Scientific Abstract Presentations: Practice Management Session 1 Friday, October 10 Fri, Oct 10 2:00-3:30 p.m. CDT

Background: Social media has emerged as an essential platform for plastic surgeons to advertise to potential new patients. Among the various factors influencing a patient's choice of physician, implicit bias plays a significant role.(1-5) This study aims to investigate whether a surgeon's gender or race, as presented in their social media profile picture, affects the perception of their competence and the likelihood of attracting patients.

Methods: Two side-by-side sample Instagram posts were created. Each post displayed a before-and-after photograph of a common plastic surgery procedure and featured one of eight possible profile pictures generated using artificial intelligence, with variations only in gender and race. Surveys containing the posts, which only differed in the surgeon's profile pictures, were distributed to respondents to evaluate perceived surgeon competence, likelihood of recruiting patients, likelihood of making a referral, and willingness to visit the surgeon's profile.

Results: A total of 1,777 respondents participated. The average scores were 3.74 (SD=0.98) for competence, 3.64 (SD=1.06) for patient recruitment likelihood, 3.72 (SD=1.00) for referral, and 3.68 (SD=1.05) for social media influence. Surgeon race or gender did not significantly affect scores, and no significant pairwise differences were found between respondent and surgeon race across all categories. However, competence (p = 0.0073), patient recruitment (p = 0.0003), referral (p < 0.001), and social media influence scores (p < 0.001) varied significantly across racial respondent groups. Hispanic respondents gave the highest average competence score (4.27), while Black respondents gave the lowest (3.39).

Conclusions: Our results showed no significant differences in patient recruitment, referral likelihood, perceived competence, or social media influence based on surgeon gender or race. These findings suggest that using controlled images, which standardize factors like clothing, name, and other superficial identifying features, may help reduce the influence of demographic biases. Furthermore, black respondents consistently provided lower scores across multiple metrics, which may reflect historical mistrust in the medical system. Conversely, Hispanic respondents gave the highest competence scores, possibly indicating greater trust or different cultural attitudes toward physicians.

1. Laveist T. A., Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 2002;43(3):296-306.
2. Champagne-Langabeer Tiffany, Hedges Andrew L. Physician gender as a source of implicit bias affecting clinical decision-making processes: a scoping review. BMC Medical Education. 2021;21(1):171.
3. Bhat D., Kollu T., Ricci J. A., Patel A. What's in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill. Plast Reconstr Surg. 2021;147(6):948e-56e.
4. Bhat D., Kollu T., Ricci J. A., Patel A. How Do You Like Me Now? The Influence of "Likes" and Followers on Social Media in Plastic Surgery. Plast Reconstr Surg. 2022;149(4):1012-22.
5. Bhat D., Kollu T., Giutashvili T., Patel A., Ricci J. A. Does Surgeon Training Affect Patient Perception of Surgeon Skill in DIEP Flap Breast Reconstruction? J Reconstr Microsurg. 2022;38(5):361-70.

Purpose: No-show appointments place a significant burden on healthcare systems and increase the risk of readmission for trauma patients. This study examines risk factors associated with missed follow-ups at plastic surgery clinic within a level 1 trauma center following facial, hand, or lower extremity trauma. We compare no-show trends before and after the COVID-19 pandemic to identify potential shifts in patient adherence.

Methods: A retrospective review was conducted on trauma patients consulted to plastic surgery at a level I trauma center before and after the COVID-19 pandemic. The COVID-19 pandemic was officially declared by the Centers for Disease Control in March of 2020. Thus, Cohort A (pre-pandemic) included patients from August 2019 to March 2020, and Cohort B (post-pandemic) included patients from April 2020 to November 2020. No-shows were defined as missed follow-ups within 30 days of discharge. Collected data included demographics, injury details (insurance status, injury location, mechanism of injury), and social work or violence recovery program (an institutional social services program) intervention. The area deprivation index was calculated using zip codes. Univariate analysis was performed to assess differences between Cohort A and Cohort B as well as between no-show and follow-up groups within each cohort. Logistic regression was conducted to identify independent predictors of no-show.

Results: A total of 336 patients were included in Cohort A and 452 in Cohort B. There was not a significant difference in no-show rate between cohorts (p=0.091). However, insurance status (p<0.001), mechanism of injury (p<0.001), location of injury (p<0.001), disposition (p=0.029), and social work or violence recovery program intervention (p<0.001) differed significantly between cohorts. Within Cohort A, significant differences were found between patients who attended follow-up (n=222) and patients who did not (n=114) for race (p=0.007) and insurance status (p<0.001). Within Cohort B, patients who missed their follow-up (n=128) and patients who attended (n=324) differed significantly in race (p=0.008), insurance status (p<0.001), state area deprivation index (p=0.049), mechanism of injury (p=0.004), location of injury (p<0.001), and disposition (p=0.004). Logistic regression analysis identified Medicaid (OR 3.355, p=0.003), out of network insurance (OR 4.237, p<0.001), and lack of insurance (OR 6.068, p<0.001) as independent predictors of no-show rate in Cohort A. Similarly, in Cohort B Medicaid (OR 2.643, p=0.005) and out of network insurance (OR 23.864, p<0.001) were predictive of no-show. Additionally, ballistic violence (OR 0.342, p=0.042) was associated with attending follow-up appointments in Cohort B.

