Machine learning analysis of online patient questions regarding breast reconstruction.

BACKGROUND: Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction. METHODS: Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers. RESULTS: 522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?" CONCLUSIONS: Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

A multimetric health literacy analysis of online gender affirmation surgery materials: From facial to genital surgery.

BACKGROUND: The transgender patient population is expanding, and gender affirming surgery (GAS) volume is increasing. Accurate, comprehensive, and easily navigable resources on GAS are lacking. We aim to evaluate the readability of online materials for specific gender affirming surgical procedures to identify mechanisms of improving information access for transgender patients. MATERIALS AND METHODS: "Facial feminization", "facial masculinization", "MTF breast augmentation", "FTM chest masculinization", "MTF vaginoplasty", "metoidioplasty", and "FTM phalloplasty" were searched on Google. Per keyword, the first 75 text-containing results were included. Text was analyzed for reading difficulty using the Flesch-Kincaid Reading-Ease (FKRE) test and grade level using the Flesch-Kincaid Grade Level (FKGL) formula, Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman-Liau Index (CLI). Scores were compared using independent t-and ANOVA tests (α = 0.05). RESULTS: Mean readability scores (FKRE 37.44) and grade-levels (FKGL 12.87, GFI 15.61, SMOG 11.91, CLI 15.00) correlated with college-level difficulty. Masculinizing surgical materials were more difficult to read than feminizing ones (p ≤ 0.023). Top surgery materials were easier to read than facial and genital surgery materials (p ≤ 0.013). Specifically, chest masculinization resources were more difficult to read than those for breast augmentation (p ≤ 0.006). No differences were found between facial feminization and masculinization surgery resources, nor between resources for different gender affirming genital surgeries. CONCLUSION: Online GAS materials are written above the recommended 6th grade reading-level, with resources for transgender men being significantly more challenging to understand. Improving readability of online resources can help overcome barriers to care for the transgender patient population.

Reconstruction of Acquired Defects of the External Genitalia: A 24-Patient, Single-Institution Experience.

PURPOSE: Patients undergoing resection of the external genitalia are often faced with significant deformity and decreased quality of life. Plastic surgeons are tasked with the challenge of reconstructing these defects to minimize morbidity and increase patients' quality of life. The authors have set out to investigate the efficacy of local fasciocutaneous and pedicled perforator flaps in external genital reconstruction. METHODS: A retrospective review was conducted of all patients undergoing reconstruction of acquired defects of the external genitalia from 2017 to 2021. In total, 24 patients met inclusion criteria for the study. Patients were allocated into 2 cohorts: patients with defects reconstructed using local fasciocutaneous flaps (FF) versus patients with defects reconstructed using pedicled islandized perforator flaps (PF). Comorbid conditions, ablative procedures, operative times, flap size, and complications were compared across all groups. Fisher exact test was used to analyze differences in comorbidities, while independent t tests were used to analyze age, body mass index, operative time, and flap size. Significance was set at P < 0.05. RESULTS: Of the 24 patients included in the study, 6 underwent reconstruction with islandized PFs (either profunda artery perforator or anterolateral thigh), and 18 underwent reconstruction with FFs. The most common indication for reconstruction was vulvectomy for vulvar cancer, followed by radical debridement for infection, and lastly penectomy for penile cancer. The PF cohort had a significantly higher percentage of previously irradiated patients (50% vs 11.1%, P = 0.019). Although mean flap size was larger in the PF cohort, this difference did not reach statistical significance (176 vs 143.4 cm2, P = 0.5). Perforator flaps had significantly longer operative times when compared with FFs (237.33 vs 128.99 minutes, P = 0.003). Average length of stay was 6.88 days in FF and 5.33 days in PF (P = 0.624). Complication profile including flap necrosis, wound healing delays, and infection were similar between groups despite a significantly higher rate of prior radiation in the PF cohort. CONCLUSIONS: Our data suggest that PFs such as profunda artery perforator and anterolateral thigh flaps are associated with longer operative times but may offer a suitable option for reconstruction of acquired defects of the external genital compared with local FFs, especially in the setting of prior radiation.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery.

