Scientific Abstract Presentations: Practice Management Session 2 Friday, October 16 Fri, Oct 16 8:00-9:30 a.m. CDT

PURPOSE: The COVID-19 pandemic disrupted hand surgeons' practices, particularly elective procedures. However, the most recent study on utilization of hand surgery for the Medicare population ended in 2019. The aim of this study is to analyze trends in Medicare utilization and spending for hand surgery in the COVID-19 period. METHODS: The CMS Medicare Physician & Other Practitioners database was queried for procedures billed by hand surgeons from 2013 – 2022. Outcomes included the number of services per million beneficiaries, standardized Medicare payment, non-Medicare payment (deductible, co-insurance, and third-party payments), submitted charge, and percent reimbursed per year. Interrupted time series analyses were used to analyze changes in outcomes occurring in 2020. Dollar amounts were inflation-adjusted to 2022 estimates. RESULTS: 3,651,788 services for 2,778,423 beneficiaries covering 378 procedures performed by 2,022 hand surgeons from 2013 to 2022 were included. The volume of procedures increased across the study period, while average Medicare standardized payment, non-Medicare payment, submitted charge, and percent reimbursed decreased. ITSA analysis demonstrated abrupt drops in volume (-1,304.6 per million beneficiaries), average Medicare standardized payment (-$7.10), non-Medicare payment (-$1.60), charge (-$58.00), and an increase in percent reimbursed (2.0%). In 2020, the volume of tendon and joint injections and median nerve releases decreased, while hand fractures, forearm fracture, and integumentary repairs increased. CONCLUSIONS: The early COVID-19 period is associated with decreased utilization and Medicare payments, and a shift from elective to emergent, trauma-related procedures for hand surgery. Further research is warranted to evaluate how these changes have impacted patient care and outcomes.

Introduction: Resident salaries influence recruitment, retention, and overall physician well-being. For integrated plastic surgery programs, compensation varies depending on program funding, institutional size, and regional costs. While prior studies have described nominal differences in pay, less is known about salary increases throughout residency after accounting for inflation and cost of living. This study investigates year-to-year wage growth after accounting for inflation and regional salary differences among integrated plastic surgery programs. Methods: Resident salary data were collected from the 2025 AAMC Residency Explorer Tool for integrated plastic surgery (PRS) residency programs in the U.S. Programs without available data were excluded. Programs were then divided into four CDC regions (Midwest, Northeast, South, and West). Annual salary increases were calculated within each program and adjusted for inflation using the regional consumer price index (CPI) as a surrogate for inflation. Additionally, wages were adjusted for cost of living using regional price parity by urban city and state relevant to each program. Mean salaries and mean percentage changes were calculated by region. Kruskal-Wallis and One-Way ANOVA tests were used to test differences between groups with post-hoc tests adjusted by Bonferroni correction were used to assess significance (p<0.05). Results: Seventy-seven of the 89 PRS programs were included in the study. The West offers the highest RPP-adjusted mean salary ($81,817.31) amongst PRS programs while the South offers the lowest ($75,046.20). The South offers significantly less salary than Midwest ($79,324.53, p<0.001), Northeast ($80,352.40, p<0.001), and West (p<0.001). Interestingly, the South has the greatest mean growth after inflation (1.66%) amongst all regions while the West demonstrated the lowest (1.12%). Significant differences in mean adjusted salary growth exist between the South and the Midwest (1.27%, p=0.003), South and Northeast (1.16%, p<0.001), and South and West (p<0.001). Discussion:
Although the South trails in absolute pay for residents in integrated plastic surgery programs compared to other regions, it demonstrates the greatest year-to-year salary growth above inflation, which may help lower financial strain as responsibilities increase over training. In contrast, the West demonstrates the opposite trend, where higher entry salary but slower growth may cause undue stress from lack of perceived financial growth These trends highlight the need to not only continually renew baseline salaries, but also salary trajectories relative to ever-increasing inflation and cost of living. Programs and policymakers should consider both cost-of-living adjustments and long-term salary trajectories when addressing resident financial well-being.

Introduction: Third-party medical financing is increasingly offered to patients undergoing elective procedures. Plastic surgery represents a particularly relevant setting for its use given the high proportion of elective procedures and significant out-of-pocket costs. Despite their integration into plastic surgery practices, the existing literature on third-party financing within plastic surgery remains limited. Therefore, the objective of this study was to characterize and assess the use of third-party financing in U.S. plastic surgery spaces.

