One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders.

BACKGROUND: Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction. METHODS: In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1-2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed. RESULTS: In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7-14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period. CONCLUSIONS: Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.

What are Board-Certified Plastic Surgeons Posting on Instagram?

BACKGROUND: Plastic surgeons increasingly use social media to market their practices and educate prospective patients. Previous studies have investigated plastic surgery content on Instagram from the angle of hashtags and most popular plastic surgeons. However, very little is understood about what plastic surgeons themselves post on Instagram and what plastic surgery content average users engage with. OBJECTIVES: The aim of this study was to analyze Instagram posts from accounts related to plastic surgeons in the USA to establish suggestions for growing one's practice with this powerful platform to reach patients. METHODS: Board-certified plastic surgeons from all US regions that were active from February 1, 2023 to April 12, 2023 were randomly chosen. Their Instagram accounts were accessed for post analysis. For procedural posts, engagement statistics and multiple variables were collected. Dixon's outlier test was used to determine outliers in the data. ANCOVA and Tukey analysis was used to determine whether procedure type influenced engagement. RESULTS: 120 surgeon accounts were identified with 2157 posts analyzed, yielding notable differences in posts among regions. Most posts were aesthetic procedures (94.4%) and of female patients (90.3%). Surgical procedures were also predominant (86.1%). In addition, Reels had higher engagement than photograph posts. Users engaged with Body procedures at the highest rate. CONCLUSIONS: This cross-sectional analysis shows plastic surgeons tend to overwhelmingly post female patients, aesthetic procedures, and surgical content. These insights may be used to guide social media content and improve the effectiveness of Instagram as a tool for marketing or education. LEVEL OF EVIDENCE IV: 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.

Paucity of Online Information About Gender-Affirming Surgery Fellowships in the United States.

BACKGROUND: Despite growing demand for gender-affirming surgery (GAS), there are few formal GAS fellowships in the United States. Paucity of online information about GAS fellowships may discourage potential applicants and decrease the visibility of the field. Thus, it is important to analyze the existing online information about GAS fellowships to improve fellow recruitment and patient outcomes. OBJECTIVE: To identify the number of GAS fellowship websites (GASFWs) and evaluate their robustness. Second, to report the social media presence of GAS fellowships. METHODS: To identify GASFWs, existing databases sponsored by plastic surgery associations and Google query were used between April and May 2023. Thirty-five independent variables based on previously published data were evaluated for presence in a bivariate fashion on GASFWs. Accounts on popular social media websites were also identified by Google query. Website and social media analysis were also done for GAS fellowships that were offered by departments/specialties other than plastic surgery. RESULTS: In total, only 6 GASFWs associated with plastic surgery departments were identified and analyzed. Eight nonplastic surgery GASFWs were included for analysis. Overall, both categories of GASFWs were not robust; key information such as previous fellow listing and selection criteria was often missing. Furthermore, important topics specifically related to GAS such as community engagement and programmatic building are often not found on GASFWs either. In addition, none of the fellowships had any independent Facebook, Instagram, or Twitter. CONCLUSIONS: To ensure patient safety and quality outcomes, it is important to promote GAS by recruiting more applicants for specialized training beyond residency. With increased Internet use, improving GASFWs and social media presence as well as considering the use of a centralized database or match system can foster the growth of the field.

Perceptions of Surgical Drains among Breast Reconstruction Patients and Health Care Staff: A Qualitative Survey Study.

BACKGROUND: Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk of infection with prolonged use. We aimed to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience. METHODS: Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1 to 5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate. RESULTS: Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was 2 weeks (N = 13). The surgical site infection (SSI) rate requiring antibiotics was 28% (N = 8). On a scale of 1 to 5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were "frequently" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort. CONCLUSION: Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to SSI. Overall, these data provide insight to drive future improvements in the patient drain experience.

