We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction.

INTRODUCTION: Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients. METHODS: A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care. RESULTS: The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively. CONCLUSIONS: Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.

Utility of a Neuromuscular Activation Exercise Protocol on Surgeon Posture.

BACKGROUND: Surgeons are at risk for musculoskeletal disorders from ergonomic strain in the operating room. These deficits may stem from neuromuscular control deficits. Neuromuscular activation exercises (NMEs) may strengthen the brain-muscle connection. This study aimed to assess the utility of a surgeon-oriented NME protocol on posture. METHODS: Surgeons, operating room staff, and medical students completed a professionally established NME routine. An electronic application, PostureScreen®, assessed participants' posture. A long-term cohort was assessed before and after a 2 to 6-week routine. A short-term cohort was assessed immediately before and after completion. All participants additionally completed a postintervention survey. RESULTS: After intervention, the short-term cohort (n = 47) had significantly reduced frontal and sagittal postural deviation (P < 0.05). A significant decrease in effective head weight was additionally demonstrated with decreased neck flexion and increased cerebral-cervical symmetry (P < 0.05).The long-term cohort (n = 6) showed a significant postintervention decrease in lateral and anterior shoulder translation (P < 0.05). Total anterior translational deviations demonstrated trend-level decrease (P = 0.078). This demonstrates that after intervention, participants' shoulders were more centered with the spine as opposed to shifted right or left. Survey results showed participants favored exercises that immediately brought relief of tension. CONCLUSIONS: A decrease in postural deviations associated with NME in both cohorts demonstrates NME as a potential mechanism to protect surgeon musculoskeletal health and improve well-being. Survey results demonstrate areas of refinement for NME protocol design.

Reported Variability in General Surgery Training Across Integrated Plastic Surgery Residency Programs.

BACKGROUND: Since their development, integrated plastic and reconstructive surgery (PRS) residency training programs have established diverse methods of incorporating general surgery training into graduate medical education. Programs have questioned the necessary duration and timing of such training. The aim of this study is to assess the landscape of general surgery exposure in integrated PRS residency programs. METHODS: Thirty-six integrated PRS residency programs were included based on the availability of postgraduate year (PGY)-level rotation data. Rotations were measured in units of weeks with descriptive titles maintained as advertised by the program. Individual general surgery rotations were also categorized as being either PRS-aligned, American Board of Plastic Surgery (ABPS) Required Clinical (RC) or ABPS Strongly Suggested (SS). Statistical analyses were carried out on the relative proportions of each subcategory in the 2 parent groups. RESULTS: All 36 programs evaluated required general surgery rotations in years PGY- 1 to -2. By PGY-3, 69% of programs required general surgery, and by PGY-6, 25%, and these were limited to 4- to 6-week rotations in burn, breast, or trauma. Looking across all 6 years, with 312 weeks of training total, the minimum number of weeks spent in general surgery rotations was 32, and the maximum number was 119, with an average of 61 weeks (±21).Programs were subcategorized into 2 groups based on whether they spent more (n = 16) or less (n = 20) than the net average number of weeks in ABPS RC + SS rotations. No significant difference was found in the relative proportion of PRS-aligned general surgery across groups. Programs with <60 weeks of general surgery had a relatively greater proportion of ABPS RC and SS rotations. CONCLUSIONS: These data demonstrate that there exists significant variability in overall duration of general surgery training across integrated PRS training programs. When controlling overall general surgery exposure for variables of interest like PRS-aligned exposure or compatibility with ABPS requirements, we found no discernable educational model or patterns to explain the observed range in exposure. These results warrant reexamination of an ideal general surgery track within the integrated plastic surgery training model that optimizes training for the PRS resident.

Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery.

INTRODUCTION: Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS: All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS: Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). CONCLUSIONS: This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Recent Training Trends in Independent Plastic Surgery Graduates: American Board of Surgery Certification and Academic Priorities.