Methods: A scoping review was conducted in accordance with PRISMA-ScR guidelines of articles published from 2010–2025 addressing third-party financing products in U.S. plastic surgery. Structured Boolean searches combining third-party financing and plastic surgery-related terms were performed, with backward and forward citation tracking to identify additional eligible sources. Qualitative data were extracted on source characteristics (publication type, year, focus), financing model descriptions, product features (e.g., deferred interest, annual percentage rates [APR], installment structures), regulatory and legal considerations and references to plastic surgery procedures. A secondary analysis of a published national web-scrape dataset of medical credit card–accepting locations was refined to U.S. plastic surgery practices. Practice locations were classified using Rural-Urban Commuting Area (RUCA) codes to characterize geographic distribution.

Results: Nineteen sources published between 2013 and 2025 met inclusion criteria, including peer-reviewed clinical or health services research (n=4), legal scholarship (n=2), federal reports (n=4), professional society commentary (n=1), industry communications (n=6), and business intelligence entries (n=2). Six sources examined medical credit cards (e.g., CareCredit and Alphaeon), commonly describing deferred-interest promotions and high APRs. Seven focused on fintech-based installment platforms (buy-now-pay-later models). Regulatory and legal sources emphasized transparency concerns, deferred interest, and medical debt risk, whereas industry sources framed financing as expanding access and supporting practice growth. Within plastic surgery, third-party financing was predominantly embedded in urban practices. This was rehashed with secondary geographic analysis, which identified 2,072 CareCredit-affiliated and 1,450 Alphaeon-affiliated U.S. plastic surgery practice locations in 2023, with the majority classified as urban by RUCA criteria.

Conclusion: Via either medical credit cards or fintech-based installment platforms, third-party medical financing is increasingly embedded within the U.S. plastic surgery ecosystem, yet specialty-specific evidence remains scarce. Regulatory and legal sources emphasize concerns related to deferred-interest structures, high interest rates, and point-of-care marketing, while professional societies and industry stakeholders frame these products as tools to expand access and support practice sustainability in predominantly cash-pay environments. The heterogeneity of available sources and the absence of outcomes-based research highlight a critical knowledge gap within plastic surgery.

Purpose: Orthoplastic surgery is an integrated specialty that combines the principles of both orthopedic and plastic surgery. It has grown significantly as a discipline for complex lower extremity reconstruction. This abstract describes the systematic development and outcomes of an orthoplastic surgery program at a Level 1 trauma center serving a large regional catchment area. It also details the multidisciplinary infrastructure, communication systems, and operative protocols required for a successful orthoplastic program.

Methods and Materials: A retrospective chart review was performed to asses all patients who underwent free flap reconstruction within our orthoplastic surgery program from 2017 to 2024. Patients demographics, mechanism and classification of injury, flap type and donor site, timing of reconstruction, length of stay, postoperative complications, flap failure, and need for secondary procedures or amputation were collected for analysis. We also describe the structural and operational elements of our program, including recruitment of a core surgical team (plastic surgery, orthopedic trauma, and vascular surgery), ancillary specialists, dedicated inpatient coverage with 24/7 on-call plastic surgery support, weekly multidisciplinary case conferences, nurse navigator model, consolidated operating room scheduling, and a standardized postoperative free flap dangle protocol.

Experience/Results: From 2017 to 2024, our program performed 87 free flaps, all fasciocutaneous, with the anterolateral thigh flap as our preferred donor site (92%, n=80). In the first phase (2017 to 2021), a single extremity plastic surgeon performed 45 free flaps: 33% (n=15) were acute trauma patients transferred directly for management of open orthopedic injuries, and 40% (n=18) were delayed trauma patients who were referred for complex revisions including nonunion, malunion, chronic osteomyelitis, and unstable soft tissue envelopes following index reconstruction at outside institutions. Following recruitment of a second extremity plastic surgeon in 2021, the program completed an additional 42 free flaps through 2024, with delayed trauma patients comprising 57% of this cohort. Program expansion was accompanied by improvements in efficiency: median length of stay decreased from 26 to 24 days in acute trauma patients and from 31 to 20.5 days in delayed trauma patients. Over the seven-year program, 9 free flaps failed (10.3%), resulting in 4 lower extremity amputations (4.6%). Of the 9 initial failures, one patient elected amputation and the remaining 8 underwent a second free flap attempt, of which 2 failed and proceeded to amputation, and 1 additional patient required amputation due to chronic osteomyelitis despite successful soft tissue reconstruction. Relative to published complex lower extremity reconstruction and revision, our outcomes compare favorably.

