Scientific Abstract Presentations: Practice Management Session 3 Saturday, October 17 Sat, Oct 17 8:00-9:30 a.m. CDT

Purpose: Patients with Robin Sequence (RS) often have feeding difficulties, leading to gastrostomy tube (G-tube) placement. The need for G-tube placement in these patients is questionable, as some studies have shown improved oral intake with mandibular distraction osteogenesis (MDO). Given that G-tube placement is an invasive procedure with potential major complications, the authors performed a systematic review to evaluate G-tube placement rates, timing of placement relative to MDO, and available data on duration of G-tube use and associated complications.

Methods: A systematic review following PRISMA 2020 guidelines was conducted using Scopus, PubMed, Medline, and CINAHL databases covering studies until August 2025. English language, original studies involving pediatric patients with RS who underwent MDO and reported feeding outcomes relevant to gastrostomy tubes (placement, timing, indications, complications) or other feeding outcomes (full oral feeding, swallowing, weight gain) were included. Of 205 articles identified, 81 duplicates were removed, 124 were screened, 27 underwent full-text review, and 20 met the inclusion criteria.

Results: Among 1,585 patients with RS undergoing MDO across the 20 reviewed studies, 484 patients (30.5%) underwent G-tube placement. Placement rates varied from 10% to 66.2%. Nine of these studies provided a breakdown of syndromic versus isolated RS in patients who received a G-tube. Among those, 60% of patients who received a G-tube had associated syndromes, while 40% had isolated RS. The timing of G-tube placement relative to MDO was variable and inconsistently reported, with placements occurring before, concurrently with, or after MDO. Few studies provided detailed information regarding the duration of G-tube use and the rate of weaning to full oral feeding. Complications specific to G-tube placement were also inadequately reported. Only one study explicitly documented complications, with surgical site infections occurring in 3 out of 16 patients.

Conclusion: Rates and timing of G-tube placement among patients with RS undergoing MDO are variable. Reporting on the duration of G-tube use, successful weaning to full oral feeding, and G-tube specific complications is also limited and inconsistent. These findings emphasize the need for standardized clinical guidelines and suggest that routine or aggressive recommendations for G-tube placement may not be necessary for all patients with RS undergoing MDO.

Background: The distribution of plastic and reconstructive surgeons varies significantly across the United States, presenting barriers to quality reconstructive care for minority and underserved patient populations. In 2018, the Association of American Medical Colleges reported that 13% of plastic surgeons who completed an integrated residency program from 2008-2017 were working in Medically Underserved Areas (MUAs). Furthermore, 25% of those who completed craniofacial fellowship and 23% of those who completed a hand surgery fellowship were working in MUAs. While previous studies have evaluated access to plastic surgeons with specific fellowship training, this is the first study to analyze access to a comprehensive list of plastic and reconstructive surgeons by both ACGME-accredited and non-ACGME accredited fellowship training. Our study also aims to evaluate the distribution of fellowship-trained plastic surgeons in MUAs based on the Area Deprivation Index (ADI), a measure of neighborhood socioeconomic disadvantage, to better understand practice settings and further characterize disparities in access.

Methods: Plastic and reconstructive surgeons practicing in MUAs in the United States were identified using the National Provider Index (NPI) database. Surgeons were categorized by fellowship training (e.g. aesthetic, craniofacial, hand, microsurgery, multiple). Practice addresses were geocoded and linked to National 2020 ADI percentiles. The distribution of surgeons by fellowship relative to ADI was assessed categorically (ADI quartiles) using chi-square and Poisson regression tests. Continuous ADI national rankings were also compared across fellowship types using one-way ANOVA. A p-value of <0.05 was considered statistically significant.

Results: Of 8,579 plastic and reconstructive surgeons in the NPI database, 1,179 (13.7%) practice in MUAs, and 379 of the 1,179 (32.1%) reported fellowship training. In 7 states, there were no fellowship-trained plastic surgeons in MUAs. There were no significant differences in the distribution of plastic surgeons by fellowship training across ADI quartiles (χ2 =14.59, df=27, p=0.97) and continuous ADI national rankings (ANOVA p=0.34). Fellowship-specific Poisson regression revealed a significant decrease in the number of microsurgery-trained surgeons with increasing ADI (p<0.05).

Conclusion: Less than 20% of plastic surgeons currently practice in MUAs and even fewer are fellowship trained. In some states, there are no reported plastic surgeons within MUAs, highlighting substantial geographic gaps in specialist access. ADI adds critical socioeconomic context beyond MUA designation and may help better identify communities at risk. While most subspecialties maintain equitable distribution across ADI, fewer microsurgery-trained plastic surgeons are located in more disadvantaged areas. This may disproportionately affect patients requiring complex oncologic, traumatic, or limb-salvage reconstruction. These findings underscore the importance of targeted workforce planning, resource allocation, and policy interventions that support equitable access to advanced reconstructive care.