Comparison of Low-Dose Computed Tomography Versus Conventional-Dose Computed Tomography in the Evaluation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRFs) are common upper extremity fractures and often require surgical fixation when they are intraarticular. Preoperative computed tomography (CT) has emerged as a surgical planning tool to evaluate intraarticular DRFs. Although CT affords additional details, patients receive higher radiation doses than standard radiographs. We aim to develop a low-dose CT (LDCT) protocol, relative to the institutional standard-dose CT wrist for intraarticular DRFs although providing adequate detail for surgical decision-making. METHODS: A single-institution prospective study was conducted on patients with intraarticular DRFs who underwent closed reduction and below-elbow splinting who otherwise would undergo wrist CT. Observations were defined as total measurements taken, with each view undergoing 44 measurements. Patients underwent 2 scans with a standard dose and a 10× dose reduction. Articular step and gap measurements were recorded in the sagittal and coronal images. RESULTS: A total of 11 patients were enrolled (7 women and 4 men). The mean age was 55 years (SD = 20.1). There were a total of 4 reviewers: 1 attending surgeon, 2 resident physicians, and 1 student. When comparing LDCT and conventional-dose CT (CDCT), there were no significant differences in step and gap measurements across all reviewers. CONCLUSION: This study demonstrated that LDCT provides comparable imaging quality for surgical planning as a CDCT without significant diagnostic decay in the setting of DRFs. This comes with the added benefit of a 10-fold reduction in radiation exposure. These results suggest that LDCT is an opportunity to reduce effective radiation in patients although providing beneficial preoperative imaging.

Identifying Barriers Faced by Applicants without a Home Residency Program when Matching into Plastic Surgery.

Background Applying into plastic surgery (PS) is competitive. Lacking a home residency program (HRP) is another barrier. Our goal is to characterize challenges faced by PS applicants without HRPs and identify solutions. Methods Surveys were designed for current integrated PS residents and applicants in the 2022 Match without HRPs. Surveys were distributed electronically. Only U.S. allopathic graduate responses were included. Results Of 182 individuals surveyed, 74 responded (39%, 33 residents, 41 applicants). Sixty-six percent reported feeling disadvantaged due to lack of an HRP. Seventy-six percent of applicants successfully matched. Of these, 48% felt they required academic time off (research year) versus 10% of unmatched applicants. Ninety-seven percent of matched applicants identified a mentor versus 40% of unmatched applicants ( p < 0.05). Matched applicants identified mentors through research (29%) and cold calling/emailing (25%). Matched versus unmatched applicants utilized the following resources: senior students (74 vs. 10%, p < 0.05) and social media (52 vs. 10%, p < 0.05). Among residents, 16 had PS divisions (48%). Thirty-six percent with divisions felt they had opportunities to explore PS, compared with 12% without divisions. Residents without divisions felt disadvantaged in finding research (94 vs. 65%, p < 0.05), delayed in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%) and letters of recommendation (31 vs. 24%). Conclusion PS residents and applicants without HRPs reported feeling disadvantaged when matching. The data suggest that access to departments or divisions assists in matching. We identified that external outreach and research were successful strategies to obtain mentorship. To increase awareness for unaffiliated applicants, we should increase networking opportunities during local, regional, and national meetings.

Preference Signaling and the Integrated Plastic Surgery Match: A National Survey Study.

OBJECTIVE: Rooted in economics market strategies, preference signaling was introduced to the Plastic Surgery Common Application (PSCA) in 2022 for integrated plastic surgery residency applicants. This study surveyed program and applicant experience with preference signaling and assessed how preference signals influenced likelihood of interview invitations. DESIGN: Two online surveys were designed and distributed to all program directors and 2022-2023 applicants to integrated plastic surgery. Opinions regarding the utility of preference signaling were solicited, and the influence of preference signals on likelihood of interview offers was assessed. SETTING: All integrated plastic surgery programs. PARTICIPANTS: All 88 program directors and 2022-2023 applicants to integrated plastic surgery. RESULTS: A total of 45 programs and 99 applicants completed the survey (response rates, 54.2% and 34.2%, respectively). Overall, 79.6% of applicants and 68.9% of programs reported that preference signals were a useful addition to the application cycle. Programs reported that 41.4% of students who sent preference signals received interview offers, compared to 84.6% of home students, 64.8% of away rotators, and 7.1% of other applicants; overall, students who signaled were 5.8 times more likely to receive an interview offer compared to students who were not home students and did not rotate or signal. After multivariable adjustment, programs with higher Doximity rankings, numbers of away rotators, and numbers of integrated residents per year received more preference signals (all p < 0.05). CONCLUSIONS: Applicants and programs report that preference signaling was a useful addition to the integrated plastic surgery application cycle. Sending preference signals resulted in a higher likelihood of interview offers among nonrotators. Preference signaling may be a useful tool to reduce congestion in the integrated plastic surgery application cycle.

Flipping Tradition on Its Head: A Single-Institution Study on United States Medical Licensing Examination Step Order.

