Scientific Abstract Presentations: Research & Technology Session 1 Thursday, October 15 Thu, Oct 15 3:30-4:30 p.m. CDT

INTRODUCTION: The increasing popularity of cosmetic procedures combined with pervasiveness of large language model (LLM) chatbot-derived medical information has created inevitable challenges within the field of Plastic and Reconstructive Surgery by creating potentially unrealistic or erroneous expectations. While patients are advised not to follow the instruction of the LLM artificial intelligence (AI) models, their widespread prevalence and accessibility make avoidance unrealistic. Thus, understanding the strengths and limitations of these tools is necessary to better tailor patient counseling and expectations. Here, we aim to analyze the differences amongst different AI chatbots in and their individual literacy-defined accessibilities and utilities as a patient education tool for common plastic surgery procedures.

METHODS: The most searched cosmetic procedures between 2015-2025 were determined through Google Trends. The top eight procedures were queried in ChatGPT-5, Microsoft Co-Pilot-5 and Gemini 2.5 independently with the two prompts: "What to expect for X procedure?" (pre-operative) and "What to do after X procedure?" (post-operative). Readability of the responses were determined through the Flesch-Kincaid Grade Level Tool and the Coleman-Liau Index. Grouped procedural outputs were reviewed by two blinded raters using Patient Education Materials Assessment Tool (PEMAT) and DISCERN grading scales. All statistical analysis was performed using R (v4.5.1).

RESULTS: Outputs of all models were determined to be at an average of tenth-grade level or above reading level on both the Flesch-Kincaid scale and the Coleman-Liau index. Both scored Co-Pilot significantly higher at college level readability (F2,45= 13.37, p<.001 and F2,45= 6.76, p<.002). Intraclass Correlation Coefficient of the two blinded graders were found to be 0.968(p<.001), indicating high reliability. PEMAT understandability of ChatGPT was found to be highest amongst the three while actionability was highest in Gemini (F2,93= 6.76, p<.001). Interestingly, DISCERN scores were significantly higher for Gemini than the other two modalities, with no significant difference found between ChatGPT and Co-Pilot (F2,93= 75.07, p< .001). Notably, distinct mentions of board-certified plastic surgeons were highest in Gemini outputs (62.5%), followed by ChatGPT (37.5%) and Co-Pilot (12.5%).

CONCLUSIONS: High literacy levels required for comprehension of all outputs raises skepticism in the true accessibility of AI modalities to supplement patient education materials. Despite ChatGPT's predominating usage, Gemini was found to provide the highest quality outputs. Yet analysis of Gemini's actual effectiveness as a patient education source was merely deemed "fair" at best. Moreover, language modalities must be further refined through quality control to ensure accurate representation of who performs these procedures. With the increasing popularity of cosmetic procedures, AI's role in patients' preemptive planning remain inevitable. Plastic surgeons must remain vigilant in the consultation and post-operative stages, dispelling any unrealistic expectations while ensuring informed understanding of post-operative instructions.

Introduction: Breast implant associated squamous cell carcinoma (BIA-SCC) is a rare subtype of breast cancer that occurs in approximately 1 in 164,884 individuals with breast implants (1). Similar to a Marjolin ulcer, one hypothesis is that the pathogenesis of BIA-SCC may occur from cells already present in the capsule that undergo squamous metaplasia. This may be in part due to chronic inflammation and wound repair secondary to mechanical forces exerted by nearby muscle on the capsule (2). The purpose of this study is to perform a cytometric analysis of breast implant capsules to identify the subpopulation of native capsule cells that express squamous cell markers and may represent cellular progenitors for BIA-SCC.

Methods: Human capsule was collected and processed via enzymatic digestion using Collagenase P (3.7 mg/mL), Dispase (5 U/mL), and DNase I (12.5 U/mL) in HBSS for 40 minutes at 37°C with agitation. Digested cells were filtered through 100 μm and 70 μm strainers and underwent RBC lysis. For flow cytometric analysis, cells were stained with viability dye and antibodies targeting CD45, CD3, CD19, CD163, CD206, CD49f, CD90, CD140b, CD324 (E-Cadherin), CD326 (EpCAM), and EGFR to identify immune (T cells, B cells, monocytes) and non-immune stromal/epithelial populations. Data were acquired and analyzed using standard pre-gating strategies to resolve live, CD45⁺ and CD45⁻ compartments.