Background Breast reconstruction is a central component of post-mastectomy care, though medicolegal patterns within reconstructive practice have not yet been characterized. Understanding litigation trends may identify high-risk clinical scenarios and inform patient counseling.

Methods A retrospective legal case review was performed using Nexis Uni and CourtListener databases. U.S. malpractice cases involving breast reconstruction from 1977–2025 were identified through targeted keyword searches. Cases were analyzed for reconstruction modality, allegation types, cited complications, defendants involved, legal outcomes, and financial awards.

Results Seventy-two malpractice cases were identified. Reconstruction types of the cases included 44 (61.1%) tissue-expander/implant cases, 14 (19.4%) autologous reconstruction, and 14 (19.4%) unspecified; half of autologous claims occurred within the past five years. Beyond malpractice-related damages, common allegation claims involved lack of informed consent (n=26, 36.1%), poor preoperative risk-assessment (n= 8, 11.1%), and inadequate surgical technique (n=7, 9.7%). Plastic surgeons were the most frequent defendants, though breast surgeons, anesthesiologists, and infectious disease physicians were also implicated. Most trials resulted in defense verdicts (n=40, 55.6%); however, the mean plaintiff jury award was $454,697, with two settlements reaching $1.78 and $3.5 million. Frequently cited complications included infection, implant or flap loss, pain, and disfigurement, while rare events included compartment syndrome, compression injury, and retained foreign body. Ten implant-related cases involved early silicone implant litigation.

Conclusion Existing breast reconstruction litigation most commonly involves implant-based procedures, though autologous claims may rise with expanding microsurgical practice. The predominance of allegations surrounding informed consent and perioperative decision-making highlights actionable areas for improved patient counseling and risk-optimization.

Institutional Variation in Research-Year Composition Among Integrated Plastic Surgery Residents

Introduction: The application process for integrated plastic surgery residency has become increasingly competitive, with many applicants electing to take dedicated research-years prior to matriculation. Although research participation is widely perceived to influence residency preparation, limited longitudinal data exist describing how research-year utilization varies across institutions. Existing literature primarily evaluates applicant-level characteristics, while institutional patterns in resident entry profiles remain poorly characterized. The objective of this study was to quantify institutional variation in the prevalence of prior research years among matriculating integrated plastic surgery residents over the past 30 years.

Methods: A retrospective cohort study was conducted of integrated plastic surgery residents. The dataset was collected from publicly available institutional websites, alumni listings, match announcements, and documented co-authorship records from major U.S. academic institutions between 1996–2026. Variables collected included: (1) institution or specific lab/program, (2) research year prior to matching for each individual, (3) U.S.-graduate vs international graduate status for each individual, and (4) graduation timing relative to research year. For reference, a research year was defined as any dedicated research period completed either during medical school or after graduation prior to residency matriculation. Institutional research-year proportions were calculated for each institution as the number of residents with a prior research year divided by the total number of matriculated residents at each institution represented in the study cohort. Institutional proportions were ranked from lowest to highest, and the median proportion and interquartile range (IQR; 25th–75th percentiles) were calculated to characterize the central tendency and variability of research-year composition across programs. Secondary analyses included comparisons of research-year proportions by citizenship status (U.S. citizen vs International), plus a stratification of research timing (pre-graduation vs post-graduation if a research year was taken).

Results: A total of 169 residents across 20 institutions were identified and included in the analysis. Overall, 69.82% of plastic surgery residents had a documented research year prior to matriculation. The median institutional research-year proportion was 100% (IQR 50%–100%). Of the 20 institutions assessed, 70% of institutions demonstrated ≥75% research-year candidates, whereas 15% matriculated ≤25%, demonstrating a polarized distribution across programs. 78.69% of residents were U.S.-national graduates, while 21.30% were international graduates. Among residents who completed a prior research year, the proportion of international graduates was higher than that of U.S.-national graduates (77.78% vs 67.16%). Among residents with research years, 26.27% completed research before graduation, whereas 73.72% completed research after graduation.

Discussion: Integrated plastic surgery programs demonstrate substantial variation in research-year composition among matriculating residents over the past three decades. While some institutions appear to matriculate predominantly research-year candidates, others demonstrate a much greater proportion of direct-entry candidates. International graduates demonstrated a higher prevalence of prior research years compared to U.S.-national graduates. Variation in research timing (pre- vs post-graduation) may reflect differences in institutional signaling for readiness, mentorship networks and resources, or applicant selection patterns at the institutional level. These findings may contribute to broader discussions of equity and access within the plastic surgery training pathway as it pertains to research pursuits.