Given the recent change in Step 1 grading, medical students are faced with decisions surrounding the optimal Step examination order and timing. There is a current lack of guidance outside commonly used United States Medical Licensing Examination study blogs. The aim of this study was to characterize current practices in Step examination order and understand the factors influencing student examination preference. To gather data, we used a 24-item survey and electronically distributed it through three separate email requests to medical students. Participants included medical students (MS1-4) attending a single institution, interested in a surgical residency. In total, 56 students responded to the survey (response rate of 20%). Most students (63.6%) opted to take Step 2 before Step 1. Justifications included the perceived importance of Step 2 for residency applications (33.3%), the change to pass/fail grading (27.0%), the relevance of Step 2 after rotations (27.0%), and a desire to obtain a Step 2 score earlier (7.9%). Step examination order did not lead to differences in Step 2 score (P = 0.459), time used to prepare for Step 1 (P = 0.396), or time used to prepare for Step 2 (P = 0.078). Due to the perceived importance of Step 2, most medical students at our institution who are interested in pursuing a surgical residency are reversing the traditional Step examination order. As this may represent a national trend, additional work needs to be done to provide guidance to medical students and identify the optimal step examination testing strategy.

Anatomy Versus Biology: What Guides Chemotherapy Decisions in Older Patients With Breast Cancer?

INTRODUCTION: With the increasing utilization of genomic assays, such as the Oncotype DX recurrence score (RS), the relevance of anatomic staging has been questioned for select older patients with breast cancer. We sought to evaluate differences in chemotherapy receipt and/or survival among older patients based on RS and sentinel lymph node biopsy (SLNB) receipt/result. METHODS: Patients aged ≥ 65 diagnosed with pT1-2/cN0/M0 hormone-receptor-positive (HR+)/HER2-breast cancer (2010-2019) were selected from the National Cancer Database. Logistic regression was used to identify factors associated with chemotherapy receipt. Cox proportional hazards models were used to estimate the association of RS/SLNB group with overall survival. A cost-benefit study was also performed. RESULTS: Of the 75,428 patients included, the majority had an intermediate RS (58.2% versus 27.9% low, 13.8% high) and were SLNB- (85.1% versus 11.6% SLNB+, 3.3% none). Chemotherapy was recommended for 13,442 patients (17.8%). After adjustment, chemotherapy receipt was more likely with higher RS and SLNB+. After adjustment, SLNB receipt/result was only associated with overall survival among those with an intermediate RS. However, returning to the OR for SLNB is not cost-effective. CONCLUSIONS: SLNB receipt/result was associated with survival for those with an intermediate RS, but not a low or high RS, suggesting that an SLNB may indeed be unnecessary for select older patients with breast cancer.

Assessing the Benefits and Downsides of Physician Review Websites to Plastic Surgeons: A Cost-Benefit Analysis.

BACKGROUND: Patients often evaluate the reputations of plastic surgeons based on their performances on physician review websites. This article aims to compare rating methodologies and conduct a cost-benefit analysis of physician review websites to further understand how plastic surgeons and their patients can utilize review websites to inform their practice and care. METHODS: A review of online literature, blogs, and 17 of the most common physician review websites was conducted to identify information on review website methodology, cost, and benefits most pertinent to plastic surgeons and their patients. RESULTS: Physician review websites utilize various combinations of physician-related and unrelated criteria to evaluate plastic surgeons. Across 17 reviewed platforms, most (71%) utilize star ratings to rate physicians, 18% require an appointment to conduct a review, and 35% feature search engine optimization. Many websites (53%) allow physicians to pay for benefits or extension packages, with benefits offered including advertising, search engine optimization, competitor blocking, social media marketing, consultant services, and data analytics. Competitor blocking was provided by the most number of websites who offered additional services for pay (78%). CONCLUSIONS: Appointments are not required to post physician reviews on many review websites, and many websites allow physicians to purchase packages to enhance their search engine optimization or consumer reach. Accordingly, plastic surgeons' reputations on review websites may be influenced by factors extraneous to actual patient care. Patients and physicians should be cognizant that physician review websites may not be reflective of factors related to quality of patient care.

Educational Podcasts in Plastic Surgery: A Cross-Sectional Analysis of Content, Metrics, and Target Audiences.

