Scientific Abstract Presentations: Practice Management Session 2 Saturday, October 11 Sat, Oct 11 8:00-9:30 a.m. CDT

Introduction: The landscape of plastic surgery is diverse, encompassing a wide range of subspecialties, each with distinct procedural focuses and complexities. As reimbursement models increasingly rely on Relative Value Units (RVUs), understanding how RVUs vary across subspecialties is essential for both financial planning and resource allocation within the field. This study aims to compare RVUs across the subspecialties within plastic surgery using operative time as a surrogate for complexity [1]. By analyzing RVU data, we seek to uncover differences in the financial value associated with each subspecialty, providing insights into the economic factors that influence surgical practice and compensation.

Methods: This retrospective study analyzed the National Surgical Quality Improvement Program (NSQIP) database from 2009 to 2023, including only plastic surgery procedures. Seven plastic surgery subspecialties were defined: aesthetics, burn, breast, adult craniofacial, gender-affirming surgery (GAS), hand and upper extremity, and microsurgery. Subspecialty procedures were selected based on the five most common Current Procedural Terminology (CPT) codes, selecting by frequency of CPT or, for burn and gender-affirming procedures, through International Classification of Diseases (ICD) filtering. Both work RVU (wRVU) and efficiency (wRVU/min) were analyzed. The Kruskal-Wallis test with Dunn's post-hoc analysis and Bonferroni correction assessed inter-subspecialty differences. Linear regression examined associations between wRVU, operative time, and efficiency.

Results: The wRVUs across subspecialties correlated strongly with operative time (R2 = 0.8416). The median wRVU efficiency varied across plastic surgery subspecialties. Among the seven subspecialties analyzed, breast surgery exhibited the highest median wRVU efficiency (0.1595 wRVU/min), followed by adult craniofacial (0.1588 wRVU/min), while microvascular procedures had the lowest median efficiency (0.0942 wRVU/min). There were statistically significant differences in wRVU efficiency between most subspecialties (p < 0.001), the largest differences were observed between microsurgery vs. breast, GAS vs. breast, and burn vs. breast.

Discussion: The findings highlight disparities in wRVU efficiency, with higher-efficiency subspecialties generating more RVUs per operative minute than lower-efficiency fields like microsurgery. This has key implications for trainees considering career paths, attending surgeons optimizing practice models, and the development of equitable reimbursement structures. Specialties with lower efficiency may be associated with longer OR hours and a higher risk of burnout, underscoring the need for compensation models that better reflect surgical effort and time investment.

1. Shim JY, Stoffel V, Neubauer D, Gosman AA, Matros E, Reid CM. "The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties." Plast Reconstr Surg. Published online February 15, 2023. doi:10.1097/PRS.0000000000010306

Purpose: At this time, medical training lacks adequate and effective fertility and family planning education. Future and current plastic surgeons at all stages of the pipeline endorse minimal support and guidance. The aim of this study was to assess the outcome of a less than two-hour virtual event on attenuating attendees knowledge gaps regarding REI and family planning as well as the effectiveness of peer engagement and mentorship in alleviating role stress.

Methods and Materials: A virtual event targeted toward current and future plastic surgeons at all levels of training was held on April 20, 2024. The event consisted of short lectures followed by themed breakout sessions. Pre- and post-event surveys were distributed to assess the change in REI and family planning knowledge and the effectiveness of the intervention in alleviating role strain and stress. Data was analyzed using descriptive statistics and paired samples t-tests.

Results: A total of 113 individuals attended the event and spent an average of 82.75 ± 43.33 minutes. The pre-event survey had a 54.6% response rate while 69.9% completed the post-event survey. Excluding partners and spouses, 72 pre- and post-event responses were assessed. The average age of respondents was 29.13 ± 3.48 years, with most participants identifying as female (90.3%) and heterosexual (81.9%). The majority were married or in a relationship (75%), with few having children (9.7%) or expecting (5.6%). Following the event, participants showed significant improvement in their understanding and preparedness to meet the financial, emotional, and logistical costs of REI and child-rearing (p < 0.01). Knowledge of surgeon infertility statistics and peer engagement also significantly increased (p < 0.01). When assessed for role success, attendees went from feeling as though they were "in crisis" to feeling as though they were at minimum "surviving" in their role as a physician following the event (p < 0.01). A significant improvement in rating of work-life balance was also observed (p < 0.01).

Conclusion: The current lack of REI and child-rearing education may leave future plastic surgeons underprepared to meet the realities and demands of family planning. This late awareness of the financial, emotional, and logistical costs of fertility and family planning may impact the ability of plastic surgeons to plan and effectively manage the responsibilities of parenthood. The significant increase in family planning knowledge and role success observed from this under two-hour, easily portable intervention highlights the effectiveness of targeted education in promoting wellness, preventing burnout, and attenuating the crisis state. These findings demonstrate a clear need for integrative and proactive education throughout medical training.