Purpose Operating rooms (ORs) are known to contribute significantly to overall hospital waste production. Waste reduction efforts commonly follow the principles of the "5 R's": refuse, reduce, reuse, repurpose, and recycle. These strategies significantly impact cost savings and decrease waste produced by the OR, but they also limit access to materials that medical students require for hands-on surgical training. Our aim was to repurpose commonly unused materials for educational opportunities by using data-driven decisions to divert these OR materials to our cadaver lab for medical student educational use. Methods A prospective waste-reduction initiative was conducted over six months within a plastic surgery department. Four common procedures (scalp excision (SE), pressure ulcer excision (PU), vaginoplasty (V), and bone graft (BG)) were selected based on procedure frequency and OR staff collaboration. For each surgery type, procedures were done consistently by a single surgeon to minimize operator bias and inter-surgeon variability. Opened, unused sterile materials were collected in the OR, categorized by procedure. Types of material, cost, and weight (for emission calculations) were recorded. Per-case cost savings were calculated by multiplying the cost of materials by the number of units wasted. Non-biohazard waste diversion reduction was estimated by aggregating the weight of supplies per case. Procedural volume over the collection period was calculated using SlicerDicer for one specific NPI per case. A formal overflow system was implemented to repurpose unused materials for hands-on medical student surgical skills training, with benefit assessed via repurposing usage. Non-biohazard trash • $60.54/ton Material Cost Gowns $2.38 Gloves $1.30 Suture $5.00 (average) Raytec $0.75 Blue Towels $0.38 Lap Sponge $1.24 Stapler $6.10 Marking Pen $0.77 Irrigation Bulb $0.53 Supply costs Results Across the four procedures, per case cost reduction ranged from $6.88 to $15.22. Extrapolated over the collection period, total cost savings were $545.91 per surgeon. Repurposing the opened materials in this way reduced the cost of processing non-biohazard waste by 3%. Repurposed materials were successfully incorporated into medical students' hands-on training sessions. Conclusion Repurposing unused OR materials for educational initiatives generated measurable cost savings and waste reduction while enhancing hands-on medical student surgical education. These findings demonstrate that sustainability efforts in the operating room can provide a reliable source of materials for surgical skills training. Future research will focus on standardizing OR packs based on surgeon preference cards to further minimize waste and quantify the impact of this initiative on medical student education.

Introduction: Reduction mammoplasty, one of the most frequently performed plastic surgery procedures in the United States, exhibits considerable variability in cost due to differences in surgeon practice patterns, operative length, and institutional resource utilization [1,2]. Identifying key cost drivers is essential for improving financial sustainability while maintaining high-quality patient care. Traditional cost accounting methods, including cost-to-charge ratios and relative value units, frequently yield imprecise figures that obscure true spending during a surgical procedure, limiting opportunities to streamline expenses [3]. In contrast, Time-Driven Activity-Based Costing (TDABC) offers a more precise estimate of financial burden by providing a process-focused approach that allocates costs based on the actual time and resources consumed throughout a surgical episode [4]. By providing granular data, TDABC has been shown to enhance understanding of how specific factors-such as operating room time, personnel, and facility overhead-contribute to overall surgical costs [5]. This study applies Time-Driven Activity-Based Costing (TDABC) to analyze the primary contributors to cost variation in reduction mammoplasty.

Methods: A retrospective analysis was conducted on 2,583 reduction mammoplasty cases at a single academic institution. TDABC methodology was used to calculate total costs by assessing supply usage, personnel involvement, and operative duration [3-5]. Multivariable regression models were used to identify key cost drivers.

Results: The mean total surgical cost was $3,032.14 ± 680.53, with personnel expenses ($1,953.21 ± 484.91) comprising the largest portion. Surgeon identity was the most significant predictor of cost variation, with Surgeons L and M incurring higher total costs (P < 0.001), while Surgeons B and C had lower costs. BMI was significantly associated with increased costs (β = $16.42 , P < 0.001), reflecting the impact of longer operative times and higher resource utilization. Surgical location also influenced costs, with Location 2 exhibiting the highest expenses ($1,156.33, P < 0.001), suggesting institutional efficiency as a contributing factor.

Conclusions: TDABC effectively identified surgeon variability, BMI, and surgical location as major cost drivers in reduction mammoplasty. These findings highlight opportunities for cost reduction through standardized surgical workflows, optimized personnel allocation, and improved hospital efficiency. Implementing these interventions may enhance financial sustainability and support value-based care models. Future research should focus on multi-institutional studies and targeted cost-containment strategies.

