS has collected information on injuries and complications related to consumer products for over 45-years. NEISS conducts a national probability sample on U.S hospital emergency room visits to depict larger epidemiological trends related to consumer products. Within our own dataset, patients were included if they had suffered a facial fracture or a dental trauma while engaging a leisure related activity. Mean ages were computed for each activity category, as well as distribution of injuries between sexes and different categories of activities.

Results: Male patients represented the vast majority of injuries, with a nearly 3:1 male to female ratio. Except for horse-riding and scooters, all other categories consisted of mostly male patients. Activities with highest prevalence of facial fractures were basketball, soccer and football in the adolescent age group; as for adults (20 years and older) vehicles (two-wheeled vehicles, scooters, mopeds, cycles, all-terrain vehicles) and exercise without equipment were responsible for the greatest number of facial fractures. A vast majority of the group either had a facial fracture (72.1%) or dental injury (24.5%) and solely 3.44% sustained both. Among patients whose race was listed, 71.4% identified as White, 20.5% Black, 2.8% Asian and 5.3% Other.

Conclusion: Our study found that roughly 3% of oral-maxillofacial injuries related to leisurely activities had concomitant facial and dental injuries. Overall, incidents with two-wheeled vehicles were the most frequent etiology of facial injuries. More granularly, we found a high prevalence of maxillofacial injuries in children to be most related to playground equipment. In the adolescents age group, recreational ball-sports played a major role in such injuries. While in older patients, exercise without equipment, which gained popularity during the COVID-19 shutdowns, were a notable etiology of orofacial injuries. Finally, Black patients were over-represented in comparison to the racial distribution of the United States, a trend which can be justified disparities in head-gear use in minorities; these finding warrant increased access, education and encouragement for the usage of protective head-gear in minority populations.

Introduction: Some evidence suggests that lymphedema could be caused by an age-related decline in lymphatic pump function. We hypothesize that younger patients have better lymphedema improvement than older patients. This study evaluated the efficacy of lymphovenous bypass surgery (LVB) in two age groups to determine the association.

Methods: Adult patients that underwent upper extremity LVB were included. The mean percentage change in volume difference was calculated as follows: % Change = [(postoperative difference) – (preoperative difference)/(preoperative difference)] * 100, where postoperative difference is the absolute difference between the affected and unaffected limbs' volume at a specific endpoint and the preoperative difference is the absolute difference between the affected and unaffected limbs' volume preoperatively. The endpoints were 2 weeks, 2 months, and 6 months after the surgery. The World Health Organization defines "elderly" as more than 65 years old. However, patients were classified as <60 or 60 years and older to balance the sample size for each group for statistical analysis. After evaluating the endpoints for normality using Shapiro-Wilk tests, differences per endpoint among age groups were evaluated using Kruskal-Wallis tests. The limb volume change is expressed as a percentage. Data is presented as mean ± standard deviation.

Results: 70 patients were identified for this study ('younger than 60' = 33, '60+' = 37). Kruskal-Wallis's test was used to assess for significant differences in endpoint values among the age categories. The test, which compares median values, was not statistically significant at any endpoint (χ2 = 0.3377, df = 1, p-value = 0.5612 for week 2; χ2 = 0.86624, df = 1, p-value = 0.352 for month 2; χ2 = 0.028622, df = 1, p-value = 0.8657 for month 6; χ2 = 2.048, df = 1, p-value = 0.1524 for year 1). Despite this, large differences in the mean volume change were observed between the age categories. The mean percentage change in volume difference among age categories at 2 weeks was as follows: '<60 years', - 50.8% ± 54.3; '60 +', - 67.1% ± 105. At 2 months, the mean percentage change in volume difference among age categories was the following: '<60 years', -36.5% ± 70; '60 +', - 22.6% ± 62.2. The mean percentage change in volume difference among age categories at 6 months was: '<60 years', - 41.7% ± 32.6; '60 +', - 40% ± 29.9. At 1 year, the mean percentage change in volume difference among age categories was the following: '<60 years', - 55.2% ± 24; '60 +', - 27.3% ± 58.8.

Conclusion: In the statistical analysis, our data indicate that no relationship between younger patients and lymphedema measurements at each endpoint could be established. However, there are significant differences in the mean percentage change in volume difference between age groups at different endpoints. These findings imply that age may have an effect on volume change following LVB. However, the relatively small sample size may have influenced the statistical significance and normality of the endpoints.

Purpose: Previous literature suggests that nipple reconstruction improves Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being after breast reconstruction, compared to those without nipple reconstruction.1,2 Despite the importance of nipple reconstruction to complete breast reconstruction, not all patients undergo the procedure.3 This study aimed to present sociodemographic disparities that exist within nipple reconstruction.

Methods: A single-center, retrospective analysis of patients who underwent skin-sparing postmastectomy breast reconstruction between 2018 and 2021 was performed. Nipple reconstruction included local skin flaps, grafts, and tattoo. Sociodemographic variables collected were age, race, ethnicity, BMI, employment, insurance, marital status, primary language (English versus non-English), travel distance, and income while surgical characteristics included timing (immediate versus delayed), type of reconstruction (autologous versus implant), and laterality.

Results: Of the 4,104 skin-sparing postmastectomy breast reconstruction patients included, 2,480 (60%) patients did not undergo nipple reconstruction and 1,624 (40%) did elect for nipple reconstruction. Majority of the patients were White (73%), not Hispanic (86%), married (72%), and primarily spoke English (97%).

Patients who elected for the nipple reconstruction were more likely to be younger (OR=1.02; 95% CI: 1.0, 1.03; p=0.007), White (vs. Asian, OR=1.32; 95% CI: 1.02,1.69; p=0.034), and actively working (OR=1.19; 95% CI: 1.02, 1.38; p=0.027) than those who did not undergo nipple reconstruction. Patients with Medicare insurance were less likely to have nipple reconstruction than those with Commercial insurance, and the p-value approached significance (OR=0.80; 95% CI: 0.64, 1.01; p=0.06). Patients who had implant reconstruction (OR=0.33; 95% CI: 0.11, 0.40; p<0.001), unilateral (OR=0.86; 95% CI: 0.75, 0.99; p=0.034), and delayed reconstruction (OR=0.70; 95% CI: 0.58, 0.84; p<0.001) were significantly less likely to receive nipple reconstruction.

Conclusion: After skin-sparing postmastectomy breast reconstruction, 40% of patients undergo nipple reconstruction. Patients who are older, Asian, not actively working, and under Medicare may require additional counseling regarding nipple reconstruction in order to complete their breast reconstruction. Those who have unilateral, delayed, and implant-based reconstructions may also benefit from further discussions on the advantages of nipple reconstruction. Overall, our findings suggest that despite nipple reconstruction being a patient-preference operation, traditional healthcare disparities are still present.

References: 1. Egan KG, Cullom M, Nazir N, Butterworth JA. Patient Satisfaction Increases with Nipple Reconstruction following Autologous Breast Reconstruction. Plast Reconstr Surg. 2021 Aug 1;148(2):177e-184e. doi: 10.1097/PRS.0000000000008180. PMID: 34133405. 2. Bykowski MR, Emelife PI, Emelife NN, Chen W, Panetta NJ, de la Cruz C. Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer. J Plast Reconstr Aesthet Surg. 2017 Feb;70(2):209-214. doi: 10.1016/j.bjps.2016.10.009. Epub 2016 Nov 9. PMID: 27988150. 3. Nelson JA, Voineskos SH, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Elective Revisions after Breast Reconstruction: Results from the Mastectomy Reconstruction Outcomes Consortium. Plast Reconstr Surg. 2019 Dec;144(6):1280-1290. doi: 10.1097/PRS.0000000000006225. PMID: 31764633; PMCID: PMC6934401.

Introduction: Non-tuberculosis mycobacterium (NTM) is a rare cause of periprosthetic infection after mastectomy and breast reconstruction¹. Despite periprosthetic NTM having high reported rates of drug resistance and difficult courses of treatment, prior case examples, knowledge of optimal antimicrobial regimens, and guidelines for surgical management remain limited. The purpose of this study is to review the current literature for available experience with NTM periprosthetic infections in breast reconstruction with a focus on treatment and outcomes, in addition to a discussion regarding the management of three cases at our institution.

Methods: A literature search was conducted in PubMed, BMC, and Cochrane databases starting from inception to February 2023 with the following search terms: "mastectomy" and/or "breast" and "reconstr" and "mycobacter." Searches identified a total of 112 abstracts. Ten papers ultimately met the study inclusion criteria, which required detailed descriptions of the medical and surgical treatment for specific instances of periprosthetic NTM infection.

Results: Ten prior case reports or series included a total of 17 patients that received 27 breast reconstruction procedures. Average patient age was 50.5 years. Mycobacterium Fortuitum was isolated in most patient cases (n=11, 65%). All 17 patients had undergone reoperation and implant removal, with 48% (n=8) requiring additional subsequent operations due to infection. Successful delayed reimplantation after completion of antibiotics (mean duration 18 weeks) was performed in nine patients (53%). More than one-half of patients were originally started on an antimicrobial regimen consisting of ciprofloxacin (n=9), including six patients with M. Fortuitum infection. Three cases of M. Fortuitum (30%) infection described the effect of sensitivity results on the final treatment regimen, all of which yielding some degree of resistance to ciprofloxacin (100%) that led to modification of original antimicrobials in two patients (67%). Three cases of NTM occurred within our own institution in a three-year timespan. Two patients had isolated M. Abscessus that was resistant to the original antimicrobial regimen that included levofloxacin and doxycycline. The third patient had Mycobacterium neoaurum, making this the first documented periprosthetic case. Mean incubation period for NTM in our institution's patients was four months. Implant salvage after negative pressure therapy and intravenous antimicrobial regimens was attempted in two of the patients, though the implants were later removed prophylactically after positive culture results per recommendations of infectious disease (ID). None of the three have had delayed reconstruction reattempted.

Conclusions: In cases of NTM breast implant infections following reconstruction, M. Fortuitum is most common. M. Fortuitum appears to be highly drug resistant, emphasizing the importance of sensitivity testing. Obtaining information on antimicrobial sensitivity can be a lengthy process and therefore, guidance for antibiotic and surgical treatment with ID specialists is recommended. It continues to remain unknown whether implant salvage can be attempted in specific patient scenarios. Cases of NTM periprosthetic infection should continue to be documented as they become available.

¹ Washer LL, Gutowski K. Breast implant infections. Infect Dis Clin North Am. 2012 Mar;26(1):111-25.

Introduction: Everyone has a unique composition of micro-organisms present in their gut known as the gut microbiome, and prior studies in other surgical fields have suggested changes to the gut microbiome can influence surgical complications.¹⁻³ Post-mastectomy implant infection rates have been cited as high as 28%, with no clear evidence regarding the utility of prophylactic oral antibiotics in protecting against serious infections.⁴⁻⁵ The potential influence of the gut microbiome in these implant infections remains unknown. In a pilot study using 16s rRNA sequencing to characterize the gut microbiome, we explore the impact of prophylactic antibiotics on the gut microbiome in post-mastectomy tissue expander patients and its role in clinical tissue-expander infections.

Methods: We designed a two-arm randomized-controlled trial for mastectomy patients undergoing two-stage implant-based reconstruction. Patients were randomized to 7 days of prophylactic post-operative Keflex (Cohort A), versus only 24 hours of Cefazolin (Cohort B) at the time of surgery. A stool sample was collected pre-operatively and 1 week post-operatively. Microbial analysis with 16S rRNA microbiome sequencing was performed by MRDNA. Statistical comparisons were made with ANOVA and post hoc pairwise comparison with Tukey's test.

Results: Of the 39 enrolled patients, 19 patients were in Cohort A and 20 patients in Cohort B. 16 pre-op and 18 post-op samples were provided from Cohort A, and 20 pre-op and 20 post-op samples from Cohort B patients. With 7 days of Keflex (Cohort A), the relative abundance in stool of the species Flavonifractor (p=0.001), and Collinsella (p=0.002) significantly increased post-operatively, and Eubacterium(p=0.009) and streptococcus (p=0.01) decreased post-operatively, while no changes were seen in these organisms in Cohort B. In contrast, with only 24 hours of Cefazolin(Cohort B), stool Staphylococcus increased post-operatively (p=0.009) with no change seen in Cohort A. For both cohorts, Lachnoclostridium(p=0.036) increased, while Blautia (p=0.035) decreased. While alpha diversity (a measure of the diversity or species richness) did not differ significantly between pre-op cohorts A and B (p=0.75), diversity was significantly lower in Post-op A compared to Pre-op A (p=0.04), and Pre-op B compared to Cohort B (p=0.05). Clinically, there was a 34.4% infection rate in Cohort A, compared to 15.6% in Cohort B (p=0.083). Implant removal was required in 7 breasts (22%) of Cohort A, compared to 5 breasts (15.6%) of cohort B (p=0.200). Mean time from mastectomy to explant was 92 days (cohort A) vs 63 days (Cohort B) p=0.426.

Conclusion: Significant changes were seen to the gut microbiome after administration of antibiotics that varied between cohorts, including decreased Streptococcus and other fecal flora with 7 days of antibiotics, and increased Staphylococcus with 24 hours of antibiotics. Overall microbial diversity decreased with any antibiotic regimen. Clinically, increased infections and delayed explantations were seen with 7 days of antibiotics. Our data reflects marked changes to the balance of the microbiome seen in the gut, and provides novel insight into the impact of prophylactic antibiotics in these patients.

References: 1. Lederer AK, Pisarski P, Kousoulas L, Fichtner-Feigl S, Hess C, Huber R. Postoperative changes of the microbiome: are surgical complications related to the gut flora? A systematic review. BMC Surg. Dec 04 2017;17(1):125. doi:10.1186/s12893-017-0325-8 2. Ward T, Nichols M, Nutter J. Can Probiotics Improve Your Surgical Outcomes? Plast Surg Nurs. 2016 Apr-Jun 2016;36(2):74-7. doi:10.1097/PSN.0000000000000143 3. Chowdhury AH, Adiamah A, Kushairi A, et al. Perioperative Probiotics or Synbiotics in Adults Undergoing Elective Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg. 06 2020;271(6):1036-1047. doi:10.1097/SLA.0000000000003581 4. Yamin F, Nouri A, McAuliffe P, et al. Routine Postoperative Antibiotics After Tissue Expander Placement Postmastectomy Does Not Improve Outcome. Ann Plast Surg. 07 01 2021;87(1s Suppl 1):S28-S30. doi:10.1097/SAP.0000000000002826 5. Phillips BT, Fourman MS, Bishawi M, et al. Are Prophylactic Postoperative Antibiotics Necessary for Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial. J Am Coll Surg. 06 2016;222(6):1116-24. doi:10.1016/j.jamcollsurg.2016.02.018

Introduction The underlying principles of preservation rhinoplasty (PR) center around maintaining the soft tissue envelope, dorsum, and alar cartilage through surgical manipulations and tip suture techniques. In particular, the let-down (LD) and push-down (PD) techniques have been described, although reports of indications and outcomes in the literature are sparse. Methods A systematic review of the literature was performed using search terms "preservation" OR "let down" OR "push down" AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and Embase databases. Patient demographic information, operative details, and surgical outcomes were recorded. Sub-cohorts for patients who underwent LD and PD techniques were analyzed utilizing Fischer's exact test for categorical variables and Student's t-test for continuous variables. Results Overall, there were 5967 PR patients in 30 studies in the final analysis, with 307 patients in the PD cohort and 529 patients in the LD cohort. The Rhinoplasty Outcome Evaluation Questionnaire showed a significant increase of patient satisfaction after PR (62.13 vs 91.14; p<0.001). There was a significantly lower rate of residual dorsal hump or recurrence of 1.3% (n=4) in the PD when compared to 4.6% (n=23) in LD cohorts (p=0.02). The revision rate of PD (0%, n=0) was also significantly lower than that of LD (5.0%, n=25) (p<0.001).

Conclusion Preservation rhinoplasty is a safe and efficacious procedure with improved dorsal aesthetic lines, reduced dorsal contour irregularities and excellent patient satisfaction. In particular, the PD technique has fewer complications and revisions than LD approach, although PD is often indicated in patients with smaller dorsal humps. Although, our indepth analysis of published results demonstrated frequent imperfections and scarcity of the flawless results which will be the subject of another report.

Background: Facial gender affirming surgery (FGAS) has been associated with improving gender dysphoria in transgender patients. This study aims to quantify the impact of surgery on patient facial satisfaction using the FACE-Q, a validated patient reported outcome tool, and a quality-of-life (QoL) survey.

Methods In this single-center cohort study, transfeminine patients were recruited to complete the FACE-Q, a demographics survey, and the World Health Organizations QoL Scale-Short Form (WHOQOL-BREF) if they were planning to or had undergone FGAS. Procedures performed included frontal sinus setback/brow contouring, rhinoplasty, genioplasty, mandibular contouring, and chondrolaryngoplasty. FACE-Q were completed at a minimum of 3 months postoperatively. FACE-Q modules completed included "satisfaction with facial appearance overall," "facial attributes (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck)," "decision," "outcomes," "expectation," "psychological function," and "social function." WHOQOL-BREF assesses patient QoL through four domains: physical, psychological, social relations, and environment. A demographics survey was used to assess patient experience obtaining gender affirmation surgery. Statistical analysis was performed comparing preoperative and postoperative cohorts, as well as a sub-analysis comparing matched patients who completed both preoperative and postoperative surveys.

Results In total, 48 of 55 (87%) patients recruited preoperatively and/or postoperatively completed the FACE-Q. There were 68 FACE-Q surveys completed, 31 preoperatively and 37 postoperatively. Most patients received frontal sinus setback/brow contouring (83%) followed by rhinoplasty (81%). Among all patients undergoing FGAS, mean FACE-Q scores increased significantly (p<0.05) from preoperatively to postoperatively in all facial attributes and in "satisfaction with facial appearance overall." The WHOQOL-BREF's psychological and physical domain both improved significantly. Similar results were seen among the 20 matched patients who completed the surveys both preoperatively and postoperatively (p<0.05). There were no significant differences in individual FACE-Q scales (e.g., "Satisfaction with Facial Attributes: Nose") when comparing an anatomic region between patients who underwent surgery in that region versus those who did not. Wait time for surgery of less than 6 months (β=-22.42, p=0.02) and undergoing the procedure at a younger age (β=-1.04, p<0.01) were each independently associated with higher scores for "satisfaction in facial appearance overall."

Conclusion Transfeminine patients experienced significant improvements in satisfaction with facial appearance and QoL following FGAS. Undergoing surgery at a younger age and shorter wait times for surgery were important factors in patients' overall facial satisfaction.

