Aesthetic Specialization: A Comparative Study Across Medical and Surgical Specialties.

BACKGROUND: Post-residency fellowship training has become increasingly popular as a career option. Specifically, the subspecialty of aesthetic surgery has grown tremendously over the past two decades within several fields, including plastic and reconstructive surgery (PRS), otolaryngology, dermatology, and ophthalmology. However, the popularity of aesthetic specialization through fellowship remains unknown. The present study aims to analyze trends in aesthetic specialization across these specialties and compare its popularity to other fellowships. METHODS: A retrospective review of data from the San Francisco Match, National Resident Matching Program, American Society for Dermatologic Surgery, and the Accreditation Council for Graduate Medical Education was performed. Data on graduating residents and applicants to fellowship were collected. ANOVA and t-tests were used to compare differences between groups. RESULTS: Significant disparities were observed in applicants and matched applicants to aesthetic fellowships among the four residencies (p<0.001). Aesthetic fellowship was the most popular option after otolaryngology residency (12.5%-27% depending on the year) and second most popular choice after PRS (8%-17%) and dermatology (2%-5%). A comparison between PRS and otolaryngology demonstrated a significantly higher percent of the latter choosing aesthetic fellowship over time (p<0.001). However, no significant difference in applicants to aesthetic fellowship was found between dermatology and ophthalmology (t-test, p=0.060). CONCLUSIONS: The number of applicants to aesthetic fellowship has increased over time across all eligible residencies with the more surgical heavy specialties (ENT and PRS) having the highest percent of applicants. Differences in aesthetic training between fields was also observed, which may reflect underlying variations in training and residency exposure.

The Statistical Fragility of Outcomes on Breast Reconstruction with Acellular Dermal Matrix: A Systematic Review of Randomized Controlled Trials.

INTRODUCTION: Acellular dermal matrix (ADM) is pivotal in breast surgery, yet the statistical robustness of surgical outcomes remains underexplored. This study employs the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to investigate the statistical fragility of ADM breast reconstruction outcomes. METHODS: Randomized controlled trials (RCTs) (2013-present) with dichotomous outcomes were sourced from PubMed, Embase, SCOPUS, Medline, and Cochrane databases. FI and rFI-event reversals needed to alter outcome significance-and FQ-standardized fragility across trials-were computed and reported as median (IQR). Subgroup analysis focused on intervention types. RESULTS: Out of 33 studies screened, 19 RCTs comprising 204 outcomes were included, with a median FI of 4 (3 - 5) and FQ of 0.039 (0.029 - 0.070). Twenty-six outcomes achieved statistical significance, with a median FI of 3.5 (1 - 5) and FQ of 0.033 (0.010 - 0.073). The remaining 178 outcomes were nonsignificant, exhibiting a median FI of 4 (3 - 5) and FQ of 0.040 (0.030 - 0.070). Of the 204 outcomes, 18% had a number of patients lost to follow up equal to or surpassing the FI. By intervention type, the median FIs were similar in value but remained low. CONCLUSION: ADM-related breast reconstruction outcomes are statistically fragile, so reversal of a few outcomes or maintaining follow-up with patients may alter the significance of findings. Future researchers are thus recommended to report FI and FQ metrics with P-values to accurately portray reconstructive surgery outcomes.

"The Association of a Research Year With Matching Into an Integrated Plastic Surgery Residency".