References: 1. 2022 ASPS Procedural Statistics Release. Plast Reconstr Surg, 2024. 153(1S): p. 1-24. 2. Robert S. Kaplan, M.E.P., How to solve the cost crisis in health care. Harvard Business Review, 2011. 89(9): p. 46-52. 3. Akhavan, S., L. Ward, and K.J. Bozic, Time-driven Activity-based Costing More Accurately Reflects Costs in Arthroplasty Surgery. Clin Orthop Relat Res, 2016. 474(1): p. 8-15. 4. Kaplan, R.S., et al., Using time-driven activity-based costing to identify value improvement opportunities in healthcare. J Healthc Manag, 2014. 59(6): p. 399-412. 5. Calotta, N.A., et al., Outpatient Reduction Mammaplasty Offers Significantly Lower Costs with Comparable Outcomes: A Propensity Score-Matched Analysis of 18,780 Cases. Plast Reconstr Surg, 2020. 145(3): p. 499e-506e.

Background: Hospitals operate under narrow margins, making it essential to identify which reconstructive strategies contribute positively or negatively to institutional financial performance. Decisions regarding integration of advanced technologies should be informed by comprehensive, real-world economic analysis rather than isolated procedural cost assessments. Skin substitutes and regenerative matrices have faced increasing scrutiny due to perceived expense and variable reimbursement. However, limited data evaluate their true longitudinal economic impact within the broad spectrum of reconstructive options and compared to alternative approaches. This study analyzes the real-world economic performance of piscine-derived regenerative dermal matrix (PDRM) across inpatient and operative outpatient settings using four-month downstream financial capture with a subset comparison to theoretical costs associated with free tissue transfer.

Methods: After IRB approval, a retrospective review was performed of all patients treated with PDRM by a single plastic surgeon at a rural community hospital and affiliated wound center (n=102). Patients were included if treated as: (1) inpatients identified by a multidisciplinary limb salvage team, or (2) outpatients undergoing operative matrix placement in the operating room. Hospital contribution margin was calculated using direct costs, reimbursement, and total financial performance captured for four months following application, including all downstream visits, additional procedures, and readmissions. Comprehensive capture including additional procedures was included to demonstrate value of keeping patients in hospital system. A subset of inpatients who met traditional criteria for lower extremity free tissue transfer but were instead managed with matrix-based reconstruction (typically combined with split-thickness skin grafting) underwent modeled comparison to theoretical free tissue transfer using institutional cost and reimbursement data.

Results: Of the 102 patients included for study, 18 underwent inpatient application and 84 underwent operative outpatient placement. Eighty patients required a single application; 12 required multiple applications (10 with two, 1 with three, 1 with four). Inpatients demonstrated an average contribution margin of –$2,345 per admission, improving modestly to –$2,264 after four-month downstream capture. Six patients underwent subsequent split-thickness skin grafting. Outpatients demonstrated average procedural reimbursement of $748. With all four-month revenue included, mean contribution margin per patient was $9,105 per patient. Thirty-six patients underwent additional reconstructive procedures. Modeled free tissue transfer in the inpatient subset yielded an estimated contribution margin of –$97,851 per case. Matrix-based reconstruction demonstrated an average margin improvement of $95,587 compared to theoretical microsurgical reconstruction.

Conclusions: At our institution PDRM demonstrated economic sustainability across inpatient and operative outpatient reconstructions. Importantly these findings are considered relevant in the setting of judicious and targeted matrix use when clinically appropriate and aligned with patient-centered reconstructive goals. According to our data, in cases where matrix-based reconstruction may reduce procedural morbidity compared with more complex alternatives, reimbursement concerns should not deter its use. Our findings underscore that single-episode cost analyses incompletely represent institutional impact. Longitudinal economic evaluation is essential to accurately define value and guide responsible, data-driven integration of regenerative technologies within hospital systems.

Purpose: Operating room block allocations are typically based on historical precedent rather than prospective demand forecasting, generating predictable patterns of underutilization and capacity strain. Our craniofacial program performs over 155 procedures annually within a fixed weekly OR block. We propose an AI-driven framework to forecast weekly OR demand, identify capacity exceedance weeks, and simulate scheduling strategies that improve utilization and revenue capture without expanding allocated time.

Methods: A 12-month retrospective dataset of clinic intake, operative logs, case-level financial data, surgeon availability records, and regional live birth statistics was compiled. Weekly consults were linked to operative cases to quantify conversion rates and consult-to-surgery lag distributions, establishing the demand pipeline from referral to OR utilization. A gradient-boosted regression model with temporal lag features will be trained to forecast weekly case volume and OR minutes. Planned inputs include rolling consult volume, block utilization, case mix, surgeon availability, and regional birth trends. Surgeon availability will be modeled as effective weekly capacity adjusted for planned absences and historical unplanned unavailability. Performance will be evaluated using mean absolute error and calibration of prediction intervals under rolling cross-validation. Forecasts will be integrated into a constrained optimization model simulating scheduling configurations within existing block allocation, maximizing throughput and revenue density while minimizing surgical delay subject to block and surgeon availability constraints. Monte Carlo simulation will account for variability in case duration, conversion rates, surgeon availability, and demand fluctuation.