Introduction

Language barriers continue to challenge the success of global surgery programs. Accurate and timely communication between providers and patients is critical to the overall success of the program. During a mission trip to Giridih, India (literacy rate: 63.1%), plastic surgeons sought to improve preoperative communication (1). In previous trips, written or verbal instructions alone were often insufficient, resulting in surgical delays and cancellations due to NPO violations or incorrect arrival times of patients. While studies suggest visual aids and educational materials may improve communication, little research has examined their use in global surgical missions (2-4). This quality improvement initiative aimed to enhance preoperative communication by implementing written and visual instruction handouts to reduce surgery delays. We hypothesized that these aids would improve adherence to preoperative instructions, minimizing preventable disruptions in surgical care.

Methods

A three-item preoperative instruction handout was developed, covering fasting before surgery, date and arrival time for surgery, and avoidance of home remedies before surgery. These were translated into Hindi, verified for accuracy, and supplemented with images to enhance comprehension. Two surgical teams conducted preoperative screenings: one provided verbal instructions only, while the other used the handout alongside verbal instructions. Patients who received the handout were able to take it home for reference. Data was collected on NPO violations and late arrivals. Descriptive statistics were used for analysis with Fisher's exact test used to evaluate differences between NPO violations and late arrivals between instruction groups.

Results

Fifty-five patients were screened for surgery of which, 7 patients canceled their surgery. Of the 48 screened patients who underwent surgery, 27 patients were provided the preoperative instruction handout, and 21 patients were given verbal preoperative instructions only. Of the 27 patients in the preoperative handout group, none had any NPO violations or late arrivals. Of the 21 patients in the verbal-only instruction group, there were 9 patients with NPO violations (p<0.001) and 4 patients with late arrivals (p<0.031). Surgeries performed included cleft lip repairs, burn contracture releases, and various hand surgeries.

Conclusion

The use of written and visual preoperative communication aids significantly improved adherence to surgical preparation guidelines. These findings suggest incorporating visual and written materials into preoperative communication can enhance surgical preparedness and reduce preventable disruptions in surgical care during global mission trips. Further research should explore the scalability of this intervention in low-resource settings.

References:

1. Giridih District, Government of Jharkhand. Census Data 2011. Available at: https://giridih.nic.in/census-data-2011/. Accessed February 27, 2025.

2. Sudore RL, Schillinger D. Interventions to Improve Care for Patients with Limited Health Literacy. J Clin Outcomes Manag. 2009;16(1):20-29.

3. Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician. 1996;53(1):205-211.

4. Meherali S, Punjani NS, Mevawala A. Health Literacy Interventions to Improve Health Outcomes in Low- and Middle-Income Countries. Health Lit Res Pract. 2020;4(4):e251-e266. doi:10.3928/24748307-20201118-01

Purpose: Telemedicine revolutionized healthcare post-COVID-19 by accelerating virtual care. In plastic surgery, it has facilitated patient consultations, post-operative care, and inter-physician collaboration. However, the pandemic's impact on its adoption and effectiveness in this field remains underexplored. This study compares pre- and post-pandemic telemedicine in plastic surgery, focusing on outcomes, accessibility, and satisfaction, aiming to guide best practices and improve care.

Methods: A systematic review was conducted using PubMed, Medline, and Web of Science, following PRISMA guidelines, for articles published through November 2024. Extracted data included author, year, country, sub-specialty, pandemic classification, sample size, demographics, utilization purpose, barriers, travel time and distance, satisfaction, complications, and appointment duration. Meta-analyses used a random-effects model for pooled averages with 95% confidence intervals. Funnel plots and Egger's test assessed publication bias, with trim-and-fill analysis for asymmetry. Welch's t-test compared pre- and post-pandemic results, analyzed using R 4.4.1.

Results: We identified 450 publications, with 73 meeting inclusion criteria, involving 9467 subjects aged 47.99 years. 79% (95% CI: 65-93%; p<0.05) of patients would use telemedicine again, and 93% (95% CI: 88-98%; p<0.05) were satisfied. The pooled satisfaction score was 85.9 (79.4-92.5; p<0.05). Meta-analysis showed significant reductions in travel time (120 minutes; p<0.05) and distance (187 miles; p<0.05). Five studies reported a mean appointment duration of 16.07 minutes. Complications were rare, with a pooled rate of 7% (95% CI: 2-12%; p<0.05). Post-pandemic patients reported lower satisfaction (82.5 vs. 94; p=0.015). Other post-pandemic estimates did not significantly differ from pre-pandemic (p>0.05).