Conclusion: Despite baseline differences between pre- and post-pandemic cohorts, including injury mechanism and location, there were similar no-show rates. Across both cohorts, a major predictor of no-show rates was Medicaid insurance status or lack of coverage, emphasizing the impact of socio-economic factors on follow-up attendance. Although there was increased social work intervention post-pandemic, socio-economic factors remain significant barriers to clinic attendance.

Background: Every year, approximately 12.5% of plastic and reconstructive surgeons (PRS) in the United States (US) are implicated in a malpractice claim. This rate is considerably higher than the typical US physician, whose mean malpractice claim rate is 7.4% per year. Most literature on PRS litigation uses Westlaw or LexisNexis databases to draw conclusions. In this review, evidence from studies on PRS litigation over the past two decades is synthesized. We aim to analyze litigation trends and identify recurring common factors contributing to malpractice claims, with the ultimate goal of reducing legal disputes while enhancing patient safety and satisfaction.

Methods: A systematic review was conducted in accordance with PRISMA guidelines, with studies using Westlaw or LexisNexis databases. Articles were independently screened, extracted, and evaluated for quality by two researchers. Meta-analysis was performed using the "metafor" package in R.

Results: Of the litigation described in the 28 studies, 85% of the cases went to court, whereas 11% were decided by settlement or pre-court arbitration. Of the cases that went to court, the decision was favorable for the defending surgeon 60% of the time, whereas a decision favoring the plaintiff occurred 25% of the time. For the cases that resulted in jury-decided awards, the average indemnity payment was $680,892.06 (95% confidence interval: $392,092 - $969,693). For cases decided by settlement or pre-court arbitration, the average indemnity payment was $584,117.21 (95% confidence interval: $417,079 - $751,155). The most commonly cited reason for litigation was procedural error (55%), followed by diagnostic errors (24%) and informed consent (23%).

Conclusions: The importance of surgeons operating within their scope of practice is highlighted by the fact that 55% of PRS cases were litigated due to procedural error. This was likely a result of significant overlap between specialties, notably otolaryngologists and plastic surgeons, whose scopes within the head and neck space share many procedures. Another common theme identified in studies centers on physician-patient communication and proper informed consent. Our analysis found that as the proportion of cases related to informed consent increases, the proportion of cases won by plaintiffs statistically significantly increases. Surgeons, hospitals, private practices, and medical councils should place increased importance on ensuring expectations are clear and that patients understand the complete risks of procedures.

Purpose: On October 27, 2021, the FDA implemented a boxed warning on implants, the highest level of safety labeling restriction for medical devices. Previous cross-sectional survey studies suggested that patients would be less likely to consider receiving implants following the black-box warning and implementation of standardized checklists (1); however, real-world impacts on practice patterns remains unclear. This study employed an Interrupted Time Series Analysis (ITSA) of nationwide data to quantify changes in trends of Implant-Based Reconstruction (IBR), offering the first assessment on the impacts of a black-box warning on surgical practice patterns.

Methods: We queried the Epic Cosmos nationwide healthcare database for monthly procedural frequencies of IBR (CPT 11970,19340,19342) from January 2017 through January 2025. ITSA was performed using a multivariable regression approach, with the black-box warning modeled as an interruption to the existing trend in monthly rates of IBR. Independent variables included the following: number of months elapsed from January 2017, a binary variable representing post black-box warning status, and the number of months elapsed after the black-box warning. These variables were tested for the presence of level or slope changes in IBR trends post-warning.

Data from 2020 was omitted to avoid confounding effects due to the COVID-19 Pandemic. We accounted for seasonality of procedures by controlling for the month in which procedures occurred. To account for possible delays in implementation of checklists or impact of the boxed warning, we conducted sensitivity analyses by shifting the time of interruption by +/- 3 months from October 2021. Regression models were ultimately selected on the basis of best fit by adjusted R-squared.

Results: We identified 179,560 IBR procedures that occurred during the 8-year study period. Pre-warning, IBR procedures were steadily increasing at a rate of 16.20 procedures per month (CI: 14.1-18.3, p<0.001); accounting for seasonality, this represented a month-to-month average growth of 1.41% in the pre-warning period. October 2021 was found to be the intervention point with optimal fit (R^2 = 0.953). The model was further controlled for seasonality, revealing a significant monthly variation with procedural volumes peaking in October through December (additional 429.23 to 441.31 cases, p<0.0001).

Immediately following implementation of the boxed warning, a substantial level change was observed, with a sharp decrease of 675.03 procedures (CI: -927.4 to –422.6, p<0.001) to the pre-warning trend. This represented an immediate 36% reduction in monthly IBR procedures. Following the initial drop in IBR procedures, rates started to recover at an additional 6.96 (p<0.0001) procedures per month.