Results: 3 million cells at 63% viability were obtained in single-cell suspension. The capsule tissue demonstrated 38.6% viability on live/dead staining, reflective of a relative paucity of cells compared to collagen, extracellular matrix, and debris in capsule tissue. 57.4% of live cells were CD45-, indicating a significant population of non-hematopoietic cells present. Within the CD45- fraction, there was phenotypic heterogeneity consistent with the expected stromal composition of capsule tissue, including CD90 and CD49f markers characteristic of fibroblasts and cells of myoepithelial lineage. Within the CD45- population, a group of cells discrete from the stromal cell population co-expressing epithelial adhesion molecule EpCAM (CD326) and E-cadherin (CD324) was identified, consistent with an unique epithelial phenotype. Co-expression of EGFR (Epidermal Growth Factor Receptor), highly expressed in squamous epithelial type cells, was also present with EpCAM+ cells in the capsule tissue.

Conclusion: These results demonstrate a distinct population of epithelial expressing cells present in capsular tissue that have a cellular phenotype unique from native capsular hematopoietic cells. Further research is necessary to determine the cell type expressing squamous specific intracellular markers to definitively identify the distinct cellular progenitors of BIA-SCC.

References: 1. Santanelli di Pompeo F, Firmani G, Stanzani E, Clemens MW, Panagiotakos D, Di Napoli A, Sorotos M. Breast Implants and the Risk of Squamous Cell Carcinoma of the Breast: A Systematic Literature Review and Epidemiologic Study. Aesthet Surg J. 2024 Jun 14;44(7):757-768. doi: 10.1093/asj/sjae023. PMID: 38307034. 2. Abdi MA, Yan M, Hanna TP. Systematic Review of Modern Case Series of Squamous Cell Cancer Arising in a Chronic Ulcer (Marjolin's Ulcer) of the Skin. JCO Glob Oncol. 2020 Jun;6:809-818. doi: 10.1200/GO.20.00094. PMID: 32530749; PMCID: PMC7328103.

Background: Blood transfusion is common during pediatric craniosynostosis surgery, but transfusion volumes and intraoperative cell salvage (ICS) use vary considerably across patients and institutions. This variability complicates preoperative planning, including blood product preparation and decisions regarding ICS setup. We aimed to develop and internally validate machine learning (ML) models that provide individualized estimates of both perioperative transfusion risk and expected transfusion volume in pediatric patients undergoing craniectomy procedures for craniosynostosis.

Methods: We performed a retrospective analysis of pediatric craniosynostosis cases recorded in the American College of Surgeons NSQIP-Pediatric dataset (2016–2023). Eligible patients were ≤36 months old and underwent craniectomy for craniosynostosis. We developed two stages of ML models: 1) a classifier to predict the risk of requiring perioperative transfusion (defined as requiring transfusions intraoperatively or within 72 hours postoperatively), and 2) probabilistic or quantile regression models to estimate the conditional median weight-adjusted transfusion volume (mL/kg) with interquartile range (IQR). Missing data was imputed using Multivariate Imputation by Chained Equation. Training data was further pre-processed using Robust normalization. Hyperparameters for all algorithms were tuned using Bayesian optimization across 5-fold cross-validation. The optimal model configuration was selected to minimize cross-entropy loss for the classifier stage, and selected to minimize pinball loss for the regressor stage. Performance of the modeling pipelines was evaluated using nested cross-validation with 5-fold outer loops. Local and global feature importance was assessed by SHAP.

Results: A total of 8,045 patients were included; 4,091 (50.9%) received perioperative transfusion.

For the classification stage, the optimal model configuration was a LightGBM classifier. The modeling pipeline achieved a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.77 (95% CI 0.75–0.78) and mean Brier score of 0.20 (95% CI 0.19–0.20) across nested cross-validation. At the high-sensitivity classification threshold, mean sensitivity was 0.81 (95% CI 0.80–0.83) and specificity was 0.60 (95% CI 0.58–0.62). Based on SHAP, the most important features for predicting the need for blood transfusion were surgical approach (endoscopic vs open), ASA classification, and bone graft requirement.

For the regression stage, the optimal model configuration was a probabilistic NGBoost regressor. The modeling pipeline achieved an average median absolute error of 6.86 mL/kg (95% CI 6.61–7.11), with mean IQR coverage of 53% (95% CI 52-53%). Based on SHAP, the most important features were patient sex, pre-existing structural CNS abnormalities, and patient weight.

The final models are deployed as a clinical risk calculator, available at https://craniostrip.shinyapps.io/apps/ as the Craniosynostosis Surgery Transfusion Requirement Inference Platform (Cranio-STRIP).