BACKGROUND: Among independent plastic surgery graduates, most have general surgery training, but the utility of American Board of Surgery (ABS) certification in plastic surgery practice is unclear. We elucidated attitudes and trends of ABS certification in American Board of Plastic Surgery diplomates. METHODS: American Board of Plastic Surgery diplomates from 2018 to 2020 were reviewed to identify independent plastic surgery graduates. These graduates were anonymously surveyed regarding demographics, employment, fellowships, practices, and attitudes toward ABS certification. RESULTS: Of 568 American Board of Plastic Surgery diplomates, 223 independent graduates (39%) were identified. Sixty-eight percent of these graduates were ABS certified, 80% of whom achieved certification during the beginning of plastic and reconstructive surgery training; 41% were fellowship trained. About half are in private practice, 25% are part of a hospital group, and 17% work in universities. Of 223 independent graduates, 54 (24.4%) completed the survey; 85.2% reported ABS certification, and 21.7% perform general surgery procedures. Most stated that general surgery training was valuable to their career, regardless of certification. Most agreed that ABS certification benefited their career; 63% plan to recertify. Of those surveyed, 59.3% had completed a plastic surgery fellowship. Non-fellowship-trained surgeons felt more strongly that ABS certification was beneficial (P = 0.014) and valued by patients (P = 0.026) compared with fellowship-trained surgeons. CONCLUSIONS: American Board of Surgery certification is a priority to independent plastic surgery trainees, despite potential disruption to training, personal costs, and unclear utility to their practice. Although few perform general surgery procedures, most plan to recertify. Future studies should investigate recertification among surgeons later in their careers and the impacts of dual board certification on plastic surgery practice.

The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach.

BACKGROUND: Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption. METHODS: All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy. RESULTS: Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months. CONCLUSIONS: Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden.

Reduction of Work-Related Musculoskeletal Disorders in Plastic Surgeons by Introduction of a Posture Training Device.

BACKGROUND: Plastic surgeons have an increased risk for the development of musculoskeletal disorders because of frequent poor ergonomics of the operating room. This study characterizes selected plastic surgery procedures, with an attempt to identify high-risk procedures and procedural components as well as the impact of biofeedback on surgical ergonomics. METHODS: A commercially available posture training device was used to initially record neck and spine positioning and later to send biofeedback to prompt surgeons to correct posture. Device data were correlated with in-person observations to characterize factors associated with more time spent in the slouched/nonneutral cervical and thoracic spine posture. RESULTS: The proportion of time spent in the upright position during surgery was significantly different among male and female participants, level of training, participant height, in the sitting versus nonsitting positioning (P < 0.001), with loupes use, and if there was more than an 8-inch height difference between 2 participants (mean, 0.70 ± 0.285). Using the device intervention, all participants spent a larger proportion of operating time upright. Half of these improvements in posture were statistically significant. While in feedback mode, participants experienced shorter and more frequent periods of slouching/nonneutral posture. When comparing the same participant performing the same procedure with and without device biofeedback, 72.2% of participants spent more time in the upright/neutral posture during the surgery when the device was sending feedback. CONCLUSIONS: Biofeedback devices used in the operating room can lead to improved surgical posture, which may translate to reduction of workplace injuries, and overall physician health. This study found that a commercially available posture training device and sitting stools in the operating room could significantly improve physician cervical and thoracic spine posture.

The Ideal Microsurgery Fellowship: A Survey of Fellows and Fellowship Directors.

BACKGROUND: Although microsurgery fellowships have existed since the 1980s, there is no established curriculum. Microsurgery fellowships vary greatly in clinical caseload, case diversity, and training resources, and there is no consensus on the appropriate composition of a microsurgery fellowship. This study surveys fellowship directors (FD) and recent microsurgery fellows (MFs), graduates, to describe the ideal microsurgery fellowship program. METHODS: A 15-item questionnaire was sent to 38 FDs and 90 recent microsurgery fellowship graduates. This questionnaire addressed program attributes, case volumes and compositions, ideal experiences, and time allocation to different fellowship experiences. Data were analyzed using descriptive statistics, t-tests, and Chi-squared tests. RESULTS: The FD and MF surveys had a response rate of 47 and 49%, respectively. Both MF and FD agreed that exposure to microsurgical breast reconstruction is the most important characteristic of a microsurgery fellowship (p = 0.94). MF ranked replantation and supermicro/lymphatic surgery as the next most important microsurgical cases, while FD ranked the anterolateral thigh (ALT) flap and free fibula flap (p < 0.001). Both agreed that revisional surgery after microsurgical reconstruction is a very valuable fellowship experience (p = 0.679). Both agreed that 1 day of clinic a week is sufficient. CONCLUSION: Microsurgical training programs vary in quality and resources. The ideal microsurgery fellowship prioritized breast reconstruction, head and neck reconstruction, and lower extremity reconstruction. Although microsurgical technical expertise is important, a fellowship should also train in revisional surgeries and clinical decision making.

