A national analysis of burn injuries among homeless persons presenting to emergency departments.

INTRODUCTION: Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs). METHODS: Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling. RESULTS: Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021). CONCLUSION: Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

Travel distance and national access to gender-affirming surgery.

BACKGROUND: Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location. METHODS: Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery. RESULTS: Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014. CONCLUSION: Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.

The Geographical Impact of Plastic Surgery Residency to Fellowship and Residency/Fellowship to First Job Placement.

INTRODUCTION: The location of trainees' plastic surgery residency or fellowship has implications on their subsequent careers, which can inform future trainees and faculty decisions, and may affect access to care nationwide. This study explores historic geographic trends of the location where trainees complete residency or fellowship and where they pursue a fellowship program or first job. METHODS: Graduates from US integrated plastic surgery residency or fellowship programs from 2015 to 2021 were identified along with their proximity to fellowship or first job. Location was categorized based on whether the graduate's fellowship/first job location to residency/fellowship was within 100 miles, the same state, the same geographic region, the United States, or international. A χ2 value was calculated to determine the significance of relative geographical location after training. RESULTS: Three hundred sixty-five graduates that attended fellowship were included, representing 76.5% (65/85) of integrated plastic surgery residency programs. There were 47.7% (n = 174) that stayed within the same geographic region and 3.6% (n = 13) pursued training internationally. The location of the residency or fellowship program appears to have an influence on the location of the graduate's fellowship or first job. CONCLUSION: Graduates who completed integrated residency or fellowship in a certain geographic location were more likely to stay in that area for their fellowship or first job. This may be explained by graduates continuing training with their original program, the established network, and personal factors such as family and friends.

Is Plastic Surgery Training Equitable? An Analysis of Health Equity across US Plastic Surgery Residency Programs.

Achieving health equity includes training surgeons in environments exemplifying access, treatment, and outcomes across the racial, ethnic, and socioeconomic spectrum. Increased attention on health equity has generated metrics comparing hospitals. To establish the quality of health equity in plastic and reconstructive surgery (PRS) residency training, we determined the mean equity score (MES) across training hospitals of US PRS residencies. Methods: The 2021 Lown Institute Hospital Index database was merged with affiliated training hospitals of US integrated PRS residency programs. The Lown equity category is composed of three domains (community benefit, inclusivity, pay equity) generating a health equity grade. MES (standard deviation) was calculated and reported for residency programs (higher MES represented greater health equity). Linear regression modeled the effects of a program's number of training hospitals, safety net hospitals, and geographical region on MES. Results: The MES was 2.64 (0.62). An estimated 5.9% of programs had an MES between 1-2. In total, 56.5% of programs had an MES between 2 and 3, and 37.7% had an MES of 3 or more. The southern region was associated with a higher MES compared with the reference group (Northeast) (P = 0.03). The number of safety net hospitals per program was associated with higher MES (P = 0.02). Conclusions: Two out of three programs train residents in facilities failing to demonstrate high equity healthcare. Programs should promote health equity by diversifying care delivery through affiliated hospitals. This will aid in the creation of a PRS workforce trained to provide care for a socioeconomically, racially, and ethnically diverse population.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis.

BACKGROUND: Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. CONCLUSION: Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery.

BACKGROUND: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing. METHODS: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals. RESULTS: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed. CONCLUSIONS: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.

Global Health Microsurgery Training With Cell Phones.

BACKGROUND: Lack of surgical care for trauma, burns, congenital anomalies, and other surgical diseases is a growing portion of global disability and death accounting for 30% of the global disease burden. Global surgical and anesthesia care aim to achieve excellence and equality of clinical care through leadership, innovation, teaching, research, and advocacy. Stanford University Division of Plastic Surgery faculty partnered with ReSurge International to teach reconstructive microsurgery in low- and middle-income countries. CHALLENGE: Global surgery teaching and training are challenged by limited resources. Surgical loupes and operating microscopes used to perform complex microsurgery magnify the surgical field are very expensive. Our goal was to identify low-cost alternatives to teach and practice microsurgery suturing. INNOVATION: Use cell phone camera with zoom capacity to teach and practice microsurgery suturing. RESULTS: Cell phones with zoom feature are widely available even in low- and middle-income countries. A cell phone was placed on a stand over a microsurgery practice station. The camera was used to zoom and focus on the suturing station to mimic a surgical field with loupes or microscope magnification. Nine attending surgeons and 7 residents practiced microsurgery with microsurgical instruments and 9-0 nylon suture under the magnification of a cell phone camera. The Stanford Microsurgery and Resident Training Scale was used to track their progress. A feedback survey was given to the participants to identify the usefulness of the cell phone setup for microsurgery suture practice. CONCLUSIONS: Global surgery teaching and training face many challenges especially limited resources. Identifying low-cost alternative is crucial. Cell phone camera with zoom is a low-cost alternative to loupes or operating microscope for microsurgical teaching and training.

An Evaluation of the Utility of the Breast Reconstruction Risk Assessment Score Risk Model in Prepectoral Tissue Expander Breast Reconstruction.