BACKGROUND: Podcasts provide an efficient means for asynchronous learning. However, no study to date has thoroughly assessed the landscape of educational podcasts in plastic surgery. Thus, this study aims to evaluate and characterize current educational plastic surgery podcasts to ultimately inform future efforts. METHODS: Three platforms were queried for educational plastic surgery podcasts: Apple Podcasts, Spotify, and Google Podcasts. Podcast descriptions and episodes were then independently reviewed to determine primary target audiences, performance metrics, and content categories. RESULTS: There were a total of 163 plastic surgery podcasts. 145 of these 163 podcasts were targeted toward a nonmedical audience. The remaining 18 podcasts met inclusion criteria as educational plastic surgery podcasts. Of all educational podcast episodes, 8.8% targeted a medical student audience, 33.8% targeted trainees (residents/fellows), and 57.4% targeted practicing surgeons or emphasized recent research in the field. Episode content categories included breast (14.2%), cosmetic (11.8%), experimental (0.5%), hand/peripheral nerve (8.6%), pediatric/craniofacial (8.2%), reconstructive (15.6%), practice management (14.8%), residency (6.6%), and others (19.6%). CONCLUSIONS: Despite the large number of plastic surgery podcasts available, few podcasts focus on educating a medical audience. Within this small subset, there is a paucity of content targeted towards medical students interested in plastic surgery. While there is a wide breadth of content available, there is significant room for growth and refinement in the podcast sector for plastic surgery education.

Development of a prospective biliary dashboard to compare performance and surgical cost.

BACKGROUND: Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system. METHODS: Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes. RESULTS: Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers. CONCLUSION: Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.

Social Media Usage by United States Plastic Surgery Subspecialty Fellowship Programs.

Social media can be a powerful tool for plastic surgery training programs. Previous studies have shown the value social media may have in integrated residency program recruitment and program reputation. These findings may generalize to fellowship programs, but this space has not been comprehensively studied to date. Therefore, this study aims to characterize plastic surgery fellowship programs' social media usage and identify subsequent opportunities for program leadership to generate engagement. Methods: United States plastic surgery fellowship programs in four major subspecialties (hand, microsurgery, craniomaxillofacial, and aesthetic) were identified and evaluated for social media presence on Instagram, Facebook, and Twitter. Platform-specific parameters were collected and statistically analyzed in aggregate. Results: There were a total of 25 Instagram accounts, four Facebook accounts, and three Twitter accounts across all investigated subspecialties. Hand surgery had the greatest social media presence on Instagram (19.5%) and Twitter (3.4%). Microsurgery had the greatest presence on Facebook (4.7%). Between 2015 and 2022, Instagram was the platform with the greatest increase in adoption by fellowship programs. Geographically, microsurgery and craniomaxillofacial accounts were primarily owned by Midwest programs (66.7%, 100%), and aesthetic primarily by programs in the South (83.3%). Number of Instagram posts and followers were not significantly correlated with hospital reputation (P = 0.12, P = 0.63). Conclusions: Social media is underutilized by plastic surgery fellowship programs. While Instagram metrics such as posts and followers are not correlated with hospital reputation, the skewed distributions of fellowship accounts, both geographically and across platforms, represent areas of potential growth.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction.

BACKGROUND: Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensity score-matched cohort. PATIENTS AND METHODS: Patients undergoing immediate tissue expander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline). RESULTS: A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03). CONCLUSIONS: Within a propensity score-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

The Influence of Age on Complications After Correction of Congenital Breast Deformities: A National Analysis of the Pediatric and Adult NSQIP Data Sets.

BACKGROUND: Timing of surgical intervention is controversial among patients seeking correction of congenital breast deformities. OBJECTIVES: This study aimed to assess the influence of age on 30-day complications and unplanned healthcare utilization after reconstruction of congenital breast deformities. METHODS: Female patients undergoing breast reconstruction for congenital breast deformities and Poland syndrome were identified on the basis of International Classification of Diseases (ICD) codes in the 2012 to 2021 pediatric and adult National Surgical Quality Improvement Project (NSQIP) data sets. Complications based on age at correction were compared, and multivariate logistic regression was used to identify predictors of overall and wound healing complications. RESULTS: Among 528 patients meeting inclusion criteria, mean (SD) age at surgical correction was 30.2 (13.3) years. Patients most commonly underwent implant placement (50.5%), mastopexy (26.3%), or tissue expander placement (11.6%). Across the cohort, overall incidence of postoperative complications was 4.4%, most commonly superficial surgical site infection (1.0%), reoperation (1.1%), or readmission (1.0%). After multivariate adjustment, increasing age at time of correction was associated with higher incidence of wound complications [odds ratio (OR) 1.001; 95% confidence interval (CI) 1.0003-1.002; P = .009], in addition to BMI (OR 1.002; 95% CI 1.0007-1.004; P = .006) and tobacco use (OR 1.06; 95% CI 1.02-1.11; P = .003). CONCLUSIONS: Breast reconstruction for congenital breast deformities may be safely undertaken at a young age with a low associated risk of postoperative complications. Large, multi-institutional studies are needed to assess the influence of surgical timing on psychosocial outcomes in this population.