Conclusions: A structured, multidisciplinary orthoplastic surgery program can be successfully developed through deliberate team assembly, standardized communication frameworks, and institutional investment into strong operative infrastructure. The framework described is translatable beyond acute trauma and can also be applied to oncologic, vasculopathic, and amputee reconstructive care.

Background: Secondary overtriage (SO) of isolated craniomaxillofacial (CMF) fractures overwhelm trauma centers and represent a significant resource burden while ultimately delaying patient care. In response, a multidisciplinary expert consensus developed an interfacility transfer protocol (1), the efficacy of which has yet to be evaluated. The objective of this study was to implement these guidelines at a tertiary level 1 trauma center and review the preliminary utilization findings. Methods: A tertiary academic medical center adopted the transfer protocol through the use of an AgileMD clinical decision support pathway for use in regional referral centers. The protocol identifies when consultation with a specialized on-call provider is warranted based on a patient's clinical presentation relative to recommending outpatient follow-up. This study conducted a retrospective cohort analysis on all patients with isolated CMF trauma where the AgileMD pathway was activated from September 2024 to September 2025. Results: The AgileMD transfer pathway was utilized 55 times for isolated CMF trauma patients in one year. The majority of traumas involved fractures of the nasal bone (52.7%), orbit (30.9%), or maxillary sinus (21.8%), and were most often caused by a fall (49.1%). On-call specialist consultation occurred 18.2% of the time - down from 100% of cases prior to guideline institution. The majority of patients (78.2%) were discharged with outpatient follow-up instructions, while 16.4% were transferred. These dispositions followed the guidelines 90.9% of the time. Conclusions: This is the first pilot study on the implementation of isolated CMF trauma interfacility transfer guidelines. The 81.8% reduction in transfer center activation for on-call specialist consultation represents a meaningful offloading of the call burden for specialized surgical providers while preserving hospital resources for use in other trauma cases. Broader adoption of similar interfacility transfer protocols can further reduce SO, reduce hospital costs, and mitigate wait times.

References: 1. Pontell ME, Steinberg JP, Mackay DR, et al. Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus. Plast Reconstr Surg. 2022;150:835E-846E. doi:10.1097/PRS.0000000000009553

Plastic surgeons caring for Medicare beneficiaries increasingly encounter medically complex patients with multiple comorbidities. Chronic illness is a well-established contributor to surgical complications. Hypertension, diabetes, and obesity are significantly associated with wound dehiscence, hematoma, and infection in body contouring surgery (1). Similarly, patients with diabetes undergoing plastic surgery face higher risks of surgical and respiratory infections, cardiovascular events, impaired wound healing, and acute kidney injury (2). As plastic surgery expands its role in the Medicare population, gaps remain in understanding how patient complexity varies geographically and how variation influences outcomes, workforce planning, and resource allocation.

To elucidate these trends, we analyzed a Centers for Medicare & Medicaid Services (CMS) dataset containing provider- and patient-level information on services billed by plastic surgeons nationwide (3). Our objective was to characterize comorbidity prevalence across U.S. states and identify patterns in CMS risk scores of Medicare beneficiaries between 2017 and 2022. CMS risk scores incorporate age, disease severity, and disease burden, serving as a standardized proxy for patient complexity and anticipated healthcare expenditures.

Our analysis demonstrates geographic heterogeneity in cardiovascular, metabolic, and musculoskeletal health across the United States. Nationally, the three most prevalent chronic conditions are hypertension (69.5%), hyperlipidemia (68.0%), and arthritis (49.3%). Puerto Rico and the Deep South, including Mississippi, Alabama, Louisiana, Kentucky, and West Virginia, exhibit the highest hypertension prevalence (>70%), surpassing national average and reflecting persistent Stroke Belt phenomenon (4). Hyperlipidemia prevalence was highest in New Jersey, Florida, Michigan, and Texas. Arthritis prevalence exceeded 50% in Idaho, West Virginia, Puerto Rico, Michigan, Kentucky, and Louisiana.

In contrast, Mountain West and Northern states, including Utah, Vermont, Colorado, and Wyoming, demonstrated lower prevalence of hypertension (<70%), hyperlipidemia (<60%), and arthritis (<50%), reflecting lower or near-average disease burden. Other comorbidities, including diabetes (32.7%), CKD (25.1%), COPD (20.6%), atrial fibrillation (20.6%), cancer (31.3%), and dementia (13.3%), remained meaningful contributors across regions.