INTRODUCTION: Individualized postsurgical risk assessment models provide surgeons and patients with information that is vital to the surgical decision-making process. One such tool, the Breast Reconstruction Risk Assessment (BRA) score, uses a limited selection of patient-specific factors to predict 30-day postsurgical risk of surgical site infection, seroma, dehiscence, reoperation and explantation associated with immediate submuscular tissue expander breast reconstruction. This model's performance in prepectoral tissue expander reconstruction has not been previously reported. Here, we evaluate the performance of the BRA score model in a population of patients who underwent immediate prepectoral tissue expander breast reconstruction. MATERIALS AND METHODS: A retrospective chart review was conducted of prepectoral breast reconstructions performed in 2 institutions between January 2017 and December 2018. Complications occurring within 30 days postoperatively were documented and compared with the BRA score predicted risk for each patient. RESULTS: Overall 247 patients (average age, 49.2 years) were included in the study. The mean BRA score predicted 30-day risk of a complication was 13.0% (7.5-41.5%). The observed rate of 30-day postoperative complications was 31.2% (77 patients), though only 36 (14.6%) patients had complications included in the model. The remaining patients experienced skin necrosis or hematoma as their only early complication. The 30-day BRA score model demonstrated good fit for the overall occurrence of any of the BRA score predicted complications (Hosmer-Lemeshow 0.7167), though the model discrimination was poor (C statistic <0.60). Notably, half of the 30-day postsurgical complications observed in this study were due to skin necrosis, a complication not currently included in the 30-day BRA score model. CONCLUSIONS: Our results indicate that the current 30-day BRA score model may have poor predictive value in prepectoral breast reconstruction. The most common early complication observed, skin necrosis, is not currently included in the model, suggesting that caution should be applied when using this risk predictive calculator as an adjunct to patient evaluation and counseling.

Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures.

BACKGROUND: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures. OBJECTIVES: The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis. METHODS: The "related queries" feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. RESULTS: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: "eyelid plastic surgery" (ASPS R2 = 0.336, P = 0.048; ASAPS R2 = 0.661, P = 0.001); "facelift" (ASPS R2 = 0.767, P ≤ 0.001; ASAPS R2 = 0.767, P = 0.001); "lip injections" (ASPS R2 = 0.539, P = 0.007; ASAPS R2 = 0.461, P = 0.044); and "rhinoplasty surgery" (ASPS R2 = 0.797, P ≤ 0.001; ASAPS R2 = 0.441, P = 0.01). Several search terms demonstrated no significant relationships or were significant with only one database. CONCLUSIONS: GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

Using Mesh to Reinforce the Abdominal Wall in Abdominal Free Flaps for Breast Reconstruction: Is There a Benefit? What are the Risks?

INTRODUCTION: Abdominal wall integrity may be compromised after abdominal flap harvest for breast reconstruction, leading to bulging or herniation due to weakening of the abdominal wall and dissection through the rectus muscle. Mesh can be used to reinforce the abdominal wall to reduce the risk of hernia formation postoperatively, especially in patients who may be at high risk. In this study, we describe this institution's experience with the use of mesh in the abdominal wall and critically evaluate its impact on patient outcomes and complications. METHODS: We retrospectively reviewed all patients with an abdominal free flap harvested for breast reconstruction at Stanford Health Care from 2005 to 2015. Multivariate-adjusted logistic regression analysis was used to compare the odds of abdominal complications-infection, bulging, and herniation-between patients with and without an abdominal mesh implanted during breast reconstruction. RESULTS: Three hundred eighty patients met inclusion criteria. One hundred sixty-one patients received mesh, whereas 219 received no reinforcement. In the mesh group, there were 7 (4.3%) cases of postoperative abdominal bulging, 11 (6.8%) cases of abdominal infection, and no (0.0%) cases of herniation. In the group without mesh, there were 17 (7.8%) cases of abdominal bulging, 11 (5.0%) cases of abdominal infection, and 5 (2.3%) cases of herniation. There was a significant difference in the odds of bulging (odds ratio [OR], 0.30; P = 0.01). There was not a significant difference in the odds of herniation (OR, 2.26E-10; P = 0.99) or infection (OR, 1.21; P = 0.69). CONCLUSIONS: In our current treatment algorithm, patients who received mesh were selected based upon several criteria, including obesity, weak fascia identified during surgery, and extensive muscle dissection. We confirm that the risk of bulging and herniation is decreased in patients receiving mesh. Furthermore, the risk of wound infection was not associated with the use of mesh; instead, a patient's elevated body mass index, as well as tension of closure, and other comorbidities are more likely causes of superficial wound complications. We find the use of mesh to be safe and beneficial in select patients undergoing abdominal free flap breast reconstruction who are at risk for hernias and bulges.

Quality Measures in Breast Reconstruction: A Systematic Review.

BACKGROUND: The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development. METHODS: We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality. RESULTS: We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures. CONCLUSIONS: Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.