Balancing the Scales: Caution in Reduction Mammaplasty Recommendations for Obesity Class III Patients.

INTRODUCTION: The prevalence of obesity has risen worldwide, posing a problem to surgeons as obesity is a well-known risk factor for surgical outcomes. While prior studies have suggested performing reduction mammaplasty (RM) in patients with obesity, the variance in outcomes and quality of life (QoL) for obesity classes are ill-defined. We investigated whether obesity classes should be considered for RM by examining the surgical outcomes and QoL across different weight classes, aiming to pinpoint when outcomes become less favorable. METHODS: Patients undergoing RM by nine surgeons from 2016 to 2022 were included. Body mass index (BMI) cohorts were formed according to the Center for Disease Control and Prevention (CDC) guidelines: Healthy (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obesity class I (30-34.9 kg/m2), II (35-39.9 kg/m2), and III (>40 kg/m2). QoL was assessed by comparing preoperative and postoperative BREAST-Q scores within cohorts. A comparison analysis was performed between weight classes. RESULTS: A total of 461 RM patients were identified (healthy: 83, overweight: 178, I: 142, II: 39, III: 19). Percentage of Black patients, procedure length, weight of tissue removed, and inferior pedicle technique all significantly increased as BMI increased (P < 0.001). Higher BMI cohorts, especially class III, had significantly higher rates of surgical site infections (healthy: 0%, overweight: 1.1%, I: 1.4%, II: 0%, III: 15.8%, P < 0.01), fat necrosis (healthy: 1.2%, overweight: 5.1%, I: 7%, II: 0%, III: 22.2%, P = 0.01), dehiscence (healthy: 3.6%, overweight: 2.8%, I: 2.1%, II: 5.1%, III: 31.6%, P < 0.01), delayed healing (health: 4.8%, overweight: 11.2%, I: 16.9%, II: 28.2%, III: 42.1%, P < 0.01), minor T-point breakdown (healthy: 10.8%, overweight: 15.7%, I: 23.9%, II: 23.1%, III: 52.6%, P = 0.01), and surgical site occurrence requiring procedural intervention (healthy: 6.0%, overweight: 5.6%, I: 6.3%, II: 15.4%, III: 21.1%, P < 0.05). When compared to the other weight classes independently, class III was associated with unfavorable outcomes (P < 0.05). Significant improvement in average postoperative QoL scores in satisfaction with breast, psychosocial well-being, sexual well-being, and physical well-being were seen in all cohorts except class III (P < 0.05). CONCLUSIONS: Severe obesity class III patients undergoing RM have a higher yet still acceptable risk profile and should be counseled on the risks despite its improved quality of life.

Impact of High-Fidelity Microvascular Surgery Simulation on Resident Training.

BACKGROUND: Microsurgery requires a high level of skill achieved only through repeated practice. With duty-hour restrictions and supervision requirements, trainees require more opportunities for practice outside the operating room. Studies show simulation training improves knowledge and skills. While numerous microvascular simulation models exist, virtually all lack the combination of human tissue and pulsatile flow. METHODS: The authors utilized a novel simulation platform incorporating cryopreserved human vein and a pulsatile flow circuit for microsurgery training at two academic centers. Subjects performed a standardized simulated microvascular anastomosis and repeated this task at subsequent training sessions. Each session was evaluated using pre- and postsimulation surveys, standardized assessment forms, and the time required to complete each anastomosis. Outcomes of interest include change in self-reported confidence scores, skill assessment scores, and time to complete the task. RESULTS: In total, 36 simulation sessions were recorded including 21 first attempts and 15 second attempts. Pre- and postsimulation survey data across multiple attempts demonstrated a statistically significant increase in self-reported confidence scores. Time to complete the simulation and skill assessment scores improved with multiple attempts; however, these findings were not statistically significant. Subjects unanimously reported on postsimulation surveys that the simulation was beneficial in improving their skills and confidence. CONCLUSION: The combination of human tissue and pulsatile flow results in a simulation experience that approaches the level of realism achieved with live animal models. This allows plastic surgery residents to improve microsurgical skills and increase confidence without the need for expensive animal laboratories or any undue risk to patients.

Increased Patient Age as a Risk Factor Following Free Flap Reconstruction after Breast Cancer: A Single Institutional Review of 2,598 Cases.

