The Medical Student Race to Research: Who Presents More at National Plastic Surgery Conferences?

BACKGROUND: presentations increase research output and facilitate networking for medical students applying to plastic surgery. We aim to determine predictors of increased medical student presentation at national plastic surgery conferences, identifying disparities in access to research opportunities. METHODS: Abstracts presented at the 2 most recent meetings of the American Society of Plastic Surgeons, American Association of Plastic Surgeons, and Plastic Surgery Research Council were extracted from online archives. Presenters without MDs or other professional credentials were classified as medical students. Presenter gender, medical school ranking, plastic surgery division/department, National Institutes of Health funding, number of total and first-author publications, H-index, and research fellowship completion status were recorded. Students with 3 or more (>75th percentile) presentations were compared with those with less by χ2 tests. Univariate and multivariable regressions identified factors associated with 3 or more presentations. RESULTS: Of 1576 abstracts, 549 (34.8%) were presented by 314 students. The gender distribution was 46.5% male and 53.5% female. Most were from the Northeast (36.9%), 35% came from top 20 medical schools, and 85% attended schools with home plastic surgery programs. While 61.8% presented once, 14.6% presented 3 or more times. Those who previously presented, completed research fellowships or had more publications or higher H-indices were likely to present more ( P ≤ 0.007). On multivariable-adjusted analysis, completing research fellowships (odds ratio [OR], 2.34-2.52; P = 0.028-0.045), affiliation with institutions having higher National Institutes of Health funding (OR, 3.47-3.73; P = 0.004-0.006), or having more total number of publications (OR, 3.81; P = 0.018) or first-author publications (OR, 3.84; P = 0.008) was associated with 3 or more presentations. Presenter gender, geographic region, medical school ranking, home program status, and H-indices were not significant predictors on multivariable analysis. CONCLUSIONS: There are several potential inequities in access to research opportunities for medical students, disadvantaging those with less well-funded plastic surgery programs and existing research experience. Improving the equitability of these opportunities is crucial for limiting bias in trainee recruitment and diversifying representation in the field.

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.

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center.

STUDY DESIGN: Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient. OBJECTIVES: The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management. METHODS: Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded. RESULTS: Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair. CONCLUSIONS: Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.

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.

Assessment of Panfacial Fractures in the Pediatric Population.

PURPOSE: Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population. PATIENTS AND METHODS: We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected. RESULTS: We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival-or before arrival-at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died. CONCLUSIONS: Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.

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.

Pediatric Facial Fractures: An Assessment of Airway Management.

Pediatric facial fractures present unique and challenging management considerations, especially with regards to airway management. Anatomical differences in children increase both airway resistance and the difficulty of intubation. A surgical airway may be required if intubation is unable to be performed. The purpose of this study was to examine a single center's experience with pediatric facial fractures to determine the frequency of advanced airway use, as well as the risk factors that may predispose a patient to requiring an advanced airway. A retrospective review of all facial fractures at a level 1 trauma center was performed from 2000 to 2012. Patients age 18 years and younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, services consulted, and surgical management strategies. Information was collected regarding the need for an advanced airway, including intubation and the need for a surgical airway. A total of 285 patients met inclusion criteria. Of these, 57 patients (20%) required emergency intubation and 5 (1.8%) required a surgical airway. Intubation was significantly related to fractures of the midface, frontal sinuses, spine, skull, and pelvis, as well as depressed Glasgow coma scores and traumatic brain injury. The need for a surgical airway is extremely uncommon (1.8%), and tracheostomy was only needed in the setting of penetrating head trauma. Both emergent intubation and tracheostomy are associated with complications, but these complications must be weighed against the potentially life-saving measure of securing an airway.

A look inside the courtroom: an analysis of 292 cosmetic breast surgery medical malpractice cases.