Conclusion: We developed and internally validated a two-stage ML tool that estimates both transfusion risk probability and the anticipated transfusion volume (with predicted variance) for pediatric patients undergoing craniosynostosis surgery. These models may support individualized blood product preparation and selective ICS planning, with the potential to improve perioperative resource allocation. External validation and further real-world testing are needed prior to the clinical implementation of this tool.

PURPOSE: Biomatrices are increasingly used in reconstructive surgery, yet their mechanical stability remains a limiting factor. Photochemical Tissue Passivation (PTP) uses a photoactive dye, Rose Bengal (RB), and green light to covalently cross-link collagen fibers, enhancing tissue stability and strength. We investigated the effect of PTP on decellularized collagen matrices.

METHODS: Descellularized Collagen Matrix samples (OviTex® 4 Core) were divided into two groups. In both groups two pierces of OviTex were approximated with a single interrupted suture (n=22; 11 per group). Controls were incubated in saline for 5 minutes per manufacturer instructions, whereas treated specimens were incubated in RB for 5 minutes and irradiated with a Green Light. All samples underwent uniaxial tensile testing for maximum load, ultimate stress, elastic modulus, extension at maximum load, and energy absorption.

RESULTS: PTP significantly enhanced the biomechanical properties of OviTex. Ultimate stress (normalized maximum load) increased by 38% (931.55 ± 142.85 kPa vs. 1,283.55 ± 154.56 kPa; p < 0.001). Elastic modulus increased by 33% (2,258.09 ± 714.72 kPa vs. 3,006.45 ± 996.46 kPa; p = 0.026), and energy absorption increased by 23% (343.51 ± 81.19 Nmm vs. 424.02 ± 95.63 Nmm; p = 0.0024).

CONCLUSION: PTP improves the strength and stiffness of collagen matrices without compromising elasticity. By inducing collagen crosslinking, PTP enhances tissue stability and may slow enzymatic matrix degradation. This data suggests PTP may be helpful in improving the mechanical performance of tissue matrices in reconstructive surgery by improving suture stability and delaying matrix resorption.

Purpose The balance between peer-reviewed research and opinion-driven publications is critical to the integrity of the plastic surgery literature. Letters, commentaries, and editorials, while valuable for scholarly discourse, typically undergo minimal peer review compared with original studies. This creates an opportunity for clinical impact limited to opinion and conjecture without critical appraisal and debate.

Methods & Materials We reviewed the publication record and the citation pattern of a single author with unusually high output to assess the proportion of peer-reviewed versus minimally reviewed contributions.

Results Of the author's 239 publications, 165 (69%) were minimally reviewed formats, including letters, comments, discussions, editorials, and viewpoints. In contrast, 61 publications (26%) were peer-reviewed journal articles, and 11 (5%) were review papers. The remaining output consisted of one case report and one book review. In addition, 158 (66%) were published as open access, and the author cited themselves a total of 67 times. Overall, minimally reviewed and open access publications substantially outnumbered peer-reviewed studies, with letters alone exceeding all original investigations combined.

Conclusions Examining a single author's record demonstrates a disproportionate reliance on minimally reviewed and open access publications. While these contributions support academic discourse, their predominance can overstate productivity relative to rigorous, evidence-generating research with broad generalizability beyond one surgeon's experience or ideas. This pattern also reflects a meaningful financial investment, as open-access publishing carries substantial costs for authors. To safeguard the integrity of the plastic surgery literature, greater emphasis must be placed on rigorous peer review and prioritization of original studies, systematic reviews, and clinical trials.

Introduction: Injury to the inferior alveolar nerve (IAN) is a well-documented risk of bilateral sagittal split osteotomy (BSSO), resulting in long-term numbness of the chin, drooling, and lip biting in up to 30% of patients. The IAN courses through the mandible, requiring a high degree of spatial awareness that is difficult to acquire without repeated practice. However, current surgical training tools provide limited opportunities for trainees to develop this intuition and practice nerve-sparing techniques.

Hypothesis/Aim: This study developed and tested a low-cost, high-fidelity 3D-printed mandible model with a pressure sensing (piezoelectric) cable to simulate and detect nerve injury in real-time.

