A Work in Progress: Women's Status in the Plastic Surgery Workforce and Recommendations for Success.

BACKGROUND: Only 20% of the current plastic surgery workforce is female, but since 2022, most matched applicants in integrated plastic surgery programs have been women. This study aimed to examine current practice models among female plastic surgeons, including those outside of academia, as the field continues to evolve. OBJECTIVES: This study surveyed female plastic surgeons in different practice models to elicit perspectives, career path advice, characterize/project trends, and provide recommendations for success. METHODS: A 37-question survey focusing on demographics, practice models, career paths, desire for practice changes and advice for women trainees was emailed to 1342 members of the American Society of Plastic Surgeons and The Aesthetic Society. Chi square analyses compared practice type characteristics (academia, employed roles, private practice), at a significance level of 0.05. RESULTS: Response rate was 53%. Most respondents were age 35-45, in solo practice, trained via traditional pathways, without fellowships, and lacked female mentors. Private practice surgeons were very satisfied in their career, employed surgeons were moderately satisfied and academic surgeons were mildly satisfied. Academic surgeons reported a higher number of working hours (>60) and cases per month (20-30) than employed or private practice surgeons. Recommendations for success included seeking female mentorship, enhancing business skills and building a social media platform during training. CONCLUSIONS: Results highlight the importance of female mentorship, acquiring business skills, and indicate private practice leads to greater career satisfaction. Training programs should consider accounting for these factors to better promote women's success and improve equity in academic practice.

Work/Life Balance: It Is Just Plain Hard.

Graduating surgeons are constantly told to be "available, affable, and able." Frequently, the need to put patients first can result in an imbalance between work and life. Ultimately, the consequence of work/life imbalance is burnout, which can manifest itself in atypical behavior toward patients, colleagues, and family. It is imperative that all surgeons learn to take care of themselves and develop a better integration of work and life.

A 9-Year Review of Ethics Complaints to the American Society of Plastic Surgeons.

PURPOSE: The American Society of Plastic Surgeons (ASPS) provides an avenue for filing formal complaints regarding unethical behavior of Members. These complaints are investigated by the Ethics Committee and referred to the Judicial Council if a violation may have occurred. METHODS: A review of complaints filed with the ASPS from 2013-2021 was performed. Data surrounding both complaints and complainant type were reviewed, as well as region of complaint origin. Categories of violations resulting formal investigations and Judicial Council referrals were also reviewed. RESULTS: A total of 584 complaints were filed with the ASPS Ethics Committee from 2013-2021, which was nearly 100 fewer than from a prior review of 2004-2008. Twenty-one percent of complaints were formally investigated by the Ethics Committee, and 26% of these were referred to the Judicial Council. The most common complaint investigated was related to advertising/misleading communications, whereas the most common complaint referred to the Judicial Council was regarding expert testimony. Most complaints were filed by ASPS members. CONCLUSIONS: The total number of complaints filed decreased significantly, the reasons for which are unclear. Evolution of culture and thought likely impacted not only specific behaviors, but also the likelihood of reporting those behaviors. It remains incumbent on plastic surgeons to utilize the self-regulating mechanisms available in order to maintain the autonomy we enjoy as a profession.

Framework for the Creation of Ethical and Professional Social Media Content.

BACKGROUND: Social media are powerful tools that allow users to communicate directly with an online community. Plastic surgeons were early adopters of social media, recognizing their educational and marketing potential. With the use of social media comes ethical and legal concerns. The lack of professional society policies on social media use has led to calls for the American Society of Plastic Surgeons to establish guidelines regarding the use of social media in medical practice. The authors propose a framework for the creation of ethical and professional social media content. METHODS: The authors reviewed the updated American Society of Plastic Surgeons Code of Ethics, current professional organization codes of ethics and social media guidelines, recently published articles, and legal documents pertaining to social media use in medical practice. RESULTS: The updated American Society of Plastic Surgeons Code of Ethics provides adequate guidance for the professional use of social media in plastic surgery practice. The authors drew on the American Society of Plastic Surgeons Code of Ethics along with existing professional society guidelines to develop a framework for the professional and ethical creation of social media content. The authors also propose a sample informed consent form for social media use. CONCLUSIONS: Social media are powerful tools that will continue to transform the practice of plastic surgery and medicine at large. Plastic surgeons must uphold values of professionalism and ethics when using social media to protect patients and maintain the high professional standards of the specialty.

An Analysis of Differences in the Number of Children for Female and Male Plastic Surgeons.