Importantly, CMS risk scores did not uniformly mirror disease prevalence. The District of Columbia (2.05) and Texas (1.69) ranked among the highest risk scores despite moderate comorbidity prevalence, reinforcing that the metric reflects a composite of disease burden, health care utilization, expenditures, and demographic complexity. Wyoming (1.11) and Maine (1.20) had the lowest risk scores.

These findings illuminate regional disparities in comorbidity burden and patient complexity among individuals receiving plastic surgery, with implications for surgical risk stratification, policy, and workforce development. Section 126 of the Consolidated Appropriations Act proposes expanded graduate medical education funding for underserved areas. We argue regional comorbidity burden and CMS risk scores should inform eligibility criteria for new residency positions to align training capacity with patient needs and advance equitable care delivery.

References 1. Garoosi K, Mundra L, Jabbari K, et al. Comorbid conditions and complications in body contouring surgery. Aesthet Surg J Open Forum. 2023;5:ojad080. 2. Zhang X, Hou A, Cao J, et al. Diabetes mellitus and postoperative complications after noncardiac surgery. Front Endocrinol. 2022;13:841256. 3. Centers for Medicare & Medicaid Services. Medicare Physician Practitioners Data, 2017–2022. 4. Howard G, Howard VJ. Progress toward understanding Stroke Belt. Stroke. 2020;51:742-750.

Background The COVID-19 pandemic prompted U.S. residency programs to transition to virtual interviews, offering reduced financial burden, improved accessibility, and decreased environmental impact (1). Despite continued recommendations from the Association of American Medical Colleges (AAMC) supporting virtual interviews, many competitive surgical subspecialties have resumed in-person formats. Plastic surgery, one of the most selective specialties in the National Resident Matching Program (NRMP), has issued shifting guidance in recent cycles. In 2023, the American Council of Educators in Plastic Surgery (ACEPS) recommended that all plastic surgery residency programs conduct virtual interviews to promote equity in the application process (2). However, in the 2025 cycle, ACEPS reversed its guidance, strongly recommending that programs be given the option to conduct in-person interviews, citing specialty competitiveness, post-interview feedback, and recruitment considerations (2). Given this policy shift, it remains unclear how programs responded in practice. This study evaluated interview formats among integrated plastic surgery residency programs during the 2025 NRMP cycle and examined associations with program characteristics.

Methods A cross-sectional analysis was conducted of 89 integrated plastic surgery residency programs participating in the 2025 NRMP cycle. Military programs and those in U.S. territories were excluded. Data on geographic region, resident class size (small: 1–2; large: 3–5 residents per year), Doximity Reputation ranking quartile (Q1–Q4), and interview format (in-person, virtual, hybrid) were collected from Doximity Residency Navigator, program websites, the ACEPS database, and direct correspondence with program coordinators to confirm accuracy. Interview format data were verified for 88 programs (98.9%). Since a near-complete census was obtained, findings were treated as population-level estimates without inferential statistical testing.

Results Among 88 programs, 75 (84.3%) conducted in-person interviews, 7 (7.9%) were fully virtual, and 6 (6.7%) offered hybrid formats. Regional variation was observed: Midwest programs conducted interviews exclusively in-person (100%), whereas programs in the West demonstrated the highest adoption of alternative formats (30%). Programs in the Northeast, Southeast, and Southwest held in-person interviews at rates of 82.6%, 78.3%, and 75%, respectively. By prestige, Q1 programs overwhelmingly conducted in-person interviews (95.7%), while Q4 programs utilized virtual or hybrid formats more frequently (16.7%). Interview modality did not substantially differ by class size (in-person: 86.8% large vs. 83.0% small programs). Compared with 22 other medical and surgical specialties analyzed by our group, plastic surgery had the second-highest proportion of in-person interviews (84.3%), behind only otolaryngology (90%).

Conclusions The 2025 plastic surgery match cycle reflects a marked reversion to in-person interviewing following ACEPS's shift in guidance and despite national recommendations supporting virtual formats. Interview modality appears associated with geographic region and program prestige, suggesting institutional and cultural factors influence recruitment practices. Given the demonstrated financial savings, improved access, and reduced environmental impact associated with virtual interviews, the specialty's strong preference for in-person formats raises important questions regarding equity, sustainability, and alignment with evolving graduate medical education priorities. Establishing specialty-wide consensus may help balance program identity and applicant experience with broader goals of cost-effectiveness and environmental responsibility.