BACKGROUND: Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery. METHODS: The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified. RESULTS: In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover. CONCLUSION: This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Increasing Incidence of Hand and Distal Upper Extremity Injuries Associated With Electric Scooter Use.

PURPOSE: Electric scooters (e-scooters) have seen an increase in popularity in cities across the United States as a form of recreation and transportation. The advent of ride-sharing applications allows anyone with a smartphone to easily access these devices, without any investment or experience required. In this study, the authors analyze scooter-related injuries of the hand and upper extremity. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of e-scooters between 2010 and 2019. Data collected included demographic information, the location of the injury, the injury diagnosis, and disposition. National estimates (emergency room visits in the United States) were calculated using the weight variable included in the NEISS database. Miscoded reports were excluded. As a corollary, Google Trends data were utilized to establish a correlation between e-scooter-related injuries and the relative number of e-scooter hits on the Google search engine. RESULTS: From 2010 to 2019, there were 730 e-scooter-related injuries reported to the NEISS database. This corresponds to an estimated 26,412 injuries nationally during this time period. The incidence of scooter-related injuries increased by over 230% (2,130 national injuries in 2010; 7,213 national injuries in 2019; relative difference 5,083). Injuries most commonly occurred in patients aged 10 to 18 years (30.3%). The most frequent site of injury was the wrist (41.9%). The most common injury diagnosis was fracture (55.3%). Additionally, there was a correlation between the number of Google Trends e-scooter hits and the number of injuries during this time period. CONCLUSIONS: The incidence of e-scooter-related upper extremity injuries increased dramatically in the United States between 2010 and 2019. CLINICAL RELEVANCE: As novel e-scooter-sharing apps become increasingly popular, it is imperative that users are educated about the risk of injury and that use of proper protective equipment is encouraged.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction.

BACKGROUND: Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures. METHODS: The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis. RESULTS: Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279). CONCLUSION: Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.

Relevance of Academic Productivity in the Assessment of Integrated Plastic Surgery Applicants.

BACKGROUND: The academic productivity of an integrated plastic surgery applicant is strongly considered during the ranking process but is often difficult to assess. The h-index is a tool that provides an objective measure of both the quality and impact of an author's academic works. The goals of this study were to assess whether the h-index of recently matched plastic surgery interns correlates with their home and eventual residency program characteristics. METHODS: A database of all 2018 interns in integrated plastic surgery programs was created. The SCOPUS database was queried for the h-indices for each individual. RESULTS: In 2018, 77 integrated plastic surgery programs offered a total of 168 PGY1 positions; data was able to be obtained for 131 individuals. The mean h-index was 1.26 (range 0-14), with a mean of 4.22 publications (range 0-58). The h-index increased in concordance with overall number of publications. The h-index of applicants matching at Top 50 NIH Funded institutions had a significantly higher h-index (1.57) compared to those that matched to all other institutions (0.76) (p<0.05). Applicants matching at a "top 20" program as determined by Doximity reputation rankings also had a significantly higher h-index (1.96) compared to those matching at all other programs (0.83) (p< 0.05). CONCLUSIONS: The h-index of recently matched integrated plastic surgery interns correlates with several factors including program reputation and level of NIH funding. As applicants become increasingly well-qualified and the number of the publications increases commensurately, programs that place an emphasis on academic productivity may consider incorporating the h-index into their evaluation.

The Cost of the "July Effect" in Microsurgery.

The existence of the "July effect," or the idea that the new academic year intrinsically has an increased complication rate is evaluated in microsurgical free tissue transfer procedures. The National Surgical Quality Improvement Program registry was queried for all free flap procedures performed between 2005 and 2016 (n = 3405). Cases were grouped as having occurred in the first academic quarter (Q1: July 1-September 30) or fourth quarter (Q4: April 1-June 30). Demographical data and complications were compared using univariate χ analysis, multivariate logistic regression was used to control for confounding variables, and inpatient stay and operating cost estimates were created. Of a total of 1722 cases, 905 were performed in the first academic quarter and 817 were performed in the fourth academic quarter. There was no significant difference between Q1 and Q4 in readmission rate (P = 0.378) or reoperation rate (P = 0.730). Patients in Q1 had significantly longer operative times (P = 0.001) and length of stay (P = 0.002) compared with those in Q4. In addition, cost of inpatient stay and operating costs associated with each free flap were significantly increased in Q1 compared with Q4 (P = 0.029; P = 0.001). The total cost per quarter for free flaps was also significantly more expensive in Q1 vs Q4, with the highest average difference in cost of $350,010.64 (P = 0.001). Having surgery early in the academic year does not put patients at any increased risk for major complications but is associated with increased operating time, length of stay, and total cost.