Detailed analysis of the impact of surgeon and hospital volume in microsurgical breast reconstruction.

BACKGROUND: Prior investigations of microsurgical breast reconstruction have not distinguished the effects of surgeon versus hospital volume and failed to address the effect of patient clustering. Our data-driven analysis aims to determine the impacts of surgeon and hospital volume on outcomes of microsurgical breast reconstruction. METHODS: Nationwide Inpatient Sample (NIS) data from 2008 to 2011 was analyzed for patients who underwent microsurgical breast reconstruction. Volume-outcome relationships were analyzed with restricted cubic spline analysis. A multivariable mixed-effects logistic regression was used to account for patient clustering effect. RESULTS: A total of 5,404 NIS patients met inclusion criteria. High-volume (HV) surgeons had a 59% decrease in the risk of inpatient complications, which became non-significant after clustering correction. For HV hospitals, there was a 47% decrease in the risk of inpatient complications (odds ratio = 0.53; 95% confidence intervals 0.30, 0.91; p = 0.021) that was statistically significant with the clustering adjustment. Neither the volume-cost relationship for surgeons nor hospitals remained statistically significant after accounting for clustering. CONCLUSIONS: Hospital volume plays a significant impact on outcomes in microsurgical breast reconstruction, while surgeon volume has comparatively not shown to be similarly impactful. The complexity of care related to microsurgical breast reconstruction warrants equally complex and engineered health systems.

A Comparison of Intracranial Volume Growth in Normal Children and Patients With Metopic Craniosynostosis.

BACKGROUND: The impact of metopic craniosynostosis on intracranial volume (ICV) and ICV growth is unclear. In addition, the relationship between head circumference (HC) and ICV in these patients is not previously described. METHODS: A retrospective review of 72 patients with metopic craniosynostosis was performed. The ICVs were calculated from manually segmented preoperative computed tomography scans. Magnetic resonance imaging data for 270 healthy children were available. The ICVs were calculated in FreeSurfer.First, a growth curve for metopic patients was generated and a logarithmic best-fit curve was calculated. Second, the impact of metopic craniosynostosis on ICV relative to healthy controls was assessed using multivariate linear regression. Third, the growth curves for metopic patients and healthy children were compared.Pearson's correlation was used to measure the association between HC and ICV. RESULTS: Mean metopic ICV was significantly lower than normal ICV within the first 3 to 6 months (674.9 versus 813.2 cm; P = 0.002), 6 to 9 months (646.6 versus 903.9 cm; P = 0.005), and 9 to 12 months of life (848.0 versus 956.6 cm; P = 0.038). There was no difference in ICV after 12 months of age (P = 0.916).The ICV growth in patients with metopic craniosynostosis is defined by a significantly different growth curve than in normal children (P = 0.005).The ICV and HC were highly correlated across a broad range of ICVs and patient age (r = 0.98, P < 0.001). CONCLUSION: Patients with metopic craniosynostosis have significantly reduced ICVs compared to healthy children, yet greater than normal ICV growth, which allows them to achieve normal volumes by 1 year of age. The HC is a reliable metric for ICV in these patients.

The Cost to Attending Surgeons of Resident Involvement in Academic Hand Surgery.

PURPOSE: For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. METHODS: Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. RESULTS: A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. CONCLUSIONS: Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.

Process of Care in Breast Reconstruction and the Impact of a Dual-Trained Surgeon.