References:

1. Association of American Medical Colleges. AAMC Guidance on Virtual and In‑Person Interviews. Last updated June 2024. Accessed June 21, 2025. https://www.aamc.org/about-us/mission-areas/medical-education/aamc-guidance-virtual-and-person-interviews

2. American Council of Educators in Plastic Surgery (ACEPS). ACEPS 2024-2025 Interview Policy. Published April 18, 2023. Accessed November 16, 2025.

Purpose: Craniofacial trauma (CF) care spans several surgical specialties with overlapping but distinct clinical expertise. Historically, plastic and reconstructive surgery (PRS) has played a central role in the operative management of CF fractures; however, care is now frequently distributed across multiple service lines, including otolaryngology (ENT) and oral and maxillofacial surgery (OMFS). While prior studies have compared some outcomes across service lines, differences in injury patterns, management, and care continuity remain underexplored. Our objective was to compare injury distribution, management characteristics, outcomes, and postoperative follow-up (FU) among patients undergoing CF fracture repair by PRS, ENT, and OMFS.

Methods: Adults who had undergone operative CF fracture repair between 2019–2025 at four urban trauma centers were retrospectively reviewed. Demographics, comorbidities, injury mechanisms, operative details, and hospital course data were extracted. Fractures were further classified according to injury location: nasal, mandible, ZMC, orbital floor, and complex (defined as LeFort or multi-bone fractures). Outcomes included inpatient hospital length of stay (LOS), time to intervention (TTI), postoperative FU, FU duration, complication, and readmission rates. Chi-square analysis and nonparametric tests were employed to evaluate differences across specialties. Statistical significance was set at p<0.05.

Results: Among 527 patients, 167 (30.4%) were managed by PRS, 79 (14.4%) by ENT, and 277 (50.5%) by OMFS. Injury patterns differed significantly by service (p<0.001). PRS managed a higher proportion of complex (p=0.013) and isolated orbital floor fractures (p<0.001); nasal fractures were commonly managed by ENT, and mandible fractures were more commonly managed by OMFS (both p<0.001).

On univariate analysis, PRS-managed cases had significantly longer TTI compared with ENT and OMFS, reflecting an increased rate of outpatient procedures (p=0.001). However, on multivariable analysis adjusting for fracture location, speciality was no longer independently associated with TTI (p=0.898), while fracture type remained independently associated with TTI (p=0.010). Overall complication rates were similar between services (p>0.05); however, postoperative infection rates differed on pairwise comparison, with PRS demonstrating a lower infection rate compared with OMFS (1.2% vs 5.8%, p=0.019). Rates of reoperation were low overall and did not differ significantly between services. LOS differed by service overall (p<0.001); ENT demonstrated the shortest LOS, and median LOS did not differ between PRS and OMFS. Adjusted analysis accounting for fracture location, service line remained independently associated with LOS (p=0.003), with fracture severity remaining a strong predictor of longer hospitalization (p<0.001). Operative time did not differ significantly by service on overall comparison (p=0.20).

Follow-up rates differed significantly by service (p<0.001). After adjusting for fracture location, the service line remained independently associated with follow-up adherence (p<0.001). Compared with OMFS, PRS demonstrated significantly higher odds of postoperative follow-up (aOR 3.54), whereas no significant difference was observed between ENT and OMFS (aOR 1.20, p=0.541).

Conclusions: Despite managing a disproportionate share of complex fractures, PRS achieved lower infection rates with comparable operative efficiency and overall complication rates. Furthermore, PRS patients demonstrated independently higher odds of postoperative follow-up, reflecting strong continuity of care. These findings highlight the integral role of plastic surgeons in the management of complex CF trauma.

Introduction: Individuals experiencing homelessness face disproportionately high rates of burn injuries and often sustain more severe burns than the housed population.(1) After discharge, they frequently have limited access to both wound care supplies and reliable follow-up, which contributes to worse outcomes. Street medicine programs provide low-barrier medical care to this population and may help bridge the gap by supporting continuity of burn care after hospitalization and for those who never present to traditional care settings.(2) However, the epidemiology and treatment patterns of burn injuries in this setting remain poorly defined. This study aims to characterize burn patients evaluated by an urban street medicine team and describe injury patterns, treatments, and follow-up outcomes in order to identify strategies for better resource utilization in this austere environment.

Methods: A retrospective review was conducted of all patients evaluated for burn injuries by a single street medicine team between 2021 and 2025. The main outcomes of interest were follow-up rates, time from burn injury to visit, wound care provided, infection rates, and if patients presented to a burn center or emergency department. Basic demographic variables (age, sex, comorbidities) and burn characteristics (burn size, location, mechanism) were also collected.