Conclusions: Our study provides the first quantitative evidence that FDA boxed warnings can substantially influence surgical practice patterns. The boxed warning produced an immediate, significant decrease in IBR following October 2021. While a gradual recovery occurred, rates remained lower than pre-warning projections. These results establish an evidence-based foundation to guide future FDA policy on risk communication, underscoring their potential to transform clinical practice patterns and improve shared decision making amongst patients and physicians.

References: Hyland CJ, et al. Public Perceptions of Breast Implant Complications and the FDA Boxed-Warning. Plast Reconstr Surg Glob Open. 2022.

Introduction: Median sternotomy, a cornerstone procedure in cardiac surgery, is performed on over 500,000 patients annually in the United States (1). While wire cerclage has long been the standard for sternal closure, post-sternotomy complications such as dehiscence, mediastinitis, and non-union remain significant concerns, with mortality rates reaching up to 15% (2). These complications often necessitate sternal debridement, wire removal, and implementation of sternal rigid plate fixation (SRPF).

From the senior author's experience, two key factors contribute to preventable complications with SRPF: (1) Variability in closure methods: Despite some cardiothoracic surgeons being trained in SRPF, there is considerable variation across hospitals in primary sternal closure techniques. Some surgeons exclusively use SRPF, while others reserve it for select cases or consult plastic surgery for closure in certain scenarios. Plastic surgery involvement often occurs after complications have arisen. Earlier collaboration during the initial median sternotomy for SRPF closure could potentially prevent many of these complications, especially for cardiothoracic surgeons less experienced with the technique. (2) The absence of clear guidelines: Current cardiothoracic surgery guidelines do not provide specific indications for prophylactic SRPF in median sternotomy patients. This absence of clear criteria makes it challenging for surgeons to determine when SRPF is necessary and when early plastic surgery consultation is warranted.

This study aims to investigate current practices, interdisciplinary collaboration patterns, and decision-making processes regarding sternal closure techniques among cardiothoracic surgeons in the United States.

Methods: To assess current practices, a nationwide survey was distributed to practicing or recently retired cardiothoracic surgeons. The survey gathered data on current sternotomy closure practices, collaboration patterns with plastic surgery teams, decision-making processes for high-risk patients, and attitudes towards the adoption of SRPF. Additionally, the survey assessed the interest in and potential utility of standardized decision-making tools for sternal rigid plate fixation.

Results: The survey has been sent to 100 cardiothoracic surgeons across the United States. As data collection progresses, we anticipate finding significant variations in sternal closure practices across institutions, with some cardiothoracic teams routinely using SRPF for high-risk or even all patients, while others rely exclusively on wire cerclage. The study may uncover diverse collaboration models between cardiothoracic and plastic surgery teams, ranging from routine involvement to consultation only after complications arise. Key risk factors influencing the selection of closure methods, particularly for high-risk patients, may be identified, including obesity, diabetes, osteoporosis, and advanced age. This research might also highlight a need for additional training in SRPF techniques for cardiothoracic surgeons to increase adoption and improve outcomes.

Conclusion: We anticipate that our findings will help improve collaboration between cardiothoracic and plastic surgery teams, particularly at institutions where cardiothoracic surgeons are not trained in SRPF techniques. The results may support the development of standardized decision-making tools for sternal rigid plate fixation, potentially leading to more consistent and improved patient care. Furthermore, the study could provide evidence to support the wider adoption of SRPF, especially for high-risk patients, potentially reducing post-sternotomy complications and improving overall outcomes in cardiac surgery.

1. Allen KB, Thourani VH, Naka Y, et al. Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg. Apr 2017;153(4):888-896 e1. doi:10.1016/j.jtcvs.2016.10.093

2. Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis. Eur J Cardiothorac Surg. Aug 2004;26(2):367-72. doi:10.1016/j.ejcts.2004.04.038

Background: Gender disparities in academic surgery persist, with women underrepresented as first authors and facing significant barriers to research productivity [1, 2, 3]. Family-supportive policies, including Paid Family Leave (PFL) and reproductive rights protections, have been suggested as potential solutions to mitigate these disparities [4, 5]. However, their impact on female representation in surgical research has not been comprehensively evaluated.

Study Design: This AI-driven, cross-sectional analysis examined 198,542 first-author publications from 388 PubMed-indexed surgery journals published between 2010 and 2022. Gender differences in research output and representation were assessed across U.S. states with and without family-supportive policies, specifically mandatory PFL and protective reproductive rights. We compared female representation among first authors and analyzed the average number of publications per female author, examining gender disparities at publication thresholds of 1, 2, and 5 papers.