BACKGROUND: For postmastectomy reconstruction, the most common model in the United States is a two-team approach, consisting of breast and plastic surgeon. In other countries, a single-surgeon approach trained in both plastic and oncologic surgery is well described. We hypothesized that a dual-trained breast and plastic surgeon would decrease the postoperative care burden for the patient without compromising outcomes and serve as a model for team-centered breast reconstruction care. METHODS: A retrospective review was performed of patients undergoing mastectomy with immediate expander reconstruction from January 2013 to October 2014. Patient data up to 1 year postoperatively was recorded. Patients were stratified by treatment to "single-surgeon" or "two-surgeon" team. Demographic and operative data were recorded. Google Maps was used to calculate travel distance. A standard of mean cost of travel per mile and mean hourly wage for San Diego County was used. The primary outcome was the total number of postoperative clinic visits. In addition, factors predictive of postoperative clinic visits were evaluated. RESULTS: During the study period, 147 patients were included in analysis (69, single-surgeon; 78, two-surgeon). The mean cost of travel per mile was US $59.2 cents and mean hourly wage for San Diego County was US $25.49. For the 1-year follow-up period, patients with the single surgeon had a mean (SD) of 9.3 (3.72) postoperative visits compared with 15.6 (3.96) for patients in the two-surgeon team (P < 0.0001).There were no statistical differences between groups in the rate of complications. In the final model, treatment team, bilateral mastectomies, and complications (operative and nonoperative) were significant predictors of the total number of postoperative visits. Patients in the two-surgeon team spent an additional 11.13 hours and 216 miles commuting and in clinic. In total, the additional 6.3 clinic visits for patients in the two-surgeon team resulted in an average of US $695.33 additional dollars spent on travel and lost wages. CONCLUSIONS: Single-surgeon patients required fewer postoperative visits. Fewer postoperative clinic visits may have significant socioeconomic and psychological benefits to patients. Given these results, we believe that streamlining care into an integrated multidisciplinary model would be beneficial.

Predictors of Postoperative Complications of Craniosynostosis Repair in the National Inpatient Sample.

INTRODUCTION: Timing of intervention and complication profiles in surgical repair of craniosynostosis have been widely debated. Early intervention is frequently promoted as a means of decreasing morbidity while maintaining favorable outcomes via minimally invasive techniques such as endoscopic strip craniectomy. Immediate postoperative morbidity due to complications of early vs late intervention remains a key element in comparing timing and technique for craniosynostosis repair. In addition, concurrent fronto-orbital advancement with open cranial vault remodeling may increase the risk of postoperative complications. We present an evaluation of surgical timing and the presence of fronto-orbital advancement as independent predictors of in-hospital complications after craniosynostosis repair. METHODS: Retrospective analysis was performed in the National Inpatient Sample database from 1998 to 2009. Patients younger than 3 years having undergone elective surgical repair for craniosynostosis were identified. Comorbidities, demographics, transfusion status, and syndromic diagnosis were included as covariates. A multivariate regression model was used to characterize the association between age at the time of surgery and in-hospital complications. A subgroup analysis using the variable of concurrent fronto-orbital advancement was restricted to patients 8 to 24 months of age to exclude endoscopic craniosynostosis repair, which is traditionally repaired less than 6 months of age. Multivariate logistic regression was used to assess the impact of concurrent fronto-orbital advancement on postoperative complications. RESULTS: A total of 6010 craniosynostosis surgery cases (42.9%, age 0-7 months; 29.5%, age 8-12 months; and 27.6%, age 13-36 months) were included. Patients in the 7-to 12-month age group were more likely to experience complications when compared with the 0- to 6-month age group (odds ratio [OR],1.32; P < 0.05) and 13-to 36-month age group (OR, 1.32; P = 0.056). Syndromic patients (OR, 1.92; P < 0.001) and patients receiving an intraoperative blood transfusion (OR, 1.60; P < 0.05) demonstrated an increased risk for complications. In the subanalysis of 2936 patients aged 8 to 24 months, 15.1% of patients received frontoorbital advancement, which was associated with a significantly increased risk of complications (OR, 1.43; P < 0.05). CONCLUSIONS: Intermediate age (7-12 months) and concurrent fronto-orbital repair were independent risk factors for immediate postoperative complications. These findings may better inform the decision-making process for craniosynostosis repair in terms of timing and need for concurrent fronto-orbital reconstruction.