Methods: We created mandible models using high-resolution CT imaging and a resin-based 3D printer (Anycubic PhotoM3 Max), threaded with a piezoelectric cable to replicate the IAN. The cable was attached to a microcontroller board (Arduino Uno R3) which converted pressure differences to changes in voltage. Minor nerve injury (0.024 V), moderate (0.098 V), and major (0.49V) resulted in green, yellow, and red LED illumination in real time, respectively, while major nerve injury also set off a loud audio alarm. A Python script continuously recorded the degree of nerve injury over the course of the simulation. Model creation costs were calculated to assess affordability.

Results: Bench testing was conducted on 6 nerves. Mean simulation time was 43.46 seconds. The mean time spent in the degree of minor, moderate, and major nerve injury was 0.11 seconds, 0.70 second, and 0.14 seconds, respectively. There were 4/6 nerve transections. The model was successfully constructed at a low recurrent cost of $6.23 per mandible. The microcontroller board had a one-time cost of $33. All software was free. Time for segmentation of the CT scan and model fabrication totaled 25 minutes, while total print time was 14 hours for 4 mandibles.

Conclusion: This piezoelectric-enhanced BSSO model represents a novel approach to IAN preservation training. By providing real-time graded feedback on simulated nerve contact, it has the potential to enhance surgical awareness and improve patient safety. This low-cost simulator has broad applicability to other surgical procedures in which outcomes may be improved through nerve-sparing techniques.

Introduction: 2-octyl cyanoacrylate (2-OCA), used in topical skin adhesives for wound closure, is increasingly recognized as a cause of allergic contact dermatitis (ACD), producing erythema, irritation, and impaired wound healing.(1,2) Reported rates vary widely, and the population-level incidence remains uncertain as postoperative reactions are frequently unrecognized and therefore underreported.(3) We performed a systematic review and meta-analysis to characterize the incidence, clinical features, and risk factors of 2-OCA-associated ACD across surgical specialties.

Methods: We conducted a PRISMA systematic review of randomized, observational, and case-report studies in PubMed, Embase, and Web of Science (January 1, 2008, to November 7, 2025) describing human wound closure with 2-OCA-based topical skin adhesives and reporting cutaneous hypersensitivity or ACD. Risk of bias was assessed using ROBINS-I and RoB 2. For analytic cohorts reporting both exposed patients and ACD events, incidence was pooled using a random-effects inverse-variance model with prespecified subgroup analyses by surgical specialty; case reports and case series were summarized descriptively.

Results: Seventy-four studies involving 26,330 exposed patients were included; 20 analytic cohorts (25,442 patients) contributed to meta-analysis. The pooled incidence of ACD was 4% (95% CI, 3-5%) with substantial heterogeneity (I2 = 94.5%). Across analytic cohorts, study-level incidence ranged from 0.5% to 24%. Subgroup meta-analysis demonstrated pooled ACD incidence of 4% (95% CI, 2-5%) in orthopedic cohorts (13 studies, n = 24,166) and 8% (95% CI, 3-16%) in plastic-surgery cohorts (5 studies, n = 511), with lower pooled rates in dermatology and obstetrics-gynecology cohorts. Re-exposure was consistently associated with higher reaction rates, including increases from approximately 1% after initial exposure to 22% after second exposure in staged bilateral procedures, and from 12% at first exposure to 21% with repeat exposure in pediatric cohorts. Prior adhesive or contact allergy and prior cosmetic acrylate exposure were repeatedly described as contributors to risk, including sensitization from artificial nail and eyelash adhesives and other consumer acrylate-containing products.(4) Diagnosis was most commonly clinical; patch testing was used in selected cases. Treatment typically involved adhesive removal and topical corticosteroids, often with oral antihistamines; systemic corticosteroids and/or antibiotics were generally reserved for more extensive reactions or when secondary infection was suspected.

Conclusion: Allergic contact dermatitis to 2-octyl cyanoacrylate topical skin adhesives is a recurrent and clinically important complication of wound closure across multiple surgical specialties. Incidence varies substantially across study settings, with higher pooled rates observed in plastic-surgery cohorts. Risk increases markedly with re-exposure and prior sensitization, reflecting the cumulative sensitization potential of repeated 2-OCA exposure. Given the consistency of reactions reported across specialties, procedures, and adhesive formulations, 2-OCA-associated ACD should be recognized as an inherent risk of topical cyanoacrylates used in wound closure.