Introduction Phalloplasty for gender affirmation is a complex surgery that utilizes pedicled or free flaps to create an aesthetically pleasing phallus allowing for standing micturition, tactile and erogenous sensation, and penetrative intercourse.¹ However, phalloplasty is associated with a high rate of complications, including urethral strictures, urethro-cutaneous fistulas, flap loss, and the need for reoperation.²⁻³ This study aimed to evaluate the impact of flap choice on the rate of complications in phalloplasty. Methods This retrospective cohort study was conducted at a single institution from March 2019 to December 2022. Patients were 18 years or older at the time of surgery, had a diagnosis of gender dysphoria, and underwent phalloplasty. Patients were assigned groups based on the type of flap used (radial forearm (RFFF), anterolateral thigh (ALT), and pedicled abdominal flap). Complications were defined as urethral stricture, urethral fistula, necrosis of neophallus, infection, wound dehiscence, and flap loss. A univariate analysis was conducted. Results A total of 32 patients underwent phalloplasty. RFFF was used in 14 (43.8%) patients, pedicled abdominal flaps in 13 (40.6%) patients, and ALT flaps in 5 (15.6%) patients. The overall complication rate for phalloplasty was 43.8%. RFFF had the highest complication rate (71.4%), followed by ALT (60%) and pedicled abdominal flaps (7.6%) (p=0.001). Reoperations were most likely in the RFFF (64.3%) group followed by the ALT (40%) and pedicled abdominal flap (7.6%) groups (p=0.01). Flap choice was also significantly associated with urethro-cutaneous fistulas. RFFF had the highest rate of fistulas at 50%, while the ALT and pedicled abdominal flaps had rates of 20% and 7.6%, respectively (p=0.046). Urethral strictures were more likely in the ALT (60%) group compared to the RFFF (42.9%) and pedicled abdominal (7.6%) groups (p=0.087). Of note, no significant difference in complications was found based on race, ethnicity, BMI, age, medical comorbidities, or psychiatric comorbidities, and none of the flaps had partial or complete loss. Discussion The choice of flap appears to play a role in phalloplasty complications. RFFF was found to have a significantly higher rates of overall complications, reoperation, and development of urethro-cutaneous fistulas relative to ALT and pedicled abdominal flaps. The higher rates of complications maybe due to the overlying suture pattern of the neophallus and urethra. However, RFFF may still be the preferred option for patients who desire a single-stage urethral lengthening, more erogenous sensation, and increased ability to have penetrative intercourse. Pedicled abdominal flaps have fewer complications, but they are limited by decreased erogenous sensation, the need for a second surgery for urethral lengthening, and the presence of prior surgical scars. As one of the most common flaps used in phalloplasty, insight into clinical outcomes associated with its use is vital to both surgeons and their patients when participating in shared decision making. Larger, multi-institutional studies are necessary to better characterize and to provide interventions aimed at decreasing complications in transgender men undergoing phalloplasty.
References 1. Heston AL, Esmonde NO, Dugi III DD, Berli JU. Phalloplasty: Techniques and outcomes. Translational Andrology and Urology. 2019;8(3):254-265. doi:10.21037/tau.2019.05.05 2. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. Urethral complications after gender reassignment surgery: A systematic review. International Journal of Impotence Research. 2020;33(8):793-800. doi:10.1038/s41443-020-0304-y 3. Bryson C, Honig SC. Genitourinary complications of gender-affirming surgery. Current Urology Reports. 2019;20(6). doi:10.1007/s11934-019-0894-4

Background: Amidst a marked surge in online traffic, plastic surgeons and plastic surgery (PRS) patients utilize social media platforms with growing frequency. Moreover, it has been postulated that the more time an individual spends online viewing PRS-related content, the more likely they are to opt for plastic surgery themselves. In this study, we aim to investigate the frequency with which the general public encounters PRS-related material and the predominant platform where they come across such content.

Methods: A survey was distributed to adults in the United States using the Amazon Mechanical Turk crowdsourcing platform. Questions assessed respondent demographic information, prior exposure to PRS, usage of online mediums, and frequency of encountering PRS-related content. Responses were grouped into two cohorts: those with prior experience or interest in pursuing PRS (Interest) and those without interest in pursuing PRS (Non-Interest). Multivariate ordinal logistic regression was used to assess relationships between demographic variables and frequency of PRS content exposure. Wilcoxon rank sum and Fisher exact test were used to compare the Interest and Non-Interest groups.

Results: A total of 474 complete responses were analyzed. The median age of respondents was 33 (IQR: 30 - 44). The majority of respondents reported frequent Internet use, with 70% using the Internet at least once a day. Within the last six months, 45% of respondents reported seeing PRS-related content or advertising on social media. Increasing household income (p = 0.002) and interest in PRS (p < 0.001) were significantly associated with a greater frequency of active information seeking about PRS-related content. Beyond intentional searches, the Interest group significantly encountered PRS content more frequently than the non-Interest group on 7/8 social media platforms, through general online internet advertising, and in printed media.

Conclusion: The findings of this nationwide survey demonstrate a notable and steady surge in the general public's exposure to PRS content, with social media serving as the primary conduit for such information. Subsequently, the PRS patient population may increasingly be exposed to online content with variable degrees of accuracy. As such, it is essential to conduct further studies to gauge the public's perception of the reliability and veracity of online PRS-related material. By undertaking such research, we may characterize and identify ways to mitigate risks associated with the ever-growing exposure to online PRS-related content.

Background In 2021, 1.9 million dermal filler procedures were performed, with the tear trough as a popular region. While the complication rate is unknown, severe or permanent complications such as skin necrosis and blindness are possible due to retrograde embolization of the filler from the angular artery through the dorsal nasal arterial system. Traditional methods to avoid intra-arterial injection have included lateral injection with massage that moves the filler medially. High-resolution, hand-held ultrasound has become increasingly popular in the field of aesthetic surgery for facial mapping. The purpose of this study was to map the angular artery at the medial canthus, specifically depth and distance from supraorbital rim. Precise knowledge of the angular artery at this location may allow accurate prediction and avoidance during filler injection.

Methods Twelve subjects underwent high-resolution ultrasound mapping (Clarius, L15 HD, 8-20 MHz) of the angular artery at the medial canthus. The ultrasound probe was placed at the supraorbital rim at the medial termination of the eyebrow and angled parallel and longitudinal to the nasolabial fold bilaterally. Color flow doppler was utilized to assist in identification of the artery. The depth and distance from the supraorbital rim at the medial eyebrow were measured bilaterally. Statistical analysis was performed.

Results Five (42.7%) subjects were male and seven (58.3%) were female. The average age was 27.9. The angular artery average distance from the supraorbital rim at the medial eyebrow was 13.6 ± 4.5 mm. The angular artery's average depth was 3.4 ± 1.0 mm.

Conclusion High-resolution ultrasound can be utilized to map the location of the angular artery at the medial canthus prior to tear trough filler injection. Distance from the supraorbital rim at the medial eyebrow and depth can be used to predict the location of the angular artery rather than relying on traditional safety measures. We continue to gather data to increase our study's sample size and include all facial vasculature.

PURPOSE: Gender-affirming mastectomy or top surgery continues to increase in prevalence; however, the most aesthetically favorable mastectomy incision design is unknown in the transgender male population. While patient-specific factors or preferences may influence the approach, this study aims to determine the ideal mastectomy design for gender-affirming top surgery. Further, to assess patient-reported experiences surrounding top surgery to enhance shared decision-making and optimize patient satisfaction.

METHODS: Five different mastectomy incision designs (curvilinear, diagonal, horizontal, lateral, and medial curves) served as patterns to digitally create the resulting scars using Adobe Photoshop on two cisgender male volunteers of normal and obese BMI class. Using crowdsourcing, respondents were asked to independently rank each option in preferential order on both models, in both the front and oblique views. Further, a cohort of post-mastectomy transgender male patients was asked to evaluate their perioperative experience.

RESULTS: Five hundred fifty-five respondents participated in the survey (503 general population and 52 post-mastectomy patients). Overall, the lateral curve design (total score avg. = 8.81) was ranked significantly higher than the diagonal (total score avg. = 16.15; p<.0001), curvilinear (total score avg. = 13.37; p<.0001), and medial curve (total score avg. = 11.52; p=0.0086) designs, but was not significantly different from the horizontal design (total score avg. = 10.15; p=0.4606). The diagonal design was ranked significantly lower than all other designs. This remained consistent within the post-mastectomy subgroup analysis. Within the post-mastectomy cohort, 71.1% were able to identify their design, 63.5% were knowledgeable of the design options, and 9.6% attributed this knowledge to their surgeon. Patient-initiated discussion surrounding design preference was reported by 17.3%, while the surgeon initiated 36.5%.

CONCLUSION: The lateral curve and horizontal designs were the preferred options, while the diagonal design was the least favored. Patient-dependent factors, preference, and surgeon experience influence the chosen incision design. However, the unique aesthetic considerations during gender-affirming mastectomy distinct from oncologic indications allow the plastic surgeon to tailor the incision design that ensures patient-centered care and supports the patient's desired outcome.

Background: Prosthetic breast reconstruction remains the most common approach for women after mastectomy. However, the reliance on implanted devices introduces the persistent risk of infection, which can necessitate removal in severe cases. For mild infectious symptoms, oral or intravenous antibiotic therapy may be attempted first with the goal of avoiding removal. Without reliable culture data, empiric antibiotic selection is required, and should be guided by expected organisms based on patient characteristics. We reviewed the causative species in all reconstructive patients undergoing expander or implant removal at our institution to better understand how patient characteristics and cancer therapy influence the types of microbes and resistance patterns observed.

Methods: This is a retrospective study that evaluated post-operative outcomes of breast reconstruction patients who underwent implant or tissue expander removal due to infection between January 2013 – November 2022 by 6 reconstructive surgeons at UCLA. The primary outcome variable was infectious species, and the secondary outcomes were antimicrobial resistance and susceptibility as well as length of time to explantation. Patient characteristics, which included demographic information, comorbidities, smoking status, and cancer treatment (chemo, endocrine, or radiation therapy) were summarized for the cohort.

Results: Forty-three patients were evaluated as a part of this study who underwent removal of their implantable device due to an unresolved infection. Twenty-five (58%) patients had a documented history of chemotherapy, and 21 patients had previously undergone radiation (49%). All patients that were infected with S. epidermis (n=3) and P. acnes (n=2) had a history of chemotherapy while all patients with P. aeruginosa (n=4) infection did not have a history of chemotherapy. Infections caused by S. aureus were found in similar proportions of subjects with a history of chemotherapy (n=8, 19%) and without (n=6, 14%). Radiation was not associated with microbial species observed. Additionally, no trend was detected to indicate that bacterial species and antimicrobial resistance meaningfully differ between pre-pectoral and sub-muscular placement.

Conclusion: This study showed that infections caused by gram negative P. aeruginosa were exclusively found in patients without a history of chemotherapy, while less virulent gram positive bacteria such as S. epidermis and P. acnes were exclusively found in patients with a history of chemotherapy. This type of information can help guide treatment and improve antibiotic stewardship in a reconstructive surgeon's practice.

Background: Facial soft tissue can vary based on characteristics unique to sex assigned at birth. While transfeminine patients can pursue operative interventions to enhance facial fat distribution, gender-affirming feminizing hormone therapy (HT) has also been known to have a qualitative effect on facial fat volumes. However, the relationship between HT duration and the quantitative changes in facial fat pad volumes in transfeminine patients is unknown despite its importance in patient counseling and procedural decision-making in facial feminization surgery (FFS). In this study, we assessed for the volumetric differences of the malar and temporal fat pads in transfeminine patients on various durations of HT.  

Methods: Our retrospective, single-institution, study included transfeminine patients 20-29 years of age with normal body mass index seeking their initial FFS. Patients who were non-binary, seeking facial masculinization surgery, or revision FFS were excluded. OsiriX (Pixmeo SARL, Geneva, Switzerland) was used to perform a volumetric assessment of the bilateral malar and temporal facial fat pads on high resolution, non-contrast craniofacial computed tomographic imaging of transfeminine patients. Patients were divided into two cohorts in order to assess for effects of HT duration on facial fat pad volumes: short-term HT (<24 months) and long-term HT (≥24 months). All data was acquired by two, independently blinded measurers. 

Results: Forty-five transfeminine patients, with a mean age of 24.4 years, SD = 2.8, were included in this study. The 30 patients in the long-term HT cohort demonstrated a duration of HT nearly threefold greater than that of the 15 patients in the short-term HT cohort (median (interquartile range, IQR): 44.5 (33.5-65.6) months vs. 15.0 (11.0-18.0) months, p<0.001). Long-term HT was associated with a 1.6-fold increase in average bilateral malar fat pad volumes than short-term HT (median (IQR), 48.1 (38.1-61.0) cm3 vs. 29.5 (24.2-38.6) cm3, p<0.001). There was also a 1.5-fold increase in average bilateral temporal fat pad volumes in long-term HT compared to short-term HT (median (IQR), 17.0 (14.6-25.0) cm3 vs. 11.7 (10.4-19.5) cm3, p=0.018).  

Conclusions: Gender-affirming transfeminine HT greater than 2 years duration is associated with increased average facial fat pad volumes in the malar and temporal regions bilaterally. In the future, we hope to assess the effects of HT duration on facial fat pad volumes in a larger cohort of patients from various age groups for greater generalizability of our results.

Background: Ear molding is a safe, non-surgical approach to treat newborns with congenital ear anomalies. While caretaking burden and aesthetic outcomes have been investigated in the short term, there is dearth of long-term studies assessing outcomes. In this study, we aimed to evaluate long-term aesthetic outcomes and caretaker satisfaction from ear molding therapy.

Methods: A retrospective chart review from 2018 to 2020 was conducted for infants who underwent ear molding treatment at our institution. Patient demographics, age at treatment, race, ear dysmorphology, insurance, length of treatment, and complications were collected. Caretakers were surveyed regarding their experience, expectations, and aesthetic outcome at approximately 1 year (short-term) and after 3 years (long-term) from treatment. Outside plastic surgeons rated outcomes from pre- and post-treatment photographs. Responses were converted to a Likert scale (1-5), with 5 representing most desirable. Survey responses were compared to an earlier study of a matched cohort.

Results: Overall, 38 patients from our original cohort of 42 participated in our follow up study (90%) for a total of 62 ears. Average follow-up was 3.31 ± 0.50 years after completion of treatment. Mean age at treatment was 23.2 ± 19.7 days with a mean treatment duration of 21.7 ± 7.7 days. There were 52 ear deformations (84%) and 10 ear malformations (16%). Seven patients (11%) reported complications, all of which were skin erosions. The average caretaker response regarding the accuracy in resemblance to a normal ear did not change from the short-term survey (long-term: 4.2 vs. short-term: 4.1, p=0.54). Of note, there was a significant decrease in caretakers' anticipated social distress and observed social distress due to ear appearance (long-term: 1.1 vs. short-term: 1.8, p<0.001). Physician assessments of aesthetic outcomes were similar to caretakers' (4.3 vs. 4.2, p=0.51) and increased significantly from short-term physician grading (4.3 vs. 3.5, p<0.001). When comparing long-term outcomes between ear deformations and malformations, no difference was found in patients' anticipated and current social distress (1.09 ± 0.29 vs. 1.15 ± 0.38, p=0.55) or satisfaction with expectation (4.25 ± 1.32 vs. 4.23 ± 1.48, p=0.97). Mean satisfaction with expectation of treatment did not decrease significantly between patients treated more than 60 days of age and patients treated less than 60 days of age (3.67 ± 2.31 vs. 4.3 ± 1.2, p=0.41).

Conclusion: Caretaker satisfaction from ear molding therapy remained high after long-term follow up and social distress from the perception of their child's ears decreased with time. Aesthetic outcomes as assessed by physicians improved from the short to long-term.

BACKGROUND

The aim of this study is to assess if lymphaticovenular anastomosis (LVA) imparts distant therapeutic benefit beyond the area in which surgery was performed. We hypothesize that LVA performed in a single extremity will result in improved lymphatic flow in non-operated extremities with subclinical lymphatic disease.

METHODS

All consecutive cases of LVA performed for primary lymphedema at Cleveland Clinic from February 2020 to April 20222 were included. All patients had previously failed lymphedema therapy and underwent standardized diagnostic and tracking protocol including patient report, circumference measurements, and indocyanine green (ICG) lymphography preoperatively and at predetermined postoperative intervals.

RESULTS

Fifteen patients with primary lymphedema underwent lymphaticovenular anastomosis procedures as well as pre- and post-operative ICG lymphography of all four extremities during the study period. Over half of patients (n=8, 53%) were symptomatic in bilateral lower extremities, while the remainder were symptomatic in a unilateral lower extremity (n=5, 33%) or all four extremities (n=2, 13%). Mean BMI was 25.6 9 (std. dev. 4.8) and mean duration of clinical symptomology was 110 months (min.-max. 24-300). LVA was performed in a single extremity in all cases: left leg in 53% (n=8) and right leg in 47% (n=7). Preoperative ICG imaging indicated stardust or diffuse dermal backflow patterns in all operated limbs and limited flow distance (i.e., failure to reach groin). The mean number of LVAs performed in each patient was 6.8 (min.-max. 5-9, std. dev. 1.3). Mean follow-up was 6.9 months (std. dev. 3.2). No complications were observed. At the time of latest follow-up, all operated limbs showed improvement in pattern of lymph flow (i.e., normalized linear flow or less-severe dermal back flow) and ICG distance traveled (i.e., more proximally-tracking ICG flow). Amongst non-intervened limbs (i.e., 0 LVAs performed), 14 limbs exhibited dermal back flow patterns and 24 limbs exhibited ICG flow that failed to reach the groin/axilla before surgery. Postoperatively, 50% (n=7) of the 14 non-intervened limbs that had preoperative dermal back flow patterns exhibited less-severe dermal back flow or normalization to linear flow (p=0.03). Of the 24 non-intervened limbs with preoperative ICG flow that failed to reach the groin/axilla, 63% (n=15) exhibited postoperative ICG flow that tracked more proximally (p<0.001).

CONCLUSION

The results of this study suggest that LVA may have systemic benefit such that the therapeutic effects are seen beyond the intervened body area. This, in turn, offers hope that worsening of undetected distant, subclinical disease may be mitigated by supermicrosurgical lymphedema treatment.

Introduction: Lymphedema is a chronic and debilitating disorder. Surgical treatments are effective in select patients but may be underutilized. This study aims to characterize the etiologies, costs, and patterns of surgical care for commercially insured patients with a lymphedema diagnosis.

Methods: Patients with lymphedema diagnoses were queried from the 2007-2021 MarketScan Databases with International Classification of Disease diagnosis codes and Current Procedural Terminology codes for surgical treatment for lymphedema. Procedural frequencies and out-of-pocket costs were assessed. Patient demographics and lymphedema etiology were used as predictors in a multivariate logistic regression to estimate the likelihood of receiving any form of lymphedema surgery.

Results: 398,882 patients were identified: 319,139 were diagnosed with lymphedema not elsewhere classified (80.0%), 63,574 (16.0%) with postmastectomy lymphedema syndrome, and 15,959 (4.0%) with hereditary lymphedema. A total of 2,319 (0.6%) unique patients underwent a lymphedema operation. In the postmastectomy cohort, the median time between mastectomy and lymphedema operation was 181 days (IQR: 64-406). Female sex (OR 1.94, 95% CI 1.71-2.21, P<0.001) and postmastectomy lymphedema syndrome diagnosis (OR 1.80, 95% CI 1.42-2.30, P<0.001) were associated with an increase in the likelihood of undergoing surgical treatment.

Conclusion: Less than 1% of all lymphedema patients receive surgical treatment. The profile of patients who undergo surgery is a post-mastectomy female. Out-of-pocket costs were relatively low, suggesting that finances are not a barrier. Access to lymphedema procedures is likely limited by other factors including insurance coverage and knowledge of benefits within the medical community.