Results: A total of 38 patients with an average of 2.79 encounters were identified. Of the 38 patients, 16 patients (42.1%) had one or multiple follow up burn visits with the street medicine team. Only 18 patients (47.4%) were seen by the street medicine team within 1 week from the time of their initial burn injury. The mean age was 44.84  10.66 years, and 57.9% were male (n = 22). The burns were most commonly small (average % Total Body Surface Area = 2.91), accidental (n = 20, 52.6%), and of thermal etiology (n = 22, 57.9%). Initial wound care technique varied, but was mostly Medihoney (n = 7, 18.4%) dressed with Kerlix (n = 11, 28.9%) and Coban (n = 10, 26.3%). Ten unhoused burn victims (26.3%) had been hospitalized for their burn prior to their street medicine visits, and five (13.2%) suffered burn wound infections and subsequently received antibiotics. No patients presented to an emergency department or burn center after being seen by street medicine.

Conclusion: Street medicine teams are well positioned to deliver accessible medical care and provide resources to support unhoused patients. Despite a high prevalence of burn injury in this population, our study found that few unhoused burn survivors seek immediate or post-admission street medical care, highlighting a gap in outpatient burn management. Expanded community outreach is necessary to increase awareness and access to these services that can improve longitudinal burn care. Wound care technique was varied and infection common in the unhoused population, suggesting that protocolized evidence-based burn management and street medicine provider education are additional priorities.

References: 1. Vrouwe SQ, Johnson MB, Pham CH, et al. The Homelessness Crisis and Burn Injuries: A Cohort Study. J Burn Care Res. 2020;41(4):820-827. doi:10.1093/jbcr/iraa023 2. Kaufman RA, Mallick M, Louis JT, Williams M, Oriol N. The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review. Int J Environ Res Public Health. 2024;21(6):760. Published 2024 Jun 12. doi:10.3390/ijerph21060760

Background: Informal caregivers play a central role in supporting patients with limb loss, assisting with mobility, wound care, medical coordination, and psychosocial adjustment. Although clinical focus is often directed toward patient recovery, caregivers frequently experience substantial emotional, physical, and financial strain that goes unrecognized. Caregiver distress has been associated with poorer health outcomes, reduced quality of life, and decreased capacity to provide sustained support. Therefore, optimal amputation care requires attention to both members of the patient–caregiver dyad. Despite their critical role in rehabilitation and long-term adaptation, caregiver well-being and predictors of distress remain underexplored in the amputee population.

Methods: In this single-institution, cross-sectional study, 57 adult amputee patient–caregiver dyads were surveyed between November 2023 and March 2024. Demographic variables included caregiver sex, cohabitation status, and relationship to the patient. Distress was assessed using the validated Distress Thermometer (DT), anxiety and depression symptoms were measured using the Patient Health Questionnaire-4 (PHQ-4), and caregiver burden was evaluated using the Caregiver Reaction Assessment. Descriptive statistics are reported as mean ± standard deviation. The Mann–Whitney U test was used to compare ordinal outcomes between groups.

Results: Among the 57 dyads, 50 informal caregivers completed surveys and were included in the analysis. Twenty caregivers identified as male and 30 as female. Forty-two caregivers cohabitated with the patient, whereas eight lived separately. Most caregivers were spouses (n = 39, 78%), followed by parents (n = 6, 12%). Female caregivers reported higher DT distress scores than male caregivers (5.2 ± 2.1 vs 3.25 ± 2.5, p < 0.05). Caregivers who cohabitated with patients reported higher distress than those living separately (4.8 ± 2.4 vs 2.5 ± 2.6, p < 0.05).

Fourteen caregivers (28%) agreed or strongly agreed that caregiving placed a financial strain on them, 17 (34%) were neutral, and 10 (20%) disagreed or strongly disagreed. Similarly, 14 caregivers (28%) agreed or strongly agreed that their health had worsened since becoming caregivers, 14 (28%) were neutral, and 22 (44%) disagreed or strongly disagreed.

Regarding patient depressive symptoms, 25 patients (50%) reported feeling down, depressed, or hopeless "not at all" in the prior two weeks; 21 (42%) reported "several days"; four (8%) reported "more than half the days"; and none reported "nearly every day."