BACKGROUND: Autologous breast reconstruction (ABR) after mastectomy is increasing due to benefits over implant-based reconstruction. However, free flap reconstruction is not universally offered to patients of advanced age due to perceived increased perioperative risk. METHODS: Patients undergoing free flap breast reconstruction at our institution from 2005 to 2018 were included. Risk-adjusted logistic regression models were fit while controlling for demographic and comorbid characteristics to determine the association of age with the probability of venous thromboembolism (VTE), delayed healing, skin necrosis, surgical site infection (SSI), seroma, hematoma, hernia, and flap loss. Linear predictions from risk-adjusted logistic regression models were used to create spline curves and determine the risk of outcomes associated with age. RESULTS: A cohort of 2,598 patients underwent free flap breast reconstruction in the period examined. The median age was 51 with approximately 9% of patients being 65 or older. Increased age was associated with a greater risk of delayed healing, skin necrosis, and hematoma after surgery. There was no increased risk of medical complications such as VTE or complications such as flap loss, seroma, or SSI. CONCLUSION: A set age cutoff for patients undergoing free flap breast reconstruction does not appear warranted. There is no difference in major surgical complications such as flap loss with increasing age. However, older age does predispose patients to specific wound complications such as hematoma, skin necrosis, and delayed wound healing, which should guide preoperative counseling. Further, medical complications do not increase with advanced age. Overall, however, the safety of ABR in older patients appears uncompromised.

The Impact of Breast Cancer Type, Staging, and Treatment on Vascular Complications of Immediate Free-Flap Breast Reconstruction.

BACKGROUND: Patients with advanced cancer staging have a greater risk of developing venous thromboembolism than noncancer patients. The impact of breast cancer stage and treatment on outcomes after autologous free-flap breast reconstruction (ABR) is not well-established. The objective of this retrospective study is to determine the impact of breast cancer characteristics, such as cancer stage, hormone receptor status, and neoadjuvant treatments, on vascular complications of ABR. METHODS: A retrospective review was conducted examining patients who underwent ABR from 2009 to 2018. Breast cancer stage, cancer types, hormone receptor status, and treatments were collected in addition to demographic data. Intraoperative vascular concerns, postoperative vascular concerns, and flap loss were analyzed. Univariate analysis and fixed-effects models were used to associate breast cancer characteristics with outcomes. RESULTS: Neoadjuvant hormone therapy was associated with increased risk for intraoperative vascular concern (odds ratio, 1.059 [ P = 0.0441]). Neoadjuvant trastuzumab was associated with decreased risk of postoperative vascular concern (odds ratio, 0.941 [ P = 0.018]). Breast cancer stage, somatic genetic mutation, receptor types, neoadjuvant chemotherapy, and neoadjuvant radiation had no effect on any vascular complications of ABR. CONCLUSION: Autologous free-flap breast reconstruction is a reliable reconstructive option for patients with all stages and types of breast cancer. There is potentially increased risk of intraoperative microvascular compromise in patients who have neoadjuvant hormone therapy. Trastuzumab is potentially protective against postoperative microvascular compromise. Patients should feel confident that, despite higher stage cancer, they can pursue their desired reconstructive option without fear of vascular compromise.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

OBJECTIVE: To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. BACKGROUND: IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. METHODS: A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. RESULTS: Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. CONCLUSIONS: Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies.

BACKGROUND: Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS: Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS: From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS: All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis.

ABSTRACT: It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x? = 2330.6 PMP), 28,004 surgeons (x? = 83.5 PMP), and 746 training positions (x? = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P   <  0.01), surgeon (70.8 versus 98.8, P  < 0.01), training positions (0 versus 3.4, P  < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P  < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P  < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS: Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS: One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION: The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.

Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. METHODS: A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. RESULTS: The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. CONCLUSIONS: Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

The Linton A. Whitaker Legacy: Cultivating Craniofacial Surgeon Leaders.

BACKGROUND: Linton A. Whitaker is a pioneer of craniofacial surgery. He served as chief of plastic surgery at the Children's Hospital of Philadelphia and University of Pennsylvania and director of the craniofacial training program. Herein, the authors reflect on his legacy by studying the accomplishments of his trainees. METHODS: Dr Whitaker's trainees who completed (a) craniofacial fellowship training while he was director of the program or (b) residency training while he was chief were identified. Curricula vitae were reviewed. Variables analyzed included geographic locations, practice types, academic leadership positions, scholarly work, and bibliometric data. RESULTS: Between 1980 and 2011, 34 surgeons completed craniofacial fellowship training under Dr Whitaker, and 11 completed plastic surgery training under his chairmanship and subsequent craniofacial fellowship. The majority had active craniofacial practices after training (83.3%) and practice in an academic setting (78.0%). Most settled in the northeast (31.1%) and south (31.1%) but across 24 states nationally. Overall, the mean ± SD number of publications was 76 ± 81 (range, 2-339); book chapters, 23 ± 29 (0-135); H-index, 18 ± 12 (1-45); and grants, 13 ± 16 (0-66). Of those who pursued academia, 53.1% were promoted to full professor, 46.9% had a program director role, 75.0% directed a craniofacial program, and 53.1% achieved the rank of chief/chair. CONCLUSIONS: Equally important to Dr Whitaker's clinical contributions in plastic and craniofacial surgery is the development and success of his trainees who will undoubtedly continue the legacy of training the next generation of craniofacial surgeon leaders.