Purpose: This objective of this study was to assess factors contributing to complications following prepectoral direct-to-implant (DTI) breast reconstruction. Methods: A chart review of all consecutive, prepectoral DTI breast reconstruction performed between March 2017 and July 2022 at a single center was conducted. Demographics, operative characteristics, and complications were extracted for all patients. Major complications included any complication involving the breast that required readmission or reoperation while minor complications included any breast complication requiring outpatient antibiotics, procedure, or wound care. p<0.05 was considered statistically significant. Results: A total of 55 patients (98 breasts) were included. On average, women were 49 years old, non-smoker (100%), non-diabetic (96%), and had a body mass index (BMI) of 28. Over half of breasts (56%) underwent prophylactic mastectomies, and the remaining 44% underwent therapeutic mastectomies. The majority of mastectomies were nipple sparing (58%), followed by skin sparing (26%), and simple (16%). Mean mastectomy weight was 677 ± 521 grams. Twelve patients received chemotherapy (15% adjuvant, 4% neoadjuvant, 4% both), and five breasts were radiated (4% adjuvant, 1% prior radiation). Average length of follow up was 17 months. All implants were smooth implants, and average size was 443 ± 181 ccs. Soft tissue support was used in 90 (92%) breasts and consisted of acellularized dermal matrix (ADM) in 39%, vicryl mesh in 2%, and a combination of the above in 59%. Major complications occurred in 8 (8%) breasts and consisted of infection requiring explantation in 4 breasts, fat necrosis requiring operative excision in 1, bilateral nipple necrosis in 1, and implant malposition requiring implant exchange in 1 breast. Major complications were not associated with any demographic or operative characteristics on univariate or multivariate analysis. Minor complications occurred in 29 (30%) of breasts. These consisted of infection in 11 breasts, implant flipping in 7, wound healing complications in 7, breast redness in 6, mastectomy flap necrosis in 6, seroma in 3, clogged drain in 1, and fat necrosis in 1 breast. Minor complications were associated with higher BMI (31 vs. 26, p<0.001), radiated breasts (100% vs. 0%, p<0.01), mastectomy weight (1210 grams vs. 579 grams, p<0.01), and implant size (525 ccs vs. 409 ccs, p<0.01). Higher implant size was associated with occurrence of infection (624 vs. 410, p<0.01) and explantation (571 vs. 430, p=0.03), however lower implant size was associated with exchange (248 vs. 451, p=0.027). Notably, the use of soft tissue support was not associated with the occurrence of any type of complication. In multivariable models controlling for age, BMI, mastectomy weight, radiation, implant size, and soft tissue support, no significant predictors of major or minor complications were identified, however radiation was associated with a higher odds of infection (OR 11.8 [1.3, 264.1], p=0.05). Conclusions: In a study of nearly 100 breasts reconstructed with the prepectoral DTI approach, minor complications were associated with predictable patient-related factors such as higher BMI, mastectomy weight, and radiation. Higher implant size was also frequently associated with complications.

Necrosis of the nipple-areolar complex (NAC) is a rare, but feared outcome following breast augmentation, mastopexy, and nipple-sparing mastectomy. Superficial arteries of the breast that supply this region are often obscured intraoperatively and damage to them can lead to poor perfusion and ischemia following NAC re-approximation, leading to necrosis and possible tissue compromise. In addition, necrosis of the NAC can threaten the prosthesis itself, requiring potential re-operation [1]. Postoperative guidelines following breast augmentation are designed to mitigate the most common complications, such as infection or thrombosis. Yet, they often do not address ischemia. Furthermore, there is a scarcity of evidence-based methods to rectify a threatened ischemic NAC when the surgeon cannot be immediately consulted, or the patient cannot readily translocate for consultation.

The authors present a case of a patient in the emergency department (ED) three days post implant-based breast augmentation and mastopexy who was suspected of threatened ischemia of the NAC without wound dehiscence. The patient was successfully managed medically with IV methylprednisolone and topical nitroglycerin ointment as immediate consultation with the operating surgeon was not possible.

This case highlights the successful use of topical nitroglycerin ointment in post-mastopexy, post-implant-based breast reconstruction NAC ischemia in a setting where surgical consult was unavailable. The proposed mechanism of action for nitroglycerin in this setting is venodilation of patent vessels draining the NAC, which alleviates venous congestion and allows for greater tissue oxygenation. Additionally, arterial vasodilation of patent vessels supplying the NAC compensates for decreased blood flow from superficial vessels that may have been damaged intraoperatively or due to postoperative inflammation [2]. Topical nitroglycerin is rapidly acting, requiring only 5-10 minutes for full transdermal absorption, making it an ideal choice in acute care settings [3]. In our case, reperfusion of the NAC was clearly visible thirty minutes after the first application. Adverse effects of the ointment are very limited and include flushing, rash, and dermatitis, which resolve shortly after cessation of use [3]. Our patient did not exhibit any of these complications.

References: 1. Salibian AA, Frey JD, Bekisz JM, Karp NS, Choi M. Ischemic Complications after Nipple-sparing Mastectomy: Predictors of Reconstructive Failure in Implant-based Reconstruction and Implications for Decision-making. Plast Reconstr Surg Glob Open. 2019 May 23;7(5):e2280. doi: 10.1097/GOX.0000000000002280. PMID: 31333984; PMCID: PMC6571321.

2. Rafat Mosalli, Wed Khayyat, Sarah Al Qarni, Amirah Al Matrafi, Mohamed El Baz, Bosco Paes, Topical nitroglycerin in newborns with ischemic injuries: A systematic review, Saudi Pharmaceutical Journal, Volume 29, Issue 7, 2021, Pages 764-774, ISSN 1319-0164, https://doi.org/10.1016/j.jsps.2021.05.008.

3. Kim KH, Kerndt CC, Adnan G, et al. Nitroglycerin. [Updated 2022 Sep 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482382/

Purpose: Adult-acquired buried penis often occurs in morbidly obese patients. The 5-Factor Modified Frailty Index (mFI-5) is a 5-point scale that accounts for hypertension, chronic obstructive pulmonary disease (COPD), dependent functional status, type 1 or type 2 diabetes, and history of congestive heart failure. Given the significant association of these variables with morbid obesity, we sought to determine whether the mFI-5 predicts postoperative complications after surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to the ASA physical status classification.

Methods and Materials: We included all patients who underwent surgical management for adult-acquired buried penis at an academic level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, surgical outcomes, and postoperative complications.

Results: A total of 55 patients underwent surgical management for adult-acquired buried penis with 26 postoperative complications (47.3%). The mean age was 57.2 (SD 14.9) years at the time of surgery and the mean preoperative BMI was 45.7 (SD 11.7). Factors significantly associated with postoperative complications following buried penis surgery included the mFI-5 (OR 3.40; 95% CI: 1.56 – 7.42; p = .002) and BMI (OR 1.12; 95% CI: 1.04 – 1.20; p = .002). The mFI-5 was not predictive of returns to the emergency room (OR 1.33; 95% CI: .226 – 7.85; p = .752). ASA classification (OR 1.59; 95% CI: .544 – 4.63; p = 0.40) and age (OR 0.97; 95% CI: .928 – 1.00; p = 0.07) were not associated with postoperative complications. The median length of follow-up was 118 days (IQR: 64 – 281).

Conclusion: The mFI-5 is a significant predictor of postoperative complications following adult-acquired buried penis surgery, while the ASA classification does not predict complications. The mFI-5 may serve as a useful tool for complication risk assessment during preoperative counseling prior to buried penis surgery.

Background Health insurance reimbursement has been changing considerably with patients being increasing responsible for their healthcare costs. Lack of transparency for patients and providers with limited understanding of out-of-pocket expenses may produce a financial burden for patients. Increased out-of-pocket expenses may delay access to care, treatment and contribute to worse health outcomes. Furthermore, barriers to access care may exist depending on the insurance plan type. The present study sought to evaluate nationwide insurance coverage type and out-of-pocket expenses for patients undergoing functional rhinoplasty.

Methods The Truven MarketScan Database was analyzed to identify patients who underwent primary, functional rhinoplasty (CPT 30400, 30410 and 30420) in 2021. Total and out of pocket expenses paid for the surgery including deductible, co-payment, and coinsurance were assessed. Furthermore, analyzes was performed to evaluate cost variation between the regions. To compare these characteristics t-test was applied, all values were reported as mean (standard deviation) and a value of p<0.05 was considered significant.

Results In total 1491 patients were identified in 2021 year. The majority of patients were female (n=844, 56%) 18-34 years old (n=739, 50%) residing in South region (n=521, 35%), followed by North Central (n=427, 29%), West (n=309, 21%), and Northeast (n=230, 15%). Most patients were insured either through preferred provider organization plan (PPO) (n=710, 48%), health maintenance organization (HMO) (n=225, 15%) or high deductible health plan (HDHP) (n=205, 14%). Most common diagnosis was deviated nasal septum (n=575, 39%), followed by acquired deformity of nose (n=317, 21%). Mean out of pocket cost was $584 ($935) and total payment cost was $5410 ($5003). Out of pocket cost did not vary by region (p=0.741) but varied by insurance plan type (p<0.001) with HMO plan type being lowest and HDHP highest (mean $234 ($653) vs $936 ($1125)). For total cost expenses there was statistical significance for both region (p<0.001) and insurance plan type (p=0.011). The highest cost was in North Central region ($6194 ($5281)) and exclusive provider organization (EPO) coverage ($6377 ($7685)).

Conclusion When compared to other plans where patients may be subjected to the effects of gatekeeping and have limited access to care, majority of patients in the present study had a PPO plan and were freely able to obtain treatment from preferred or out-of-network providers. Given the difference in expenses for out-of-pocket costs between insurance plans, healthcare systems and providers should be more transparent in sharing cost information. To minimize the financial burden placed on patients, providers and policymakers should be aware of the impact of out-of-pocket expenses for patients requiring surgery.

Background: The use of social media to disseminate medical information has exploded in the past decade. However, much of this social media use consists of advertising, inaccurate medical content, or content submitted by non-surgeons or physicians who are not board-certified in their relative fields. While some physician organizations provide guidance for the specific use of social media, there are no studies that examine guidance provided by major plastic surgery organizations. We therefore sought to characterize the current landscape of social media and communication-related policies held by plastic surgery organizations.

Methods: A list was generated of national plastic surgery organizations, plastic surgery subspecialty organizations, and relevant organizations hosted by specialties other than plastic surgery. Organization websites, member-only content, and public-facing content were reviewed to identify policies that specifically discuss the use of social media, and content suggesting a committee had been established to examine social media use. Social media policies were grouped into 4 categories – "general social media use", "advertising", "photograph use", and "medical advice".

Results: There were 13 organizations identified across plastic surgery, hand surgery, pediatric and craniomaxillofacial surgery, and facial plastic surgery (otolaryngology). There were 5 organizations for which a webpage was identified suggesting a social media committee had been created. However, only 2 organizations had accessible policies that specifically governed the use of social media. Data collection criteria was therefore expanded to include general content regarding advertising, photograph use, and medical advice.

On further review, policies regarding social media use generally required that surgeons include disclaimers stating that social media posts were the views of the poster, and not reflective of any organization. Policies regarding advertising placed strict bans on any manipulated or misleading photographs, offered guidelines and restrictions on solicitation, and offered extensive details on specific use cases that were or were not permissible. Policies specific to photography stated that photographs must reflect "typical results", but did not clarify consent processes for photograph use.

Conclusions: Most plastic surgery organizations do not have an accessible social media policy, and many do not have committees specifically designed to regulate social media use. However, when organizations did have policies relevant to social media use, they often were well-enumerated, with substantial detail. A follow-up study is underway to examine specific social media use cases and needs for plastic surgeons and plastic surgery patients, which will be provided to major plastic surgery organizations to aid in development of these policies.

Purpose: In autogenous auricular reconstruction for microtia repair, maintaining long-term projection of the constructed auricle can be compromised due to insufficient auricular support or scar contracture. To combat these adverse outcomes, we developed a low-cost ear elevation splint that maintains desirable auricular projection with external support.

Methods: An ear elevation splint was designed from Aquaplast, a splinting material that becomes flexible in hot water, to provide rigid support along the posterior auricle. It was held in place by a Neoprene headband. Each splint was custom-made for all patients undergoing second-stage autogenous auricular reconstruction at their two-week postoperative clinic visit and was worn for one month. Ear projection was monitored at 2 months, 3 months, 6 months, and 1 year post-operatively.

Results: Each splint took 15 minutes to make and costs approximately $35. The splint was held in place by a Neoprene headband and was less bulky compared to the previously-used sponge and gauze dressing. Seven patients have been treated with this ear elevation splint since January 2022. After having the splint in place for one month, all patients did not have notable reduction in projection or shallowing of the sulcus at a median postoperative period of six months (range 2 - 12 months). Wound healing was not inhibited by splint placement in all patients.

Conclusions: This novel ear elevation splint is a convenient, low-cost, and non-invasive addition to post-operative management of autogenous auricular reconstruction. Although longer term study is needed to further elucidate significant improvements, reduction in auricular projection usually occurs within the 6-month postoperative period based on the senior author's experience after two decades of practice, signifying promising results based on implementation of this splint.

Background: The US continues to face an opioid crisis. Over 70% of postoperative pain prescriptions remain unused, increasing risk for new opioid use. Within hand surgery, many outpatient procedures require minimal pain management, but ~50% of these patients receive postoperative opioids. While older adults are at higher harm risk of opioids, little is known about opioid prescribing practices for individuals undergoing hand surgery procedures across this age cohort This study aims to characterize the prescription habits of hand surgeons in the Medicare population.

Methods: The Centers for Medicare and Medicaid Services Medicare Part D Prescription Drug Program Prescribers Public Use File was used to extract regional, state, and individual provider-level prescription data for prescribers identified as "Hand Surgeons" from 2015-2019. This database captures approximately 76% of the total Medicare population.

Results: From 2015-2019, 1,752 Hand Surgeons were identified in the Medicare Part D database with a five-year average of 231,405 opioid claims, comprising 53% of all pharmaceutical claims made by hand surgeons. The median opioid prescription rate decreased yearly from 2015-2019(61.4% to 53.3%), as did the annual claim count. Significant regional and state-level variation was identified. Overall, the South had higher numbers of opioid prescriptions per hand surgeon compared to all other regions and prescribed for more days, but the Midwest and West regions had larger proportions of opioid claims.

Conclusions: The overall opioid prescribing rate decreased 8% among all hand surgeons from 2015-2019, along with annual proportion of opioid prescriptions and in average days per opioid claim (6.3 to 4.7 days). There is large state and region level variability between opioid prescription patterns. This may reflect differences in state-level legislation and institutional practices but warrants further research as to why this regional variability occurs. Progress has clearly been made to curb excessive opioid prescription amongst hand surgeons. Continued efforts are necessary to optimize and standardize opioid prescribing practices.

Purpose: Vermilion lip defects secondary to Mohs micrographic surgery (MMS) present significant challenges to the reconstructive surgeon as the lip is a crucial aesthetic and functional subunit of the face. Patient-reported outcomes of MMS defects of the lip have not been previously evaluated.

Methods: A retrospective review of patients who underwent MMS and subsequent reconstruction of defects involving the vermilion lip between 2017-2021 was performed. Relevant instruments from the FACE-Q Head and Neck Cancer module were prospectively administered to patients who met inclusion criteria via email. Patients were stratified by the MMS defect area in cm2. The impact of defect size on FACE-Q scores across modules was modeled utilizing multivariable linear regressions adjusting for patient demographic characteristics and reconstructive technique.

Results: A total of 119 patients met inclusion criteria, and of those, 72 patients completed the FACE-Q survey (response rate: 60.5%). Of the cohort, the mean age was 65.6 years, and there were 51 females. Thirty-one patients (43.0%) had MMS defects smaller than 1.5 cm2, 23 (31.9%) had defects between 1.5 and 3.0 cm2, and 18 (25.0%) had defects larger than 3.0 cm2. Functionally, on average, patients reported the most positive outcomes in speech (98.4 +/- 6.0) and eating (97.3 +/- 7.9). Patients were most impacted functionally in smiling (88.6 +/- 17.2). Patients reported the lowest overall domain score in appearance distress (74.7 +/- 33.6). Increased MMS defect area was independently predictive of reduced facial appearance (beta = -1.7, p = 0.03), eating and drinking (beta = -0.8, p = 0.02), and smiling (beta = -2.0, p = 0.005) scores. Defect area did not predict reductions in oral competence, speaking, appearance distress, drooling distress, or smiling distress scores. Further, reconstructive technique did not predict differences in FACE-Q scores across domains.

Conclusion: Overall, patients reported generally positive outcomes following reconstruction of MMS defects of the vermilion lip, with many patients experiencing minimal difficulties with eating, oral competence, and speech. Patients were most negatively impacted by facial appearance distress, likely related to impact on their smiles following reconstruction. Larger defects were independently predictive of worsened patient-reported outcomes in multiple domains, and patients for whom a large excision is anticipated should be counseled appropriately.

Purpose: To investigate the perceptions of integrated plastic and reconstructive surgery (PRS) residency applicants on the need for having social media during the application process.

Methods: A cross-sectional survey study was conducted during the 2022 match cycle at our institution to assess integrated PRS residency applicants' perceptions on the role of social media during the match. Univariate and multivariate analyses were performed to evaluate associations between variables of interest. Qualitative analysis was conducted on free-form responses.

Results: Seventy-nine surveys were completed (response rate: 24%). The majority of respondents were educated in the U.S. (92%), and 89% were current medical students. Instagram was the most commonly used social media platform (92%). Of those surveyed, 18% thought that social media was beneficial to the application process. Twenty-nine percent of the respondents agreed that a social media presence increases one's chances of matching into PRS residency, and 44% endorsed stress about maintaining a social media presence in PRS. Having mentors who recommended maintaining a social media presence was associated with the belief that social media increases one's chances of matching (OR 8.1, 95% CI 1.1-40.4, p=0.011) and stress about maintaining a social media presence (OR 6.3, 95% CI 1.2-33.3, p=0.030). Applicants who did research years had lower odds of experiencing stress (OR 0.16, 95% CI 0.04-0.70, p=0.015).

Conclusions: The growing role of social media in the residency selection process may be exacerbating applicants' stress and anxiety. PRS programs may consider establishing clear policies for how social media will be used in evaluating candidates.

Purpose: There is limited evidence for appropriate postoperative opioid prescribing in breast reconstruction. While previous studies have characterized patterns of post-discharge opioid consumption after tissue expander placement, most of the literature quantifying opioid consumption after autologous breast reconstruction describes in hospital opioid consumption only. Little is known about outpatient opioid consumption after discharge. We sought to describe postoperative outpatient prescription opioid use patterns following discharge after free flap breast reconstruction with and without viewing an educational video on proper opioid consumption.

Methods: Patients 18 years or older undergoing DIEP reconstruction were given a 28-day postoperative pain and medication logbook from August 2018- Feburary 2022. Beginning in 2021, our practice implemented an educational video upon discharge on proper opioid consumption. The video discusses 1) how to consume over the counter (OTC) pain medication alongside opioids for optimal pain control, 2) that prescribed opioids should only be used to treat pain related to their surgery and 3) the proper disposal of unused opioids. Descriptive statistics on patient characteristics, intraoperative and postoperative opioid consumption, and outpatient prescription opioid use after discharge were compared between those who viewed the video with those who did not.