Utility of Regional Anesthesia in Extremity Reconstruction.

BACKGROUND: Regional anesthesia (RA) may help to circumvent the well-documented risks associated with general anesthesia, increase patient comfort and satisfaction, and mitigate costs. This study aims to investigate the utility of RA in extremity reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all cases of extremity reconstruction including muscle, myocutaneous, or fasciocutaneous flaps from 2005 to 2016. Two groups were created based on anesthesia technique, regional/epidural and general. Postoperative complications included reoperation, readmission, and wound complications. Propensity score matching was utilized to control for variation in sample size, significant comorbidities, and demographics in the analysis of complications. RESULTS: A total of 2,874 cases were identified with general anesthesia utilized in 2,820 cases and RA in the remaining 54. After propensity score matching, 53 cases were identified in each group. In both unmatched and matched cohorts, there was no statistically significant difference in the rates of reoperation, readmission, or wound complication rates. In the matched cohort, mean operative time in the RA cohort was significantly shorter, 157.64 (±112.36) minutes compared with 293.06 minutes (±201.35 minutes) in the general anesthesia group (p < 0.001). While no statistically significant difference was detected in mean length of stay (LOS) between the two groups, the RA group experienced a clinically significant shorter LOS of 5.77 days (±5.87 days) compared with 7.02 (±5.61) days in the general anesthesia group (p = 0.269). CONCLUSION: RA may be a safe, reasonable alternative to general anesthesia in extremity reconstruction without increase in postoperative complications. Additionally, RA use is associated with a significant reduction in operative time, potentially leading to shorter and safer procedures without compromising outcomes.

Refusal of Cancer-Directed Surgery in Head and Neck Squamous Cell Carcinoma Patients.

OBJECTIVES/HYPOTHESIS: To investigate the risk factors for refusal of recommended surgery in head and neck squamous cell carcinoma (HNSCC) treatment STUDY DESIGN: Retrospective review of a national database. METHODS: The Surveillance, Epidemiology, and End Results database was queried for all cases of HNSCC from 1989 to 2014. Patients who underwent recommended surgery (N = 98,270) were identified and compared to patients who refused recommended surgery (N = 3,582). Groups were compared for patient demographics, socioeconomic variables, and tumor characteristics including stage, grade, and primary site. Binary logistic regression was performed to determine independent predictors of surgery refusal. RESULTS: Of the total population, 1.8% of patients refused cancer directed surgery. Following regression, the strongest predictors of surgery refusal were found to be age greater than 75years (odds ratio [OR]: 4.23 [95% confidence interval {CI}: 3.00-5.96]), and stage III (OR: 4.19 [95% CI: 3.15-5.57]) or stage IV at diagnosis (OR: 4.49 [95% CI: 3.46-5.80]). Black race was significantly predictive (OR: 1.71 [95% CI: 1.37-2.13]) as well as marital status other than married (OR: 1.76 [95% CI: 1.49-2.07]) and Medicaid insurance status (OR:1.46 [95% CI: 1.20-1.77]). Primary site of larynx (OR: 2.01 [95% CI: 1.71-2.37]) or base of tongue (OR: 2.34 [95% CI: 1.87-2.92]) additionally predicted surgery refusal. CONCLUSIONS: A number of demographic, socioeconomic, and tumor-related variables are associated with refusal of cancer-directed surgery in head and neck squamous cell carcinoma. Recognition of these factors may help identify situations where more active education and support are needed to help patients accept optimal care. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1368-1373, 2019.