Results: Women comprised 33.0% of all first authors, with representation decreasing at higher publication thresholds. States with PFL showed higher female representation among first authors compared to non-PFL states (34.2% vs. 32.3%; p<0.001), and similarly, protective reproductive rights states had more female representation than restrictive states (33.9% vs. 32.0%; p<0.001). Among authors with 5 or more publications, women represented 25.1% in PFL states versus 22.6% in non-PFL states (p = 0.005), and 24.6% in reproductive rights states versus 22.3% in restrictive states (p = 0.010). States with these policies also showed significantly higher average publications per female author (p<0.001).

Conclusion: State-level PFL and reproductive rights policies are associated with improved female representation and reduced gender disparities in surgical research. These findings underscore the critical role of family-supportive policies in advancing gender equity in academic surgery.

References: 1. Davis EC, Risucci DA, Blair PG, Sachdeva AK. Women in surgery residency programs: evolving trends from a national perspective. J Am Coll Surg. 2011 Mar;212(3):320-6. doi: 10.1016/j.jamcollsurg.2010.11.008. Epub 2011 Jan 17. PMID: 21247778. 2. Farmer DL. The Future of Health Care Is Female. JAMA Surg. 2024 Jan 1;159(1):50. doi: 10.1001/jamasurg.2023.5131. PMID: 37851437. 3. Karamitros G, Goulas S. Women representation in plastic surgery across the globe: A cross-sectional study of human capital and research output using artificial intelligence. J Plast Reconstr Aesthet Surg. 2023 Jun;81:91-93. doi: 10.1016/j.bjps.2023.04.056. Epub 2023 Apr 18. PMID: 37130445. 4. Altieri MS, Pryor A, Torres MB, Miller ME, Möller MG, Diego EJ, Reyna C; Association for Women Surgeons Publications Committee and the Association for Women Surgeons He For She Committee. Support of pregnancy and parental leave for trainees and practicing surgeons. Am J Surg. 2022 Dec;224(6):1501-1503. doi: 10.1016/j.amjsurg.2022.08.005. Epub 2022 Aug 15. PMID: 35987658. 5. Diaz A, Cochran A. Leaky Pipelines and Emptying Wells: Concerns from a Survey of the US Surgeon Workforce. J Am Coll Surg. 2020 Mar;230(3):293-294. doi: 10.1016/j.jamcollsurg.2019.12.002. PMID: 32093898.

Purpose: The viability and efficacy of breast reconstruction in female patients with de novo stage IV metastatic breast cancer (dnMBC) remains controversial. Given the recent advancements of systemic therapy, the overall survival (OS) of dnMBC patients has been steadily improving, with some evidence of curative outcomes. In the present systematic review, we summarize the evidence of clinical outcomes for immediate and delayed breast reconstruction in dnMBC patients and characterize appropriate surgical candidates, since there remains no consensus for this patient population.

Methods and Materials: A systematic review was conducted across PubMed/MEDLINE, Scopus, and Web of Science and searched for studies of patients with dnMBC who underwent breast reconstruction from January 1, 2000, and up to August 17, 2024. The study methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included articles were qualitatively assessed using the Joanna Briggs Institute Critical Appraisal tool. Inclusion criteria were the following: adult females aged 18 years or older with a clinical diagnosis of dnMBC prior to mastectomy and underwent breast reconstruction; longitudinal studies; randomized controlled trials; case series; and available full-text articles. Review articles, editorials, commentaries, clinical trial designs, non-English articles, case reports and chest wall reconstruction patients were excluded. Data on patient demographics, tumor and metastatic disease characteristics, oncologic therapy details, surgical details, and post-operative events were collected. The primary outcomes of interest included survival rates and post-operative adverse events.

Results: The search yielded 4,404 articles. Eleven articles met inclusion criteria, ten of which were longitudinal in design and one survey-based study. Seven articles included original data for 2,635 female dnMBC patients. The mean (SD) age of all participants was 48.4 (1.10) years. Only three articles differentiated between oligometastatic and metastatic disease and identified 505 oligometastatic patients. The most frequent sites of metastasis were bone (28.2%), liver (10.2%), lung (7.55%), and brain (0.99%). Approximately 84.0% (n=2,213) and 48.9% (n=1,288) of patients underwent neoadjuvant/adjuvant chemotherapy or radiation therapy, respectively. Invasive ductal carcinoma was the most prevalent type of breast cancer (50.2%, n=1,324). There was no difference in the frequency of type of breast reconstruction performed, with 28.9% (n=761) implant-based and 28.7% (n=757) autologous-based reconstruction. Approximately 0.46% (n=12) of patients had complications, such as hematoma, partial necrosis of mastectomy skin flap, implant malpositioning, wound dehiscence, and explantation due to local relapse. Readmission rates for major complications ranged between 5.90% and 23.1% in two studies. Three studies reported an average (SD) median OS of 58.4 (2.33) months or 100% OS rate.

Conclusions: Breast reconstruction in de novo stage IV metastatic breast cancer has been demonstrated to be a safe and viable option, especially among younger patients with less aggressive disease statuses. The overall rates of post-operative complications were very low with the majority of studies reporting no complications. Breast reconstruction had substantial impact on quality of life, coping, and psychosocial outcomes. Moreover, breast reconstruction appeared to extend OS in some cases. Future studies are encouraged to further investigate optimal surgical timing, surgical techniques, and patient selection criteria.