Results: A total of 54 logbooks were completed with 18 patients in the no video cohort and 36 in the video cohort. Patient characteristics including age at surgery, laterality of reconstruction, BMI, surgical characteristics, incidence of postoperative complications, and comorbidities were similar between the two cohorts. Intraoperative and postoperative in-hospital MME's were similar between the no video and video cohorts, at 53.7 versus 46.7 (p=0.39) and 115.1 versus 106.2 (p=0.94) respectively. 11.1% of the no video and 13.8% of the video cohorts did not consume opioids at all after discharge. On average, the days to cessation of opiates was statistically significantly longer in the no video cohort (10.9 days versus 5.1 days, p=0.03). The average number of oxycodone 5mg equivalents consumed following discharge was 17.5 (median 12, IQR 4.5, 26) in the no video cohort and 8.4 (median 4.5, IQR 2, 11.2) in the video cohort, which approached significance (p=0.05). The number of oxycodone 5mg equivalents prescribed was higher in the no video cohort (39.8 versus 22.4, p=0.001). Overall, the percentage of opioids consumed in the no video cohort was 43.1% versus 29.4% in the video cohort.

Conclusion: Patient reported opioid consumption can provide a benchmark which plastic surgeons can use to guide opioid prescribing. For patients discharging home after DIEP breast reconstruction, we recommend a prescription for 12 oxycodone 5 mg tablets. Additionally, use of an educational video regarding proper opioid consumption is a feasible method to clinically reduce outpatient opioid use following hospital discharge. Additionally, nearly 13% of patients did not consume any opioids following discharge making nonnarcotic pain regimens for some a possibility.

Background: Abdominal surgeries such as deep inferior epigastric perforator flap (DIEP) reconstruction may weaken the abdominal wall and increase risk of postoperative herniation. The practice of abdominal mesh placement after DIEP reconstruction is largely provider dependent. This study seeks to characterize demographic trends and outcomes for patients receiving abdominal mesh during DIEP breast reconstruction. Methods: This retrospective study included patients who underwent DIEP breast reconstruction between January 2019 and July 2022 at a single academic institution. Demographics and outcomes were compared using two-sample t-test or Chi-square analysis.
Results: Overall, 355 patients were included, with 176 (50%) patients who received abdominal mesh and 179 (%) who did not receive mesh. The abdominal mesh cohort had longer hospital length of stay (4.0 d vs. 3.0 d, p<0.001). There were no significant differences in age (51 years vs 50 years), BMI (29.0 vs 28.0), history of diabetes (12% vs 7.3%), length of surgery (8.97 hr vs 9.73 hr), rate of hospital readmission (9.1% vs 6.7%), reoperation (15% vs 12%), or postoperative abdominal hernia rate (3.4% vs 2.8%) in mesh versus no mesh cohorts, respectively. Conclusions: Patients receiving abdominal mesh had no differences in safety and surgical outcomes when compared to those who did not receive abdominal mesh during DIEP breast reconstruction. Further research is needed to determine risk factors for post-operative abdominal hernias and characterization of patient populations who may benefit from abdominal mesh placement in order to enhance patient safety and cost-effectiveness.

Purpose: Osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses for lower limb amputees. They eliminate the socket-skin interface and allow for weight-bearing directly on the skeletal system, which can reduce pain and improve mobility. However, the stoma through which the osseointegrated implant attaches the external prosthesis creates an ingress route for bacteria, and infection rates as high as 66% have been reported.1 These infections may lead to osteomyelitis and weaken the integrity of the bone-implant interface. The aims of this study are to classify the types and time courses of infections, their treatment protocols, and the long-term outcomes in this patient population.

Methods: An IRB-approved retrospective analysis was performed on all patients who received lower-limb osseointegration at our institution between 2017 and 2022. Diagnostic and treatment data were collected for all patients with clinically diagnosed or culture-proven infections. Patients were stratified by infection type, then Chi-squared and unpaired t-tests were performed on categorical and continuous data, respectively, using a p-value cutoff of 0.05.

Results: 40 patients met our study criteria; 7 had multiple, distinct infections, resulting in a total of 50 infections. This cohort included 20 males and 20 females with 21 transfemoral and 19 transtibial amputations. There were 28 (56%) superficial stomal infections, 15 (30%) deep soft tissue infections, and 7 (14%) cases of osteomyelitis. The most common pathogens were Staphylococcus aureus (10), Streptococcus agalactiae (6), and Staphylococcus epidermidis (5). Osteomyelitis cases were significantly more likely than stomal infections to be polymicrobial and more likely to contain gram-negative microorganisms (e.g., Pseudomonas aeruginosa, Klebsiella oxytoca) (p<0.03). These infections appeared at a median of 102 days after implantation (range: 19 – 1,064 days) and did not differ between groups. All infections were treated with oral or intravenous antibiotics, with mean durations of 24 and 36 days, respectively. Additionally, 2 (7%) stomal infections, 2 (13%) deep soft tissue infections, and 5 (71%) cases of osteomyelitis required reoperation with washout and/or debridement (p<0.001). 2 (29%) patients with osteomyelitis underwent explantation. The overall implant salvage rate was 96% across all infections.

Conclusions: This study describes our institution's experience managing infection after osseointegrated implantation and soft tissue reconstruction. Early clinical assessment and appropriate treatment is essential to prevent progression of soft tissue infection to osteomyelitis, which carries greater risk of reoperation and explantation. Understanding the pathogenesis, microorganisms involved, and successful management of these infections will be essential for plastic surgeons engaging in this growing field.

1. Souza JM, Mioton LM, Harrington CJ, Potter BK, Forsberg JA. Osseointegration of Extremity Prostheses: A Primer for the Plastic Surgeon. Plast Reconstr Surg. 2020;146(6):1394-1403. doi:10.1097/PRS.0000000000007364

Introduction: Lower extremity ulcers are associated with significant morbidity and high healthcare costs, estimated to cost $79 billion in the US per year. (1) They may necessitate amputation, despite the best possible care, further aggravating costs and morbidity. We hypothesized that nutritional status, defined by serum albumin, would be associated with worse wound outcomes. The study aimed to investigate the association between protein-calorie malnutrition and outcomes in diabetic patients with lower extremity ulcers. Methods: In this retrospective cohort study, all patients with lower extremity ulcers presenting to wound care clinics at a large multi-hospital single healthcare network were included (2016-2022). Baseline demographic data were gathered, including age, sex, race, area deprivation index (ADI), albumin level, and wound count. Since albumin was the exposure of interest, patients with missing albumin levels were excluded. Patients were divided into low albumin (LA; <3.5 g/dL) and normal albumin (NA; ≥3.5 g/dL) groups. The primary outcome was amputation-free survival. Standard statistical analytics were used to compare baseline characteristics between groups. Multivariate Cox proportional hazards models were generated to assess association between albumin and time-to-amputation, adjusting for clinically and statistically significant variables. P<0.05 was considered statistically significant. Results: We identified 2,922 patients, 1,556 (53.25%) LA and 1,366 (46.75%) NA. LA patients were more likely to be older (67.4±12.8 vs 66.3±12.7, p=0.019), female (42.6% vs 36.3, p<0.01) and living in areas with higher ADI (70.7±16.2 vs 68.9±16.7, p=0.002). Race distribution was similar between groups (88.5% White LA vs 90.6% White NA, p=0.11). Baseline glycemic control and glomerular filtration rate were worse in LA groups as well (HbA1c: 7.9±2.1 vs 7.7±1.9, p=0.049; GFR: 52.2±24.9 vs 60.9±22.8, p<0.01). LA patients had higher total wound count (3.4±2.3 vs 3.0±2.1, p<0.001) and more likely to have multiple wounds (74.4% vs 69.1%, p=0.001). Mean follow-up duration was 29.2±19.4 months. The mean and median number of wounds that healed per patient were 1.01±1.23 and 1±0.2 respectively. Normal albumin was associated with greater wound healing (55.9% vs 44.7%, p=0.001) in patients with single wounds, but not in in patients with multiple wounds, (2.87±0.07 NA vs 2.87±0.07 LA, p=0.97). Amputation-free survival was better in NA patients at all time points (3 months: 96.1±0.5% vs 91.5±0.7%; 12 months: 91.9±0.8% vs 85.1±0.9%; 24 months: 87.5±1.0% vs 80.7±1.1%; p<0.01). On adjusted analysis, normal albumin continued to be associated with healing and limb salvage (adjusted HR=0.66[95% C.I. 0.54-0.81], p<0.01).

Conclusions: In diabetic patients with lower extremity ulcers, low albumin levels were associated with delayed healing and greater amputation risk. Our findings reiterate the importance of nutritional status in wound healing and identify a modifiable target for limb salvage teams involved in the care of this challenging patient population. Utilizing protocols and policies to create accessible dietary protein support may prevent amputations, promote wound healing, and lower the overall healthcare cost in diabetic patients with lower extremity ulcers.

1. Armstrong, D. G., Swerdlow, M. A., Armstrong, A. A., Conte, M. S., Padula, W. V., & Bus, S. A. (2020). Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. Journal of foot and ankle research, 13(1), 16. https://doi.org/10.1186/s13047-020-00383-2

PURPOSE Fingertip defects of the thumb have profound consequences on hand function, including range of motion, grip and sensation. Several locoregional flaps exist to reconstruct the deficient distant portion, each with inherent advantages and disadvantages. The Moberg flap, or homodigital neurovascular advancement flap, is a versatile option with minimal donor site morbidity. The aim of this study was to systematically review the reported outcomes and complications of the Moberg flap for fingertip reconstruction of the thumb.

METHOD A systematic review was conducted in adherence with PRISMA guidelines. Two independent reviewers assessed titles, abstracts and full-texts for relevance. Patient characteristics, functional outcomes and complications were analysed as means of central tendency.

RESULTS Keywords yielded a total of 1794 articles that were analysed for relevance. A total of 15 studies were included in the systematic review, accounting for a total of 169 patients. Five articles reported a mean follow-up of 28.6 months. There was 100% flap viability in 136 patients reported by 12 studies. Outcomes pertaining to thumb esthetics revealed that 92% of patients (n=59) had favourable results with the Moberg flap in 6 studies. Complications included cold intolerance in 29.8% and postoperative infection in 10.3%. No patients reported flexion contractures from homodigital flap advancement.

CONCLUSION Outcomes from Moberg flaps for fingertip reconstruction of the thumb were largely positive in terms of flap viability and esthetics. Low rates of complications included cold intolerance and infection, making the Moberg flap a safe and effective locoregional flap.

TEACHING OBJECTIVE • Participants will be able to assess the viability of flaps undergoing a Moberg procedure. • Participants will be able to quantify the improvement in esthetic outcomes following a Moberg flap. • Participants will be able to verify the potential complications when undergoing such a flap in order to deduce its utility in a clinical environment.

Purpose: Zygomaticomaxillary complex (ZMC) fractures are common injuries, accounting for approximately 40% of all facial fractures. These injuries may compromise facial aesthetics and lead to functional deficits, such as malar depression and trismus. The ZMC is also critical for its formation of the inferior orbit, therefore, these fractures necessarily involve some violation of the orbital floor. However, guidelines for orbital floor exploration in the setting of these injuries remain controversial. Proponents of routine exploration suggest that floor defects may not appear obvious on preoperative imaging. Rather, these injuries may unveil following zygomatic fracture reduction. Therefore, routine floor repair may obviate the need for a future secondary procedure should orbital symptoms develop. However, floor exploration is not without functional or aesthetic risks, which include eyelid malposition and scarring. In this study, we aim to refine indications for orbital floor exploration by identifying clinical and radiographic parameters which portend need for intervention.

Methods: A retrospective review of a prospectively maintained database was performed to identify all patients with ZMC fractures evaluated by the plastic surgery department at a tertiary academic medical center between January 2015 and August 2019. Patient demographic and clinical data were recorded from the medical record. Preoperative computed tomography (CT) imaging was examined for radiographic parameters of interest, including zygoma rotation angle, anterior-posterior displacement, vertical displacement, lateral-medial displacement, and lateral maxillary wall impaction. Patients were stratified into those receiving and not receiving orbital floor reconstruction. Data was split into training, validation, and testing sets using a 60%-20%-20% weighted random distribution. Receiver operating characteristic curves were calculated with sensitivity, specificity, and area under the curve (C-statistic) to predict patients not needing floor repair. A decision tree was formulated utilizing a naïve Bayes estimate to guide operative decision making.

Results: Of 232 patients with ZMC fractures, 14 (6.0%) underwent orbital floor exploration and repair. Mean age between repaired (32.1  13.2) and unrepaired (49.0  21.4) cohorts was significantly different (p < 0.001). Concomitant nasoorbitoethmoid (p < 0.001, OR 4.36), LeFort (p = 0.003, OR 4.06), or medial orbital wall (p < 0.0001, OR 5.19) fracture portended need for floor repair. Radiographically, fractures requiring floor reconstruction demonstrated significantly increased posterior displacement of the zygoma (p = 0.0048). Remaining CT parameters did not meet criteria for significance. A nominal logistic regression model including the variables of age, zygoma rotation angle, and anterior-posterior demonstrated sensitivity, specificity, and C-statistic of 85.7%, 81%, and 0.9345, respectively. Below 1.72 mm of posterior zygomatic displacement, 0% of patients required floor repair.

Conclusions: Several demographic, clinical, and radiographic parameters are associated with need for orbital floor reconstruction in the setting of ZMC fracture. Our nominal logistic regression model including features such as zygoma rotation and anterior-posterior displacement predicted the absence of need for floor exploration and repair in 93.5% of patients. Further, our model suggests that few patients with A-P displacement < 1.72 mm require floor repair. We believe these findings will serve to better delineate the operative management of patients presenting with these injuries.

Background: As the obesity crisis in the United States continues, different renal transplantation centres have loosened their BMI criteria necessary for surgery. With more individuals of larger body-habitus comorbid with End-Stage Renal Disease (ESRD) qualifying for renal transplantation, surgical modalities existing in other fields have migrated to serve this patient population. Panniculectomy has been successfully carried in ESRD patients prior to transplantation as an attempts to improve surgical field access and post-transplant outcomes.

Methods: In order to assess surgical outcomes of panniculectomy in the context of renal transplantation and ESRD, the authors performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 Anticipating lack of primary studies, we also retrospectively collected data on patients with ESRD undergoing panniculectomy form the National Surgical Quality Improvement Program (NSQIP) to evaluate outcomes of body contouring in this patient population.

Results: From the systematic review, a total of 783 ESRD patients underwent panniculectomy among the studies identified. Of these, 91 patients underwent panniculectomy simultaneously to RT while 692 had their pannus resected prior to kidney transplant. The most common complication was hematoma followed by wound dehiscence. From the NSQIP analysis, 24,868 patients met the inclusion criteria for analysis. In the setting of renal transplant, patients with diabetes, hypertension requiring medication, and requiring dialysis were more likely to suffer postoperative complications (OR 1.31, 1.15, and 2.2, respectively). However, upon sub-analysis of specific types of complications, the only retained association was between diabetes and wound complication

Conclusion: Panniculectomy in ESRD patients appears to be safe and may improve transplant candidacy. Pannus resection is associated with good post-transplantation outcomes with good long-term graft survival. Panniculectomy prior to transplant appears to be safe without increased comorbidity in the ESRD population

PURPOSE: Pediatric facial fractures frequently arise from trauma and are a common cause of emergency department visits and hospital admissions. Though much has been written on the mechanism of injury and clinical management, comparatively little has been published on the social determinants of health for pediatric facial fractures. This study aims to investigate the contribution socioeconomic status, race, education, household structure, English-language proficiency, and insurance status has on the management and outcomes in pediatric facial fracture patients.

METHODS: A 16-year retrospective cohort study was performed between 2006-2021 of patients under age 18 who were evaluated for facial fractures at a pediatric level I trauma center. Variables collected included demographic information, injury characteristics, management, outcomes, and the Centers for Disease Control and Prevention's (CDC) Social Vulnerability Index (SVI), including per-capita income, educational attainment, household structure, English-language proficiency, and possession of a vehicle, among others.

RESULTS: Pediatric facial fractures were diagnosed in 3334 patients. Of those, 2691 patients met inclusion criteria. A total of 492 patients (18.3%) were non-white, of whom 389 (14.5%) were Black. Of the total population, 875 (32.5%) were female, and the median age was 10.43+2.340. Most fracture subtypes (orbital, mandibular, skull) were associated with an increased SVI, unemployment, and a single parent household (p<0.0001). Black patients were 1.62 times more likely than White patients to present with mandibular fractures (p<0.001). When controlling for fracture type, Black patients were 2.4 times more likely to receive imaging (p<0.0001) than White patients, but 0.52 times as likely to receive surgery (p<0.0001). Furthermore, Black patients were 2.2 times as likely to be uninsured as White patients (p=0.00021) and 1.5 times as likely to be lost to follow-up (p=0.00019). Additionally, across all fracture types, increased rates of individuals in a particular region without a high school diploma and dwelling in mobile homes were found to be significant predictors of injury (p-value <0.001), whereas having a high rate of residential housing with 10 or more units, was found to be a significant protective factor against facial fractures (p-value <0.0001). Lastly, there was no difference by race in referral to further specialty care.

CONCLUSION: Despite the notion of equal access to pediatric emergency care, our results show that social determinants of health, especially considering SVI, influence treatment pathways and outcomes in pediatric facial fractures. The effect of health disparities may be amplified with the acuity of facial fractures. Identifying systemic barriers that impact management and outcomes in vulnerable patients is necessary to overcome healthcare gaps and optimize clinical outcomes.

Purpose Extensor pollicis longus (EPL) rupture is a potential complication of distal radius fracture (DRF) fixation. It is commonly assumed protruding dorsal screw tips are usually the cause of rupture. However, EPL ruptures after non-operative treatment of distal radius fractures are also well-described and it would be logical that some EPL ruptures are not related to screw prominence. This research sought to analyze a cohort of patients with EPL ruptures after volar locked plating of distal radius fracture to characterize if some ruptures may be unrelated to dorsal screw prominence. Methods This is a retrospective, observational, descriptive cohort study of all adults with operative fixation of a closed DRF fracture and an EPL rupture at a single institution between 2002 and January 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. Median follow-up time was 14.5 months (IQR: 7-39 mo). Operative findings and screw length relative to the lunate depth as described by Ljungquist et al. was analyzed for the cohort to determine likelihood of screw prominence (1). Results Average time from distal radius fracture and DRF fixation to EPL rupture was 3.7 and 3.4 months respectively. Based on the operative record, in 2 of 18 patients (11%) the rupture was directly attributed to prominent hardware; however, in 4 of 18 patients (22%) rupture was believed not to be related to prominent hardware, and cause was indeterminate in 12 patients (67%). After radiologic measurements of radiographs of patients the indeterminate group, 6 of 12 patients had screws that were likely prominent, and the other half did not. Conclusion - In patients with EPL rupture after distal radius fracture fixation, there is a subset of patients whose rupture is unlikely to be attributable to prominent dorsal screws. - Although screw prominence is an important cause of EPL rupture, it should not be assumed that prominent hardware is the only etiology of rupture.

1. Ljungquist KL, Agnew SP, Huang JI. Predicting a safe screw length for volar plate fixation of distal radius fractures: lunate depth as a marker for distal radius depth. J Hand Surg Am. 2015 May 1;40(5):940–4.