INTRODUCTION: The relationship between pursuing a research year (RY) and plastic surgery match outcomes is unclear. The present study investigated the association between a dedicated RY and the odds of matching into an integrated Plastic and Reconstructive Surgery (PRS) residency program. METHODS: Electronic Residency Application Service applications to an integrated PRS residency program from 2017 to 2021 were evaluated. Match results were determined using online public sources. Students who had taken a RY were compared with those who had not (traditional). The relationship between pursuing a RY and matching was determined with logistic regression analyses. RESULTS: In total, 974 applicants were included, of which 191 (20%) completed an RY. The RY group had significantly higher match rates (83% versus 74%, P = 0.008), more presentations (13 versus 5, P < 0.001), and more publications (11 versus 4, P < 0.001) than the traditional group. The RY group was 80% more likely to match than the traditional group (adjusted odds ratio [OR] = 1.8, P = 0.016). However, this benefit was eliminated after controlling for the number of publications. Subgroup analysis revealed that applicants who completed an RY had increased odds of matching into a top 20 PRS residency program (OR = 2.2, P < 0.001), with the strongest association observed among applicants with 15+ (OR = 2.6, P < 0.001) or 20+ publications (OR = 4.1, P < 0.001). CONCLUSIONS: An RY is associated with 80% higher odds of matching and an increased number of publications. RYs seem to be most associated with benefits for applicants aiming to increase their publication numbers or to match into a top 20 residency program.

Understanding the role of intraoperative hypothermia in perioperative opioid requirements in immediate implant-based breast reconstruction.

BACKGROUND: The relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction. METHODS: A retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure <36.0 °C) or normothermic group (majority of procedure ≥36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring "high-dose opioids" (≥100 MMEs) were collected and compared between the groups. RESULTS: In total, 536 patients (835 breasts) were included, among whom 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs. 99.1 MMEs, P = 0.007) and postoperative (45.6 vs. 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007). CONCLUSION: Hypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.

Neighborhood Deprivation is Associated With Increased Postoperative Complications After Implant-Based Breast Reconstruction.

PURPOSE: The Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction. PATIENTS AND METHODS: Patients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: "High ADI" (6-10) and "Low ADI" (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models. RESULTS: In total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05). CONCLUSION: Patients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction.

Nonsyndromic Craniosynostosis Correlation Between Ethnicity, Race, and Pattern of Affected Suture Type: Meta-Analysis.

BACKGROUND: Previous studies have sought to analyze risk factors associated with craniosynostosis and while syndromic craniosynostosis is often linked to genetic mutations, the factors impacting nonsyndromic cases are less investigated. The aim of current meta-analysis is to evaluate the relationship between ethnicity and suture type in nonsyndromic craniosynostosis patients. METHODS: The search term "craniosynostosis [Title/Abstract] AND (race [Title/Abstract] OR ethnicity [Title/Abstract])) NOT (syndrome [Title/Abstract])" was used to search the PubMed, Cochrane, and MEDLINE databases. Analyses were conducted separately for each racial and ethnic group for each suture type cohort. Odds ratios were conducted for each suture cohort and confounders were adjusted using linear mixed-effect models. Because of the homogeneity of the populations and categorical nature of the classification, binary logistic regression was run on aggregate data. RESULTS: The literature search yielded 165 articles. After reviewing titles, abstracts, and manuscript contents of these articles, 5 studies were ultimately included in a meta-analysis. Studies with missing data for a particular cohort or variable were excluded from the respective analysis. Hispanic children had higher odds of sagittal suture involvement (OR: 1.53, P <0.001), whereas Asian had coronal suture (OR: 2.47, P <0.001). Both Asian and African American children had significantly lower odds of sagittal suture involvement (OR: 0.50, P <0.001 and OR: 0.7, P =0.04, respectively). CONCLUSION: The relationship between ethnicity and craniosynostosis has been suggested as a risk factor, but without definitive conclusion. Present meta-analysis findings demonstrated association between ethnicity and suture type, however further research with larger scale and geographically varied data is warranted.

Underrepresented in Medicine Applicants are Less Likely to Successfully Match into Plastic Surgery.