Introduction: Telemedicine has emerged as a transformative tool in modern healthcare, facilitating remote communication between physicians and patients while improving access, operational efficiency, and cost-effectiveness (1,2). Its role has been extensively studied in adult primary care and surgery. However, its application in Pediatric Plastic Surgery remains unexplored. This study evaluates the impact of telehealth at a high-volume pediatric plastic surgery center, assessing its efficacy in expanding access and optimizing patient care pathways.

Methods: An IRB-approved retrospective analysis using Salesforce Data Analytics (Salesforce Inc. San Francisco, CA) was conducted on all patients referred to the Plastic Surgery department at a tertiary pediatric hospital between January 2020 and December 2024. Data collected included referring location, primary diagnosis, and home state. Key outcomes analyzed included referral-to-visit conversion rates, surgical conversion rates, and time to surgery. Comparative analyses were performed between telehealth and in-person consultations, as well as between in-state and out-of-state referrals.

Results: A total of 6,370 patients were referred during the study period. The majority (82.5%) resided within 80 miles of the hospital, with 57.3% being in-state and 42.7% out-of-state referrals. The overall referral-to-visit conversion rate was 71%. Among those who underwent consultation, 52.9% proceeded with surgery. Notably, telehealth consultations were associated with a significantly higher surgical conversion rate compared to in-person visits (60.5% vs. 36.1%; p<0.001). While consultation rates were comparable between in-state (70.9%) and out-of-state (69.8%) referrals (p=0.589), out-of-state patients using telehealth had markedly higher surgical conversion rates than those seen in person (70.1% vs. 36.9%; p < 0.001). In-State patients using telehealth also had significantly higher surgical conversion rates compared to those seen in-person (59.8% vs. 36.0%; p < 0.001). There was no significant difference in time-to-surgery between the telehealth and the in-person cohorts (167 vs. 165 days; p > 0.05).

Conclusions: This study underscores the critical role of telehealth in Pediatric Plastic Surgery, particularly in enhancing access for geographically distant patients. Telehealth consultations were associated with higher surgical conversion rates, particularly among out-of-state patients, suggesting that virtual consultations may facilitate more streamlined surgical planning and reduce unnecessary travel burdens. These findings support the broader integration of telehealth into Pediatric Plastic Surgery practice to improve patient access, optimize resource utilization, and expand care delivery for underserved populations.

References: 1. Shaver J. The State of Telehealth Before and After the COVID-19 Pandemic. Prim Care. 2022;49(4):517-530. doi:10.1016/j.pop.2022.04.002 2. Funderburk CD, Batulis NS, Zelones JT, et al. Innovations in the Plastic Surgery Care Pathway: Using Telemedicine for Clinical Efficiency and Patient Satisfaction. Plast Reconstr Surg. 2019;144(2):507-516. doi:10.1097/PRS.0000000000005884

Introduction: The Lancet Commission recently proposed a new definition of clinical obesity that de-emphasizes body mass index (BMI) in favor of adiposity-related comorbidities. Specifically, patients with BMIs between 25 and 40 are considered clinically obese only if they have associated comorbidities (1). In turn, this affects whether weight loss is recommended. Our study evaluates the relevance of this paradigm shift to plastic and reconstructive surgery by analyzing the independent and interactive effects of BMI categories and obesity-related comorbidities on 30-day complication rates.

Methods: The TriNetX health database was queried for patients undergoing plastic and reconstructive surgeries. BMI was grouped into the following categories: 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥40. All BMI categories were further stratified by the presence or absence of adiposity-related comorbidities. Cox regression analyses were performed to determine hazard ratios (HR) for all 30-day complications.

Results: A total of 957,985 patients who underwent plastic and reconstructive procedures were included. Overall, patients with BMIs of 25-39.9 with comorbid disease (HR 1.05, p<0.001) or BMIs ≥40 (HR: 1.40, p<0.0001) were noted to have significantly higher complication-risk than a reference group of patients with BMIs of 18.5-24.9. Compared to the same reference group, the effect of BMI amongst patients without comorbidities was variable. In this group, patients with BMIs 25-29.9 were less likely to develop 30-day complications (HR: 0.83, p<0.0001) and patients with BMIs 30-34.9 were at similar risk (HR: 0.0, p=0.62) as the reference group. There was an inflection point at BMIs of 35-39.9 as these were associated with increased complication-risk (HR: 1.24, p<0.001), even amongst patients without comorbidities. These effects were similar when using a reference group of patients with BMIs 18.5-24.9 who specifically did not have any of the comorbidities defined by the Lancet.