Results: Preliminary descriptive analysis of the dataset demonstrates that the program averaged 222 new consults annually with a 70% surgical conversion rate and a median consult-to-surgery interval of 3 weeks. Over 155 operative cases were performed annually. Initial analysis of scheduling patterns identified weeks of both capacity strain and meaningful underutilization within current block allocation, confirming the presence of addressable inefficiency. Surgeon availability, including planned absences and unplanned unavailability, further reduced effective weekly capacity relative to nominal allocation. Regional live birth trends within referral counties demonstrated correlation with downstream consult volume, supporting their inclusion as a structural demand feature in the forecasting model. Predictive model performance, optimization projections, and revenue density analysis are forthcoming and will be presented at the meeting.

Conclusions: Descriptive analysis confirms that predictable demand signals and surgeon availability patterns create actionable scheduling inefficiencies within fixed OR block allocations. The proposed AI-driven framework integrating clinic demand, demographic trends, surgeon availability, and revenue density has the potential to transition OR scheduling from reactive block filling to proactive, probabilistically informed capacity management. Full model results will quantify the magnitude of achievable optimization.

Background: Surgical site infection (SSI) increases morbidity following breast reconstruction after mastectomy.(1) Perioperative antibiotic prophylaxis (PAP) is key for prevention, with cefazolin commonly used as the first-line agent.(1)(2) Although true β-lactam allergy is uncommon and cross-reactivity with cefazolin is rare, penicillin allergy labels often lead to alternative prophylaxis.(3) We aimed to compare the standard of care versus alternative PAP and associated SSI rates in patients with reported penicillin allergies undergoing breast reconstruction.

Methods: We conducted a retrospective study of patients who underwent implant-based or DIEP flap breast reconstruction between July 2016 and December 2025. Penicillin allergy status and PAP were recorded. Patients were stratified based on receipt of cefazolin versus alternative prophylactic antibiotics. The primary outcomes were SSI rates between cohorts and the incidence of anaphylactic reactions among penicillin-allergy–labeled patients who received cefazolin. Categorical variables were compared using chi-square test, with two-tailed p-values < 0.05 considered statistically significant

Results: The study included 1016 patients who underwent a total of 923 implant-based and 402 DIEP flap reconstruction procedures. All patients were women, with a mean age of 56.6 years and a mean body mass index of 31. A total of 146 patients (14.3%) carried a documented penicillin allergy label (94 IBR vs 53 DIEP). Among these, 10 patients (1.0%) reported a history of anaphylaxis, 5 patients (0.5%) had a documented drug-induced hepatotoxicity reaction, and 141 patients (13.8%) reported a nonanaphylactic reaction or had no documented reaction type. SSI rates were significantly higher among patients who received alternative prophylactic antibiotics compared with those who received standard cefazolin prophylaxis (8.8% vs 3.8%, p < 0.05). No anaphylactic reactions to perioperative antibiotic prophylaxis were observed in either group.

Conclusion: Use of alternative perioperative antibiotic prophylaxis was associated with increased SSI rates. First-generation cephalosporins remain appropriate first-line agents for breast reconstruction, while alternative antibiotics may be best reserved for patients with clearly documented severe hypersensitivity reactions.

References 1. Kaoutzanis C, Gupta V, Winocour J, Shack B, Grotting JC, Higdon K, et al. Incidence and risk factors for major surgical site infections in aesthetic surgery: analysis of 129,007 patients. Aesthet Surg J. 2017;37(1):89-99. doi:10.1093/asj/sjw100 2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. doi:10.2146/ajhp120568 3. Dong R, Lanier K, Kraft C, Skoracki R, Lehrman C, Kraft M, et al. Safety of cefazolin perioperative prophylaxis in plastic surgery patients with penicillin allergy: a retrospective chart review. Plast Surg (Oakv). 2025;33(1):159-163. doi:10.1177/22925503231190929

Background Patients frequently consult online resources prior to body contouring consultation, yet the substantive quality and depth of publicly available educational content remain poorly defined. Academic institutions are highly visible in search rankings and are often perceived as authoritative sources. We hypothesized that academic websites would demonstrate more rigorous content characteristics and greater transparency compared with other website types.