Purpose

Nipple sparing mastectomy (NSM) is an oncologically safe option for patients at high risk for breast cancer. However, large and ptotic breasts present reconstructive challenges, particularly due to nipple-areolar complex (NAC) complications. We aimed to present the outcomes of patients treated with staged prophylactic NSM. Methods

An IRB-approved retrospective review was conducted, including all adult patients who underwent reduction mammaplasty or mastopexy (nipple delay) followed by NSM with immediate reconstruction. Patients with breast cancer at initial presentation prior to any operation were excluded. Demographics, history, high-risk criteria, breast measurements, and ptosis were recorded for each patient. Surgical data, including dates, techniques, excised tissue weight, specimen pathology, and implanted materials for each procedure were collected. The primary outcome was achievement of stable healing with a viable NAC. Secondary outcomes included prevalence, type, and management of complications, as well as additional reconstructive procedures. Continuous data are presented as mean±SD (range) and categorical data as median [IQR]. Results

Fourteen patients (median age 38 [34-40] years) underwent staged prophylactic NSM. At a median of 4 [3-6] months prior to NSM, patients underwent nipple delay procedures (11 breast reduction, 3 mastopexy). Half of the patients had BRCA1 mutations, 36% BRCA2, and 14% PALB2. At initial presentation, median ptosis grade was 3 [3-3]. The average sternal notch (SN) to nipple measurement was 29±3cm (25-35) for the right breast and 29±3cm (24-33) left. Nipple to inframammary fold (IMF) distance was 11±2cm (9-16) on average for the right and 11±2cm (9-16) for the left breast.

Patients had an average BMI of 30±5 (23-39). Four patients had smoking history (median 5 [3-23 pack-years]) and all quit >1yr preoperatively. One patient had a history of both antiphospholipid syndrome and Raynaud's phenomenon. None of the patients had a history of chemotherapy or immunosuppressive medications. At the time of nipple delay procedure, median ASA risk was 2 [2-2]. Nine patients had reduction mammaplasty and 3 mastopexy based on superomedial pedicles in 50%, superior 29%, and inferior 21%. NSMs were performed 4±2 months (1-8) later.

Techniques used for immediate breast reconstruction and surgical outcomes are described in Table 2. All implants and tissue expanders were wrapped in ALLODERMTM (LifeCell Corporation; Branchburg, NJ) and placed in the pre-pectoral plane. Total median follow-up was 18 [12-25] months.

Patients required a median of 1[1-3] additional procedures for symmetry or due to complications. Wound dehiscence occurred at the T-junction unilaterally in four (28%) patients (2/4 reoperated). One patient (7%) had unilateral major (required reoperation) mastectomy flap necrosis. Fat grafting was performed in 71% of patients. There were no total reconstructive failures (went flat). All patients ultimately achieved stable healing with a viable NAC bilaterally within the study period.

Conclusion

Stable healing with viable NAC was ultimately achieved for all patients who would not otherwise have been candidates for NSM. For patients with macromastia or severe ptosis at high risk for breast cancer, plastic and breast surgeon collaboration on a staged approach to risk reducing NSM resulted in reliable reconstructions without sacrificing oncologic safety.

Introduction: Recurrent panniculitis poses a significant burden to the mobility, hygiene, and skin integrity of the massive surgical weight loss (MSWL) patient. Panniculectomy after MSWL is a reliable surgical operation in improving quality of life and durability of weight loss. A Fleur-de-lis incision panniculectomy (FDL-P) is frequently performed to address the excessive horizontal and vertical skin redundancy. Wound dehiscence at the T-junction is the most common complication. The increased complication at this site is caused by reduced perfusion and increased tension at the T-junction. Incisional negative pressure wound therapy (iNPWT) is hypothesized to induce angiogenesis, off-load tension, improve collagen formation, and increase lymphatic flow. Use of iNPWT may be a powerful tool to reduce wound complications in high-risk patients.

Method: We conducted a retrospective chart review of all patients undergoing FDL-P by a single surgeon between January 2017 and November 2022. Consecutive patient records were queried for patient characteristics as well as specimen weight, type of bariatric surgery, pre-existing scars, and application of iNPWT (3M™ Prevena™ Plus, St. Paul, MN, or Smith & Nephew™ PICO™ 7 sNPWT, Fort Worth, TX) at the T-junction. iNPWT systems were left in place for 5 days. The Primary outcome measured was wound dehiscence/marginal necrosis at the T-junction. Secondary outcomes included hematoma, seroma, infection, delayed wound healing and length of hospital stay. We excluded patients undergoing concurrent procedures at the time of FDL-P. We used Fishers Exact Test to compare patients with and without iNPWT application at the T- junction in patients who underwent FDL-P. All patients have planned follow up at postoperative day 5, 3 weeks, 6 weeks, 12 weeks and one year.

Results: Patients undergoing FDL-P surgery (N=58) were grouped by iNPWT use: 19% iNPWT and 81% no iNPWT. The groups were not significantly different by age, BMI, or history of diabetes, smoking, or type of MSWL surgery. Among all patients, post-operative complication rates included Marginal necrosis or dehiscence of T- junction: 19%; seroma: 12%, hematoma: 7%, hypertrophic scarring: 3%, delayed wound healing: 26%, and wound infection or cellulitis: 5%. A decrease in marginal necrosis or wound dehiscence at the T-junction was observed in the iNPWT group versus FDL-P patients without iNPWT use (9% vs. 21%). However, this did not approach statistical significance. Delayed wound healing outside the T-junction occurred less frequently in the iNPWT group (0% vs. 35%; P=0.048). There was no significant difference in outcome between either iNPWT systems. Average follow up for all patients who had iNPWT was 12 weeks versus 42 weeks for FDL-P patients without iNPWT.

Conclusion: FDL panniculectomies offer patients with significant skin excess of the anterior abdomen an improved contour that improves quality of life. However, there is increased likelihood of wound healing issues at the T-junction. Applying iNPWT systems at the T-junction reduces delayed wound healing complications among FDL-P patients.

Introduction Hip disarticulation is a surgical procedure reserved for extreme cases, representing only 0.39% of all amputations. It can be necessary for cancers (most often due to sarcoma), trauma, infection, and ischemia (1). Reports show near-total numbers of patients struggling with prosthetic limb use post-operatively and phantom limb pain (2). Targeted muscle reinnervation (TMR) is effective alongside amputation for phantom limb pain and improving patient quality of life (3). The purpose of this study was to report outcomes of patients receiving TMR concurrently with hip disarticulation.

Methods A single-institution retrospective chart review was performed between March 2018 and March 2023. Patients were included in the study if they underwent hip disarticulation and had concurrent TMR surgery. Operative and post-operative outpatient notes were reviewed. The anatomy of the relevant nerves in the hip and leg and operative techniques were described. Data extracted included demographic information, indication for surgery, symptoms prior to operation, relevant nerve coaptation, operative time, peri- and post-operative complications (hematoma, seroma, need for re-operation, etc.), and long-term functional outcomes.

Results Of the 7 patients found on retrospective chart review of patients receiving hip disarticulation, 5 received concomitant TMR. Demographics included: 3 men, 2 women; median age was 64 years old. Indications for surgery included sarcomas/other malignancies (n=3) and resistant infection (n=2). Nerve coaptation in all cases involved the sciatic nerve: either the tibial component (n=5) and/or the peroneal component (n=4). Two cases included TMR of the femoral nerve. Motor end points were the semitendinosus (target of the tibial component), semimembranosus and biceps femoris (target of the peroneal component), and the vastus medialis (target of the femoral nerve). No patients experienced hematoma, seroma, or infection peri-operatively. Median follow-up was 13 months post-procedure. All patients receiving TMR had either no or only mild (3/10) phantom limb pain at follow-up. Patient descriptions of functional abilities post-operatively included ambulating well with prosthesis, able to perform yardwork, and even go fishing.

Conclusion We showed that patients undergoing TMR with hip disarticulation can expect significant symptomatic and functional improvement, with minimal phantom limb pain. Further research in a larger cohort of patients receiving hip disarticulation with and without TMR will help in establishing the standard of care for these patients.

1. Moura, D. L., & Garruço, A. (2017). Hip disarticulation - case series analysis and literature review. Revista brasileira de ortopedia, 52(2), 154–158. https://doi.org/10.1016/j.rboe.2016.09.008
   2. Jain R., Grimer R.J., Carter S.R., Tillman R.M., Abudu A.A. Outcome after disarticulation of the hip for sarcomas. Eur J Surg Oncol. 2005;31(9):1025–1028.
   3. Dumanian, G. A., Potter, B. K., Mioton, L. M., Ko, J. H., Cheesborough, J. E., Souza, J. M., Ertl, W. J., Tintle, S. M., Nanos, G. P., Valerio, I. L., Kuiken, T. A., Apkarian, A. V., Porter, K., & Jordan, S. W. (2019). Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. Annals of surgery, 270(2), 238–246. https://doi.org/10.1097/SLA.0000000000003088

Background: Gluteal fat grafting, also known as the Brazilian butt lift, is one of the fastest growing aesthetic procedures performed globally. Recent studies in this field have emphasized new safety standards for performing the procedure given numerous reports of fatal and nonfatal complications. This bibliometric analysis aimed to delineate emerging research trends and to assess the methodological quality of the highest impact gluteal fat grafting research.

Methods: The Top 100 most-cited articles in gluteal fat grafting were identified on Web of Science, across all available journals and years (1977-2023). Study details, including the citation count, primary subject, and outcome measures, were extracted from each article by 2 independent reviewers. The level of evidence of each study was also evaluated.

Results: The 100 most-cited articles in gluteal fat grafting were cited by a total of 1634 articles. Citation per article ranged from 152 to 1 citation (mean 19). Most articles were level of evidence 4 (n=29), representative of the large number of case series and expert-opinion articles. No articles were assessed as level of evidence 1; 17 articles were assessed level of evidence 2; 28 articles were assessed level of evidence 3; and 11 articles were assessed level of evidence 5. The main subject was related to outcomes (n=52), followed by operative techniques (n=21). Public health concerns were the main subject in 5 articles; anatomy in 4 articles; patient selection in 2 articles and radiological assessment in 2 articles. No article used validated patient-reported outcome measure (PROM) tools, such as BODY-Q.

Conclusions: The most-cited research in gluteal fat grafting largely comprised low-to-moderate quality studies, with no article achieving the highest level of evidence. Contemporary high-quality evidence, that incorporates validated outcome measures, is crucial to increase patient satisfaction and ensure provision of excellent, reproducible clinical care.

Purpose: Observational data can emulate randomized clinical trials using appropriate design and advanced analytical methods (1). This study aimed to emulate a clinical trial assessing the impact of open carpal tunnel release on cold sensitivity in patients with carpal tunnel syndrome (CTS).

Methods: We used a prospective cohort design and enrolled adult patients with CTS and cold sensitivity. We excluded patients with polyneuropathy, insulin-dependent diabetes mellitus, previous upper extremity surgeries and traumatic peripheral nerve injuries. Patients were treated with either nighttime splinting or surgery. Before and after the intervention, we assessed CTS severity using the Boston Carpal Tunnel Questionnaire (BCTQ) and cold sensitivity using the Cold Intolerance Symptom Severity (CISS) scale. We measured the propensity scores using a deep-learning feed-forward neural network to estimate the average treatment effect weights. We adjusted for confounding by indication by using an inverse probability of treatment weighting (IPTW) model.

Results: There were 88 patients included in the study: surgery (n=50); splinting (n=38). The mean age was 55 years (SD=12.9), and 61 participants were females (69.3%). The mean follow-up period was 10 months. The mean baseline CISS scores were 41 (SD=19.9) for the surgical cohort and 44 (SD=20.0) for the splinting cohort, respectively. Compared to nighttime splinting, open carpal tunnel release improved CISS scores by a mean score of 23.7 points (95% CI 17.1 to 40.8, p<0.0001) in the unadjusted model. After adjustment using the IPTW method, surgical patients improved by 21.0 (95% CI 10.0 to 32.0, p<0.001) points on the CISS compared to splinted patients.

Conclusion: Carpal tunnel release is associated with decreased cold sensitivity at follow-up compared to splinting. Early carpal tunnel release has a role in CTS patients complaining of a high degree of cold sensitivity.

References: 1. Hernán MA, Robins JM. Using big data to emulate a target trial when a randomized trial is not available. American journal of epidemiology. 2016 Apr 15;183(8):758-64.

Background Genioplasty may be performed in surgical facial feminization to improve facial gender congruence and perceived femininity. While it is accepted that feminizing genioplasty involves changing the width of the chin and improving its projection, there is a paucity of data assessing how the degree of specific changes most successfully improve perceived femininity. In this crowdsourcing study, raters assessed faces with chins digitally manipulated in three dimensions to assess which changes were perceived most favorably.

Methods Publicly available photographs of 6 male subjects and 6 female subjects were digitally combined to simulate frontal and lateral images of 6 trans women. The mental region of each of the 12 resulting images was further manipulated by narrowing 3, 6, or 9mm, increasing or decreasing the vertical height by 2 or 4mm, sagittally advancing 3 or 6mm, or setting back by 3mm, for a total of 96 unique images. 1380 laypeople on an online crowdsourcing platform were randomized to assess one frontal and lateral image of each of the 6 simulated patients, rating the images by perceived femininity, masculinity, attractiveness, friendliness, and trustworthiness. The effects of chin position on perceived gender and personality traits were assessed using linear mixed-effects models, with rater and subject ID as random effects.

Results 79,980 ratings from 1333 raters were included. 51% of raters identified as male, 45% female, and 3% as transgender, non-binary, or other gender. 16% identified as LGBT. On lateral view, 2mm of increased chin vertical height was rated most feminine (β=0.08, p=0.03) and most attractive (β=0.08, p=0.002), while decreasing vertical height by 4mm was least masculine (β=-0.08, p=0.03). Sagittal advancement of 6mm was least feminine (β=-0.07, p=0.04), advancement by 3mm was most masculine (β=0.08, p=0.02). Setback by 3mm was considered least attractive (β=-0.12, p<0.001). On frontal view, 3mm narrowing was most feminine (β=0.07, p=0.04) and least masculine (β=-0.06, p=0.04), while, in direct contrast to lateral view results, 2mm of increased vertical height was least feminine (β=-0.10, p=0.004) and most masculine (β=0.07, p=0.02). Narrowing by 9mm was considered most attractive (β=0.07, p=0.01), while decreasing vertical height by 4mm was found least attractive (β=-0.09, p<0.001). LGBT and non-cisgender raters perceived simulated patients as more feminine (LGBT p<0.001, non-cis p=0.002) and attractive (LGBT p<0.001, non-cis p<0.001), compared to heterosexual and cisgender raters.

Conclusion Our findings indicate that modifying the chin position can have a substantial impact on perceived facial femininity. Narrower, less prominent chins were rated as most feminine overall. Interestingly, the effects of changes in chin height on femininity perception differed depending on the angle of view. While increasing vertical height was found to be most feminine on lateral view, it was perceived as least feminine on frontal view, suggesting a potential trade-off in feminizing efficacy. These findings suggest that careful consideration of three-dimensional facial features is necessary when considering chin manipulations to achieve optimal feminizing outcomes.

Purpose: Lower extremity (LE) reconstruction following severe trauma, oncologic ablation or extensive chronic wounds implies many challenges for reconstructive surgeons. Despite previous, little data regarding the impact of obesity on LE reconstruction is currently available.(1-3) Currently 39.1% of adults in Mississippi are obese, making it one of the most obese state in America.(4) Many of these patients have comorbidities and are subject to multiple chronic therapeutic interventions, providing a unique population in which to study obesity and other co-morbidities and their potential effects on LE reconstruction and wound healing. The aim of this study was to examine patients who underwent surgical reconstruction of LE injuries at a single institution under the direction of a single surgeon and analyze possible trends in surgical methods, decision-making processes, and long-term outcomes. In addition, risk factors such as obesity and other comorbidities were analyzed to monitor their effects on the outcome of LE reconstructive procedures.

Methods: A retrospective review was performed on patients who underwent complex lower extremity salvage at a single institution under the direction of a single surgeon since September 2012. Records were reviewed for patient demographics, comorbidities, mechanisms of injury, and perioperative complications/characteristics. Patients were classified using the World Health Organization criteria for obesity. Rate of perioperative complications with high body mass index (BMI) vs normal BMI was the primary outcome; reoperations and limb salvage vs amputations were secondary outcomes.

Results: One hundred and one patients were included in this analysis. Mean age at surgery was 47.5 years. Average BMI was 31.6 kg/m2 with 51% of patients classified as obese (BMI ≥ 30 kg/m2). Mechanism of injury, operative characteristics, and types of flaps were similar between obese and non-obese patients. 11 patients ultimately required amputation, including 7 obese (7%) and 4 overweight (4%). The average number of comorbidities was not significantly higher in obese patients (1.25 vs. 0.98, p= 0.239), and no significant difference was seen in overall complication rates between obese and non-obese patients (p= 0.431).

Conclusions: Lower extremity salvage can present with many challenges; however, we demonstrate the safety of aggressive lower extremity reconstruction in the obese population. Obese patients, even those with higher numbers of comorbidities, can successfully undergo lower extremity reconstruction utilizing the same operative mechanisms as in healthy weight patients.

​​References 1. Cleveland E, Fischer J, Nelson J, Wink J, Levin L, Kovach S. Free Flap Lower Extremity Reconstruction in the Obese Population: Does Weight Matter? Journal of Reconstructive Microsurgery. 2014;30(04):263-270. doi:10.1055/s-0033-1357279 2. Rifkin W, Kantar R, Daar D, et al. Obesity and Lower Extremity Reconstruction: Evaluating Body Mass Index as an Independent Risk Factor for Early Complications. Journal of Reconstructive Microsurgery. 2018;35(05):346-353. doi:10.1055/s-0038-1676538 3. Iamaguchi RB, Takemura RL, Silva GB, et al. Peri-operative risk factors for complications of free flaps in traumatic wounds - a cross-sectional study. International Orthopaedics. 2018;42(5):1149-1156. doi:10.1007/s00264-018-3854-6 4. CDC. New Adult Obesity Maps. Centers for Disease Control and Prevention. Published September 27, 2022. Accessed March 6, 2023. https://www.cdc.gov/obesity/data/prevalence-maps.html

Background Lower extremity (LE) trauma within the pediatric population may be debilitating and has a wider variety of etiologies than in adults. Specifically, lawnmower injuries can cause catastrophic sequelae to the lower extremities, often requiring complex reconstruction or resulting in amputation. This study aims to present our experience with pediatric LE lawnmower injuries at one of the busiest level 1 trauma centers in the United States.

Methods An IRB-approved retrospective analysis was performed studying pediatric patients (age <18 years) who experienced LE trauma due to a lawnmower injury over a 5-year period (2012-2017). Patient demographics, perioperative data, and types of reconstruction were reviewed. Statistical analysis of the data was performed to examine trends in exposure and management of pediatric LE lawnmower injuries.

Results A total of 23 patients were identified, of which 67.1% and 32.9% were male and female, respectively. The patients had a median age of 6 years and a median Injury Severity Score (ISS) of 4. Over one-third (34.8%) of our cohort required upfront amputation. Additionally, 26.1% and 8.7% of our cohort required local and free flap reconstruction, respectively. In comparison, only 3.6% and 2.3% of all traumatic pediatric LE injuries from the same time frame required local and free flaps, respectively.

Conclusion Lawnmower injuries to the LE can be devastating, causing long-term physical, emotional, and psychosocial consequences for pediatric patients and their families. Our data suggests that pediatric LE injuries from lawnmowers more often require complex reconstruction than other traumatic LE injuries. Rapid and effective decision-making by experienced surgeons is necessary to optimize the potential for limb salvage in pediatric LE lawnmower injuries. Based on our institution's experience, we compiled a list of recommendations about when to transfer these types of injuries to more experienced tertiary centers. Additional resources should be dedicated toward improving public awareness and industrial safety features to help prevent lawnmower injuries in pediatric patients.