IMPORTANCE: The lack of underrepresented in medicine physicians in academic plastic surgery has been a topic of interest for many years, and accordingly outreach has been undertaken to address the pipeline from medical school to residency and beyond. OBJECTIVE: This study aims to assess and identify the characteristics associated with plastic surgery match success for underrepresented in medicine applicants. DESIGN: Residency application data for first time, US allopathic medical school seniors from the 2017-2018 to 2021-2022 applicant cycles were abstracted from Electronic Residency Application Service applications, and match results were determined using the National Residency Matching Program database and online public sources. Data included self-reported race, and multiple application characteristics. Multivariable logistic regression of application characteristics were used to assess the relationship between underrepresented in medicine status and successfully matching. Binary logistic regression was used in subgroup analyses of each application characteristic, and interactions regression was used to evaluate the relative weight of each characteristic on successfully matching. RESULTS: Underrepresented in medicine applicants were 57% less likely to match than non-underrepresented in medicine applicants (OR 0.43, p = 0.001), though they were 60% less likely to match (ORadj 0.4, p = 0.216) when adjusted. Subgroup analysis revealed that odds of matching as an underrepresented in medicine applicant were significantly increased if the applicant had a home program, took a research year, and had an increased number of published research and presentations (ORs 0.43-0.48, all p < 0.05). Odds of matching as an underrepresented in medicine applicant were significantly decreased if the applicant went to a medical school ranked in the highest or lowest third (ORs 0.41-0.42, all p < 0.01); however, on interaction regression the odds of matching from a highly ranked medical school was increased (OR 3.5, 95% CI 0.98-12.55, p = 0.05). CONCLUSIONS: The likelihood of matching as an underrepresented in medicine applicant is lower than the rest of the applicant population, and there are no individual applicant characteristics that can increase these odds to equal that of the general applicant population.

Litigation in gender affirming surgery: Reviewing five decades of the medical malpractice landscape.

The present study sought to analyze malpractice cases related to gender affirming surgery to provide information to physicians as it may serve to minimize the risk of malpractice suits. The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to gender affirming surgery malpractice lawsuits. A total of 26 cases were identified between 1970 and 2020, five of which were determined relevant on further review. Motives included adverse surgical and medical outcomes, and failure to treat. All cases were decided in favor of the defendant and resulted in $0 compensatory damages.

Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis.

BACKGROUND: Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS: The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS: The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION: The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.

An Analysis of Medical Malpractice Litigation Involving Orbital Fractures.

BACKGROUND: Orbital fractures frequently require operative management by a plastic and reconstructive surgeon. Due to the proximity to the globe and complexity of the reconstruction, orbital fractures, and related procedures have the potential to be a source of medical litigation. The aim of the present study was to review orbital fracture malpractice litigation, including case outcomes and compensatory damages. METHODS: The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to orbital fracture malpractice lawsuits. The Boolean terms included "orbit! /10 fracture," "orbit! & fracture," and "ocular & fracture" for both databases. Cases were included if they were state or federal cases related to both orbital fracture and medical malpractice involving surgical or medical mismanagement or misdiagnosis of orbital fracture. RESULTS: A total of 49 cases from 1994 to 2018 met inclusion criteria between the databases. The most common legal complaint was the defendant's failure to make a diagnosis either by not ordering the proper radiological tests or by not interpreting radiological tests correctly, seen in 35% of cases. In 57% of the cases, the defendant was a surgeon, 46% of which involved a plastic surgeon specifically. Cases were resolved in favor of the defendant 49% of the time. Most cases (57%) resulted in a monetary outcome of $0. However, cases that were decided in favor of the plaintiff had significant compensatory damages with the majority being over $100,000, and 1 case as high as $8 million. CONCLUSION: Although almost half of the orbital fracture malpractice cases resulted in an outcome favoring the defendant, significant monetary consequences against the defendant were possible in cases when the plaintiff prevailed.

Statistical fragility of outcomes in acellular dermal matrix literature: A systematic review of randomized controlled trials.