Aesthetic Surgery in Plastic Surgery Academia.

BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson's chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

One-Year Health Care Utilization and Recurrence After Incisional Hernia Repair in the United States: A Population-Based Study Using the Nationwide Readmission Database.

BACKGROUND: Most data on health care utilization after incisional hernia (IH) repair are limited to 30-days and are not nationally representative. We sought to describe nationwide 1-year readmission burden after IH repair (IHR). METHODS: Patients undergoing elective IHR discharged alive were identified using the 2010-2014 Nationwide Readmission Database. Transfers and incomplete follow-up were excluded. Descriptive statistics were used to describe rates of 1-year readmission, IH recurrence, and bowel obstruction. Cox regression allowed identification of factors associated with 1-year readmissions. Generalized linear models were used to estimate predicted mean difference in cumulative costs/year, which allowed estimation of IHR readmission costs/year nationwide. RESULTS: Of 15,935 identified patients, 19.35% were readmitted within 1 y. Patients who were readmitted differed by insurance, Charlson index, illness severity, smoking status, disposition, and surgical approach compared with those who were not (P < 0.05). Of readmitted patients, 39.3% returned within 30 d; 50.9% and 25.6% were due to any and infectious complications, respectively; 25.6% presented to a different hospital; 35.4% required reoperation; 5.4% experienced bowel obstruction; and 5% had IHR revision. Factors associated with readmissions included Medicare (hazard ratio [HR] 1.46 [95% confidence interval 1.19-1.8]; P < 0.01) or Medicaid (HR 1.42 [1.12-1.8], P < 0.01); chronic pulmonary disease (1.38 [1.17-1.64], P < 0.01), and anemia (1.36, [1.05-1.75], P = 0.02). Readmitted patients had higher 1-year cumulative costs (predicted mean difference $12,190 [95% CI: 10,941-13,438]; P < 0.01). Nationwide cost related to readmissions totaled $90,196,248/y. CONCLUSIONS: One-year readmissions after IHR are prevalent and most commonly due to postoperative complications, especially infections. One-third of readmitted patients require a subsequent operation, and 5% experience IH recurrence, intensifying the burden to patients and on the health care system.

A Comparison of Case Volume in Craniofacial Surgery by Plastic Surgery Residency Training Model.

BACKGROUND: Plastic surgeons in the United States are trained under 2 residency training models: integrated and independent. This study analyzes the variability of craniofacial surgery cases performed both between and within training models. METHODS: Case volume data from national data reports of 5 plastic surgery resident cohorts were analyzed (2011-2015). Craniofacial surgery case volumes across 4 major categories and 23 subcategories were compared between training models via t tests. Differences in intramodel variability were compared with F tests. Fold differences were calculated between mean case volumes and minimum requirements in craniofacial surgery. RESULTS: A total of 526 independent/combined (64%) and 292 integrated (36%) plastic surgery residents were included. Integrated residents reported more cases classified as congenital defect (118.8 ± 49.3 vs 110.3 ± 42.9, P = 0.013), neoplasm (202.0 ± 79.7 vs 163.2 ± 60.8, P < 0.001), and trauma (149.0 ± 61.8 vs 127.0 ± 52.0, P < 0.001), but not aesthetic (122.3 ± 68.6 vs 116.5 ± 50.5, P = 0.201). Integrated residents reported more case volume in 12 case subcategories, whereas independent/combined residents reported more cases in 3 case subcategories. Integrated residents had greater intramodel variability in 12 case subcategories, whereas independent/combined residents had greater intramodel variability in 2 case subcategories. Fold differences between mean case volumes and minimum requirements ranged from 1.8 times to 6.0 times. CONCLUSIONS: Integrated residents tended to report significantly more craniofacial surgery cases and exhibit greater intrapathway variability. More research is needed to understand the impact of disparate case volume on core competency training in craniofacial surgery during plastic surgery residency.

