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.

Are Opioids Out? Assessing Prescription Patterns in Plastic Surgery Using Medicare Part D Beneficiary Data.

INTRODUCTION: Since 1999, nearly 841,000 individuals have died from overdoses, 29% involving prescription opioids. Use of opioids for postoperative pain lacks evidence-based guidelines, and despite studies showing the efficacy of nonopioid agents in reducing postoperative morbidity, opioids are still routinely prescribed. However, multiple states are adopting prescription drug monitoring programs and prescription drug laws. The authors sought to investigate recent opioid prescription patterns among plastic surgeons. METHODS: This cross-sectional study used "Medicare Provider Utilization and Payment Data: Part D Prescriber" provided by the Centers for Medicare & Medicaid Services from 2016 to 2018. Entries were filtered to include plastic surgeons. Demographic variables included surgeon sex, geographic region and state, board certification status, and length of experience. The surgeon's practice was designated as academic, private, or both. Outcomes included total opioid claims, opioid prescriber rate, and days per claim. Kruskal-Wallis tests were used for statistical comparison (α = .05). RESULTS: From 2016 to 2018, plastic surgeons wrote 289,525 opioid prescriptions for 1,729,523 days (6.0 days per prescription), totaling $3,346,979.39. In 2018, 62.2% of plastic surgeons prescribed 0 to 10 opioids, 36.5% prescribed 11 to 50 opioids, and 1.3% prescribed more than 50. Furthermore, 99.5% of plastic surgeons prescribing opioids are practicing in metropolitan areas (rural-urban commuting area codes 1-3). Plastic surgeons who were male or were board certified had significantly lower opioid prescriber rates (P < 0.001). There were no significant variations in outcomes by length of surgeon experience. Geographic region was significantly associated with opioid prescription rates and days per claim, with Southern plastic surgeons having lower rates (P < 0.001) and those Northeastern ones prescribing shorter courses (P = 0.004). The number of opioid claims, days per claim, and opioid prescriber rates were all significantly lower in 2018 than in 2017 and 2016 (P < 0.001). CONCLUSIONS: Prescriptions written by plastic surgeons may have contributed to the opioid epidemic, but 2018 data suggest opioids are becoming less routine in postoperative pain control. Further studies are warranted to assess factors related to reduced and shorter opioid prescriptions by plastic surgeons in the South and Northeast, respectively. Such insight, if adopted into law and implemented into clinical practice, may help reduce the burden of the opioid epidemic.

How Comprehensive Are Aesthetic Surgery Fellowship Websites?

BACKGROUND: Fellowship programs heavily utilize websites in the recruitment of senior residents. Studies in subspecialty areas have demonstrated deficiencies in website content; however, no study has evaluated the websites of esthetic surgery fellowships. The recent establishment of the aesthetic fellowship match in 2018 highlights the need for accessible program information. OBJECTIVE: To assess the success in accessibility of educational and recruitment content of aesthetic surgery fellowship websites for prospective applicants. METHODS: Websites of aesthetic surgery fellowships were eligible for study inclusion. Aesthetic fellowship websites (AFWs) were evaluated for content regarding fellow education and fellow recruitment. Website content was analyzed using Fisher exact test and analysis of variance. RESULTS: Twenty-eight programs were compiled from the American Society of Aesthetic Plastic Surgery website. Regarding fellowship education, 35.7% of AFWs described operative experience and research requirements, and 28.6% of AFWs included information on didactics, but less than 11% outlined rotation schedules, annual meetings, or academic conferences. None listed fellow evaluation criteria. Regarding recruitment information, 85.7% of AFWs had program descriptions, but less than 33% listed affiliated hospitals, faculty, or current fellows. Of the 67.9% of AFWs that listed eligibility criteria, none listed selection criteria. When programs were stratified by the type of aesthetic training offered, fellowships that offered whole-body aesthetic training had significantly more recruitment content (P = 0.0394) on their websites than those specializing in facial aesthetics only. CONCLUSIONS: There is a paucity of information regarding recruitment and education on AFWs. Programs should strive to create a comprehensive website to better attract and assist residents applying for fellowship.

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.