References: 1. Park YH, Choi JS, Choi JW, et al. Sci Rep. 2021;11:23762. doi:10.1038/s41598-021-03319-3 2. Chalmers BP, Melugin HP, Sculco PK, et al. J Arthroplasty. 2017;32:3742-3747. doi:10.1016/j.arth.2017.07.012 3. McNichol L, Lund C, Rosen T, et al. J Dermatol Nurses Assoc. 2013;5:323-338. doi:10.1097/JDN.0000000000000009 4. Gardeen S, Hylwa S. Int J Womens Dermatol. 2020;6:263-267. doi:10.1016/j.ijwd.2020.04.007

Introduction: Enhanced Recovery After Surgery (ERAS) pathways in plastic surgery advocate for multimodal, opioid-sparing analgesia.1 Transcutaneous Electrical Nerve Stimulation (TENS) is a noninvasive, cost-effective neuromodulation technique with established efficacy in orthopedic and general surgery.2 TENS modulates pain through segmental spinal gating, descending inhibitory pathway activation, and endogenous opioid release.3 Clinically, TENS is applied via surface electrodes placed adjacent to surgical incisions or along relevant dermatomes, delivering strong but comfortable stimulation in short, repeatable sessions.4 These features make TENS particularly attractive for plastic surgery recovery protocols. Despite its potential, the role of TENS in plastic surgery remains underexplored. This systematic review evaluates the clinical evidence for TENS in plastic surgery, with emphasis on hand surgery and digital nerve repair.

Materials & Methods: A systematic review was conducted per PRISMA guidelines using PubMed and Cochrane databases. Search terms included "TENS," "pain," "plastic surgery," and its associated subspecialties. Eligible studies were original clinical trials or observational studies reporting TENS outcomes following aesthetic or reconstructive plastic surgery. Extracted data included procedure type, TENS parameters, study design, outcomes, and adverse events. A summary table outlines methodology and findings.

Results: Nine studies met inclusion criteria, encompassing liposuction, breast augmentation, orthognathic surgery, facial reanimation, hand surgery, and burn reconstruction. Two studies focused specifically on hand and digital nerve procedures: one randomized controlled trial protocol described low-frequency TENS initiated in the early postoperative period to enhance sensory recovery after digital neurorrhaphy; another cohort study showed improved sensory outcomes and reduced neuropathic pain after upper extremity surgery. TENS was consistently associated with lower pain scores, decreased opioid consumption, and favorable functional recovery. No serious adverse events were reported. However, clinical protocols varied, and few studies included standardized sensory metrics or long-term follow-up.

Conclusions: TENS is a safe, noninvasive, and evidence-supported adjunct for postoperative pain control and peripheral nerve recovery in plastic surgery. Its physiologic relevance, ease of use, and favorable safety profile support broader clinical integration, particularly for procedures involving digital nerve repair or significant sensory dysfunction. While preliminary studies are promising, standardization of dosing protocols and consistent outcome measures remain lacking. Incorporating TENS into ERAS protocols offers a low-cost, low-risk opportunity to enhance recovery. Future prospective trials are essential to define its long-term impact and optimize its role in perioperative care.

References: 1. Lombana NF, Mehta IM, Zheng C, Falola RA, Altman AM, Saint-Cyr MH. Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions. Proc (Bayl Univ Med Cent). 2023;36(4):501-509. doi:10.1080/08998280.2023.2210036 2. Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Manag. 2014;4(3):197-209. doi:10.2217/pmt.14.13 3. Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. J Pain. 2003;4(3):109-121. doi:10.1054/jpai.2003.434 4. Sierakowski A, Jing SS, Poel J, Elliot D. Transcutaneous Peripheral Nerve Stimulation for the Treatment of Neuropathic Pain in the Upper Limb. J Hand Surg Asian Pac Vol. 2016;21(1):37-43. doi:10.1142/S2424835516500041

Background: Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition characterized by recurrent nodules, abscesses, sinus tracts, and scarring (1). While surgical excision is an effective treatment for refractory disease, postoperative recurrence remains a persistent challenge (2). Currently, no standardized, real-time tool exists to assist surgeons in evaluating the extent of affected skin during HS surgery.

Objective: To evaluate intraoperative thermal patterns relative to surgeon-defined margins and assess the potential role of thermal imaging as an adjunctive tool in HS resection.

Methods : This is a prospective cohort study conducted at a single academic institution of patients undergoing surgical resection for HS. Preoperative thermal imaging was performed after patients acclimated to operating room temperature. Throughout the study, surgeons remained blinded to imaging. Thermal images were analyzed to identify regions of elevated temperature ("hotspots") within and adjacent to preoperative surgical markings. Temperature values were expressed as standard deviations (SD) relative to adjacent normal skin and adjacent affected skin. In cases of postoperative recurrence, spatial analysis was performed to correlate recurrence locations with preoperative thermal imaging findings.