Conclusion: Caregiver burden following limb amputation is prevalent, measurable, and understudied. In caring for these patients, caregivers report substantial levels of distress and symptoms of anxiety and depression. These findings underscore a gap in caregiver support and demonstrate a need for expanded mental, physical, and educational resources to prevent caregiver morbidity and mortality.

Introduction Patients who present to the emergency department with facial fractures can frequently be managed with outpatient follow-up for definitive treatment and rehabilitation. However, many encounter barriers to accessing continued outpatient care, which can negatively affect the quality and continuity of treatment. Insurance status and follow-up for traumatic hand injuries has been previously studied1, but this association has not been explored for facial fractures. This study sought to examine patterns of outpatient follow-up after initial emergency department evaluation for traumatic facial fractures, identify factors associated with inadequate follow-up, and highlight opportunities for improving care delivery.

Methods In this retrospective cohort study, we reviewed records of adult patients with acute facial fractures referred for outpatient follow-up after initial consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 242). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). The primary outcome was outpatient follow-up. Logistic regression was performed to determine factors associated with following up outpatient.

Results Factors significantly associated with failure to follow up included male sex (p = 0.036, OR, 0.521; 95 percent CI, 0.283 to 0.96). Compared to patients who had private insurance, patients without insurance (p<0.001, OR, 9.49; 95 percent CI, 2.85 to 31.6), Medicare insurance (p = 0.002, OR, 2.91; 95 percent CI, 1.46 to 5.81), and Medicaid insurance (p = 0.028, OR, 2.61; 95 percent CI, 1.11 to 6.12) were significantly associated with failure to follow-up.

Conclusions There is a marked disparity in outpatient care utilization following emergency department visits for acute facial injuries. Patients who are uninsured or covered by Medicaid/Medicare are significantly less likely to initiate recommended follow-up with a face specialist. Future research should focus on developing and evaluating targeted interventions to support these at-risk populations.

References [1] Zubovic E, Van Handel AC, Skolnick GB, Moore AM. Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study. Plast Reconstr Surg. 2021;147(3):545-554. doi:10.1097/PRS.0000000000007687

Purpose Private equity (PE) acquisition of physician practices has increased across multiple specialties, including plastic surgery. This trend is reshaping the market for practice succession and founder liquidity. Accordingly, the most common ownership transition pathways in plastic surgery are third-party sales, often PE-backed, or a traditional partner buy-in. Employee Stock Ownership Plans (ESOPs) are a federally regulated ownership transition option that is widely used in U.S. industry and some healthcare settings but uncommon in plastic surgery. ESOPs are a feasible ownership exit option in plastic surgery and may be attractive to practices seeking to preserve physician governance and long-term continuity while broadening employee equity participation. This study characterizes ESOP adoption in physician-office healthcare using a national ESOP registry and describes PE acquisition activity in plastic surgery using a national transaction dataset. We hypothesize that ESOPs are an underutilized but viable succession pathway for private plastic surgery practices relative to PE-backed transactions. Methods A retrospective, descriptive study analyzed ESOP plans from the 2025 National Center for Employee Ownership (NCEO) database (plan effective years 1970 to December 2023) and PE acquisitions from PitchBook (transactions through August 2025). PitchBook was queried for U.S. PE acquisitions of outpatient healthcare clinics, and plastic surgery practices were identified by manual review of practice branding and confirmation of at least one American Board of Plastic Surgery (ABPS) surgeon, excluding hospital or inpatient entities. The 2025 NCEO ESOP database was filtered to Health Care and Social Assistance and then restricted to Offices of Physicians, excluding Mental Health Specialists. For PE transactions, extracted variables included deal date, deal type, target location, employee count, and deal size or percent acquired when available. For ESOP plans, extracted variables included plan effective year, sponsor state, participants, employer securities, leveraged status, and corporate tax classification. Results Within Health Care and Social Assistance, 128 ESOPs were identified, and Offices of Physicians accounted for 22/128 (17%). The median physician-office ESOP had 74 participants (IQR 18–224) and $3.6M in total plan assets (IQR $1.3M–$8.5M). Among physician-office ESOPs, 59% (13/22) were S-corporations and 50% (11/22) were bank-financed leveraged ESOPs. Across healthcare, ESOP formation was concentrated after 2000, peaking in 2015–2020 (29 new ESOPs) and remaining elevated in 2020–2023 (26 new ESOPs). Within the outpatient clinic PE acquisition cohort (n=4,509), 41 (0.9%) were plastic surgery practices. Most transactions were add-ons (36/41; 88%), and 100% of the target was acquired in all deals. Median employee count was 25 (IQR 16.5–55) where reported, and deal values were rarely disclosed, limiting valuation comparisons. Plastic surgery PE activity increased after 2021 and peaked in 2023 (12 deals), with sustained volume in 2024 (8 deals). Conclusions PE-backed consolidation is increasingly common in plastic surgery practice ownership. ESOPs have been used across multiple physician-office settings, including plastic surgery, and represent a feasible ownership exit option.