An Update on Social Media in Academic Plastic Surgery Training Programs: The Rising Trend of Likes, Shares, and Retweets.

BACKGROUND: Increasing in popularity, social media provides powerful marketing and networking tools for private practice plastic surgeons. The authors sought to examine social media utilization by academic plastic surgery training programs. METHODS: Facebook, Instagram, and Twitter were queried for plastic surgery training program, program director, and chief/chair accounts. Training program posts were categorized as educational, operative, social, informational, self-promotional, visiting lecturer, research-related, and other. Factors influencing total number of followers were analyzed including number of accounts followed, frequency, total number, and types of posts as well as duration of account. Other variables included geographic location, 2018 to 2019 Doximity residency ranking, and US News and World Report rankings of affiliated hospital systems and medical schools. Social media accounts were analyzed using Kruskal-Wallis, Wilcoxon rank sum, and regression analysis. RESULTS: Facebook is the most popular social media platform among chiefs/chairs (34, 35.7%), followed by Instagram (20, 21.1%) and Twitter (19, 20.0%). Facebook is used more by program directors (31, 32.6%) followed by Instagram (22, 23.1%) and Twitter (15, 15.7%). The majority of Facebook and Twitter leadership accounts are for personal use (62%-67%), whereas Twitter is used primarily for professional purposes (60%-84%). Training program social media use is rising, with Instagram and Twitter presence growing at exponential rates (R = 0.97 and 0.97, respectively). Of 95 training programs evaluated, 54 (56.8%) have Instagram accounts, 29 (30.5%) have Facebook accounts, and 27 (28.4%) have Twitter accounts. Most training programs using social media have 2 or more accounts (37, 67.3%). West coast programs have more Instagram followers than other geographic regions, significantly more than Southern programs (P = 0.05). Program accounts with more followers are affiliated with top-ranked hospitals (P = 0.0042) or top-ranked Doximity training programs (P = 0.02). CONCLUSIONS: Similar to its adoption by private practice plastic surgery, social media use in academic plastic surgery is growing exponentially. Now, over half of residency programs have Instagram accounts. Program leaders are using Facebook and Instagram primarily for personal use and Twitter for professional use. Programs affiliated with a top-ranked hospital or ranked highly by Doximity have more followers on social media.

Are You Thinking About Going Back to School? An Analysis of Plastic Surgery Residents, Alumni, Faculty, and Program Leaders With Advanced Degrees.

BACKGROUND: The number of adults with master's, professional, and doctoral degrees has doubled since 2000. The relevance of advanced degrees in plastic surgery has not been explored. METHODS: Faculty, residents, and recent alumni with advanced degrees from the United States plastic surgery training programs were identified. Degrees were analyzed based on geography, program/hospital rankings, department versus division status, gender, leadership/editorial roles, private versus academic practice, subspecialization training, academic productivity/H-indices, and National Institutes of Health funding. RESULTS: A total of 986 faculties, 1001 residents, and 761 alumni credentials from 95 training programs were reviewed: 9.3% of faculties, 7.1% of residents, and 6.3% of alumni have advanced degrees, majority being men (71%). Residency programs ranked top 10 by Doximity or affiliated with a top 10 medical school/hospital have more faculty/residents/alumni with advanced degrees (P < 0.01). Faculty holding PhDs are less likely fellowship trained (52.5% versus 74.0%, P = 0.034). Master's in Business Administration (MBA) is associated with chair/chief status (30.0% versus 8.57%, P = 0.01) or other major academic title (eg, Dean, Director) (70.0% versus 37.14%, P = 0.01). No significant associations exist between degree type and professor status, research productivity, academic versus private practice, or subspecialization (eg, craniofacial surgery). CONCLUSION: The majority of plastic surgeons with advanced degrees have PhDs, although there is an increasing trend of other research degrees (eg, Master's in Public Health) in current trainees. MBA is associated with chair/chief status or other major academic title. Reasons for obtaining an advanced degree and impact on career deserve further attention.

Can We Predict Incisional Hernia?: Development of a Surgery-specific Decision-Support Interface.