Conclusions: This analysis highlights the evolving role of telemedicine in plastic surgery, particularly following the COVID19 pandemic. Compared to the pre-pandemic period, post-pandemic utilization of telemedicine in plastic surgery was associated with lower satisfaction, likely due to increased utilization and higher expectations. However, the overall impact of telemedicine on care delivery remains positive. Our results also highlight its effectiveness in improving accessibility with significant reductions in travel time and distance, while maintaining a lower complication rate. Continued refinement and adaptation of telemedicine protocols are essential to maximize its potential in enhancing patient outcomes, optimizing satisfaction, and supporting efficient healthcare delivery in plastic surgery.

Purpose: Lower extremity (LE) trauma can result in challenging reconstructive options for plastic surgeons and salvage of the affected limb(s) can necessitate a free flap.1 Hemodynamics management in free flap reconstruction, particularly vasopressor use, remains controversial despite their frequent use in other surgeries to improve perioperative hypotension.2,3 This is likely due to the theory that vasopressors induce vasoconstriction and vasospasm, decreasing tissue perfusion which may threaten the viability of the free flap. However, the true effects of vasopressor use on free flap outcomes are unknown.4,5 Therefore, our study aims to analyze the outcomes of traumatic LE free flap reconstruction in the setting of perioperative vasopressor use.

Methods: The TriNetX LLC. National Health Research database was utilized to identify patients who sustained lower extremity trauma and underwent free flap reconstruction between 2004-2024. The database was further queried for those who did and did not receive vasopressors within 5 days of surgery and the two cohorts were subsequently matched for their demographics and comorbidities. Then, common procedural terminology (CPT) codes were used to assess for free flap procedure outcomes (microvascular anastomosis vessel repair, flap revision, flap repair, etc.) within the 7 days post-operative period.

Results: Of the 5,697 patients who underwent traumatic lower extremity free flap reconstruction, a total of 3,378 patients were associated with vasopressor use and 2,319 were not. When the two groups were matched for their demographics and comorbidities, 1,905 patients were identified in each cohort. There was no significant difference in the rate of free flap complication rates among those who received (15%) and did not receive (13%) vasopressors perioperatively (p=0.193).

Conclusion: Our study demonstrates that perioperative vasopressor use does not significantly impact the lower extremity free flap complication rate. Patients who received vasopressors did not experience higher rates of returning to the operating room for secondary procedures, microvascular anastomosis repair, flap revision, and flap repair within in the first 7 days of index surgery. Therefore, these results imply that vasopressor may be used when clinically indicated without an increased risk of flap failure.

References: 1. Naik AN, Freeman T, Li MM, et al. The Use of Vasopressor Agents in Free Tissue Transfer for Head and Neck Reconstruction: Current Trends and Review of the Literature. Front Pharmacol. 2020;11:1248. doi:10.3389/fphar.2020.01248 2. Cordeiro PG, Santamaria E, Hu QY, Heerdt P. Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine. Ann Plast Surg. 1997;39(5):524-531. doi:10.1097/00000637-199711000-00013 3. Hahn HM, Kim TW, Thai DQ, Lee IJ. Impact of perioperative vasopressors on lower extremity free flap reconstruction. Microsurgery. 2022;42(5):470-479. doi:10.1002/micr.30870 4. Sanchez-Porro Gil L, Leon Vintro X, Lopez Fernandez S, et al. The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses. J Clin Med. 2021;10(6):1333. doi:10.3390/jcm10061333 5. Noori O, Pereira JL, Stamou D, Ch'ng S, Varey AH. Vasopressors improve outcomes in autologous free tissue transfer: A systematic review and meta-analysis. J Plast Reconstr Aesthetic Surg JPRAS. 2023;81:151-163. doi:10.1016/j.bjps.2022.08.069

Background: Breast implant illness (BII) is a term used to describe a constellation of non-specific symptoms attributed to breast implants and is increasingly discussed on social media platforms like TikTok. However, its unregulated content may amplify misinformation. This study analyzes BII-related TikTok videos to identify prevailing narratives and trends shaping public perception as understanding online discourse surrounding BII is important to better appreciate patient experiences and recognize potential impacts on patient decision-making.

Objectives: This study aims to assess available information on TikTok regarding BII by examining both video content, quality, and engagement while identifying prevailing trends in the discourse.

Methods: TikTok was queried using BII-related hashtags. Relevant videos with over 10,000 views were included. Video engagement metrics, creator type, content, and purpose were analyzed. DISCERN and Global Quality Scale (GQS) scores were utilized to assess the quality of health information.

Results: A total of 138 TikTok videos related to breast implant illness (BII) were analyzed, amassing 116.9 million views, 5.9 million likes, 297,969 shares, 229,820 saves, and 59,905 comments. The median video length was 51.5 seconds (IQR: 14–103.25). Most videos (73.9%) were posted by patients, followed by plastic surgeons (15.9%), of whom 85.7% were board-certified. Verified users had significantly higher engagement across all metrics, including views (p = 0.025), likes (p = 0.002), shares (p = 0.002), saves (p = 0.004), and comments (p = 0.012).