A Novel Method for Quantifying Intracranial Volume Change by Distraction Osteogenesis for Craniosynostosis.

INTRODUCTION: Methods of reporting quantitative results for distraction osteogenesis (DO) of craniosynostosis have been inconsistent. Therefore, the efficacy of differing techniques and timing in regard to volume change is not well established, with no uniform metric for comparisons. Given that cranial vault remodeling with DO may be completed with different approaches, analysis was made to determine (1) the relative efficiency of different approaches in expanding intracranial volume (ICV) and (2) the impact of adjusting for ICV growth on measured DO efficiency. METHODS: Patients with craniosynostosis were treated with open cranial vault reconstruction combined with internal distraction. Preoperative and postoperative computed tomography scans were used to quantify ICV change. The metric was determined by dividing percent ICV change by total distraction length. The metric was used as a proxy for efficiency to compare posterior and anterior distraction between groups using the Mann-Whitney U test and within a subgroup of patients who underwent 2-stage distraction using the Wilcoxon matched-pairs signed rank test. RESULTS: Twenty patients underwent cranial vault remodeling with DO: 14 unicoronal, 3 bicoronal, 2 multisutural, and 1 lambdoid. Results are reported in medians. Distraction efficiency was 0.99%/mm for primary anterior, unilateral distraction for unicoronal patients (n = 13, aged 9.1 months) and 4.28%/mm for posterior distraction using multiple distractors (n = 4, aged 6.3 months). In terms of the metric, primary posterior distraction was significantly more efficient than primary anterior distraction (P = 0.007). Three patients who had undergone primary posterior distraction later underwent secondary anterior distraction. Again, posterior distraction was shown to be significantly more efficient (5.16 vs 0.62, P = 0.050). For the unicoronal patients who received anterior unilateral distraction, an adjusted metric was calculated to account for normal intracranial growth. This was found to be 0.39%/mm, which was significantly different from the unadjusted metric (P = 0.0001). CONCLUSIONS: Posterior distraction is more efficient for ICV expansion than anterior distraction, which may have implications for the choice of approach for craniosynostosis repair. In addition, this is the first report of a novel standardized metric for analyzing ICV change achieved by DO. This tool allows for adjusting the efficiency metric for expected ICV growth, which significantly impacts its value.

The Impact of Residents on Patient Satisfaction.

BACKGROUND: High-quality physician communication is the foundation for achieving high patient satisfaction. Increasing importance is placed on eliciting feedback from patients. However, there have been few studies looking at the impact of resident involvement on patient satisfaction. Our hospital system values the patient's likelihood to recommend the practice as the top marker for patient satisfaction. METHODS: Between May 2016 and December 2016 at University of California, San Diego, all outpatient appointments were randomly mailed Press-Ganey surveys or an eSurvey regarding their experience. The surveys were filtered based on resident participation, and an χ test was performed to assess the impact of residents. An additional aim was to determine the degree to which the impact of resident involvement differed between surgical specialties. Binomial probability was calculated for each specialty using the 'no resident' group as the reference percentage. RESULTS: A total of 73,834 surveys were mailed or sent electronically, and 17,653 surveys were returned (23.9% response rate). Overall, patients expressed high levels of satisfaction with the quality of physician communication. Patients who had residents involved in their care reported a decrease in satisfaction with physician communication and a decrease in the likelihood to recommend the practice (88.7% vs 90.4%, P < 0.001). In the analysis of resident impact by surgical specialty, 9 specialties qualified for analysis. Resident involvement was associated with lower physician communication scores in orthopedic surgery (P = 0.032), otolaryngology (P = 0.015), and vascular surgery (P = 0.01). In all other surgical subspecialties, there was no statistically significant difference between groups. CONCLUSIONS: Overall, patients expressed high levels of satisfaction with the quality of physician communication with and without resident involvement. Resident physician involvement in surgical clinic visits was associated with lower overall patient satisfaction and decreased likelihood of recommending the practice. In addition, we observed that resident involvement was not associated with lower communication scores in most surgical specialties, including Plastic Surgery.