BACKGROUND: Acellular dermal matrix (ADM) is commonly used in plastic and reconstructive surgery. With the abundance of randomized controlled trials (RCTs) reporting P-values for ADM outcomes, this study used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate the statistical stability of the outcomes in ADM RCTs. METHODS: PubMed, Embase, SCOPUS, Medline, and Cochrane databases were reviewed for ADM RCTs (2003-present) reporting a dichotomous, categorical outcome. FI and rFI (event reversals influencing outcome significance) and FQ (standardized fragility) were calculated and reported as median. Subgroup analysis was performed based on intervention types. RESULTS: Among the 127 studies screened, 56 RCTs with 579 outcomes were included. The median FI stood at 4 (3-5) and FQ was 0.04 (0.03-0.07). Only 101 outcomes were statistically significant with a median FI of 3 (1-6) and FQ of 0.04 (0.02-0.08). The nonsignificant outcomes had a median FI of 4 (3-5) and FQ of 0.04 (0.03-0.07). Notably, 26% of the outcomes had several patients lost to follow up equal to or surpassing the FI. Based on the intervention type, the median FIs showed minor fluctuations but remained low. CONCLUSIONS: Outcomes from ADM-related RCTs were statistically fragile. Slight outcome reversals or maintenance of patient follow-up can alter the significance of results. Therefore, future researchers are recommended to jointly report FI, FQ, and P-values to offer a comprehensive view of the robustness in ADM literature.

Never events in plastic surgery: An analysis of surgical burns and medical malpractice litigation.

INTRODUCTION: Burns and fires in the operating room are a known risk and their prevention has contributed to many additional safety measures. Despite these safeguards, burn injuries contribute significantly to the medical malpractice landscape. The aim of the present study is to analyze malpractice litigation related to burn and fire injuries in plastic and reconstructive surgery, identify mechanisms of injury, and develop strategies for prevention. METHODS: The Westlaw and LexisNexis databases were queried for jury verdicts and settlements in malpractice lawsuits related to burn and fire injuries that occurred during plastic surgery procedures. The Boolean terms included "burn & injury & plastic", "fire & injury & "plastic surg!"" in Westlaw, and "burn & injury & "plastic surg!"", "fire & injury & "plastic surg!"" in LexisNexis. RESULTS: A total of 46 cases met the inclusion criteria for this study. Overheated surgical instruments and cautery devices were the most common mechanisms for litigation. Plastic surgeons were defendants in 40 (87%) cases. Of the included cases, 43% were ruled in favor of the defendant, while 33% were ruled in favor of the plaintiff. Mishandling of cautery devices 6 (13%), heated surgical instruments 6 (13%), and topical acids 2 (4%) were the most common types of errors encountered. CONCLUSION: Never events causing burn injury in plastic and reconstructive surgery are ultimately caused by human error or neglect. The misuse of overheated surgical instruments and cauterizing devices should be the focus for improving patient safety and reducing the risk of medical malpractice. Forcing functions and additional safeguards should be considered to minimize the risk of costly litigation and unnecessary severe harm to patients.

Surgery or Not? A Systematic Review of Facial Congenital Melanocytic Nevi Treatment Patterns and Outcomes.

BACKGROUND: Treatment management for congenital melanocytic nevi (CMN) on the face (FCMN) is highly variable and requires a thorough assessment of multiple factors. To date, a systematic review of FCMN treatment is lacking. The purpose of the present study was to elucidate the frequency, variety, and outcomes of treatment modalities for FCMN with different levels of complexity. METHODS: A comprehensive review of Pubmed, Embase, and Google Scholar databases from 1950 to 2022 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles reporting on FCMN treatment approaches, outcomes, and associated complications were screened and data were extracted according to inclusion criteria. Data were tabulated for thematic analysis of FCMN treatment types, anatomic locations, outcomes, and complications. RESULTS: Of the 561 studies retrieved, 34 met inclusion criteria including 19 surgical treatments, 14 nonsurgical treatments, and one combined surgical and nonsurgical treatment study, totaling 356 patients. The majority of treated FCMN were small-to-medium-sized (56%). Facial CMN treated conservatively were mostly located on the cheek (27%) and/or perinasal region (21%), whereas FCMN treated with surgery were primarily located in the periorbital region (44%) and/or the cheek (17%). Across all treatment cohorts, 22% of patients experienced at least one complication, with 12% of complications experienced by patients treated by surgery. CONCLUSIONS: There is a greater need for standardized FCMN nomenclature that encompasses nevi pattern, dimensions, anatomical coverage, and quantitative measurements of treatment outcome. Future studies should focus on identifying anatomic locations of FCMN that are more prone to complications and determine which treatment approach optimizes outcomes.