Background Based on the evidence provided by two landmark trials, the current clinical practice guidelines for melanoma consider careful observation for patients with a negative sentinel lymph node biopsy (SLNB) and low-risk micro metastatic disease.1,2 Importantly, recurrences occur in 10.4% of these patients.3 As the quantity of nodal involvement is crucial in staging patients for adjuvant systemic treatment4, and with declining rates of complete lymph node dissection (CLND) following a positive SLNB, we hypothesized patients with more nodes examined on SLNB had better survival outcomes. Methods We conducted a retrospective study using the National Cancer Database (NCDB). Following the AJCC 8th edition staging parameters, we divided the population into those who had 0, 1, 2-3 or ≥4 positive nodes between January 2018 and December 2019. We compared their overall survival with respect to the number of nodes removed, adjusting for age, race, ethnicity, gender, stage, tumor site, and treatment. Results A total of 41,088 patients were included in the study, with a median follow up time of 27.5 months. 80% of patients had a negative SLNB. From the 20% of patients with a positive result, 14% had 1 positive node, 4% had 2-3 positive nodes and 0.5% had ≥ 4 positive nodes. Of note, only 18.9% had ≥ 4 nodes examined. As expected, patients with ≥4 positive nodes had a worse median two and four year overall survival (OS) (70% and 45%, respectively) compared to patients with 0, 1 or 2-3 positive nodes, all with a median two and four year OS greater than 90% and 75%, respectively (p < 0.001). When analyzing the OS by the number of nodes examined, there was a significantly worse four year OS among patients that had only one node examined versus patients with 2 nodes (p= 0.005). Interestingly, there was no difference in survival outcomes between patients with 1 or ≥ 3 nodes examined. Conclusion This study is the first to analyze the number of nodes examined in the SLNB and its association with survival outcome using a national database. As hypothesized, limiting the number of nodes examined to one node significantly relates to worse survival, possibly a consequence of under-staging and hence, under-treating with systemic therapy. With CLND being rarely indicated, surgeons should be encouraged to remove at least two nodes when conducting SLNB.

References: 1. Leiter, U., et al., Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma (DeCOG-SLT): a multicentre, randomised, phase 3 trial. The Lancet Oncology, 2016. 17(6): p. 757-767. 2. Bello, D.M., M.B. Faries, The landmark series: MSLT-1, MSLT-2 and DeCOG (management of lymph nodes). Annals of Surgical Oncology, 2020. 27(1): p. 15-21. 3. Knackstedt, R., Gastman, B. R. (2021). Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy Improves the Accuracy of Sentinel Lymph Node Biopsy in Melanoma. Plastic and Reconstructive Surgery, 148(1), 83e-93e. 4. Amin MB, Edge S, Greene F et al. (Eds.). AJCC Cancer Staging Manual (8th edition). Springer International Publishing: American Joint Commission on Cancer; 2017 [cited 2016 Dec 28].

Introduction: ChatGPT is a Large Language Model (LLM) trained by OpenAI (San Francisco, CA) as an artificial intelligence chatbot that can understand and respond to natural language questions and tasks.1 In recent months, ChatGPT has performed well on all three United States Medical Licensing Examination (USMLE), demonstrating a high level of understanding and insight into a physician's knowledge base and clinical reasoning ability.2 LLMs have the potential to improve access to medical information, assist with clinical decision-making, and enhance medical education.

Objectives: In this study, we evaluate the performance of ChatGPT on the American Society of Plastic Surgery's (ASPS) Plastic Surgery In-Service Training Examination (PSITE). We aim to assess this large language model's clinical reasoning and decision-making ability and investigate the legitimacy of this tool related to plastic surgery competencies.

Methods: In-service examination questions from 2007-2018 were included in this study (n=2,472). Questions with clinical images, charts, and graphs were excluded (n=360). After screening, 2,114 multiple-choice questions were selected and included. ChatGPT was prompted to answer questions with the best single-letter answer choice. Questions and their respective multiple-choice answer options were entered into the ChatGPT text box, and output answers were scored as either correct or incorrect.

Results: We analyzed a total of 2,114 multiple-choice questions. The average score on the assessment was 41.46% (SD= 4.07, Range= 35.44-48.77, 95% CI [28.84%, 69.13%]). On the Shapiro-Wilk normality test, our data did not show a significant departure from the normality (W(12) = .955, p = .708).

Conclusion: Our data suggest that ChatGPT has a low level of proficiency relating to plastic surgery competencies. While ChatGPT's performance has shown promise in other medical domains, our results indicate it may not be a reliable source of information for plastic surgery-related questions or decision-making. Our findings highlight the importance of practicing caution when using large language models in specific medical domains and the need for continued research and refinement of these models to improve their accuracy and reliability.   References 1. OpenAI. ChatGPT. Accessed February 15, 2023. https://chat.openai.com/chat 2. Kung TH, Cheatham M, Medenilla A, et al. Performance of ChatGPT on USMLE: Potential for AI-assisted medical education using large language models. PLOS Digital Health. 2023;2(2):e0000198. doi:10.1371/journal.pdig.0000198

Tuberous breast is a relatively common yet poorly understood congenital breast difference that hinders breast growth during puberty. It is associated with lactation difficulties, and its mental and physical impact has not been formally studied in adolescents and young adults. The purpose of this study was to compare the physical and psychosocial effects of this condition on young women in relation to their unaffected, healthy peers.

Health-related quality of life surveys were administered to adolescent females with tuberous breast and healthy female controls, aged 12 to 21 years of age. Surveys included Short Form-36v2 (SF-36), the Rosenberg Self-Esteem Scale (RSES), and the Eating Attitudes Test-26 (EAT-26). Age and BMI data were collected and compared between the two groups. Linear regressions were fit to determine the effect of tuberous breast on survey scores, with BMI category as a covariate.

Between August 2008 and July 2022, 34 female patients with unilateral or bilateral tuberous breasts and 264 healthy female adolescents participated in this study. Subjects in these two cohorts were of similar ages (16.7 years versus 16.8 years, P = .78). Patients with tuberous breast had significantly higher body mass indices (BMI) than healthy controls (27.5 kg/m2 versus 24.2 kg/m2, P < .001), and, expectedly, a higher proportion of patients with tuberous breast were overweight or obese (74%) compared to controls (32%, P < .001).

Mean scores were significantly lower among tuberous breast patients compared to healthy controls on the RSES (P < .001) and in 5 SF-36 domains: general health (P = .01), vitality (P = .02), social functioning (P < .001), role emotional (P < .001), and mental health (P = .001). Compared to healthy controls, patients with tuberous breast had a higher mean EAT-26 score (6.0 ± 6.9 versus 11.4 ± 11.6, P < .001).

After adjusting for differences in BMI between cohorts, scores on the RSES (P < .001) and in 5 SF-36 domains remained significantly lower in subjects with tuberous breast compared to healthy controls: general health (P = .04), vitality (P = .04), social functioning (P = .01), role emotional (P < .001), and mental health (P = .01). Additionally, the difference in mean EAT-26 scores between groups remained significant (P = .004).

Tuberous breast is associated with higher BMIs and predisposes adolescents to worsened mental health and lower self-esteem while increasing their risk for disordered eating. It is imperative that healthcare providers understand the physical and psychosocial burden of tuberous breast and tailor care accordingly. Moreover, these findings underscore the need for third-party payors to broaden their coverage of tuberous correction procedures, as the condition has a tangible effect on overall well-being.

Purpose: The national volume of cosmetic surgery procedures continues to increase dramatically, with the Aesthetic Plastic Surgery National Databank statistics citing a 54% increase in surgical volume and a 44% increase in non-surgical volume between 2020 and 2021, resulting in a 63% growth in plastic surgery revenue.1 Given that over a quarter of plastic surgeons in the United States perform primarily cosmetic procedures, their revenue is dependent on optimizing their cosmetic surgery procedure pricing.2 Unfortunately, many plastic surgeons are not formally trained in economic principles, limiting their ability to maximize practice profit. Furthermore, while national averages are presented to surgeons to help understand starting price points, other factors ultimately influence a final price. This study aims to evaluate the variables that impact publicly reported prices compared to national averages to provide an economic understanding to maximize profitability. Methods: Using an internet search engine, a search was performed using the phrase "cosmetic surgery, prices" for practices that publicly report their cosmetic surgery prices. Publicly reported prices were compared to national averages generated from the 2019 and 2020-2021 Aesthetic Society Plastic Surgery National databank statistics. For each practice, data was collected on the fees included in advertised prices for each procedure, if accredited sources were referenced to generate prices, available financing, and offered discounts. The impact of geographic region, practice type, and surgeon accreditation on price values were analyzed for the top cosmetic surgery procedures. Results: Sixty-six practices were identified that reported cosmetic surgery pricing information. Practices were distributed across North America, with the greatest concentration of practices within the South Atlantic (37.8%). Publicly reported prices were significantly higher for all surgical procedures except "Nipple" procedures ($4301.40 ± 4509.37, p= 0.088), "Excision of Skin" ($11,900.00 ± 1838.48, p= 0.115), "Fat Grafting" ($6461.20 ± 3590.17, p= 0.530), "Fat Harvest" ($5150.00 ± 3747.66, p= 0.423), and "Lip Enhancement" ($3212.00 ± 1749.81, p= 0.126). Facility/OR fees (n=38) and anesthesia fees (n=34) were the most common component included in a price after surgeons' fees (n=65). Prices varied between geographic regions for all cosmetic surgeries except "Breast Augmentation" (p= 0.074) and "Liposuction" (p= 0.088)." West South Central, Mountain, and Pacific regions demonstrated the highest surgical procedure prices. There was no difference across regions for "Neurotoxins" or "Dermal Filler" (p= 0.55 and p= 0.65, respectively). No significant difference in prices was demonstrated between different surgeon accreditations or practice types. Conclusions: In this study, we demonstrate that in addition to surgeons' fees, publicly reported prices often include anesthetic and facility/OR fees bundled into the total price. Furthermore, recognizing the geographical variation in cosmetic surgeries and procedures may aid the cosmetic surgeon in pricing their services competitively. Understanding economic cosmetic surgery pricing trends, along with their components and strategies, will allow cosmetic surgeons to maximize practice profit.

References: 1. Databank N. Aesthetic Plastic Surgery National Databank Statistics 2020-2021. Aesthet Surg J. 2022;42(1):1-18. doi:10.1093/asj/sjac116 2. Gordon CR, Pryor L, Afifi AM, et al. Cosmetic Surgery Volume and Its Correlation With the Major US Stock Market Indices. Aesthet Surg J. 2010;30(3):470-475. doi:10.1177/1090820X10372209

Purpose: Feminizing Facial Gender Affirming Surgery (FFGAS) refers to a group of procedures that help to align the facial appearance of trans individuals with their gender identity. FFGAS aims to improve psychosocial well-being, abate gender incongruence, and reduce the lifetime risk of interpersonal and sexual violence as well as suicide (1). Despite advocacy for the benefits of these procedures, insurance coverage varies considerably based on geography and insurance provider. One commonly cited concern in the coverage of FFGAS is the overlap between many of these procedures and cosmetic operations undertaken by cisgender women. Utilizing patient-reported outcomes, this study aimed to better clarify the relative aesthetic and psychosocial benefits specific to FFGAS.

Methods: Following IRB approval the GENDER-Q questionnaire, a novel patient-reported outcome measure, was sent to patients who were at least 18 years of age and who previously consulted for gender-affirming surgery at our institution. This included those who did not proceed to surgery at our institution or had FFGAS elsewhere. Transgender respondents who indicated that "woman" best described their gender identity were included in the analysis. Respondents were grouped based on whether they had undergone FFGAS, and Chi-square tests were employed to compare survey responses. To enable univariate analyses of Likert scale responses, answers including the term "satisfied" (i.e. "Extremely Satisfied", "Very Satisfied", etc.) were grouped and compared with those including the term "dissatisfied".

Results: The GENDER-Q was sent to 1,057 patients of which 367 completed the questionnaires (34.7%). One-hundred self-identified trans women answered one or more of the questions of interest and were included in the final analysis. Fifty-three respondents reported having undergone FFGAS with the most common areas addressed being brows (79.2%), lips (66.0%), nose (64.2%), jawline (64.2%), and trachea (64.2%). Overall, satisfaction among patients who underwent FFGAS was 95.74% (45/47). Univariate analysis demonstrated patients who had undergone FFGAS were more satisfied with how their face aligned with their gender identity (81.13% vs. 52.17%, P-value = .002) and felt their face better affirmed their gender (79.25% vs. 60.87%, P-value = .045). FFGAS recipients also reported higher overall satisfaction with their faces (79.25% vs. 59.57%, P-value = .032). Regarding aesthetic considerations, there was no statistically significant difference found in how well-proportioned (79.25% vs. 80.43%, P-value = .883) or attractive (77.36% vs. 69.57%, P-value = .379) respondents reported their face to be.

Conclusion: This study found that satisfaction rates following FFGAS were exceptionally high and that individuals who had undergone FFGAS were more likely to perceive their faces as aligning with and affirming their gender identity. This benefit exists despite no statistically significant difference in aesthetic outcomes including perceived facial proportionality or attractiveness. These findings support the necessary role of FFGAS as a reconstructive procedure for trans women and underscore the importance of broad and comprehensive insurance coverage.

References (1) Parker AC, Brydges HT, Kimberly LL, Blasdel G, Rodriguez ED. Facing Violence: The Protective Impact of Facial Gender-Affirming Surgery. Plast Reconstr Surg. 2022;150(4):934e-935e. doi:10.1097/PRS.0000000000009509

Introduction
Adipose-derived stem cell (ADSC) secretomes have been demonstrated to have potential therapeutic applications in various conditions, including wound healing, tissue repair, and autoimmune diseases. The ADSC secretome includes a variety of proteins, growth factors, and a wide range of signaling molecules, which should be further analyzed to pave the way for the development of novel ADSC-based therapies. Prior secretome analyses have been limited to select individual donors, so it is not clear whether there is variability amongst donors. Because ADSC-based therapies would entail autologous grafting, the aim of our investigation was therefore to determine whether the secretome therapeutic benefits are consistent from donor to donor.

Methods
Lipoaspirate was obtained from 9 healthy donors undergoing elective liposuction at the Department of Plastic Surgery, University of California, Irvine. The lipoaspirate underwent a cellular isolation protocol and was passaged to obtain a pure population of ADSC's. After culturing to confluency, secretome samples were collected and sent to Eve Technologies, Inc (AB, Canada) for interrogation. The secretome report was subsequently decoded followed by classification of proteins into 3 categories: low, mid, and high secretion. This partitioned data was then imported into REACTOME and STRING for visualization and interpretation of implicated pathways and protein-protein interactions, respectively. An algorithm was then utilized to identify significant pathways and interactions present across combinations of all 3 secretion categories.

Results 23 genes and associated proteins with a low coefficient of variation were identified across all donors. A REACTOME and STRING analysis of all combined data demonstrated 152 implicated cellular pathways. After analyzing the partitioned data and evaluating for overlap between all secretion levels, 37 significant pathways were identified. The pathways were then classified according to their contributions to general biological processes. Pathways involving signaling and regulation of IL-4, IL-13, and IL-17 were associated with immunomodulation. The secretomes also contained proteins contributing to the regulation of blood vessel endothelial cell proliferation involved in sprouting angiogenesis. Lastly, Insulin-Like Growth Factor Binding Proteins (IGFB) involved in the regulation of IGF were identified.

Conclusion
Our investigation demonstrates that ADSC secretomes contain key factors that are consistently present across donors. The identified factors have been implicated in various immunomodulatory and angiogenic processes, in addition to the regulation of IGF transport and uptake through IGF binding proteins. These findings suggest that autologous grafting in patients may reliably provide consistent therapeutic advantages for wound healing, scar modulation, and autoimmune processes.

Background: Patients undergoing abdominal wall reconstruction (AWR) are at increased risk for post-operative venous thromboembolism (VTE), with reported incidence rates ranging from 0.2-7.9%. While certain patient and operative characteristics are known to be involved, unevaluated modifiable risk factors may present new opportunities to decrease incidence. Previously, intraoperative core body temperature has been associated with thrombotic events in ovarian cytoreductive surgery, intracranial tumor resection, and free tissue transfer; however, there is no literature describing the effects of intraoperative body temperature on VTE after AWR. The objectives of this study were thus to describe the rate of VTE events in the immediate post-operative period after AWR and to analyze the effects of intraoperative temperature on VTE rate.

Methods A retrospective chart review was conducted to identify patients who had undergone AWR. Patient characteristics and intraoperative details, including core body temperature, were extracted. Cohorts were defined by presence of post-operative 30-day VTE, which served as the primary outcome. VTE events were defined as imaging confirmation of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Intraoperative core body temperature was recorded as the minimum (min), maximum (max), mean, median, 1st quartile (Q1), and 3rd quartile (Q3) temperature experienced throughout the operation. Patient characteristics, operative details, and intraoperative temperatures were analyzed using descriptive statistics. Univariable logistic regression was used to assess for associations between intraoperative temperatures and post-operative VTE.

Results: A total of 354 patients were included in this study. Of these, 14 patients were diagnosed with VTE events within 30 days of surgery, giving an incidence rate of 3.95%. The VTE cohort had a longer median inpatient hospital stay than the non-VTE cohort (8 days vs 5 days, p =.001). All other baseline clinical and operative characteristics were comparable between groups (p >.05). No significant associations were found between individual temperature metrics and chance of VTE on univariable regression analysis (min temperature: Odds Ratio 0.97 [0.53-2.10, 95% confidence interval], max: 1.49 [0.72-2.86], mean: 0.84 [0.34-2.18], median: 0.79 [0.34-1.87], Q1: 0.82 [0.30-2.26], and Q3: 0.86 [0.39-1.94]).

Conclusions: Our study found that intraoperative core body temperature during AWR was not associated with an increased risk of VTE within 30 days of surgery. Given the low incidence of VTE, future studies should utilize larger samples sizes to allow for multivariable regression models that may further isolate the effect of intraoperative core body temperature on VTE rate.

Purpose: The FDA's recommended voluntary recall of textured implants due to their association with BIA-ALCL has led to a loss of one of the major benefits of the textured surface: positional stability for anatomically shaped implants. Inspired by clinical observation of tissue ingrowth seen into cranioplasty plates with millimeter size pores to allow fluid egress, our group has engineered a novel smooth breast implant surface that promotes tissue ingrowth into the implant shell which contains cylindrical "wells" 1-4mm in diameter. These features facilitate tissue ingrowth into the outer surface of the implant, thereby fixing the implant into position as the implant capsule forms. In this study, we report our early findings on the positional stability of this novel smooth implant design implant.

Methods: Anatomically shaped miniature 2cc breast implants were fabricated using polydimethylsiloxane. 3D-printed molds designed using CAD modeling were casted. Implant were molded with wells in the following variations in width (W), depth (D), total surface well count (P), and reported in millimeters: W1D2P22, W2D2P11, W2D2P22, W2D3P22. Control groups consisting of smooth and salt-imprinted textured surfaces topographically comparable to commercial implants were fabricated. Four autoclaved implants per group were implanted into a tight subcutaneous pocket on the dorsa of Sprague-Dawley rats. Rats were sacrificed at 1- and 3-month timepoints and the implant-capsule unit was explanted en bloc for positional, histological, and micro-CT analysis.