Methods A structured Google search was conducted in incognito mode using the terms "Skin Removal Surgery," "Body Lift," "Tummy Tuck," "Arm Lift," and "Thigh Lift." The first 20 U.S.-based, English-language patient-directed results per term were captured; ASPS webpages were excluded. Websites were categorized by setting (academic, private practice, commercial portal, nonprofit, health system, forum). Content characteristics evaluated included discussion of preoperative preparation, risks and benefits, postoperative care, lifestyle optimization, definitional clarity, and citation of peer-reviewed literature. Educational depth of surgical technique and risk counseling (high/medium/low) was quantified and incorporated into a 12-point Online Education Quality Index (OEQI-12), integrating content domains, authorship, citation, and transparency. Comparative analyses were performed across settings.

Results Among 132 websites, academic institutions comprised 64% of results. Overall composite quality was moderate (mean OEQI-12 4.6/12; median 4.5; maximum 10). While procedural descriptions were common, detailed risk counseling and perioperative guidance varied substantially. Mean OEQI-12 differed by setting. Commercial portals demonstrated the highest composite scores (mean 7.3), compared with private practices (5.0) and academic institutions (4.4). Higher scores among commercial portals were driven by more consistent inclusion of detailed risk explanations, postoperative care guidance, and citation of peer-reviewed literature. Academic websites did not consistently lead across content domains or transparency measures, contrary to the initial hypothesis. Mean reading grade level was 9.0, exceeding recommended health literacy standards.

Conclusion Online body contouring education demonstrates significant variability in content depth and counseling rigor. Despite their visibility and perceived authority, academic websites did not demonstrate superior composite educational quality. Improving the completeness and depth of publicly available patient education, particularly in risk counseling and perioperative guidance, may enhance shared decision-making and better align online information with clinical standards.

Background: Large language models (LLMs) have rapidly evolved from text-only systems to multimodal tools that can interpret images since late 2023. Given increasing public access to these platforms, patients may attempt to use LLMs to judge whether a skin lesion is benign or malignant and decide whether to seek medical care. However, the diagnostic performance of the latest available multimodal LLMs on clinical skin lesion images remains unclear. Methods: We assessed six commercially available LLMs (ChatGPT-4o, GPT-5.2 (OpenAI, San Francisco, CA, USA), BingAI (Microsoft Corp., Redmond, WA, USA), Gemini 2.0, Gemini 3.0 (Google LLC, Mountain View, CA, USA), and Grok 4.1 (xAI, San Francisco, CA, USA)) using 12 clinical skin-lesion photographs published by Han et al. [1] A standardized prompt was used: "The following picture represents a skin lesion. (1) Is it benign or malignant? (2) Please diagnose what the disease is." Each model was queried five times per image across designated time points (Oct 2023–Jan 2026) to account for response variability. Outcomes were (i) accuracy of benign/malignant classification and (ii) exact diagnostic accuracy. Pearson's chi-square test compared subgroup performance; P<0.05 was considered significant. Results: Mean benign/malignant classification accuracy (average of five sessions) was 83.3 ± 5.89 % (GPT-4o), 76.6 ± 5.89 % (GPT-5.2), 23.3 ± 13.6 % (BingAI), 85.0 ± 6.97 % (Gemini 2.0), 80.0 ± 17.2 % (Gemini 3.0), and 78.3 ± 11.2 % (Grok 4.1). BingAI's classification performance was significantly lower than other models (P<0.001). Across all 60 classification queries, GPT-5.2 correctly classified 52/60 (86.7%), with sensitivity 0.92 and specificity 0.83. For exact diagnosis, mean accuracy was 40.0 ± 12.36 % (GPT-4o), 50.0 ± 18.6 % (GPT-5.2), 3.33 ± 4.56 % (BingAI), 60.0 ± 13.7 % (Gemini 2.0), 50.0 ± 23.6 % (Gemini 3.0), and 21.7 ± 7.45 % (Grok 4.1). BingAI again performed significantly worse than other models (P<0.001). Notably, several models declined to provide medical judgments on images without clinical context; in contrast, BingAI's creative mode provided answers but with low diagnostic precision. Conclusions: Multimodal LLMs demonstrated moderate-to-high performance for benign/malignant triage in several models, but disease-level diagnosis remained inconsistent and, in some platforms, limited by safety refusals. Current LLMs cannot be considered substitutes for clinician assessment or dedicated medical imaging AI. Nonetheless, their improving triage performance suggests potential future roles in patient education and decision support, emphasizing the need for validation, guardrails, and clinical integration strategies.

1. Han SS, Kim MA, Lim W et al. Classification of the clinical images for benign and malignant cutaneous tumors using a deep learning algorithm. J Invest Dermatol 2018; 138:1529–38.