Regarding video purpose, personal experience was the most common (45.7%), followed by entertainment (28.3%) and education (26.1%). Entertainment videos garnered significantly more views and likes than educational or personal experience videos (p < 0.01). Patient testimonials were the most frequently observed content type (37.7%), although social videos had significantly higher views (p = 0.03). Over half of the videos (53.6%) addressed BII-related symptoms, with skin problems (41.9%) and fatigue (40.5%) most frequently mentioned. Patients and plastic surgeons were equally likely to include symptom discussions in their videos (p = 0.81).

Video quality assessment revealed a median DISCERN score of 16 and a median GQS score of 1, with plastic surgeon-created content scoring significantly higher than patient-created content (p < 0.001). Verified users also produced higher-quality content than non-verified users (p = 0.048). Video length positively correlated with information quality (DISCERN: r = 0.525, p < 0.001; GQS: r = 0.270, p = 0.001), though engagement did not correlate with quality scores. No significant differences in engagement were observed between plastic surgeons and non-surgeon creators.

Conclusion: Social media serves as an important space for BII discourse, but the predominance of anecdotal content over evidence-based knowledge raises concerns about misinformation. Plastic surgeons' videos were higher quality but did not achieve greater engagement, highlighting the need for greater provider participation to strengthen accurate and appropriate patient information. Content consumers must be aware of the possibility that not all information may be research based, and that they should always engage in meaningful conversation with their plastic surgeons about their symptoms and goals.

Purpose: To assess the industry payments received by plastic surgeon attendees of a national conference, analyze potential demographic differences in recipients of industry payments, and evaluate whether industry payments may be influencing the content presented at national meetings..

Methods: OpenPayments.gov was used to collect payment information across multiple categories for all individuals who were included in the AAPS 2022 program. Demographic information was collected for each participant, including sex, geographic region, degree type, residency training (plastics vs. other surgical specialties), fellowship training, years of practice, and practice setting (academic vs. private medicine). Kruskall Wallis and Mann-Whitney Tests were completed in SPSS to compare groups.

Results: A total of $11,107,403.13 was received in general payments by AAPS 2022 participants. While the average general payment received by a plastic surgeon in 2022 was $10,733, plastic surgeon attendees of AAPS 2022 received an average of $28,776. The ten highest paid physicians encompassed 84% of the total industry payments received by conference participants. A total of 122 companies provided payments, with one company being responsible for 71.6% of all payments. Males, those who completed plastic surgery residencies, and those with 11 to 15 years of practice were found to earn significantly greater general payments. No significant differences in general payments were observed for those in academic vs. private medicine, fellowship vs. non-fellowship trained, or different geographic regions. For specific payment categories, associated research funding was significantly greater for non-fellowship trained physicians, while food and beverage payments were significantly greater for those with 11-15 years of practice and those in the Southwest.

Conclusions: The significantly greater payments received by males, those who completed plastic surgery residencies, and those with 11 to 15 years of practice indicates that this population may possess the strongest relationships within the industry, possibly due to greater accessibility to these relationships or alternatively due to a greater interest in pursuing these external sources of income. The significantly greater industry payments received by male recipients highlights that the gender pay gap for physicians in the U.S. appears to extend to supplementary sources of income as well. This warrants future research to explore if this represents an explicit bias in the industry or conversely if this can be explained by social factors that may preclude women from pursuing industry relationships(1). As the majority of payments were received by a small group of attendees, this provides some reassurance that overall conference content may not be heavily influenced by medical companies. However, the significant difference in payments received by AAPS attendees in comparison to the national average for plastic surgeons does show that these relationships have the potential to shape what is presented at national meetings, emphasizing the importance of transparency by speakers and adequate disclosures.

1. Sullivan BG, Al-Khouja F, Herre M, Manasa M, Kreger A, Escobar J, Dinicu A, Naaseh A, Dehkordi-Vakil F, Stamos M, Pigazzi A, Jafari MD. Assessment of Medical Industry Compensation to US Physicians by Gender. JAMA Surg. 2022 Nov 1;157(11):1017-1022. doi: 10.1001/jamasurg.2022.4301. PMID: 36169943; PMCID: PMC9520440.

Background: As of 2024, the percent of male and female residents are almost equal (51%male and 49% female). This is an increase from 40% female residents in 2020 and a large jump from 14% in 1990 (1). While the percentages have equalized on the resident level, the question of gender equality, representation, and mentorship in plastic surgery program leadership remains. Prior studies in the last five years have established that there is a noticeable gender disparity in the program director and chief/chairs roles(1). The goal of this study is to evaluate if plastic surgery residency and program leadership has kept up with the changing resident patterns.