Results: All PSSI conditions demonstrated tissue ingrowth into shell features by 1 month and was evaluated through hematoxylin and eosin staining and Micro-CT imaging. Measured through Micro-CT, tissue ingrowth volume conformed completely to the shape of the well by 1 month and tissue density was consistent among PSSI conditions with no appreciable change occurring between the 1- and 3-month timepoints. At the 3-month timepoint, the smooth implant group had a mean positional rotation of 100 degrees while the textured group had a mean rotation of 36 degrees. The PSSI mean positional data at 3-months was the following: W1D2P22 at 64 degrees, W2D2P11 at 21 degrees, W2D2P22 at 17 degrees, W2D3P22 at 27 degrees, W4D2P11 at 24 degrees. There was no statistically significant difference between PSSI and textured implant positional stability at 3-months (p>0.05). Lower stability was observed with decreased well width, and no significant differences were observed between groups in capsule thickness or collagen content upon histologic evaluation.

Conclusion: Smooth implants experienced significantly more rotation than the W2D2P22 PSSI at 3-months. There was similar stability between PSSI and textured implants. Lower stability was noted when the well width decreased, and tissue ingrowth occurred by 1-month and was maintained through time. These data are an encouraging first step for this novel implant design wherein a smooth surface enhances positional stability without the use of microtextured surfaces, which have been linked to BIA-ALCL. Further studies, of longer duration, are ongoing to determine the optimal well configuration and density that maximizes implant stability.

Purpose: For decades, there has been an ongoing debate about the ideal timing of orbital fracture repair (OFR) in adults. Although there is strong consensus that extraocular muscle (EOM) entrapment is an indication for early repair, factors that should govern surgical timing in case of no EOM entrapment are unknown. Our study is the first and largest multi-center study to assess the association between surgical timing and postoperative ocular outcomes following OFR. Methods: We retrospectively reviewed trauma patients who underwent OFR at two centers from 2015 to 2019. Excluded were patients <18 years old and those with follow-up <2 weeks. The primary outcome was incidence and/or persistence of any postoperative ocular complication at >2 weeks following OFR. Surgical timing was categorized into 0-7, 8-14, 15-28, and >29 days from injury to surgery. The association between surgical timing and postoperative ocular complications was assessed using Chi-square/Fisher's exact tests in patients with EOM entrapment, enophthalmos, diplopia, and different fracture sizes. Results: Of n=253 patients, n=13 (5.1%) had preoperative EOM entrapment. Of these, patients who had OFR within 1 week of injury were less likely to develop postoperative diplopia compared to patients who had OFR within 8-14 days of injury (n=1/8 [12.5%], n=3/3 [100%]; P=.018). Patients with near-total defects were more likely to develop postoperative enophthalmos if OFR occurred 15-28 days (n=2/6 [33.3%]) or >28 days (n=8/24 [33.3%]) after injury compared to patients who had OFR within 1 week of injury (n=0/30 [0.0%]; P<.001). There was no significant association between surgical timing and postoperative ocular complications in patients with no EOM entrapment and less severe fractures, preoperative diplopia, or enophthalmos. Conclusion: We recommend surgical intervention within 1 week of injury for orbital fractures with EOM entrapment or near-total defects. Surgical delay is possible in case of less severe fractures, preoperative diplopia, and/or enophthalmos.

Background The current, standard approach to transfemoral amputation is an antiquated surgical procedure that severs agonist-antagonist muscle dyads, thereby disrupting the body's native dynamic efferent/afferent neuromuscular relationship in the residual limb. However, osseointegrated (OI) transdermal titanium implants, which eliminate the need for sockets by directly affixing the prosthetic to the skeletal system, exhibit immense potential for human-machine integration by providing the physical architecture necessary for stable neural connections. We report the first-ever surgical implementation of electronic Osseoanchored Prostheses for the Rehabilitation of Amputees (eOPRA) with Agonist-Antagonist Myoneural Interface (AMI) constructs for transfemoral amputation.

Methods Two (2) dually staged modified above-knee revision amputations were performed in the elective setting at Brigham & Women's Hospital between August 2019 and September 2022. AMIs were constructed in each subject to control and interpret proprioceptive feedback from bionic knee, ankle, and subtalar joints. Clinical data was collected in the preoperative, intraoperative, and perioperative periods, and included patient demographics, surgical time, input/output, pain control regimen and changes, and postoperative complications.

Results Gender was evenly split between male (1, 50%) and female (1, 50%). Mean subject age at the time of the first stage was 60.10 ± 0.87 years and 60.97 ± 0.18 years at the second stage. Mean operative time for stage one was 482.50 ± 61.52 minutes and 773.00 ± 65.05 minutes for stage two. Intravenous fluid requirements, estimated blood loss, and urine output were all within safe margins. Average length of post-operative stay was 3.50 ± 0.71 days for stage one and 5.00 ± 0.00 days for stage two. No complications were noted in the postoperative period.

Conclusion This case series demonstrates that the integration of AMI constructs with an osseointegration procedure holds the potential to provide the physical architecture necessary for the stable neural connections required for human-machine integration.

Introduction: Postoperative gender affirming care (GAC) for adolescents involves special consideration regarding pain management. Marginalization combined with a high burden of mental health diagnoses makes this population especially vulnerable to persistent post-operative opioid use.1 To mitigate risk, our institution previously admitted patients to the hospital after gender affirming mastectomy (GAM). However, mandated restrictions on elective procedures during the COVID-19 pandemic inspired the development of an outpatient surgical protocol to continue serving the transgender population. The purpose of this study is to describe pain management, perioperative, and complication details before and after our transition to outpatient transmasculine top-surgery.

Methods: This was a retrospective review of demographic and perioperative data for all GAM patients at Rady Children's Hospital, San Diego from 2019-2022. Patients were grouped by timing of surgery: before ("pre-pandemic" n=25) or after ("post-pandemic" n=45) implementation of the outpatient protocol. Multivariate linear and logistic regression and independent t-tests were used to compare data elements.

Results: Seventy patients were included in this study and one of four surgeons performed the mastectomy procedure. Analyses were computed adjusting for variation in surgeon, use of liposuction, patient BMI and surgical technique. Patients received an erector spinae nerve block (n=15), an intercostal nerve block (n=8) or both (n=47). Patients who received an erector spinae nerve block prior to the procedure received less morphine milligram equivalents (MME) in the 24-hour postoperative period compared to those who received the same block during or after the procedure (p=.006). While in the post operative recovery center (PACU), there was a trend in association such that patients who had liposuction received more MME (x̄=3.18) compared to those who did not have liposuction (x̄=1.44) (p=.09).

The average duration of hospital stay for the post-pandemic group was 9.5 hours (SD=3.9) compared to 26.3 hours (SD=6.0) in the pre-pandemic group (p<.001). At discharge, 28% of pre-pandemic patients were prescribed opioids compared to 9% post-pandemic. No patients presented to the emergency department postoperatively for pain management. There was no significant difference in minor complications (seromas, hematomas or scarring concerns not requiring readmission or reoperation) between the pre-pandemic (n=3) and post-pandemic cohort (n=10) (p=.49). Within the entire sample, only one patient experienced a major complication requiring readmission for a superficial wound infection which was treated non-operatively with intravenous antibiotics and drain removal.

Conclusion: In our experience, the transition to outpatient GAM procedures was successfully and safely implemented. Our findings suggest that reframing surgeon and patient expectations may yield shorter duration of hospital stay and postoperative opioid prescription without impacting the incidence of complication. This outpatient paradigm for transmasculine top-surgery aims to promote patient-centered care through consideration of the unique needs of this population.

[1] Memtsoudis SG, Zhong H, Liu J, Poeran J, Cozowicz C, Sites B. Persistent opioid use after gender affirmation surgery. Br J Anaesth. 2022 Nov 11:S0007-0912(22)00563.

Introduction:
Objective measures of successful applications in the plastic surgery match remain elusive. As the Step 1 of the United States Medical Licensing Examination (USMLE) transitions to pass-fail even less information is available. The Texas Seeking Transparency in Application to Residency (STAR) program was established to provide public, objective application data. With further changes such as virtual interviews due to COVID-19, identifying predictors of successful applicants is important to help advise the next generation of candidates. This study utilizes the Texas STAR and Association of American Medical College (AAMC) databases to provide a better understanding of trends in objective measure in plastic surgery residency applications.

Methods: Integrated plastic surgery residency application data from the Texas STAR and AAMC databases between 2019 and 2022 was retrospectively analyzed. Statistical analysis compared objective applicant measurements such as number of interviews, research experiences, and examination scores.

Results: The AAMC database consisted of 187 matched, first year plastic surgery residents' objective measures. Compared to 2019, average number of research experiences in 2022 increased from 4.7 (SD 2.6) to 5.9 (SD 3.4). Average number of work experiences increased from 3.4 (SD 2.4) to 4.1 (SD 2.8), and average number of volunteer experiences increased from 7.4 (SD 3.7) to 9.0 (SD 4.7) from 2019 to 2022. In 2019, average Step 1 score was 246.5 (SD 13.2) and Step 2 score was 252.5 (SD: 13.1). In 2022, all plastic surgery applicants passed Step 1 in their first attempt.
The total cohort from the STAR database was 221 plastic surgery applicants. From 2019 to 2022, there was a significant decrease in match rate (p<0.01) despite an increase in number of applied programs per applicant. There were significant differences in number of honors received in clerkships (p=0.04) and number of interviews attended (p<0.01) between matched and unmatched applicants. There were no significant differences between number of publications (p= 0.73), volunteer experiences (p=0.98), leadership positions (p=0.67), or Alpha Omega Alpha (AOA) status (p=0.71) between the two groups. Step 1 (p=0.14) and Step 2 (p=0.08) scores of matched and unmatched applicants were not significantly different.

Conclusions: Findings from this retrospective analysis of applicant data suggests few differences in objective measures between matched and unmatched applicants. Subjective measures such as away rotation performance, letters of recommendation, and interview impressions may play a more significant impact in the success of applicants in the Match. Analysis in this study was limited to publicly available data in the AAMC and STAR databases, which does not include comprehensive data on all applicants. Further research is necessary to characterize measurements of successful plastic surgery applicants and to guide prospective students in what qualifications our societies find most valuable.

Introduction: Autologous breast reconstruction (ABR) is an increasingly popular and effective option for post-mastectomy patients. Although the safety of ABR is well established, complications such as arterial or venous thrombosis, delayed wound healing, and flap necrosis continue to cause significant morbidity that may necessitate more complex secondary reconstruction. Vascular thrombosis is a leading cause of flap failure. Flap loss remains a feared result from these complications and can be prevented in some instances by early identification of vascular compromise. The authors sought to report the incidence and timing of these surgical complications as well as ultimate flap loss in a single surgeon series to describe trends in identification and salvage techniques.  

Methods: All ABRs (immediate or delayed) performed from 2005-2018 by the senior author were included. Vascular complications were stratified by timing (intraoperative, post-operative 0 to 48 hours, post-operative > 48 hours) along with their treatment course and outcome. Chi-squared analysis was used to determine trends in the ratio of intraoperative vascular complications identified to those identified post-operatively that necessitated take-back to operating room. Poisson regression analysis was used to determine risk-adjusted intra-operative identification of flap complication while controlling for flap number and total complication number.  

Results: A total of 1160 patients with 1871 ABR flaps were included. Of these patients, 713 (61.6%) underwent bilateral free flaps and 1257 (67.1%) flaps were performed in immediate fashion. Post-operative takebacks were performed in 205 (17.7%) patients. The overall flap success rate was 99.99% with only 16 total flap losses. The majority of intraoperative complications were arterial thromboses (82 flaps, 4.3%) while venous thrombosis was the predominant complication in the immediate postoperative period (17 flaps, 0.9%). The ratio of thromboses recognized intraoperatively compared to within the immediate postoperative period has increased over time.  

Conclusions: This is the largest single surgeon series evaluating ABR outcomes. It is evident that ABR is highly safe and post-operative complications that require takeback to the operating room are limited.  However, vascular complications can be devastating and result in flap loss. Years of microsurgical experience has resulted in the ability of the senior author to identify vascular complications earlier, either intraoperatively or in the immediate post-operative period resulting in more timely takebacks. Specifically, flap thromboses have increasingly been recognized intraoperatively and are able to be addressed immediately, likely contributing to few takebacks to the operating room and the senior author's very low rate of flap loss. 

Introduction: Clinicians may be hesitant to perform procedures in individuals with connective tissue disorders (CTDs) due to concerns surrounding wound healing and elevated risk of infection. We sought to investigate whether CTDs have an impact on surgical outcomes of gender-affirming surgery (GAS).

Methods: Using the IBM® MarketScan® Research Database, patients with a diagnosis of gender dysphoria who underwent gender-affirming surgery (GAS) (mastectomy, breast augmentation, hysterectomy, orchiectomy) between 2007 and 2021 were identified using the International Classification of Disease, ninth (ICD-9) and tenth (ICD-10) edition, and Common Procedural Terminology (CPT) codes. Among these, patients with CTDs, including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, Sjögren's, sarcoidosis, spondyloarthritides, antiphospholipid syndrome, psoriatic arthritis, dermatomyositis, polymyositis, and large, medium or small vessel vasculitides, were identified. In both CTD and non-CTD cohorts, patient demographics and procedure-related complications within 90 days of the index surgery (seroma, hematoma, dehiscence, infection, fat necrosis, tissue necrosis, deep vein thrombosis or other vascular complication, and non-specified complications) were recorded. Although patients who underwent multiple GAS procedures simultaneously were included, patients were excluded if they underwent subsequent procedures within the 90-day window following the index GAS procedure(s). Chi-squared, Schapiro-Wilk, Wilcoxon-Mann-Whitney, and multivariate logistic regression testing were used for statistical analysis.

Results: Of 5,772 patients meeting the criteria (mean age 28.90 ± 10.46), 212 (3.7%) had CTD diagnoses. Mastectomy was the most common (65%), followed by hysterectomy (22%), orchiectomy (13%), and breast augmentation (7%). CTD patients were, on average, older (p = 0.002), underwent the index procedure less recently (p = 0.001), and had higher comorbidity levels (p < 0.001). CTD patients more often underwent hysterectomy (p < 0.001). 9% of patients experienced at least one complication following the index GAS procedure. In a multivariable regression model, additional simultaneous GAS procedures (OR 2.596; p < 0.001) and Elixhauser index scores of four or higher (OR 1.531; p = 0.001) were associated with increased odds of experiencing one or more complications following the index GAS procedure, while CTD diagnoses (p = 0.790) did not affect odds of experiencing complications.

Conclusion: Overall, our study cohort highlights that CTDs presently affect a small minority of patients receiving GAS. However, this study found that CTD diagnoses are not associated with increased odds of experiencing complications following GAS, suggesting potential safety with GAS. Further research is needed to focus on more common CTDs within the gender-diverse community (Ehlers-Danlos and mast cell activation syndrome) as well as determine the role of immune modulation in these outcomes.

Introduction: Tethered cord syndrome (TCS) describes the range of functional and neurological deficits associated with spinal cord adhesion to the surrounding tissue canal. TCS can occur due to both congenital and iatrogenic etiologies. Treatment success is dependent on adequate surgical de-tethering and superficial tissue closure. For cases involving large lumbosacral defects, extensive soft tissue compromise, or medically complex patients, plastic surgeons may offer expertise with recruiting adjacent tissue to optimize closure integrity and minimize complications. However, at most institutions, routine involvement of plastic surgeons in tethered cord release is not a well-described practice.1 Our aim is to develop a machine learning model capable of predicting both the probability and quantity of complications for individual patients, utilizing their known characteristics and medical history. This information can then be used to help identify cases where plastic surgery collaboration may be necessary during surgical planning and for closure of the incision site.

Methods: A database of 116 patients who underwent tethered cord surgery with and without plastic surgery closure between 2009-2020 was constructed. The features collected included demographics, medical history, comorbidities, social history, and the surgical approach. Outcomes of interest include whether complications occurred (cerebral spinal fluid leakage retethering, infection, seroma/hematoma, wound breakdown, and other adverse events requiring reoperation) and the total number of complications. A logistic regression model was evaluated using 5-fold cross validation. Principal component analysis (PCA) and top feature selection using univariate chi-squared tests (SelectKBest) were used to improve model performance. Linear regression models were built to predict the continuous outcomes of interest.

Results: Model built with the four highest scoring features (age at surgery, dural patch closure, complex tethered cord etiology, antibiotics use for 24 hours) achieved the best performance when predicting the occurrence of post-operative complications, with model ROC AUC of 0.73+/-0.1, and overall accuracy of 76%. Linear regression model prediction of the total number of complications for each patient achieved mean absolute error +/-0.75 events.

Conclusion: Incorporating machine learning into clinical decision-making for TCR has the potential to enhance patient counseling and improve overall healthcare delivery. In cases where a high risk or an increased number of complications is anticipated based on model prediction, the collaborative efforts of plastic and neurosurgeons may lead to a more comprehensive approach to patient care and reduce the incidence of adverse outcomes. By leveraging the expertise of both specialties, patients may receive more effective and individualized care that results in better outcomes and improved quality of life.

References 1. Levi, Benjamin MD; Sugg, Kristoffer B. MD; Lien, Samuel C. BS; Kasten, Steven J. MD; Muraszko, Karin M. MD; Maher, Cormac O. MD; Buchman, Steven R. MD. Outcomes of Tethered Cord Repair With a Layered Soft Tissue Closure. Annals of Plastic Surgery: January 2013 - Volume 70 - Issue 1 - p 74-78. doi: 10.1097/SAP.0b013e31822f9ada

Purpose : As the fleur-de-lis panniculectomy (FDL) approach resects tissue in both the vertical and horizontal axes, patients are subjected to longer operative times and potential complications, despite its body contour advantage. While many plastic surgeons use a layered suturing technique for surgical closure, the absorbable dermal stapler has gained popularity. The purpose of this study was to assess the difference in overall operative time, postoperative clinical outcomes, and patient-reported quality of life (PRO) scores utilizing an absorbable dermal stapler during FDL.

Methods: A single-center, single-surgeon retrospective review from 2015-2022 was performed examining subjects who underwent FDL. Patients with complex concomitant procedures were excluded. Patient demographics, operative information, and surgical outcomes were compared between patients that had Insorb® Absorbable Subcuticular Skin Stapler (CooperSurgical, Trumbull, CT) assisted and suture-only closures. 

Results: A total of forty subjects were identified. Of which, 25 patients (62.5%) were in the dermal stapler cohort. Total procedure time was significantly reduced with the use of the dermal stapler compared to suture closure (66.76 vs. 125.33 min, p < 0.05), respectively. There was no difference among these two approaches regarding overall surgical site occurrences (40.0% vs 53.3%), aesthetic outcomes, readmissions, or reoperations (p >0.05). The use of the dermal stapler was an independent predictor of decreased operative time on multivariate regression analysis while adjusting for BMI, pannus weight, comorbidities, concurrent procedures, incisional wound VAC placements, and liposuction. PROs improved across all domains for both techniques, as measured by BODY-Q. PROs demonstrated a greater overall social function score after use of the dermal stapler (p <0.05).

Conclusion: The absorbable dermal stapler demonstrates a significant decrease in overall length of time during fleur-de-lis panniculectomy without increasing the incidence of wound healing or aesthetic dissatisfaction and sustaining equivalent quality of life improvement compared to standard suture closure. 