Introduction: Yoga has been shown to improve physical and mental well-being and has been widely studied in non-trainee populations. These benefits may be particularly beneficial to surgical residents, yet data evaluating yoga-based interventions within residency training programs are limited. Methods: Instructor-led yoga sessions were incorporated as a mandatory component of the residency wellness curriculum across the academic year. Residents (PGY1-PGY6) completed pre- and post-intervention surveys, which were analyzed descriptively. Results: A total of 18 residents completed the baseline survey prior to the yoga series, with a mean age of 31.4  4.1 years. Among respondents who reported having previously practiced yoga (16/18, 88.9%), half believed yoga has a significantly positive impact on their body (e.g. flexibility, strength, balance) (9/18, 50%). Seven residents reported unfamiliarity with yoga (7/18, 38.9%). Following the yoga sessions, 9 residents completed the post-intervention survey, with an average attendance of three yoga sessions per resident. Most respondents reported an excellent overall experience with the yoga sessions (6/9, 66.7%) and were inclined to incorporate yoga into their regular routine after participating in the series (7/9, 77.8%). Primary reasons for attending the sessions include stress relief (8/9, 88.9%), social interactions (7/9, 77.85), mental clarify (6/9, 66.7%), physical fitness (5/9,55.6%), and recommendation by others (2/9, 22/2%). Work schedule was the main barrier preventing the attendance. Most residents reported that yoga/meditation is currently part of their wellness routine (8/9, 88.9%). Discussion: A mandatory yoga-based wellness program was well received by surgical residents, with high satisfaction and strong intent to continue yoga outside of the curriculum. Residents identified stress relief, mental clarity, and social connection as key benefits, underscoring the relevance of yoga as a structured wellness strategy within the surgical training environment despite scheduling constraints. These findings contribute needed program-level data supporting the integration of yoga into surgical residency curricula and provide a foundation for future studies evaluating optimal implementation and downstream effects on resident well-being.

Background: Artificial intelligence systems in plastic surgery are rapidly evolving beyond standalone tools toward agentic architectures capable of autonomous reasoning, tool use, and multi-step clinical workflows. Applications such as AI-assisted preoperative planning, diagnostic imaging analysis, and clinical decision support depend on reliable integration between AI models and clinical data systems. However, the absence of standardized communication protocols constrains the safe and scalable deployment of these systems in regulated surgical environments. Two recently introduced protocols - Model Context Protocol (MCP) and Agent-to-Agent (A2A) framework - aim to address this gap, yet no systematic synthesis of their healthcare applications exists. Methods: Following PRISMA-ScR guidelines, we searched PubMed, IEEE Xplore, Web of Science, Scopus, and grey literature through December 2025. Studies describing technical implementations of MCP and/or A2A in healthcare contexts were included. Data extraction captured protocol architecture, agent configuration, interoperability with established healthcare standards, evaluation metrics, and governance mechanisms. The protocol was registered with PROSPERO (CRD420251271558). Results: Thirteen studies met inclusion criteria, all published between November 2024 and early 2026. MCP or MCP-aligned approaches were present in all implementations, while A2A appeared only in two hybrid systems requiring cross-institutional coordination. Applications spanned clinical decision support, diagnostic imaging, medical data standardization, laboratory automation, and federated learning. Most systems integrated HL7 FHIR and other established healthcare standards. Reported accuracy ranged from 92–100% for constrained tasks including terminology mapping and triage. Common governance mechanisms included human-in-the-loop checkpoints, audit logging, and protocol-constrained tool access. All systems remained at prototype or pilot stages with no confirmed production-level deployment. Conclusions: MCP has emerged as the dominant protocol for structuring AI agent–tool interactions in healthcare, enabling auditable, grounded workflows that reduce hallucinations in defined clinical tasks. These communication standards represent critical infrastructure for the next generation of AI-powered surgical planning, imaging analysis, and decision support tools relevant to plastic surgery practice. Current evidence supports initial deployment in assistive, backend applications rather than autonomous clinical decision-making. Critical gaps remain in agent identity verification, prospective clinical validation, and health equity considerations.