Methods: The aim of this study is to determine whether any difference in objective credentials existed between male and female plastic surgery department chairs/division chiefs, and program directors (PDs) and if progress has been made over the last five years. Information from each plastic surgery program director and chair/chief was obtained from program websites of institutions with either an independent or integrated residency program. For each- length of career, fellowships completed, and publications- were evaluated using PubMed. F-tests were used to assess equality of variance, then either Student's t-test or Welch's t-test was applied to compare group means.

Results: 101 integrated and independent residency programs were included in this study. There were twelve female chairs which made up of 11.8% percent of total chairs (9.2% in 2020). Male chairs had two more years of experience than females based on graduation from medical school, (31 years vs 29 years, p=0.49), however, females had more publications (115 vs 90, p=0.38) and longer fellowship training (1.25 years vs. 0.87, p=0.08), though not statistically significant. There were 26 female PDs (25.7%) representing an almost two-fold increase from 2020 (13.1%). Male program directors had more publications than females (58vs35,p=0.005) and three years more experience. Female chairs had more publications (35 vs 115, p=0.06) and years of experience (29 vs 23 years, p=0.11) compared to female program directors.

Conclusion: There has been an increase in female plastic surgery program directors over the last five years, reflecting similar changes in program composition. However, there has been a minimal shift on the female chiefs/chair level, despite having similar qualifications. While this pattern suggests positive changes in gender equality from five years ago, there is still room for growth, especially in larger leadership roles. Moreover, given the time it takes to become a program director or a chair, there is an inherent lag behind the growing percentage of graduates who are female. In turn, this creates a paucity of female role models for the burgeoning number current female trainees. This mentorship gap is something that is important to be aware of and to address in order to ensure continued progress, equality and support for female trainees/junior attendings in the field of plastic surgery.

References: 1.Zhang B,ChenK, HaG, etal.Plastic Surgery Chairs and Program Directors: Are the Qualifications Different for Men and Women?. PlastReconstr Surg. 2020;146(2):217e-220e. doi:10.1097/PRS.0000000000007011

Introduction Understanding reimbursement trends is crucial to maintaining a sustainable pediatric plastic surgical practice. The Center for Medicare & Medicaid Services (CMS) establishes standardized base rates for pediatric procedures, which are subsequently modified by state-specific Medicaid policies prior to physician reimbursement. However, there is limited literature on comprehensive longitudinal reimbursement trends for cleft lip and cleft palate procedures. The purpose of this study is to evaluate trends in physician fee reimbursement rates within the past two decades.

Methods National reimbursement data from fiscal years 2007 to 2024 was obtained through the Medicare Physician Fee Schedule Look-Up (MPFS) tool provided by the CMS. Cleft lip and cleft palate procedures of interest were identified through Current Procedural Terminology (CPT) codes provided by the American Society of Plastic Surgeons [1].

The following values were queried from MPFS under the National Payment Amount which includes relative value units for work, practice expense, and malpractice. The Geographic Practice Cost Indices were set at 1.000 to account for national payment values. Conversion factors were directly obtained by contacting CMS. Physician fee reimbursements calculations were conducted using the established physician fee reimbursement equation [2]. Physician fee reimbursements were adjusted for inflation using the Bureau of Labor Statistics Physicians' Service Consumer Price Index [3]. Subsequent percentage change (PC) and year-over-year (YOY) analyses were conducted.

Results 44 CPT codes were identified. Of the 44 codes, seven codes (15.91%) were directly cleft lip procedures, 14 codes (31.82%) were directly cleft palate procedures, and 24 codes (52.27%) were indirect procedures that could be used in cleft lip/palate cases.

YOY illustrated a decreasing pattern in reimbursements from fiscal years (FY) 2007-2024. Interestingly, YOY demonstrated down-trending fluctuations within cleft lip and palate physician fee reimbursements, in tandem with significant changes occurring during the Global Financial Crisis from FY2008-2009 and the SARS-CoV-2 pandemic from FY2020-2021. Noticeably, all CPT codes experienced a positive YOY change two years after these economically impacting events (2010 and 2022, respectively), possibly due to governmental intervention, and subsequently decreased again afterwards (Figure 1).

Overall, PF reimbursements decreased by an average of -29.44% (±9.21%) by the end of FY2024. All CPT codes for cleft lip and palate procedures demonstrated a decrease in reimbursements from FY2007 – FY2024 (Figure 2A-B). CPT 30140 experienced the greatest decrease in reimbursement (–69.65%) from FY2007 – FY2024. CPT 41872 experienced the smallest decrease in reimbursement at (–15.66%) from FY2007 - FY2024.