Purpose: Marketing in aesthetic plastic surgery has shifted toward digital-first strategies, with search engine optimization (SEO) increasingly shaping how patients engage with practices. Artificial intelligence (AI) is accelerating this transformation by automating keyword research, trend forecasting, and content generation. This study reviews the opportunities, challenges, and ethical considerations posed by AI-enhanced SEO in plastic surgery. Methods: A narrative literature review was conducted examining digital marketing trends, patient search behavior, SEO strategies, and AI applications in plastic surgery and related specialties. Search term analytics and keyword metrics across common plastic surgery procedures were analyzed. An institutional survey of academic plastic surgeons (N=14) assessed current SEO awareness, utilization, and attitudes. Results: Over 90% of cosmetic surgery patients search online before their initial consultation, and 46% begin specifically with a Google search (1,2). Patients younger than 35 are nearly four times more likely to follow surgeons on social media (2). Despite widespread awareness, few surveyed surgeons at our institution actively engaged in structured SEO optimization, representing an AI-addressable gap. AI-powered tools can automate keyword research, on-page optimization, and content generation, with broad search terms capturing the most traffic while localized keywords yield higher conversion rates. Website quality assessment tools are correlated with higher Google search rankings for medical websites (3). However, unrealistic patient expectations, often shaped by promotional content, remain among the strongest predictors of postoperative dissatisfaction (4). The automation of content creation raises concerns regarding misinformation, omission of surgical risks, and reinforcement of narrow beauty ideals, pitfalls that AI could amplify without physician oversight (5). Conclusion: AI-enhanced SEO offers plastic surgeons efficiency, precision targeting, and adaptability in a competitive digital marketplace. These advantages are meaningful only when deployed within an ethical framework that prioritizes patient education, informed consent, and truthful representation. Surgeons must remain actively involved in reviewing AI-generated materials to ensure accuracy and alignment with professional standards.

1. Montemurro P, Porcnik A, Hedén P, Otte M. The influence of social media and easily accessible online information on the aesthetic plastic surgery practice: literature review and our own experience. Aesthetic Plast Surg. 2015;39(2):270-277.
2. Fan KL, Graziano F, Economides JM, Black CK, Song DH. The public's preferences on plastic surgery social media engagement and professionalism: demystifying the impact of demographics. Plast Reconstr Surg. 2019;143(2):619-630.
3. Dunne S, Cummins NM, Hannigan A, Shannon B, Dunne C, Cullen W. A method for the design and development of medical or health care information websites to optimize search engine results page rankings on Google. J Med Internet Res. 2013;15(8):e183.
4. Herruer JM, Prins JB, van Heerbeek N, Verhage-Damen GWJA, Ingels KJAO. Negative predictors for satisfaction in patients seeking facial cosmetic surgery: a systematic review. Plast Reconstr Surg. 2015;135(6):1596-1605.
5. Dhawan R, Brooks KD, Shauly O, Shay D, Losken A. Ethical considerations for generative artificial intelligence in plastic surgery. Plast Reconstr Surg Glob Open. 2025;13(6):e6825.

Background: Thirty-day readmission is a key quality metric in plastic surgery, yet benchmarks and modifiable drivers vary across procedure types and institutional practice patterns. In plastic surgery, prior evidence has demonstrated wide variability in reported readmission rates and inconsistent identification of risk factors, particularly outside head and neck reconstruction. We aimed to evaluate procedure-related unplanned 30-day readmission rates across common plastic surgery operations and identify postoperative complications independently associated with readmission.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for adult (≥18 years) plastic surgery cases between 2015 and 2023. Using CPT or ICD-10-CM diagnosis codes, procedures were grouped into four categories: breast, body contouring, and non-breast free flap reconstruction. The primary outcome was procedure-related unplanned 30-day readmission. Bivariate comparisons were performed between readmitted and non-readmitted cohorts. Two multivariable logistic regression models were used. The first assessed whether the type of procedure was associated with readmission, adjusting for the covariates age, sex, race, BMI, diabetes, smoking, ASA class, inpatient/outpatient status, and operative time. The second evaluated which postoperative complications were associated with readmission, including superficial, deep, and organ/space surgical site infection (SSI), sepsis, pneumonia, and venous thromboembolism requiring therapy, while adjusting for the same covariates.

