Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis.

BACKGROUND: Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients. METHODS: A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting. CONCLUSIONS: In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.

Sociodemographic Disparities in the Diagnosis and Prognosis of Patients With Cervical Cancer: An Analysis of the Surveillance, Epidemiology, and End Results Program.

Background While the incidence and mortality rates of cervical cancer are declining due to improved prevention, screening, and treatment, inequitable access to care may contribute to worse patient outcomes. Therefore, we sought to evaluate sociodemographic disparities in the diagnosis and prognosis of patients with cervical cancer. Methodology The Surveillance, Epidemiology, and End Results (SEER) database was queried for adult women diagnosed with cervical cancer from 2010 to 2015. Sociodemographic groups of interest included patient race/ethnicity (non-Hispanic White/Hispanic White/Black/Other), residential setting (rural/urban), and county median household income (<$45,000/$45,000-59,999/$60,000-74,999/≥$75,000). Outcomes of interest included stage at diagnosis, receipt of hysterectomy, and overall survival (OS). Outcomes were evaluated using Pearson's chi-square test, multivariable logistic regression, and multivariable Cox proportional hazards. Results A total of 5,726 patients were identified with an average age of 50.1 years (SD = 14.6). Significant differences in cancer stage at diagnosis were identified based on race/ethnicity (p < 0.001) and household income (p = 0.012). On adjusted analysis, Black patients were found to be significantly less likely to receive a hysterectomy compared to non-Hispanic White patients (odds ratio (OR) = 0.46; 95% confidence interval (CI) = 0.37-0.56). Lower household income was associated with poorer survival for stage I (<$45,000 vs. >$75,000: hazard ratio (HR) = 1.53; 95% interquartile range (IQR) = 1.00-2.33), II ($45,000-59,999 vs. >$75,000: HR = 1.67; 95% IQR = 1.19-2.35), and IV (<$45,000 vs. >$75,000: HR = 1.64; 95% IQR = 1.22-2.29) disease. Black race was associated with poorer OS for stage IV disease (HR = 1.29; 95% IQR = 1.06-1.56). Conclusions This study highlights significant disparities in disease progression at diagnosis and OS for cervical cancer patients based on race/ethnicity and household income. These findings may assist policymakers in developing strategies for mitigating these disparities.

Cross-Sectional Analysis of Insurance Coverage for Lymphedema Treatments in the United States.

Importance: Lymphedema is a debilitating condition that affects approximately 1 in 1000 individuals in the United States. Complete decongestive therapy is currently the standard of care, and innovative surgical techniques have demonstrated potential to further improve outcomes. Despite the growing armamentarium of treatment options, a large proportion of patients with lymphedema continue to struggle because of limited access to care. Objective: To define the current state of insurance coverage for lymphedema treatments in the United States. Design, Setting, and Participants: A cross-sectional analysis of insurance reimbursement for lymphedema treatments in 2022 was designed. The top 3 insurance companies per state based on market share and enrollment data maintained by the Kaiser Family Foundation were included. Established medical policies were gathered from insurance company websites and phone interviews, and descriptive statistics were performed. Main Outcomes and Measures: Treatments of interest included nonprogrammable pneumatic compression, programmable pneumatic compression, surgical debulking, and physiologic procedures. Primary outcomes included level of coverage and criteria for coverage. Results: This study included 67 health insurance companies representing 88.7% of the US market share. Most insurance companies offered coverage for nonprogrammable (n = 55, 82.1%) and programmable (n = 53, 79.1%) pneumatic compression. However, few insurance companies offered coverage for debulking (n = 13, 19.4%) or physiologic (n = 5, 7.5%) procedures. Geographically, the lowest rates of coverage were seen in the West, Southwest, and Southeast. Conclusions and Relevance: This study suggests that in the United States, less than 12% of individuals with health insurance, and even fewer patients without health insurance, have access to pneumatic compression and surgical treatments for lymphedema. The stark inadequacy of insurance coverage must be addressed through research and lobbying efforts to mitigate health disparities and promote health equity among patients with lymphedema.

Examination of the Novel National Institutes of Health-Supported Relative Citation Ratio, a Measure of Research Productivity, Among Academic Plastic Surgeons.

BACKGROUND: Considerable interest has been devoted to quantifying research productivity for the purposes of academic appointment and promotion in plastic surgery. A novel bibliometric, the relative citation ratio (RCR), integrates features unavailable in prior metrics, such as the h-index, including the ability to compare researchers in distinct fields. This investigation examines the RCR in relation to established measures of academic productivity and provides the benchmark data in plastic surgery. METHODS: Online sources were queried to identify the characteristics of 955 academic plastic surgeons from 94 programs, ie, academic rank, gender, degrees, and fellowships. Bibliometric data were acquired using the iCite and Scopus databases. Comparative and correlational analyses of variables were performed. RESULTS: Academic plastic surgeons were exceptionally productive, with a mean RCR of 1.20 (interquartile range, 0.79-1.67) and a weighted RCR of 17.68 (interquartile range, 5.14-52.48). Increased mean RCR was significantly associated with advanced academic rank and fellowship training. Increased weighted RCR was significantly associated with advanced academic rank, male gender, PhD acquisition, publication experience, and fellowship training. The h-index was weakly correlated with mean RCR but strongly correlated with weighted RCR and publication experience. CONCLUSIONS: The RCR was associated with established markers of academic productivity, indicating its validity as a reliable field-normalized measure for the evaluation of plastic surgery faculty. Because scholarly output is a potential factor with respect to decisions of hiring, promotion, and allocation of funding, this modality of standardized comparison is paramount for plastic surgeons who exist within a larger general surgery department.