Conclusion Overall, physician fee reimbursements demonstrated a down-trending pattern for the majority of cleft lip and palate procedures, from 2007-2024. Variable fluctuations occurred year-over-year at certain periods, possibly due to significant economic changes.

References

1. ASPS Cleft Lip and Palate Recommended Insurance Coverage Criteria for Third Party Payer Coverage. 2022. https://www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2022-cleft-lip-palate.pdf

2. Seidenwurm DJ, Burleson JH. The medicare conversion factor. AJNR Am J Neuroradiol. 2014 Feb;35(2):242-3. doi: 10.3174/ajnr.A3674. Epub 2013 Jul 18. PMID: 23868163; PMCID: PMC7965749.

3. Bureau of Labor Statistics, United States. Consumer Price Index. 2024. https://data.bls.gov/cgi-bin/surveymost

INTRODUCTION In recent years, Medicare reimbursement rates across many medical specialties have decreased. However, the effect of these trends on plastic surgery has not been thoroughly investigated. This study analyzes changes in Medicare reimbursement rates for various inpatient plastic surgery procedures over the past 12 years.

METHODS Given that the top-billed inpatient procedures are not publicly available in the CMS Physician/Supplier Procedure Summary database, the National Surgical Quality Improvement Program (NSQIP) database was utilized to identify the 100 most frequently performed inpatient plastic surgery Current Procedural Terminology (CPT) codes. These codes were classified into six categories: breast, craniofacial, hand, excision, peripheral nerve, and integumentary. Medicare reimbursement trends for each CPT code were analyzed using the Medicare Physician Fee Schedule Database from 2013 to 2025, with gross reimbursement rates adjusted to 2013 dollar values based on the Consumer Price Index (CPI) from the U.S. Bureau of Labor Statistics. Overall reimbursement changes over the past 12 years were calculated as weighted averages across the CPT codes.

RESULTS The top 100 CPT codes identified in the NSQIP database accounted for 89.25% of all plastic surgeries (Table 1). Overall, gross reimbursement for these procedures decreased by 8.74% over the past 12 years, while inflation rose by 25.9%. Breast-related plastic surgery procedures experienced the steepest decline (-13.07%), followed by craniofacial (-4.22%), excision (-3.28%), integumentary (-2.46%), and hand (-1.57%) procedures. In contrast, peripheral nerve procedures showed the greatest increase in gross reimbursement (+8.74%). Additional details are provided in Table 1. After adjusting for inflation, these trends became more pronounced, with reimbursements falling even more sharply (range: -35.58% to -19.41%; average: -32.31%). Direct-to-implant reconstruction (CPT 19340), which accounted for 5.65% of all plastic surgery cases, experienced the steepest decline in reimbursement ($746.88 in 2025 vs. $1026.13 in 2013; -27.21%, or -46.06% after inflation adjustment). Conversely, neuroplasties (CPT 64708), comprising 0.15% of all cases, experienced the largest increase in gross reimbursement ($607.83 in 2025 vs. $505.92 in 2013; +12.54%, or -10.96% after inflation adjustment).

CONCLUSIONS Medicare reimbursement rates for breast-related plastic surgeries have not kept pace with inflation over the past 12 years. The significant divergence between inflation and medicare reimbursement, particularly in alloplastic reconstruction, warrant further policy review to support the long-term viability of and fair access too reconstructive surgery.

Background Conversational AI systems are increasingly adopted in healthcare settings, yet their usability-a critical factor in successful implementation-remains insufficiently studied. General-purpose large language models (LLMs), despite their broad capabilities, pose patient safety and liability risks due to inaccuracies, generic medical information, and tendencies to hallucinate or deflect rather than provide precise, context-specific responses. The Chatbot Usability Questionnaire (CUQ) offers a standardized method to evaluate these systems from the user perspective. Retrieval-augmented generation (RAG) has emerged as a potential solution by grounding model outputs in verified knowledge sources. However, empirical evidence of its usability advantages remains limited. This study assesses the usability of RAG-LLM-AIVA, a retrieval-augmented generation agent developed on Google's Vertex AI, representing an advanced iteration of our earlier AIVA, initially created using Google Dialogflow (1). We compare its performance to Gemini 1.5 Flash, focusing on their effectiveness in addressing post-operative plastic surgery inquiries.

Method We conducted a comparative usability evaluation with 20 healthcare workers (HCWs) who interacted with both RAG-LLM-AIVA and Gemini 1.5 Flash. RAG-LLM-AIVA, built on the Gemini 1.5 Flash architecture, was specifically trained to answer post-operative questions related to plastic surgery using a knowledge base compiled from publicly available medical resources, standardized post-operative instruction handouts, and peer-reviewed PubMed publications. Participants asked free-form, spontaneous post-operative care questions to both LLMs, mimicking real-world clinical interactions. They then completed the 16-question CUQ, which evaluates usability dimensions such as personality, clarity, and usefulness on a 5-point Likert scale (0–100). The CUQ assesses chatbot personability, friendliness, purpose, ease of navigation, comprehension, usefulness, error handling, and overall ease of use.