Comparison of Surgeon Specialty in Open Ventral Hernia Repair.

BACKGROUND: Ventral hernia repair is a common procedure and is undertaken by surgeons with varying training backgrounds. Outcomes after hernia repair depend on numerous factors, some being patient or surgeon specific. It remains unclear what the ideal roles are for general and plastic surgeons in open ventral hernia repair. We hypothesized that open ventral hernia repair by plastic surgeons is safe and comparable with general surgeons. METHODS: We performed a retrospective observational study using data from the National Surgical Quality Improvement Program database from 2007 to 2013. Patients with a primary diagnosis of ventral hernia undergoing open repair were identified. Multivariate regression modeling was performed, adjusting for surgeon specialty, patient characteristics, common concurrent procedures, and the total number of concurrent procedures. Outcomes studied were major and minor 30-day complications, operation time, readmission, unplanned reoperation, and length of hospital stay. RESULTS: We identified 53,746 patients who underwent open repair, 53,282 (99.1%) by general surgeons (GS) and 464 (0.9%) by plastic surgeons (PS). There were significantly different rates of concurrent panniculectomy (12.1% PS vs 2.4% GS) and component separation (24.8% PS vs 5.3% GS), representing increased PS case complexity. 52.3% of GS and 92.9% of PS performed panniculectomy without an alternate specialty surgeon. 81.3% of GS and 97.4% of PS performed component separation without an alternate specialty surgeon. The PS patients had a significantly longer uncorrected length of stay and operation time than GS patients (all P < 0.001). Similarly, PS was positively associated with uncorrected major and minor complications (P < 0.001). However, these relationships did not persist on multivariate analysis after adjusting for demographic characteristics, medical comorbidities, concurrent procedures, and total procedure load. Furthermore, PS was associated with lower odds of major complications (operating room, 0.49; P = 0.05) compared with GS. CONCLUSIONS: Outcomes of hernia repair by plastic surgeons are comparable with general surgeons, despite plastic surgeons being involved in many complex cases. Interestingly, we identified that general surgeons are performing adjunctive procedures to ventral hernia previously handled by plastic surgeons. Although further study is warranted, we conclude that for open ventral hernia repair, plastic surgeons provide a comparable alternative to general surgeons.

Correlating surgical clerkship evaluations with performance on the National Board of Medical Examiners examination.

BACKGROUND: Evaluation of medical students during the surgical clerkship is controversial. Performance is often based on subjective scoring, whereas objective knowledge is based on written examinations. Whether these measures correspond or are relevant to assess student performance is unknown. We hypothesized that student evaluations correlate with performance on the National Board Of Medical Examiners (NBME) examination. METHODS: Data were collected from the 2011-2012 academic year. Medical students underwent a ward evaluation using a seven-point Likert scale assessing six educational competencies. Students also undertook the NBME examination, where performance was recorded as a percentile score adjusted to national standards. RESULTS: A total of 129 medical students were studied. Scores on the NBME ranged from the 52nd to the 96th percentile with an average in the 75th percentile (±9). Clerkship scores ranged from 3.2-7.0 with a mean of 5.7 (±0.8). There was a strong positive association between higher NBME scores and higher clerkship evaluations shown by a Pearson correlation coefficient of 0.47 (P<0.001). Students clustered with below average ward evaluations (3.0-4.0) were in the 69.5th percentile of NBME scores, whereas students clustered with above average ward evaluations (6.0-7.0) were in the 79.2th percentile (P<0.001). CONCLUSIONS: A strong positive relationship exists between subjective ward evaluations and NBME performance. These data may afford some confidence to surgical faculty and surgical resident ability to accurately evaluate medical students during clinical clerkships. Understanding factors in student performance may help in improving the surgical clerkship experience.