Conclusions: These findings partially support the adoption of the new Lancet definition of obesity in the context of patients undergoing plastic surgery. For patients with a BMI of 25-34.9 and no comorbidities, weight loss may not significantly change risk. However, for patients with BMIs ≥35, and even more so in patients with BMIs ≥40, BMI remains an independent predictor of complications, regardless of comorbidity status. Based on these results, in cases of elective surgery, a comprehensive assessment of underlying comorbidities should be considered for patients with BMIs 25-34.9, and weight loss may be recommended for patients with BMIs≥35.

References: 1. Rubino F, Cummings DE, Eckel RH, et al. Definition and diagnostic criteria of clinical obesity. The Lancet. Diabetes & endocrinology. 2025. https://www.ncbi.nlm.nih.gov/pubmed/39824205. doi: 10.1016/S2213-8587(24)00316-4.

Introduction The decision-making process in selecting plastic surgeons is multifaceted, influenced by various patient-specific and systemic factors. While prior research has explored these determinants individually, comparisons of how patients perceive and choose between academic and private practice plastic surgeons remain limited (1). This study aims to investigate patient perceptions of quality of care in both academic and private practice and provide a framework for understanding how patient, provider, and practice level factors impact decision-making.

Methodology: A 51-item questionnaire was developed and anonymously distributed via Prolific (Prolific Academic Ltd, London, England) in November 2024. Participants received $1.44 in compensation upon survey completion. The survey included questions on patient demographics, past surgical experiences, preferred sources of information, and factors influencing the selection of a plastic surgeon. Respondents rated the importance of various factors on a 5-point Likert scale.

Results: A total of 203 surveys were completed. The mean participant age was 35.3 (SD= 13.0), 113 (55.7%) were female, 126 (62.1%) had obtained a bachelor's degree or higher, and 168 (82.8%) were employed. One hundred twelve (55.2%) responded "yes" or "maybe" when asked if they would consider plastic surgery in the future and 32 (15.8%) had previously undergone a procedure. When asked to choose between an academic surgeon and a private practice surgeon, 56.05% preferred private practice, 31.9% chose academic, and 12.1% were unsure. On a 5-point scale, respondents rated surgeon experience (Average = 4.48 ± 0.93) reputation (Average = 4.46 ± 0.89) and reviews (Average = 4.18 ± 0.91) as the most important factors influencing their selection of a surgeon with many willing to pay more for surgeon reputation (Average = 4.13 ± 0.99). The majority indicated that they used online searches (70.5%) and recommendations from friends and family (45%) to research surgeons. Those >46 years were more likely to rate recommendations as highly important compared to younger patients (p = 0.027) while those aged 46-55 were more willing to pay for surgeon reputation (p = 0.037). Female respondents were more likely to indicate that surgeon reputation (p = 0.012), experience (p = 0.013), and cost (p = 0.021) were important to them with thoroughness during consultation (p = 0.029), and clear communication (p = 0.018) being other important factors. Individuals with high school education indicated that online reviews greatly impacted their decision between private and academic practice (p = 0.036) while those with a graduate degree had a higher self-reported understanding of the difference between private and academic medicine (0.016).

Conclusion: Patients demonstrate a preference for private-practice plastic surgeons but often lack a clear understanding of distinctions between academic and private settings. Patients rely on internet searches and personal recommendations, prioritizing surgeons with high ratings, experience, and clear communication. Surgeons in both academic and private practice should understand what patients value in order to provide more comprehensive information and improve patient-centered care.

Reference: 1. Yahanda AT, Lafaro KJ, Spolverato G, PawlikTM. A Systematic Review of the Factors that Patients Use to Choose their Surgeon. World Journal of Surgery. 2015;40(1):45-55. doi:https://doi.org/10.1007/s00268-015-3246-7

Introduction Fertility rates in the U.S. continue to decline, potentially in part due to environmental factors, purposeful delay of childbearing, and rising incidence of infertility. Female physicians, especially in plastic surgery, experience higher infertility rates-50.7% compared to 12.9% in the general population.[1] Plastic surgeons, in particular, undergo long training programs ranging in 6 to 10 years in length (whether integrated or independent tracks) and undergo training during their prime reproductive window. These challenges have increased reliance on assisted reproductive technologies (ART) for fertility preservation (oocyte and embryo cryopreservation) and fertility treatment.

Surgical residents face logistical and financial barriers, including unpredictable treatment schedules and the need to use limited vacation time for procedures. While studies show almost a quarter of all residents are experiencing infertility, 63% of all residents feel little to no support from their program regarding fertility care.[2,3] Furthermore, parental leave had not been well outlined until July 2022 at which point the ACGME instated a policy for 6 weeks of paid leave, but did not specify how to implement the leave. The purpose of this study is to gather nationwide data regarding options for fertility treatment and parental leave at all integrated plastic surgery training programs.

Methods Data was collected from institutional graduate medical education (GME) websites and by calling human resources (HR) at these institutions if the information was not publicly available. Descriptive statistics were used to analyze the data.