Results: The cohort included 41,936 cases (breast 81.2%, body contouring 17.7%, non-breast free flaps 1.1%). Procedure-related unplanned 30-day readmission occurred in 853 patients (2.0%). Readmission rates for each procedure were 15.0% (521/34,071) for breast, 4.3% (316/7,416) for body contouring, 3.6% (16/449) for non-breast free flaps. In the multivariable model evaluating procedure category, body contouring procedures were associated with significantly higher odds of unplanned readmission than breast procedures (aOR 2.18, 95% CI 1.82-2.62, p < 0.001). Older age, higher BMI, current smoking, ASA class >1, and longer operative time were independently associated with increased odds of unplanned readmission (all p < 0.05), whereas Black/African American race and outpatient surgery were associated with lower odds (both p < 0.05). In the second multivariable model, including postoperative complications, all complications were independently associated with higher odds of unplanned readmission. The strongest associations were observed for organ/space SSI (aOR 85.1, 95% CI 59.4–122.1, p<0.001), deep incisional SSI (aOR 78.7, 95% CI 55.7–111.5, p<0.001), and sepsis (aOR 27.6, 95% CI 13.7–57.1, p<0.001). Superficial SSI, wound dehiscence, venous thromboembolism requiring therapy, and pneumonia were also independently associated with higher odds of readmission (all p<0.05).

Conclusions: In this NSQIP plastic surgery cohort, overall procedure-related 30-day readmission was low at 2.0% but varied meaningfully across procedure categories, with body contouring procedures demonstrating more than double the adjusted odds of readmission compared with breast operations. Importantly, the magnitude of association between postoperative infectious complications and readmission exceeded that of procedure category itself. These findings suggest that readmissions in plastic surgery are driven less by procedural complexity alone and more by patient vulnerability and the development of serious postoperative infections. Targeted preoperative optimization, risk stratification in higher-BMI and smoking populations, and aggressive SSI prevention and early detection strategies represent impactful opportunities for reducing readmissions.

Background: Primary care physicians and other surgical specialists serve as the primary referral source for plastic and reconstructive surgery surgeons, particularly for complex reconstructive cases. While misperceptions about the scope of plastic surgery have been documented among medical students and the general public, physician-specific perceptions remain understudied, with the majority of existing studies originating outside of the United States. This review characterizes physician knowledge of plastic surgery's scope of practice across international training contexts to identify priority areas for intervention.

Methods: A PubMed-based narrative literature review was conducted using search terms related to plastic surgery scope of practice and physician perceptions. Twenty articles were identified and reviewed for relevance; 6 studies containing extractable data on primary care physicians were included and analyzed.

Results: Across studies encompassing over 2,100 primary care and non-plastic surgery physicians in the United States (U.S.), Portugal, Saudi Arabia, the United Kingdom (U.K.), and India, plastic surgery was consistently recognized for cosmetic procedures but significantly underrecognized for core reconstructive surgical procedures. In the only U.S. national survey of primary care residents (n=1,020, including family medicine, internal medicine, and pediatrics residents), plastic surgery was the top-selected specialty for only eyelid surgery (70%) and rhinoplasty (79%), while oral maxillofacial surgery (OMFS), orthopedic surgery, and dermatology were more frequently selected for facial fractures, hand surgery, and facial skin cancer (76%, 88%, and 89%, respectively) (1). These findings were replicated in Portugal (n=430) and Saudi Arabia (n=261), where procedures involving bony repair of hand and jaw fractures were consistently attributed to orthopedic surgeons and OMFS regardless of national context (2). In the U.K. (n=335), general practitioners demonstrated better understanding than the general public but still defaulted to orthopedic surgeons for hand surgery (3). Overall knowledge assessments in Saudi Arabia revealed 44.1% of non-plastic surgery physicians had poor understanding of plastic surgery's scope, with only 16.1% deemed to have sufficient knowledge of plastic surgery's scope (2). Breast reconstruction, burns, and body contouring were most reliably associated with plastic surgery across all populations, while fracture management, hand surgery, and skin cancer treatment were most consistently misattributed.

Conclusions: Fellow physicians across specialties, training backgrounds, and countries consistently struggle to recognize plastic surgery as the primary managing specialty for procedures considered core to the field. With only one U.S.-based study identified in this review, this represents a significant gap in the literature. As clinical overlap with other specialties increases, targeted educational initiatives at the medical school, residency, and professional society levels are necessary to preserve appropriate referral patterns and the full scope of plastic and reconstructive surgery.

1. Tanna N, Patel NJ, Azhar H, Granzow JW. Professional perceptions of plastic and reconstructive surgery: what primary care physicians think. Plast Reconstr Surg. 2010;126(2):643-650. doi:10.1097/PRS.0b013e3181de1a16

2. Alnaim MF, AlRabiah NM, Kaabi HAMA, et al. Plastic Surgeon versus Orthopedic Surgeon: Where Would You go for Your Hand Injury? A Cross-Sectional Study in Saudi Arabia. Avicenna J Med. 2024;14(1):54-59. Published 2024 Feb 7. doi:10.1055/s-0044-1779487

3. Dunkin CS, Pleat JM, Jones SA, Goodacre TE. Perception and reality-a study of public and professional perceptions of plastic surgery. Br J Plast Surg. 2003;56(5):437-443. doi:10.1016/s0007-1226(03)00188-7