Results RAG-LLM-AIVA significantly improved perceived chatbot usability in plastic surgery post-operative inquiries. It achieved a mean CUQ score of 77.2 ± 11.7, significantly outperforming Gemini 1.5 Flash (65.2 ± 6.9, p < 0.005). This 12-point difference indicates a substantial usability improvement. RAG-LLM-AIVA outperformed across all measured metrics, with a higher median score (78.1 vs. 66.4) and a wider performance range (54.7–96.9 vs. 46.9–75.0). While RAG-LLM-AIVA demonstrated greater variability (standard deviation: 11.7 vs. 6.9), the overall trend indicated higher user satisfaction.

Conclusion The statistically significant 12-point improvement in CUQ scores (77.2 vs. 65.2) suggests that retrieval augmentation effectively addresses key usability limitations of general-purpose LLMs. Future research should extend usability evaluations to include direct patient interactions. Investigating patient-centered outcomes, such as satisfaction and perceived benefit from RAG-enhanced conversational AI, will be essential for validating and further refining these technologies for clinical applications.

Reference 1. Avila FR, Boczar D, Spaulding AC, et al. High Satisfaction With a Virtual Assistant for Plastic Surgery Frequently Asked Questions. Aesthet Surg J. 2023;43(4):494-503. doi:10.1093/asj/sjac290

Introduction: Approximately 20% of the United States population has Medicare health insurance coverage (1). With the aging population, this proportion is expected to increase (2). However, literature indicates that Medicare reimbursement rates to physicians are consistently decreasing after inflation adjustments. This trend has also been observed in plastic surgery which can negatively impact access and sustainability of care (3). Our study is the first to analyze reimbursement by case volume of all procedure codes billed to Medicare by plastic and reconstructive surgeons from 2013 to 2022.

Methods: All procedure codes billed to Medicare Part B by plastic and reconstructive surgeons were extracted from the CMS Physician and Other Practitioners database. Medicare reimbursement information for analyzed codes were determined through the Medicare Physician Fee Schedule database, and codes with missing information during the study period were excluded. Procedure codes were divided into subgroups based on AMA categorization, and volume-weighted changes in reimbursement rates were calculated. Dollar amounts were inflation-adjusted to 2022 estimates based on consumer price index (CPI) values.

Results: 254 procedure codes were included for analysis. From 2013 to 2022, the mean Medicare reimbursement rate for plastic surgery procedures decreased by 22.2% from $337.01 in 2013 to $262.07 in 2022 after inflation adjustment. This results in an average decrease of $7.16 annually (p<0.001). The largest average decreases in reimbursement were observed in musculoskeletal procedures (37.3%, $240.17 to $150.56) and flaps and grafts (31.7%, $617.14 to $421.50). The smallest average decreases in reimbursement were for nervous system (9.6%, $419.99 to $379.65) and hand and upper extremity procedures (14.3%, $610.64 to $523.61). Reimbursement for head and neck procedures decreased by 24.1% from $793.37 to $601.89. Reimbursement for breast procedures decreased by 19.5% from $1216.81 to $979.64. None of the procedure types in our study had an average increase in reimbursement. There was no correlation between changes in volume and reimbursement (R=0.01; p=0.848).

Conclusions: Medicare reimbursement for plastic surgery is consistently decreasing regardless of case volume. Decreases in reimbursement were greatest for musculoskeletal procedures and flaps and grafts. The continued decline in reimbursement for plastic surgeons can have negative implications for practice management and access to care for patients.

Purpose: The operating room (OR) is the most common site for adverse events, with errors occurring in approximately 14.6% of surgical patients where up to 50% of such events are considered preventable.[1] In 2009, World Health Organization's (WHO) Surgical Safety Checklist (SSC) was developed featuring three checkpoints: Sign-in (before anesthesia induction), Time-Out (before incision), and Sign-out (postoperatively).[2] The SSC has improved communication, teamwork, and patient safety worldwide, yet it leaves gaps in addressing dynamic intraoperative risks that may arise especially during prolonged reconstructive or microsurgical cases. To address these concerns, we have developed and implemented a novel system known as CAMPI (Communication, Airway, Micro-breaks, Positioning, and IV Infiltration) for hourly intraoperative safety monitoring, detailed in this report.

Methods: The CAMPI protocol was implemented at Banner Gateway Medical Center in 2022 in the Department of Plastic Surgery and then expanded to include other surgical specialties, particularly for procedures with a duration of more than six hours. Implementation involved training sessions with all OR staff to explain overarching principles and application within each role. CAMPI checks were scheduled hourly throughout cases and feedback was collected from OR teams to refine communication and workflow. Metrics such as complication rates, team satisfaction, and patient outcomes were tracked to evaluate protocol effectiveness.