Results Of 89 programs analyzed, 66 offer fertility treatment coverage, with an average benefit of $24,179. Seventy-six programs offer birthing parent leave (mean 5.24 weeks), and 72 programs offer non-birthing parent leave (mean 4.65 weeks)-leave in this study was defined as paid leave that did not require vacation or sick time to be used. Only 10 programs offer elective fertility treatment, and 25 programs explicitly state a requirement for the diagnosis of infertility before providing treatment. Most information was found on GME websites (70 programs).

Conclusion Increasing access to fertility benefits and improving transparency is essential. Residency programs should provide financial support and protected time off, ensuring female trainees can pursue fertility preservation without compromising their careers or reproductive autonomy.

1. Hemal K, Chen W, Bourne DA. Fertility and Childbearing Outcomes of Practicing Female Plastic Surgeons. Plast Reconstr Surg. 2023;151(6):1327-1337. doi:10.1097/PRS.0000000000010119
2. Rasouli MA, Barrett F, Levy MS, et al. Publicly available information about fertility benefits for trainees at medical schools in the US. J Assist Reprod Genet. 2023;40(6):1313. doi:10.1007/S10815-023-02849-1
3. Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and Childbearing Among American Female Physicians. J Womens Health (Larchmt). 2016;25(10):1059-1065. doi:10.1089/JWH.2015.5638

Introduction The plastic surgery workforce is generally at risk of experiencing shortages and already exhibits significant geographic maldistribution (1,2,3). This study assesses the migratory patterns taken by current craniomaxillofacial surgeons during their training and career to assist efforts enhancing training pathways, increasing equitable access to care, and informing both current and future craniomaxillofacial surgeons on their decision of where to train or practice.

Methods A list of active craniomaxillofacial surgeons who are members of the American Society of Maxillofacial Surgeons (ASMS) was obtained from an ASMS member. Five reviewers performed web searches across Doximity, LinkedIn, university or practice web pages, and other publicly available information to identify each surgeon's current practice type and the geographic location and regional distribution of their current practice, medical school, residency, and fellowship training programs using the United States (U.S.) Census Data regions (4).

Results Among 367 active ASMS craniomaxillofacial surgeons (318 male, 49 female), most complete medical school, residency, and fellowship in the Northeast but choose to practice in the South across all practice types. A moderate association (Cramer's V = 0.271) exists between fellowship location and current practice location. Gender distribution varies by region, with most male surgeons in the South and female surgeons in the Northeast. Across both genders, most work in an academic setting. Female craniomaxillofacial surgeons are most represented in academic practice (23%) and least represented in private practice (5%). Academic practices are more evenly spread across U.S. regions while private practices are concentrated in the South and West. Highly populated states like New York, Texas, and California have a larger number of practicing surgeons compared to less populous states.

Discussion Assessment of the migration and training patterns of craniomaxillofacial surgeons has revealed a trend of surgeons training in the Northeast but relocating to practice in the South, no matter their type of practice. A moderate correlation exists between fellowship and current practice location (Cramer's V = 0.271), indicating fellowship location has a moderate influence on practice location choice but is not a decisive factor. Gender trends show a regional skew, with male surgeons favoring the South and female surgeons the Northeast. Academic practices are the most common among both male and female surgeons, and have the greatest female representation. However, female craniomaxillofacial surgeons still remain a minority across all practice types, with the least representation in private practice. The current workforce exhibits a population-matched distribution, with an increased number of craniomaxillofacial surgeons in more populous states, aligning with a state's larger population size. These findings provide insight into regional and demographic trends that can guide future work on training pathways, access to care, and the decision of where to train and practice.

References 1. Teng TL, Hall R, Graham RA, Reiland J, Chatterjee A. Poor Access to Breast Reconstruction: A Geographical Shortage of Plastic Surgeons Relative to Breast Surgeons in the United States. Ann Plast Surg. 2019;82(4S Suppl 3):S256-S258. doi:10.1097/SAP.0000000000001846 2. Bauder AR, Sarik JR, Butler PD, et al. Geographic Variation in Access to Plastic Surgeons. Annals of Plastic Surgery. 2016;76(2):238. doi:10.1097/SAP.0000000000000651 3. Rohrich RJ, McGrath MH, Lawrence WT, Ahmad J, Force TAS of PSPSWT. Assessing the Plastic Surgery Workforce: A Template for the Future of Plastic Surgery. Plastic and Reconstructive Surgery. 2010;125(2):736. doi:10.1097/PRS.0b013e3181c830ec 4. Bureau UC. Geographic Levels. Census.gov. Accessed September 29, 2024. https://www.census.gov/programs-surveys/economic-census/guidance-geographies/levels.html

Background: Accurate keloid assessment is crucial for effective treatment planning. The Vancouver Scar Scale (VSS) is widely used but relies on subjective observation, leading to variability in scoring. Laser Speckle Contrast Imaging (LSCI) has emerged as a promising technique for objective assessment of keloid vascularity by quantifying blood perfusion. This study investigates the correlation between LSCI-derived perfusion metrics and VSS scores to evaluate their clinical utility in keloid assessment and treatment monitoring.