OBJECTIVE: The aim of this study was to identify procedure-specific risk factors independently associated with incisional hernia (IH) and demonstrate the feasibility of preoperative risk stratification through the use of an IH risk calculator app and decision-support interface. SUMMARY BACKGROUND DATA: IH occurs after 10% to 15% of all abdominal surgeries (AS) and remains among the most challenging, seemingly unavoidable complications. However, there is a paucity of readily available, actionable tools capable of predicting IH occurrence at the point-of-care. METHODS: Patients (n = 29,739) undergoing AS from 2005 to 2016 were retrospectively identified within inpatient and ambulatory databases at our institution. Surgically treated IH, complications, and costs were assessed. Predictive models were generated using regression analysis and corroborated using a validation group. RESULTS: The incidence of operative IH was 3.8% (N = 1127) at an average follow-up of 57.9 months. All variables were weighted according to ß-coefficients generating 8 surgery-specific predictive models for IH occurrence, all of which demonstrated excellent risk discrimination (C-statistic = 0.76-0.89). IH occurred most frequently after colorectal (7.7%) and vascular (5.2%) surgery. The most common occurring risk factors that increased the likelihood of developing IH were history of AS (87.5%) and smoking history (75%). An integrated, surgeon-facing, point-of-care risk prediction instrument was created in an app for preoperative estimation of hernia after AS. CONCLUSIONS: Operative IH occurred in 3.8% of patients after nearly 5 years of follow-up in a predictable manner. Using a bioinformatics approach, risk models were transformed into 8 unique surgery-specific models. A risk calculator app was developed which stakeholders can access to identify high-risk IH patients at the point-of-care.

The Impact of Training Pathway on Breast Surgery Cases Performed during Plastic Surgery Residency.

BACKGROUND: Operative volume is a critical component of surgical resident education. This study compares reported breast surgery case volume between resident training pathways in plastic surgery. METHODS: This retrospective cohort study reviewed case logs of plastic surgery residents in the independent/combined and integrated training pathways. Breast surgery case volume was compared via t tests across two major categories: reconstructive and aesthetic. Differences in intra-pathway variability were compared with F tests. Five consecutive cohorts of plastic surgery residents (n = 818): independent/combined (n = 526, 64%) and integrated (n = 292, 36%) at Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs, were included (2011-2015). RESULTS: Independent/combined residents reported significantly more aesthetic cases than integrated residents, but similar reconstructive cases. Independent/combined residents reported more breast augmentations, mastopexy, cosmetic breast fat grafting, and other cosmetic breast cases. Within the reconstructive category, independent residents reported more breast reconstruction fat grafting cases while integrated residents reported more breast reconstruction with pedicle flap, other breast reconstruction, and breast reduction cases. Independent residents had greater intra-pathway variability in five case subcategories, while integrated residents had greater variability in one case subcategory. CONCLUSIONS: Disparities in breast surgery case volume exist by plastic surgery residency training pathway. Given the importance of case volume to residents and faculty, these disparities may warrant greater attention. 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.

Does Size Matter: Evaluating the Difference between Right and Left Internal Mammary Veins in Free Flap Breast Reconstruction.

BACKGROUND: Venous congestion in breast free flap reconstruction continues to be a major reason for flap compromise requiring reoperative exploration and possible flap failure. We aim to investigate whether size of the internal mammary vein (IMV) (1) varies between the left and right sides, (2) changes with certain patient demographics or preoperative factors, and (3) correlates with postoperative complications. METHODS: We performed a retrospective cohort study examining all patients undergoing free flap breast reconstruction from September 2005 to March 2016 using internal mammary recipient veins. Venous coupler size was used as a surrogate measure of IMV diameter. Preoperative patient characteristics and factors were collected. Postoperative outcomes assessed included thrombosis, flap loss, fat necrosis, and mastectomy flap necrosis. Multivariate analyses were performed to evaluate if preoperative factors affected IMV diameter and to determine if coupler size and flap side were independent risk factors for postoperative complications. RESULTS: We examined 372 patients with a total of 561 flaps. One hundred eighty-nine patients received bilateral flaps with the IMV as a recipient. The right IMV (n = 286, average = 2.97 mm, standard deviation [SD] = 0.41) was significantly larger than the left (n = 275, average = 2.89, SD = 0.35, p = 0.008). Preoperative factors and postoperative complications were not statistically different between the left and right cohorts. The multivariable linear regression model with coupler size as the dependent variable found older age trended toward a larger coupler size but this was not significant (p = 0.05). In multilinear regression analysis, the postoperative outcomes did not have significant covariates. CONCLUSION: We found that IMV size significantly differs between the right and the left sides. However, incidence of postoperative complications was not significantly different between the left and right sides, and the multivariate analyses did not identify flap side as an independent risk factor for adverse outcomes. Prospective studies evaluating actual IMV diameter and associated complications may potentially elucidate clinical significance.

Autologous breast reconstruction in the postbariatric patient population.

BACKGROUND: Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS: Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS: Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS: As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.