The acronym's components are as follows: Communication: Clear and continuous communication among all team members, including periodic updates to ensure alignment on patient progress and anticipated challenges and proactive updates to the patient's accompanying family or loved ones. Airway: Ongoing monitoring of airway stability via close collaboration between anesthesiologists and surgeons. Micro-breaks: Scheduled 60-90 second breaks for all OR staff to stretch, hydrate, and reset their focus. Positioning: Comprehensive checks for proper patient positioning to avoid pressure sores, peripheral neuropathies, and other complications with additional care for high-risk areas like occiput, sternum, sacrum, and heels. IV Infiltration: Evaluation of IV sites using clear drapes and hourly palpation for detection of infiltration or extravasation.

Results: Since the implementation of CAMPI approximately 2.5 years ago, there have been reduced airway complications, pressure injuries, and IV infiltration rates compared to pre-CAMPI data. Additionally both patient families and surgical teams reported higher satisfaction with regards to communication and safety. Team feedback highlighted improved interdisciplinary communication and collective problem-solving via elimination of perceived hierarchy in the operating room.

Conclusion: CAMPI represents a paradigm shift in intraoperative safety, addressing critical gaps that traditional protocols overlook. By integrating structured, hourly checks that emphasize communication, airway management, micro-breaks, positioning, and IV safety assessments CAMPI not only improves patient outcomes but also fosters a culture of safety and collaboration within the OR.

References [1] de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA: The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:216–223, 2008 [2] WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009. PMID: 23762968.

Background: NSAIDs and other non-opioid treatments are widely used for post-operative pain control but are generally discouraged in post-bariatric surgery patients due to the heightened risk of peptic ulcers. (1) Long-term NSAID use (>30 days) after Roux-en-Y gastric bypass (RYGB) is linked to a higher risk of marginal ulceration, while short-term use (<30 days) may be safer. (2) Despite these concerns, there is a paucity of literature surrounding safety of NSAID use following body contouring procedures in bariatric patients, which usually occurs over a year after initial gastric bypass once the patient's weight has stabilized. (3) This study evaluates the association between NSAID use and ulcer incidence in patients with a history of RYGB or sleeve gastrectomy (SG) after panniculectomy. Methods: A retrospective cohort study of 501 patients who underwent panniculectomy at Loyola University Medical Center (January 2012–January 2025) was performed. Inclusion criteria required a history of primary bariatric surgery (RYGB or SG) and subsequent panniculectomy. The primary outcome was the incidence of symptomatic peptic ulcers. Statistical analyses included chi-square, Fischer's exact tests, and logistic regression models to evaluate associations between NSAID use and ulcer development. Results: Of 320 eligible patients, 31 males (9.7%) and 289 were females (90.3%), with an average age of 46.09 years and mean BMI of 32.17. A total of 135 patients (42.2%) had RYGB, 175 (54.7%) had SG, and 10 (3.1%) had an unknown bariatric procedure. Post-panniculectomy, 125 patients (39.1%) used NSAIDs while 195 (60.9%) did not. Gastric ulcers developed in 8 patients (2.5%), with no statistically significant difference in ulcer incidence between post-panniculectomy NSAID users and non-users (χ² = 1.42, p = 0.233, Fischer's: p=0.156). Similarly, there was no significant difference in ulcer risk between pre-panniculectomy NSAID users and non-users (χ²= 0.009, p = 0.924, Fisher's: p=1.0). Patients using NSAIDs either pre- or post-panniculectomy had a lower though non-significant ulcer risk (pre-panniculectomy: OR = 0.67, RR = 0.68, p = 1.0; post-panniculectomy: OR = 0.22, RR = 0.22, p = 0.16). The average duration of NSAID use postoperatively was 8.22 days. Logistic regression analysis demonstrated no significant association between NSAID duration and ulcer risk (p = 0.72, OR = 1.01, 95% CI: 0.98 – 1.04). Conclusions: NSAID use following panniculectomy in post-bariatric surgery patients was not associated with a significant increase in ulcer risk. These findings suggest NSAIDs may be safer than previously assumed and may serve as a reasonable alternative to stronger opioid analgesics. Further research with larger cohorts is necessary to validate these results and better define risk factors, including NSAID dosage. References: 1. Mechanick et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update. Surg Obes Relat Dis. 2020;16(2):175-247. 2. Skogar ML, Sundbom M. Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis. 2022;18(7):888-893. 3. Acarturk et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004 Oct;53(4):360-6; discussion 367. doi: 10.1097/01.sap.0000135139.33683.2f. PMID: 15385771.