BACKGROUND: Historically, the structure of surgical programs discourages women interested in both surgery and motherhood from pursuing a surgical career, and women plastic surgeons have been more likely than men to have no children or to have fewer, later in life. Female plastic surgery trainees now constitute over one-third of residents, and pregnancy rates can be expected to rise, but with women now a majority in medical schools, the specialty's maternity policies may be deterring interested women from entering the specialty. A survey study was conducted to measure reproductive outcomes and to identify current disparities between women and men plastic surgeons. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates, allowing comparisons of men's and women's responses. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Compared with male respondents, women were more likely than men to have no biological children (45.1 percent versus 23.1 percent). They were nearly twice as likely to delay having children because of the demands of training (72.6 percent versus 39.2 percent) and to experience infertility (26.3 percent versus 12.5 percent). Among the childless plastic surgeons, women were 11 times more likely to say they did not want children compared with men (20.1 percent versus 1.8 percent). CONCLUSIONS: Poor institutional maternity support results in a persistent, wide gap in reproductive outcomes between female and male plastic surgeons. Establishing a universal, comprehensive parental support policy is essential to closing that gap.

Gender Differences in the Professional and Personal Lives of Plastic Surgeons.

BACKGROUND: Although the number of women becoming plastic surgeons has increased during the past six decades, in comparison with the current gender parity in medical schools, plastic surgery still attracts disproportionately more men. Previous studies have shown disparities in the professional and personal lives of female and male plastic surgeons. A survey study was conducted to identify current challenges women and men encounter in the pursuit of a plastic surgical career to guide remedial strategies. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates for comparison between sexes. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Women were more likely than men to have experienced sexism or bias. Women were less likely to be married; be satisfied with work-life balance; or feel recognized for ideas, authorship, promotions, or raises. Women felt that their sex was a disadvantage in career advancement, with one exception: unlike men, women felt many patients chose them because of their sex. Despite these challenges, over 80 percent of all plastic surgeons were satisfied with their choice of career. CONCLUSIONS: Traditions and gender bias create disparities in the personal and professional lives of female and male plastic surgeons. Our specialty must make concrete changes to promote all plastic surgeons, both women and men, to thrive personally and professionally.

Learning How to Ask: Women and Negotiation.

Women are less likely to reach top-level leadership positions, and more likely to leave academic positions, than men, and are likely to earn less money than men. Women are also less likely to initiate a negotiation-a process that is crucial for professional advancement. This reluctance to ask hinders their advancement and can have long-lasting consequences-both financial and professional. The reasons that women do not ask are multifactorial. In this article, we will explore reasons why women are less likely to negotiate, the barriers they face when they do, and strategies that women can apply to improve their negotiation skills.

Striking a Better Integration of Work and Life: Challenges and Solutions.

Plastic surgeons are a diverse group but share a drive for excellence and dedication to their patients and the advancement of the specialty. Long hours at work and the need to be on call have limited the time that many have to spend on activities outside of the workplace. Reconciliation of the demands of surgery and private life can at times seem impossible. A failure to achieve balance between work and home life is associated with reduced job and life satisfaction, impaired mental health, family conflict, and ultimately burnout. Although the obstacles are many and varied, the authors have attempted to identify the challenges and propose solutions. The authors focus on women in plastic surgery in this article, but acknowledge that these issues are not unique to women or plastic surgery.

Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction.

BACKGROUND: Breast reconstruction is best accomplished with lower abdominal tissue, but this results in abdominal donor-site morbidity. The superficial inferior epigastric artery (SIEA) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published data comparing the donor-site morbidity of SIEA flaps to that of transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flaps. METHODS: The authors used a 12-question patient survey and retrospective chart review to compare donor-site function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period. RESULTS: Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting function (p = 0.02) and nearly significantly shorter duration of abdominal pain (p = 0.06). Bilateral reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps (p = 0.02). CONCLUSIONS: Breast reconstruction using SIEA flaps results in significantly less abdominal donor-site morbidity than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in unilateral and bilateral cases. These are clinically relevant differences that are perceived by patients and lead to the authors' recommendation to use SIEA flaps for breast reconstruction when possible to minimize abdominal donor-site morbidity.

Increased intraabdominal pressure in abdominoplasty: delineation of risk factors.

BACKGROUND: Abdominoplasty is associated with a 1.1 percent risk of deep venous thrombosis. This has been attributed to rectus plication causing intraabdominal hypertension, known to effect decreased venous return, venous stasis, and thus thrombosis. The authors conducted a pilot study to determine which components of the abdominoplasty procedure (i.e., general anesthesia, flexion of the bed, plication, and/or binder placement) may elevate intraabdominal pressures and whether this was clinically relevant. METHODS: Twelve abdominoplasty and 10 breast reduction (control) patients were enrolled prospectively. Intraabdominal pressure was transduced through the bladder before plication in the supine and flexed positions, after plication in both positions, after skin closure in the flexed position, and on postoperative day 1 with and without a binder in the flexed position. RESULTS: All intraabdominal pressures measured were clinically insignificant (<20 mm Hg). A statistically significant increase was found from flexion of the bed (mean difference, 3.80 +/- 2.0, p < 0.001, in the control group; and 4.39 +/- 1.68, p < 0.001, in the study group); rectus plication (mean difference, 2.78 +/- 2.11, p = 0.001, in the supine position; and 2.03 +/- 2.48, p = 0.016, in the flexed position); and binder placement (2.63 mm Hg for no binder versus 4.5 mm Hg with binder, p = 0.004). Both groups also showed an increase from preoperative to skin closure (mean difference, 2.03 +/- 6.7, p = 0.035, for the control group; and 2.83 +/- 3.97, p = 0.031, for the study group), suggesting general anesthesia as a risk factor. CONCLUSIONS: This study confirms the effect of rectus plication on increasing intraabdominal pressures but also implicates bed position, binder placement, and general anesthetic as risk factors. A larger study is needed to clarify the role of these variables in elevating intraabdominal pressure during abdominoplasty.

Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction.

BACKGROUND: One presumed advantage of the free deep inferior epigastric perforator (DIEP) flap over the free muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flap is decreased donor-site morbidity. The purpose of this study was to compare the donor-site morbidity and functional outcomes in women who underwent free muscle-sparing TRAM flap or free DIEP flap breast reconstruction. METHODS: All patients who underwent breast reconstruction using a free muscle-sparing TRAM flap or a free DIEP flap performed by the two senior authors at the M. D. Anderson Cancer Center between 1999 and 2003 were included in the study. The authors conducted a chart review to obtain demographic data and information regarding flap-related complications and donor-site complications. Each living patient was sent a 12-item questionnaire to elicit her perceptions about donor-site outcomes. RESULTS: One hundred sixty-four patient charts were reviewed (203 flaps). Muscle-sparing TRAM flaps were used in 124 patients (98 unilateral and 26 bilateral). DIEP flaps were used in 35 patients (27 unilateral and eight bilateral). In five bilateral breast reconstructions, a muscle-sparing TRAM flap was used for one side and a DIEP flap was used for the other side. There was no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM and free DIEP flaps. Eighty-nine of 159 patients (56 percent) responded to the questionnaire; results showed no significant difference in patient-perceived abdominal function after free muscle-sparing TRAM flaps and free DIEP flaps. CONCLUSIONS: In the authors' experience, there is no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap and the free DIEP flap. Thus, the authors advocate using the most expeditious and reliable flap based on the vascular anatomy of the DIEP system.

Management of alveolar clefts.

The management of alveolar clefts has changed through the years as medical knowledge has improved. An alveolar cleft is the result of abnormal primary palate formation during weeks 4 to 12 of gestation. The rationale for its closure includes 1) stabilizing the maxillary arch, 2) permitting support for tooth eruption, 3) eliminating oronasal fistulae, and 4) providing improved esthetic results. Methods for closure of the alveolar cleft have been solidified during the last century with the use of bone grafting. Secondary bone grafting is now the preferred method of treatment, because early grafting has proven detrimental to midfacial growth. Various materials for bone grafting have been proposed, including iliac crest, cranium, tibia, rib, and mandibular symphysis. Regardless of the timing and materials used, the main principles in approaching alveolar clefts have been well described. They include 1) appropriate flap design, 2) wide exposure, 3) nasal floor reconstruction, 4) closure of oronasal fistula, 5) packing bony defect with cancellous bone, and 6) coverage of bone graft with gingival mucoperiosteal flaps. Certain alveolar clefts are difficult to manage by grafting alone, and orthodontic preparation may be required. Complications of alveolar bone grafts include donor site morbidity as well as graft exposure and loss.

Aesthetic outcomes in patients undergoing breast conservation therapy for the treatment of localized breast cancer.

Localized breast cancer can be treated with lumpectomy and postoperative radiation therapy, also called breast conservation therapy, with an efficacy equivalent to that of mastectomy. Reports evaluating the effects of radiotherapy suggested that breast conservation therapy had "acceptable" cosmetic outcomes; thus, posttreatment evaluation for aesthetic impact has not been instituted as a standard of care. More recent reports have suggested that the effect of breast conservation therapy on aesthetic outcome is not minimal and that patients may benefit from reconstructive consultation. The purpose of this study was to measure objectively the aesthetic change in women who undergo breast conservation therapy and whether the extent of change is significant enough (objectively and subjectively) to warrant plastic surgery consultation. The authors evaluated 21 patients who had undergone breast conservation therapy. Eleven non-breast cancer patients seeking plastic surgery consultation were used as controls. Standardized five-view photographs (frontal, left and right lateral, and left and right lateral oblique views) were obtained. Patient photograph sets were compiled and evaluated independently by eight reviewers (four surgeons, two nurses, and two medical students). Reviewers evaluated the photographs using the breast asymmetry score (score range, 0 to 9) assessing breast size, ptosis, nipple-areola position, shape, scar appearance, contour deformity, and skin changes. The authors considered 2 SD above the control mean as significant. Breast conservation therapy patients also completed a 15-item questionnaire targeting objective and subjective data about treatment-related breast change. Breast conservation therapy patients had an average treatment-related asymmetry score of 1.93, with 35 percent demonstrating significant change as compared with controls. Although most patients (86 percent) were satisfied with the cancer treatment outcome, all patients noted asymmetry. The authors' data indicate that breast conservation therapy can cause significant asymmetry; thus, an option for plastic surgery consultation as part of the treatment protocol is warranted.