Methods: A retrospective study was conducted on 99 patients with 176 keloids. Blood perfusion ratios (PUkeloid/control) derived from LSCI were compared with pre- and post-treatment VSS scores. Correlation analysis and linear regression were applied to determine the relationship between perfusion metrics and VSS changes. Clinical cases were analyzed to validate the effectiveness of PUkeloid/control in guiding treatment.

Results: PUkeloid/control demonstrated a significant correlation with total VSS scores (Spearman's ρ = 0.308, p < 0.001) and its subcomponents, particularly vascularity (Spearman's ρ = 0.424, p < 0.001). The strongest associations were observed between PUkeloid/control and vascularity and pigmentation scores, emphasizing the role of perfusion in keloid severity. Linear regression analysis showed a strong association between changes in PUkeloid/control and improvements in VSS scores (R² = 0.539, p < 0.01), indicating that perfusion changes can reliably reflect therapeutic outcomes. Further subgroup analysis revealed that PUkeloid/control was superior to absolute PUkeloid values in evaluating both keloid lesions and post-surgical linear wounds. Patients who demonstrated a greater reduction in PUkeloid/control post-treatment also exhibited more substantial improvements in their VSS scores. Additionally, clinical cases demonstrated that high-perfusion areas identified via LSCI often corresponded with regions of persistent inflammation or poor therapeutic response, highlighting the potential role of targeted intervention strategies. Among the 44 patients (56 keloids) who underwent post-treatment follow-up, the most common therapeutic approaches included pulsed dye laser (PDL) combined with betamethasone and 5-fluorouracil (35.17%), and surgery with radiotherapy (19.64%). While overall VSS scores significantly improved after treatment (median: 9 [6–13] to 7.5 [4–10], p = 0.005), no significant change was observed in absolute PUkeloid/control values at the group level (p = 0.942). However, a strong correlation was noted between changes in perfusion ratio (ΔR) and changes in VSS scores (ΔVSS), suggesting that individualized perfusion changes may better reflect treatment outcomes. Clinical cases further supported these findings. One patient exhibited a marked decrease in PU ratio following combination therapy, which corresponded with improved scar pliability and pigmentation. Conversely, another patient with persistently high PUkeloid/control despite treatment demonstrated poor clinical response, reinforcing the importance of vascular assessment in treatment planning.

Conclusion: LSCI-derived PUkeloid/control provides an objective, non-invasive method for assessing keloid vascularity. This metric complements traditional tools like VSS, enhancing scar evaluation and treatment planning. Further studies are needed to optimize its clinical applications.

Abstract

Background

Billing practices for primary cleft lip repair and concurrent tip rhinoplasty remain inconsistent, contributing to variability in reimbursement and procedural documentation. The Current Procedural Terminology (CPT)-Relative Value Unit (RVU) system often undervalues cleft surgical procedures, failing to account for the complexity of combined repairs. While tip rhinoplasty is frequently performed alongside cleft lip repair, the extent to which it is billed remains unclear. This study analyzes billing trends and coding variability for primary cleft lip repair with and without separately billed tip rhinoplasty.

Methods

A retrospective review of the Pediatric National Surgical Quality Improvement Program (PNSQIP) database (2016-2021) identified patients undergoing primary cleft lip repair using CPT codes 40700 (unilateral) and 40701 (bilateral). Cases were categorized into two cohorts: Tip Rhinoplasty Group, where concurrent rhinoplasty (CPT 30460/30462) was billed, and No Tip Rhinoplasty Group, where it was not. Demographic, perioperative, and provider-related factors were compared using chi-squared and t-tests, with significance set at p < 0.05.

Results

Among 8,836 cleft lip repairs, 2,359 cases (26.7%) included a separately billed tip rhinoplasty. Patients in the Tip Rhinoplasty Group were significantly younger (240.09 ± 515.16 vs. 363.00 ± 853.64 days, p < 0.001) and more frequently inpatients (48.11% vs. 42.56%, p < 0.001). Total operative time was longer for cases with tip rhinoplasty (146.60 ± 70.47 vs. 117.04 ± 62.43 minutes, p < 0.001), as was total anesthesia time (209.00 ± 78.11 vs. 175.40 ± 68.85 minutes, p < 0.001). Plastic surgeons performed the majority of cases in both groups, though billing practices varied by specialty (p = 0.34).

Conclusions

Despite the widespread practice of performing tip rhinoplasty at the time of cleft lip repair, only 26.7% of cases had this procedure separately billed, highlighting significant variability in coding practices. The findings suggest that financial undervaluation of cleft procedures may contribute to inconsistent billing, with some surgeons opting not to code for tip rhinoplasty despite performing nasal modifications. Standardized billing guidelines and CPT-RVU model reforms are needed to ensure equitable reimbursement and accurate documentation of craniofacial procedures. Future studies should assess the impact of billing variability on surgeon compensation, institutional reimbursement, and patient access to comprehensive cleft care.