BACKGROUND: Malpractice claims affect the cost and quality of health care. OBJECTIVE: The authors examine litigation in cosmetic breast surgery and identify factors influencing malpractice litigation outcomes. METHODS: The Westlaw database was searched for jury verdict and settlement reports related to medical malpractice and cosmetic breast surgeries. Cases included for analysis were examined for year, geographic location, patient demographics, procedure performed, alleged injury, causes of action, verdict, and indemnity payments. RESULTS: Of 292 cases, the most common injury sustained was disfigurement (53.1%). Negligent misrepresentation had a 98% greater chance of resolution in favor of the plaintiff (relative risk [RR], 1.98; 95% confidence interval [CI], 1.41-2.79), and fraud had a 92% greater chance of disposition in favor of the plaintiff (RR, 1.92; 95% CI, 1.32-2.80). The most common causes of action cited were negligence (88.7%) and lack of informed consent (43.8%). One hundred sixty-nine (58.3%) cases resulted in favor of the defendant and 121 (41.7%) cases were disposed in favor of the plaintiff; 97 (33.4%) cases resulted in damages awarded and 24 (8.3%) cases resulted in settlement. No significant difference was found between the medians of indemnity payments awarded to plaintiffs ($245 000) and settlements ($300 000). CONCLUSIONS: Based on this study, negligent or intentional misrepresentation strongly favors plaintiffs in either awarded damages or settlements in cases of cosmetic breast surgery litigation. This study emphasizes that transparency and adequate communication are at the crux of the physician-patient relationship and are tools by which plastic surgeons may reduce the frequency of litigations, thereby containing health care costs at a minimum.

Beyond the operating room: a look at legal liability in body contouring procedures.

BACKGROUND: Malpractice claims affect the cost and quality of health care. OBJECTIVE: In this study, the authors examine legal litigation following body contouring surgery and identify factors influencing malpractice litigation outcomes. METHODS: The Westlaw legal database was searched for jury verdict and settlement reports related to body contouring procedures and medical malpractice. Cases included for analysis were examined for year of report, geographic location, patient demographics, procedure performed, alleged injury, causes of action, verdict, and indemnity payments. RESULTS: Of 113 cases, the most common injuries sustained were disfigurement (33.6%) and the necessitation of a revision procedure (33.6%). The most common cause of action cited was negligence (84.1%). Median plaintiff ages differed significantly (P = .003) between cases favoring the defendant (44.5 years) and those favoring the plaintiff (36 years). Of the alleged injuries, those cases citing an iatrogenic injury were 2.5 times more likely to result in either damages awarded or settlement (relative risk [RR], 2.5; 95% confidence interval [CI], 1.66-3.80). Cases that cited disfigurement were 87% more likely to result in damages awarded to the plaintiff (RR, 1.87; 95% CI, 1.08-3.26). CONCLUSIONS: Based on this study of body contouring litigation, younger plaintiff age and iatrogenic injury strongly favored plaintiffs in either awarded damages or a settlement. Disfigurement favored plaintiffs only in awarded damages. Our study emphasizes the need for adequate communication with the patient explaining realistic aesthetic results and risks of the procedure. In addition, iatrogenic organ injury must be handled expeditiously. Incorporating these recommendations into clinical practice may promote an improved physician-patient relationship while reducing litigatious health care costs.

Racial disparities in the monitoring of patients on chronic opioid therapy.

Despite well-documented racial disparities in prescribing opioid medications for pain, little is known about whether there are disparities in the monitoring and follow-up treatment of patients who are prescribed opioid medications. We conducted a retrospective cohort study to examine whether there are racial differences in the use of recommended opioid monitoring and follow-up treatment practices. Our sample included 1646 white and 253 black patients who filled opioid prescriptions for noncancer pain for ≥ 90 consecutive days at the Veterans Affairs Pittsburgh Healthcare System pharmacy in fiscal years 2007 and 2008. Several opioid monitoring and follow-up treatment practices were extracted from electronic health records for a 12-month follow-up period. Findings indicated that 26.3% of patients had opioid agreements on file, pain was documented in 71.7% of primary care follow-up visits, urine drug tests were administered to 49.3% of patients, and 21.2% and 4.2% of patients were referred to pain and substance abuse specialists, respectively. Racial differences were observed in several of these practices. In adjusted comparisons, pain was documented less frequently for black patients than for white patients. Among those who had at least 1 urine drug test, black patients were subjected to more tests, especially if they were on higher doses of opioids. Compared with white patients, black patients were less likely to be referred to a pain specialist and more likely to be referred for substance abuse assessment. Addressing disparities in opioid monitoring and follow-up treatment practices may be a previously neglected route to reducing racial disparities in pain management.