Recommendations on Attaining Departmental Status: A Survey of Division Chiefs Turned Department Chairs.

In 2009, the Association of Academic Chairmen of Plastic Surgery, now known as the American Council of Academic Plastic Surgeons (ACAPS), published a white paper endorsing the conversion of plastic surgery divisions into autonomous departments, motioning for other national organizations to follow suit. ACAPS' rationale outlined 11 factors intended to promote the favorability of attaining departmental status within an institution. Through surveying division chiefs turned founding department chairs who successfully executed this transition, we evaluate the practicality and efficacy of these guidelines. A survey was distributed to founding chairs of plastic surgery departments that were established after ACAPS' 2009 white paper. Information pertaining to institutions' demographic information and respondents' utilization of the principles and suggestions espoused in the white paper was obtained. The survey achieved an 86% response rate. The average time needed for the transition was 22 ± 12 months. Four of seven chairs were familiar with the 2009 ACAPS white paper. Garnering support from hospital administrators and institutional stakeholders, having fiscal profitability within the institution, and coordinating an integrated plastic surgery training program were ranked as the top three most important factors, respectively. This study assesses ACAPS' recommendations on transitioning from a division to a department on the basis of perceived utility by academic leaders who recently navigated the process. The most frequently cited factors for a successful transition included rallying support from institutional stakeholders and ensuring profitability. Additionally, aligning the timing with a concurrent transition of leadership can expedite the process.

Characteristics of Successful Integrated Plastic Surgery Applicants from US Allopathic Medical Schools without a Home Integrated Program.

OBJECTIVE: Integrated plastic surgery (PS) is one of the most competitive residency programs, but current literature lacks data specific to matched applicants from medical schools without home integrated PS residency programs (NHP). Therefore, there is a need to examine this specific demographic of applicants to identify key factors that led to a successful match. DESIGN: An anonymous survey was sent to PS residents who graduated from US allopathic medical schools with NHP. Survey questions focused on applicants' objective statistics (USMLE scores, research experiences, etc.), as well as various other factors, including access to resources and letters of recommendation. SETTING: All US-based integrated plastic surgery residency programs. PARTICIPANTS: PGY-1 through PGY-6 integrated PS residents who graduated from US allopathic medical schools with NHP. RESULTS: The survey was distributed to 178 NHP residents from May to June of 2021, achieving a 55.1% response rate. Thirty-seven percent attended an institution with an independent, but not integrated, residency program. Average USMLE Step 1 and 2 scores were 248 ± 10.1 and 256 ± 9.7, respectively. Respondents reported having 9.8 ± 9.5 abstracts, presentations, and publications listed on their residency applications. NHP applicants had an average of 1.5 letters of recommendation written by away rotation faculty. Forty-five percent reported accessing resources at institutions with home integrated residency programs (HP), 55.6% of whom "strongly agreed" or "agreed" that this significantly helped in matching. CONCLUSION: The USMLE Step scores and research experiences of NHP residents are similar to those which are reported among all matched applicants nationally. NHP respondents optimized their success by utilizing plastic surgery-related resources at their own institutions, while often seeking resources at other institutions.

Ranking United States University-Based General Surgery Programs on the Academic Achievement of Surgery Department Faculty.

OBJECTIVE: Rankings of residency programs are highly influential and utilized by residency applicants. Existing ranking resources often use opaque criteria that may include bias or do not accurately represent the academic achievement of current faculty. This study aims to create an updated general surgery residency ranking list based on the academic achievements of their respective surgery department faculty members. DESIGN: One hundred and six general surgery residency programs were selected from the American Medical Association Residency & Fellowship Programs Database. The names of faculty members affiliated with the departments of surgery were manually obtained. Lifetime and five-year h-indexes, a sum of grant awards from the National Institute of Health and Veterans Affairs, and a tally of journal editorial board positions were collected for the faculty. Metrics were compared among surgical departments, and the corresponding residency programs were ranked accordingly. SETTING: The study evaluated university-based general surgery residency programs in the United States from 2017 to 2019 via assessing their respective institutions' departments of surgery. PARTICIPANTS: A total of 7568 faculty members were evaluated. Faculty were required to be full-time, clinical surgeons to meet inclusion criteria. RESULTS: Based on a composite of all measured criteria, the top overall surgery department was at the University of Michigan. Massachusetts General Hospital had the highest lifetime and five-year h-indexes. Brigham and Women's Hospital had the most National Institute of Health funding, and the University of Pittsburgh Medical Center had the most Veterans Affairs funding. Washington University in St. Louis/Barnes Jewish Hospital had the most editorial board positions in their department. CONCLUSIONS: The academic success of departments of surgery was evaluated to develop a ranking list of general surgery residency programs. Through utilizing standardized methods and several measures of academic achievement, this comprehensive general surgery residency classification system will allow residency applicants to make more informed decisions.