Introduction Bleeding is a potential complication of aesthetic surgery. Surgeons have adhered to the principle of minimizing blood loss. Tranexamic acid (TXA) is an antifibrinolytic medication that has demonstrated the ability to reduce bleeding. This study aims to investigate TXA and its effect on complications and overall outcomes in aesthetic surgery patients. Methods This retrospective chart review of patients undergoing various aesthetic surgeries between 2019 and 2022 was conducted in Riyadh, Saudi Arabia. Preoperative and postoperative hemoglobin levels, blood transfusions, and complications were the primary outcomes. Furthermore, the predictors of giving TXA were studied. Results In total, 435 patients were included in the study. TXA was administered to 181 patients (41.6%). Significantly higher proportions of patients who received TXA underwent trunk aesthetic surgeries (p < 0.001), and those who underwent combined surgeries more frequently than non-users (p < 0.001). The mean operative time and length of hospital stay were significantly longer among patients who did not receive TXA (p < 0.001, and p < 0.001, respectively). The most predictors for using TXA were significantly associated with performing liposuction (OR = 5.5), trunk aesthetic surgery (OR = 4.9), and undergoing combined surgeries (OR = 2.7). No significant difference in the rate of complications between the two cohorts. Conclusion As a result of our findings, we recommend adding TXA to the usual anesthesia protocol as a routine component. However, contraindications must be taken into account. A randomized controlled trial is necessary to support the findings of this study. Our study showed excellent demographic similarities between the two cohorts, with only their BMI showing a significant difference, which ensures no demographic differences have influenced the results of our study.

Background: Utilization of three-dimensional printing (3DP) and virtual surgical planning has become common practice for many facets of plastic and reconstructive surgery (PRS). However, it is unclear how 3DP is being uniformly applied to United States' PRS resident education. Empirical research has demonstrated that the utilization of 3DP in PRS resident education can effectively mitigate errors, enhance surgical proficiencies, and bolster comprehension.1–5 The aim of this study is to determine the current attitudes of U.S. integrated plastic surgery programs toward the incorporation of 3DP into resident education.

Methods: A REDCap survey was sent to all U.S. integrated plastic surgery program directors (PDs) via email. PDs were identified and contacted through a manual review of publicly available email addresses. The survey consisted of 5 questions: (1) program access to 3DP, (2) how 3DP is incorporated into their training practices, (3) future directions of 3DP application into resident training, (4) perceived barriers to incorporation of 3DP into training, and (5) the perceived importance of 3DP in residency training. An additional literature review of the current publications utilizing 3DP in PRS was completed February 2023.

Results: Eleven of 88 PDs completed the survey (response rate 12.5%). 45% represented training programs that owned a 3D printer, while 36% reported no access to a 3D printer. 3DP incorporation into residency training was largely done via patient education opportunities (55%), discussion during lectures/grand rounds/journal clubs (45%), and during hands-on surgical training outside the operating room (45%). 36% reported no incorporation of 3D printing into residency education. 73% reported that they are currently incorporating, working to incorporate it, or intend to incorporate it within the next 5 years. When asked how important the integration of 3DP is to the future of training plastic surgeons on a Likert scale 1-5 (1 being not at all important and 5 being extremely important), the average response was 3.8 (SD 1.3). Reported barriers to the incorporation of 3DP into residency education were finances (73%), limited access to necessary equipment (45%), limited experience with 3DP (45%), and lack of peer reviewed evidence to support use (27%). The literature review showed a total of 391 publications. 279 met inclusion criteria and were included. Fifty-seven ACGME accredited PRS training program-affiliated universities and hospitals were identified as publishing institutions. 259 unique first authors and 243 unique senior authors were identified. These articles were published in a total of 152 journals with the highest output being the Journal of Craniofacial surgery (16) and Plastic and Reconstructive Surgery (10).

Conclusion: 3DP stands as a largely affordable asset to PRS, yet several obstacles hinder its complete integration into residency training. These impediments include financial constraints, insufficient access to necessary equipment, and a scarcity of practical know-how. This literature review demonstrates the increasing inclusion of 3PD into PRS residency programs' education and research. Nevertheless, further inquiry is required to continue to bolster the case for 3DP's employment in PRS residency education, which has the potential to serve as an instrumental resource for the refinement of residents' surgical acumen.

References:

1. Gupta N, Fitzgerald CM, Ahmed MT, Tohidi S, Winkler M. Feasibility of a 3D printed nasal model for resident teaching in rhinoplasty. J PlastReconstr Aesthetic Surg JPRAS. 2021;74(10):2776-2820. doi:10.1016/j.bjps.2021.05.071
2. Choi YS, Shin HS. Preoperative Planning and Simulation in Patients With Cleft Palate Using Intraoral Three-Dimensional Scanning and Printing. J Craniofac Surg. 2019;30(7):2245-2248. doi:10.1097/SCS.0000000000005983
3. Lobb DC, Cottler P, Dart D, Black JS. The Use of Patient-Specific Three-Dimensional Printed Surgical Models Enhances Plastic Surgery Resident Education in Craniofacial Surgery. J Craniofac Surg. 2019;30(2):339-341. doi:10.1097/SCS.0000000000005322
4. Zheng Y xiong, Yu D fei, Zhao J gang, Wu Y lian, Zheng B. 3D Printout Models vs. 3D-Rendered Images: Which Is Better for Preoperative Planning? J Surg Educ. 2016;73(3):518-523. doi:10.1016/j.jsurg.2016.01.003
5. Farrell DA, Miller TJ, Chambers JR, Joseph VA, McClellan WT. Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training. PlastReconstr Surg. 2020;146(5):1100-1102. doi:10.1097/PRS.0000000000007025

PURPOSE: The field of medicine faces well-documented challenges when it comes to diversity and equity, and plastic surgery is no different in this regard. Efforts to promote diversity in plastic surgery include visiting student scholarships for underrepresented applicants, intended to offset the costs of away rotations that may otherwise be prohibitively expensive. Our aim was to characterize the landscape of visiting student scholarships, including scholarship criteria and advertising modalities, to inform future efforts and promote reach in this space.

METHODS: Integrated plastic and reconstructive surgery residency programs were identified from the American College of Academic Plastic Surgeons website. Program websites were evaluated for the following variables: program name, city, state, presence of an associated medical school, presence of mission statement on program website, presence of department or division-specific mission on program website, mention of DEI in mission statement, availability of medical student scholarship, source of scholarship (plastics versus from school), eligibility criteria for individuals, advertising on website, advertising on social media, amount of funding offered, and allocation of funding if applicable (transportation, stipend, housing, other). Descriptive statistics were used to summarize variable frequencies. A content analysis was used for qualitative variables such as source of funding and underrepresented groups to count the occurrences of unique values and group them into similar categories.

RESULTS: Overall, 41 programs offered a medical student scholarship, 31 (75.6%) of which advertised on Instagram. Funding sources listed were the health system or school (n = 10), department of surgery (n = 3), plastics division (n = 1), named donation (n = 3), with data not available or not applicable to 67 programs. The scholarship amount was listed for 35 programs. When considering the highest scholarship amount offered by each individual program, the average scholarship amount was $2,051.43 (range $500 to $4000). The majority of programs specified that their scholarships could be allocated to transportation, housing, and additional stipend. Seven programs additionally covered application fees, and three programs indicated that additional funds would be allocated to food. Of the 41 programs offering scholarships, 39.02% (n=16) did not specify criteria beyond "underrepresented in medicine." The most common identity markers mentioned across scholarships pertained to race and ethnicity (n = 82, 58.16%), specifically Black and African American (n=20), Hispanic and Latinx (n=20), and Native American/Native Alaskan (n=20). Two programs included Asian populations in their criteria, both specifying ethnic groups including Hmong, Hmong-American, Filipino, Vietnamese, and Laotian. Additional common identity markers related to being "socioeconomically disadvantaged" (n=16, 11.3%) and to gender and sexuality (n=16, 11.3%). The least common identity markers mentioned were ability status (n=2, 1.42%) and first generation status (n=1, 0.71%).

CONCLUSIONS: A substantial proportion of plastic surgery residency programs offer visiting student scholarships. Within these scholarships, there is significant heterogeneity in the amount of funding allocated, modality of advertising, and criteria for application. Students may wish to look at program websites or Instagram accounts on a case-by-case basis if interested in applying to certain scholarships.

Introduction: Brow rejuvenation is aimed at reversing brow ptosis and elevating the lateral brow (Botox or neuromodulators typically deal with forehead/glabellar rhytids). With changing brow aesthetics, younger patients now ask for 'snatched' brows with a more profound lateral lift. Since the traditional subcutaneous brow lift or endoscopic procedures cannot effectively achieve this result, we designed a procedure based on 1) Tessier's 'Mask-lift',¹ 2) Zarem's 'Browpexy',² and 3) Knize's 'ligamentous release'.³ Outcomes were assessed using Artificial and Human Intelligence age assessment and patient reported outcomes.

Methods: Patients aged 25-55 years old who desired a 'snatched' brow appearance underwent a brow lift technique (n=51): 1) blepharoplasty incision, superior orbital ROOF fat excision, superior temporal ligamentous release, supraorbital ostectomy/contouring, 2) lateral temporal zig-zag scalp excision, 3) fascial anchoring lift. Age assessment outcomes of preoperative and postoperative (6 months) images were performed by 4 neural networks (software algorithms trained with millions of images) and by public perception from a crowd-sourcing platform (Amazon Mechanical Turk). FACE-Q patient satisfaction assessment was also used; ANOVA for significance.

Results: A detailed lateral 'snatched' brow lift technique video will be shown. Perioperative complications were minimal (2% alopecia/asymmetry). Anatomically, the lateral brow peak was moved 5mm±0.4 up and 3mm±0.2 laterally (Pre-op to Post-op). Neural network age accuracy score was 100.8±9 (100 correct age). Age reduction after snatched brow lift was 4.1±0.5 years (less than patient self-assessment of 6.2±0.7 years). Similarly, crowdsource age reduction was 4.3±0.6 years. High patient satisfaction was measured for peri-brow aesthetics (overall, brow, forehead, hairline, eyes) (77.8±7), quality of life (77.8±7), and process of care (77.8±7) scores. Interestingly, satisfaction scores correlated to increased age reduction measured with AI and public perception.

Conclusions: Changing brow aesthetics in younger patients that desire a 'snatched' appearance may be addressed successfully with a technique that involves temporal ligamentous release, bony contouring, and a lateral scalp lift; with successful age reduction and patient satisfaction.

References: 1. Tessier P. Le lifting facial sous-périosté [Subperiosteal face-lift]. Ann Chir Plast Esthet. 1989;34(3):193-197. 2. Zarem HA. Browpexy. Aesthet Surg J. 2004;24(4):368-372. doi:10.1016/j.asj.2004.05.004 3. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009;124(6):2118-2126.

INTRODUCTION:

The Snapshot Near Infrared Spectroscopy (NIRS) device (Kent imaging, Calgary, CA) allows the user to image an area of interest and swiftly calculates tissue oxygen saturation (StO2) in superficial tissue. Snapshot is hand-held, completely non-invasive, less costly than other perfusion assessment devices, and was shown to identify ischemia/flap necrosis in an animal model. We have previously used the device to monitor changes in skin flap perfusion in breast reconstruction throughout the operative course. In this study, we investigated the use of Snapshot NIRS for longitudinal, point-of-care perfusion assessment after reduction mammoplasty.

METHODS:

Patients undergoing reduction mammoplasty were imaged throughout the course of care. Images were obtained (i) pre-operatively, (ii) after tissue removal, (iii) at closure, and (iv) at up to three follow-up visits within six weeks of surgery. A blinded reviewer selected areas of the images for analysis. StO2 measurements were taken from the medial, lateral, and inferior breasts. Measurements were compared to un-operated, control tissue within the same images.

RESULTS:

10 patients undergoing reduction mammoplasty of 16 breasts were enrolled. Images of three patients with high Fitzpatrick scores (≥5) could not be analyzed due to limitations of the device. 6 patients received a Wise pattern reduction, and one patient received a Periareolar reduction. We observed one instance of skin flap necrosis. Among patients who did not develop necrosis, StO2 levels in the medial and lateral breasts increased after tissue removal, remained elevated at closure, and returned to baseline within 6 weeks, post-operatively. StO2 levels of the inferior breast more closely resemble those of the control tissue, likely due to less undermining of the tissue during surgery compared to that of the medial and lateral operative areas with Wise pattern reductions. Observed changes in control tissue StO2 likely reflects physiologic changes related to skin temperature or anesthesia.

One patient receiving a Wise pattern reduction developed necrosis of the lateral skin flap. Necrosis presented at the first follow-up appointment. We did not observe an intra-operative increase in StO2 relative to un-operated control tissue, unlike the observed changes in patients who did not develop necrosis. StO2 was higher (Follow-up 2: 70%, Follow-up 3: 81%) than all-patient controls (Follow-up 1: 52%, Follow-up 2: 47%, Follow-up 3: 52%) throughout the course of multiple post-operative follow-up visits. This trend may be due to a sustained inflammatory response at the site of necrosis throughout the post-operative period.

CONCLUSIONS:

Here we present the use of a NIRS device for point-of-care perfusion assessment in reduction mammoplasty. The device detected normal changes in perfusion following breast reduction. The device did detect possible aberrant changes in tissue oxygenation in one patient with skin flap necrosis, but further research is required to validate this observation. Snapshot NIRS could facilitate early identification of tissue at risk of ischemia/necrosis.

BACKGROUND:

Plastic surgery patients experience a myriad of physical and psychosocial challenges throughout their surgical experience1. Improved patient education is imperative in optimizing the patient experience and may reduce medical and surgical complications, behavioral problems, and emotional distress2. While there are no uniformed guidelines in addressing the educational needs of the surgical patient, the literature supports the importance of a personalized approach that goes beyond generic educational brochures3. In this study, we explored the utility of ChatGPT, a novel chatbot that has recently been released by OpenAI, as a personalized, educational resource to enhance patient education in Plastic Surgery.

METHODS:

We surveyed the literature regarding current applications of artificial intelligence (AI) in patient education and current protocols for educating patients on plastic surgery procedures. We noted common pre- and post-operative questions and concerns of patients, input these into ChatGPT, and recorded the program's responses.

RESULTS:

ChatGPT has a wide range of benefits for both patients and their families. Pre-operatively, ChatGPT can answer questions succinctly, and to a level of depth that can be adjusted by preference. The software can help patients better understand how to look for a surgeon, pre- and post-operative expectations, what various surgeries entail, medical/surgical terminology, and more. The software is also free to use, which reduces costs by having patients avoid unnecessary consult fees, increasing accessibility to patients from a wider socioeconomic background. Alongside these benefits, there are risks, such as potential misinformation spread through the software, which raises concerns about liability and the need for additional paperwork to protect surgeons. ChatGPT also currently lacks the framework to be HIPAA compliant because of how information is currently stored. But although the software has limitations, its emergence shows incredibly promise to advance surgical education forward.

CONCLUSION:

Although a technology platform cannot replace the physician-patient relationship, ChatGPT has the potential to be used as an additional, free-to-use resource to improve patient education in plastic surgery. We believe that surgeons should take a proactive role in managing new technologies that emerge from ChatGPT, such as surgery-specific websites and applications, to ensure the highest quality of information is available to patients.

References:

1. Pinto A, Faiz O, Davis R, Almoudaris A, Vincent C. Surgical complications and their impact on patients' psychosocial well-being: a systematic review and meta-analysis. BMJ Open. 2016 Feb 16;6(2):e007224.
2. Ganry L, Hersant B, Sidahmed-Mezi M, Dhonneur G, Meningaud JP. Using virtual reality to control preoperative anxiety in ambulatory surgery patients: A pilot study in maxillofacial and plastic surgery. J Stomatol Oral Maxillofac Surg. 2018 Sep;119(4):257-261.
3. Dimarco C, Bray P, Covvey HD, Cowan DD, Diciccio V, Hovy E, Lipa J, Yang C. Authoring and generation of individualized patient education materials. AMIA Annu Symp Proc. 2006;2006:195-9.

Introduction: Despite existing regulations to support gender equality in Germany, it is unclear how these policies have translated into leadership opportunities for female plastic surgeons. This study investigated the gender distribution of leadership positions in German plastic surgery departments.

Methods: This cross-sectional study collected demographic data on the physician workforce in 102 plastic surgery departments in Germany in May 2022. Data were gathered from publicly available resources.

Results: Of the 812 physicians identified, male residents and specialists slightly outnumbered their female counterparts. However, the proportion of women declined steadily with increasing hierarchical rank, with only 7.55% of department heads being female. Male surgeons held significantly more leadership positions than female surgeons (84.04% vs. 15.96%, p < 0.0001), and this gap persisted across all hospital types. After adjusting for academic rank, male physicians were still more likely to hold leadership positions (OR, 2.655, 95%CI: 1.628-4.041).

Conclusions: Our findings reveal a significant gender gap in leadership positions in German plastic surgery departments, even after accounting for academic rank. These results highlight the need for continuous monitoring and implementing gender equality policies to address this disparity. Specifically, targeted interventions should be developed to promote the career advancement of female plastic surgeons.

BACKGROUND: Improvement in orthoplastic and microsurgical techniques has led to an increase in the ability to salvage limbs after high energy trauma. Patients undergoing salvage procedures with free flaps require more complex wound care regimens than those undergoing amputation. Surgical site infection (SSI) after free flap reconstruction (FFR) has been a feared complication since the infancy of microsurgery, and the true nationwide burden of infection remains elusive. We sought to quantify the rate of surgical site infection (SSI) readmission after FFR and describe the healthcare utilization and characteristics of patients in this cohort. METHODS: All patients undergoing FFR for lower extremity trauma were identified in the Nationwide Readmission Database (NRD; 2013-2019). Patient, injury, healthcare utilization, and hospital level characteristics were abstracted to compare patients who suffered readmission due to SSI within 6 months compared to those that did not. RESULTS: A total of 760 patients undergoing FFR after acute trauma were identified. The overall 30- and 60-day SSI readmission rate was 6% and 10% respectively. Readmitted patients did not differ from non-readmitted patients and were mostly male (71.5%), had public insurance (Medicare/Medicaid, 66.8%), were mostly in the top two income quartiles (52.6%), treated at the top quartile of trauma volume (86.9%) with teaching status (84%; all P>0.0%). The mean age of those readmitted was 50.8 years old (SD 16.9) and had an Injury Severity Score of 8.5 (SD 7.8). The two cohorts did not differ in terms of their rate of infection during index admission (6.0% vs 6.6%, P=0.958). The specific comorbidities smoking history, hypertension, diabetes, peripheral vascular disease, and obesity did not differ between the two groups (P all > 0.05). However, patients readmitted with SSI did have a greater overall comorbidity burden (Elixhauser comorbidty index: 2.9 vs 1.8, P=0.027). A majority of patients who were readmitted for SSI had their flaps performed within 72 hours of acute injury (73.7%) which did not differ with those who did not suffer an SSI readmission (84.2%, P=0.462). Patients with SSI readmission had on average a 16 day longer total length of stay (index + readmission; P=0.016) and their total hospital cost was on average $36,519 greater than those not readmitted for SSI (P=0.0124). CONCLUSIONS: Readmissions due to SSI remains high in patients receiving FFR after acute lower extremity trauma compared to other clean surgical procedures. Further studies will need to quantify the granular impact on patients and efforts should be made to reduce SSI readmission after FFR.