Contextualizing the Impact of Pop Culture on Breast Implant Illness and its Medical Relevance.

INTRODUCTION: Despite a lack of data demonstrating causation, there is growing concern over breast implants and systemic illness. This study examines the impact of rising public interest in breast implant illness (BII) and its implications on breast implant removals (BIR). METHODS: A Google Trends (GT) analysis of each year between 2010 and 2022 was performed globally, and then separately for the United States alone (US), using the search terms "capsular contracture," "breast implant illness," and "breast implant(s) removal". Linear regression was performed to determine significant correlations. Data on BII-related Facebook advocacy groups, relevant pop culture events, numbers of BIR surgeries, and number of BII-related publications were collected and analyzed alongside GT data to determine relevance. RESULTS: For global GT, there was a significant relationship between "breast implant illness" and "breast implant(s) removal" in 2016 (R2=0.62, ß =0.33, p<0.01), 2020 (R2=0.53, ß =0.23, p=0.01), and 2022 (R2=0.60, ß =0.44, p=0.01). In the US, 2016 (R2=0.53, ß =1.75, p=0.01) 2018 (R2=0.61, ß =1.93, p<0.01) and 2020 (R2=0.72, ß=0.91, p<0.01) were significant. In 2020, "capsular contracture" and "breast implant(s) removal" was significant in the US (R2=0.58, ß=0.4, p=0.01). In 2016, Facebook was the platform for the largest BII advocacy group and in 2020 YouTube was the platform for the first BII documentary and TEDx talk. From 2010 to 2020, PubMed publications containing "ASIA" and "BII" increased 24-fold and ASPS reports on BIR rose 70%. CONCLUSION: This study suggests that BII is a topic of global concern and has implications on both academic medicine and clinical practice. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Are Gender-Affirming Plastic Surgeons Adequately Compensated? An Analysis of Relative Value Units.

BACKGROUND: Gender-affirming surgery (GAS) has a complicated history within US health care. As GAS procedures and reimbursement availability continue to uptrend, the present study aims to investigate whether compensation is equitable between GAS procedures and general plastic surgery procedures. METHODS: The National Surgical Quality Improvement Program database was queried for all surgeries performed by plastic surgeons from 2016 to 2020. Cases were assigned to the GAS or non-GAS cohort using ICD-10 codes. Duplicate Current Procedural Terminology (CPT) codes were removed for analysis. Operative time, total wRVUs, wRVUs per hour (wRVU/h), reoperation/readmission rate, and number of concurrent procedures were compared between the cohorts. RESULTS: A total of 132,319 non-GAS and 3,583 GAS were identified. After duplicate CPT removal, 299 cases (21 unique CPTs) remained in the GAS cohort and 20,022 (37 unique CPTs) in the non-GAS cohort. Operative time was higher in the GAS cohort (262.9 vs 120.7 min, P < 0.001), as were total wRVUs (59.4 vs 21.6, P < 0.001). Reoperation/readmission rate (7.0% vs 6.0%) and wRVU/h (15.8 vs 15.1) were not significantly different (all P > 0.05). There was a positive correlation between total operative time and total wRVUs (P < 0.001) and a negative correlation between total operative time and wRVU/h (P < 0.001). CONCLUSIONS: Proportional wRVUs are allocated to gender affirming plastic procedures. However, the RVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries. Compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries; however, there is no difference in wRVUs per hour on comparison.