Results: Seven patients (5 women, 2 men) between the ages of 20-62 underwent surgical resection for HS. Patients represented a range of HS severity, anatomical locations, resection sizes, closure method, and postoperative outcomes. Within individual resections, hotspots demonstrated consistently greater standardized thermal elevation than adjacent surgical marking sites. When referenced to adjacent normal skin, hotspots were hotter than marking sites across all segments (14/14, 100% significant). When referenced to adjacent affected skin, hotspots remained hotter in most segments (12/14, 85.7% significant). Most patients healed without recurrence. In patient 01, a single recurrence with temperature elevation greater than one SD above adjacent normal skin. In patient 05, recurrence sites exhibited temperatures within one SD of baseline after exclusion of masking regions of maximal thermal elevation. In patient 03, thermal imaging demonstrated lateral extension beyond surgical markings, which was confirmed intraoperatively with methylene blue mapping.

Conclusion: Thermal imaging identifies regions of elevated thermal signal beyond surgeon-defined margins, and may serve as a feasible adjunctive tool for visualizing inflammatory extension and subclinical disease present in the preoperative stage.

References (1) Riddle, A., et al., Current Surgical Management of Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis. Dermatol Surg, 2021. 47(3): p. 349-354. (2) Ballard, K. and V.L. Shuman, Hidradenitis Suppurativa, in StatPearls. 2024: Treasure Island (FL).

Introduction: Authorship is a central marker of scholarly contribution, accountability, and academic advancement in medicine. Despite widespread adoption of International Committee of Medical Journal Editors (ICMJE) guidelines, unethical authorship practices (namely ghost and honorary authorship) remain prevalent across scientific disciplines. Medical students pursuing plastic and reconstructive surgery (PRS) may be particularly vulnerable due to hierarchical pressures, power imbalances, and increasing demands for research productivity in a highly competitive residency application environment. Understanding how trainees perceive, experience, and navigate authorship challenges is critical to fostering a transparent and ethical research culture within the specialty. This study aimed to assess medical students' knowledge of authorship standards, exposure to unethical practices, and attitudes toward ethical conduct in PRS research.

Methods: An IRB-approved, cross-sectional, anonymous electronic survey was distributed to medical students interested in PRS. A 29-item questionnaire assessed demographics, research experience, awareness of authorship guidelines, exposure to unethical practices, and attitudes toward ethical conduct. Question formats included multiple-choice, Likert-scale, binary, and open-ended responses. Descriptive statistics were calculated, and respondents were stratified by training level. Group comparisons were performed using Mann-Whitney U and chi-square tests (p < 0.05). Qualitative responses were analyzed thematically.

Results: Among 46 eligible respondents, 82.6% reported awareness of established authorship criteria; however, only 21.7% had received formal training on authorship guidelines. Familiarity with ICMJE standards was limited, with 60.8% reporting being completely or not very familiar. Misconceptions regarding legitimate authorship were common: while most endorsed substantial contribution and manuscript drafting as necessary, many also considered data collection alone (32.1%), supervision without direct involvement (21.7%), or securing funding (21.7%) as sufficient for authorship. Unethical authorship practices were frequently reported. Ghost authorship was witnessed or experienced by 32.6% of respondents, most commonly attributed to seniority pressures and lack of clear guidelines. Honorary authorship was more prevalent, reported by 52.2%, often driven by institutional norms, reciprocal expectations, and adding senior figures to enhance credibility. Authorship order was perceived as unfair by 37.0% of students, and 28.3% reported involvement in authorship disputes. Despite this, only 6.5% were aware of institutional dispute-resolution mechanisms. Upperclassmen reported significantly greater research experience (p = 0.011) but were less confident that their medical schools adequately prepared them for ethical publication practices (p = 0.037). Additionally, 71.7% reported observing or using artificial intelligence (AI) tools in research, most commonly for editing, literature review, and drafting, while fewer than half were aware of formal AI guidelines.

Conclusions: Unethical authorship practices and misconceptions about authorship criteria are common among medical students interested in PRS. Limited formal training, hierarchical pressures, institutional norms, and emerging technologies contribute to these challenges. The discrepancy between awareness and accurate understanding of authorship standards underscores the need for structured curricula, early and transparent authorship discussions, and visible dispute-resolution pathways. Targeted educational interventions, mentorship models emphasizing accountability, and institutional reforms are urgently needed to promote ethical and equitable research practices within plastic surgery training.