Moral Injury: How It Affects Us and Tools to Combat It.

Introduction: Moral injury comprises feelings of guilt, despair, shame, and/or helplessness from having one's morals transgressed. Those underrepresented in health care are more likely to experience moral injury arising from micro- and macroaggressions. This workshop was designed for interprofessional health care providers ranging from students to program leadership to raise awareness about moral injury and provide tools to combat it. Methods: This 75-minute interactive workshop explored moral injury through a health care lens. It included components of lecture, case-based learning, small-group discussion, and individual reflection. Participants completed anonymous postworkshop evaluations, providing data on satisfaction and intention to change practice. We used descriptive statistics to analyze the quantitative data and applied content analysis to the qualitative data. Results: The workshop was presented at two local academic conferences. Data were collected from 34 out of 60 participants, for a response rate of 57%. Ninety-seven percent of participants felt the workshop helped them define and identify moral injury and was a valuable use of their time, as well as indicating they would apply the information learned in their daily life. One hundred percent would recommend the workshop to a friend or colleague. Almost half felt they could implement strategies to address moral injury after participating in the workshop. Discussion: This workshop proved to be a valuable tool to define and discuss moral injury. The materials can be adapted to a broad audience.

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-To-Implant Trends.

BACKGROUND: Direct-to-implant breast reconstruction is an attractive choice for appropriately-selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value healthcare, therefore, it is important to investigate utilization of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis. METHODS: This was a retrospective investigation of direct-to-implant reconstruction between 2010-2018 in the United States, using the National Inpatient Sample (NIS) database. All study analyses were undertaken using Stata v15.0. RESULTS: The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010-2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures significantly increased (p=0.03), relative to staged and delayed implant-based procedures. While direct-to-implant patients were younger, more likely to be white and privately-insured, the proportion of non-white, publicly-insured patients undergoing direct-to-implant reconstruction significantly increased by 2018 (p<0.05). Furthermore, direct-to-implant utilization amongst Medicaid patients increased at 2.2 times the rate in Medicaid expansion states compared to non-expansion states. Direct-to-implant patients had significantly higher APR-DRG risk scores in 2018 than in 2010 (p=0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures (p=0.03), when considering expander placement and expander-implant exchange. CONCLUSION: Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

The Positive Patient Experience: A Comprehensive Analysis of Plastic Surgery Online Reviews.

BACKGROUND: Subjective online physician evaluation is an important component of patient decision-making. Understanding reviews may improve satisfaction and build positive online reputation. OBJECTIVES: The aim of this study was to analyze and compare the top predictive factors driving patient satisfaction across the most popular plastic surgery procedures. METHODS: Online reviews were analyzed from RealSelf, Yelp, and Google for the 5 highest-rated plastic surgeons in 6 US metropolitan areas. Blank, non-English, consultation, duplicate, and unrelated reviews were excluded. Data from free-text reviews included physician rating, patient-reported reasons for rating, procedure, and complications. Univariate analysis was performed to compare predictive factors of online ratings. RESULTS: In total, 11,078 reviews were included. RealSelf had the highest average rating (4.77), and Yelp had the lowest (4.66). Reviews in Miami, Philadelphia, New York City, and Chicago were mostly published on RealSelf, whereas Houston and Los Angeles mostly used Google and Yelp, respectively. Reconstructive procedures were rated significantly higher than cosmetic procedures (P = 0.035). Aesthetic appearance was the strongest predictor of rating across all procedures. Buccal fat removal (98.8%) and abdominoplasty (98.1%) had the highest satisfaction, and Brazilian butt lift had the lowest (88.2%) (P < 0.001). Additional significant contributors included staff interaction, bedside manner, health outcomes, complications, and postoperative care (P < 0.001). CONCLUSIONS: Although aesthetic outcome is an important predictor of satisfaction, other aspects of care, such as bedside manner and staff interaction, provide an important foundation of support. Excellent patient-surgeon communication and postoperative care may mitigate patient dissatisfaction and elicit high-satisfaction online patient reviews.

The Zoom Effect: A Google Trends Analysis.

BACKGROUND: Increased video-chatting, stimulated by the COVID-19 pandemic, has been correlated with increased appearance concerns. Initial lockdown restrictions correlated with a decrease in aesthetic/cosmetic plastic surgery case volumes. OBJECTIVES: The authors aimed to delineate public interest in aesthetic procedures surrounding the COVID-19 pandemic via Google Trends. They hypothesized that because of the pandemic, public interest in plastic surgery procedures increased, especially localized above the shoulder. METHODS: Trends in the United States for given search terms and volumes were gathered via Google Trends between January 2015 and March 2021. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the stay-at-home orders. RESULTS: The following search terms had statistically significant (P < 0.000) increases in search volumes after February 2020: blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, buccal fat removal, hair transplantation, lip augmentation, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty. Chi-squared analysis demonstrated a statistically significant association (chi-squared = 4.812, P = 0.028) between increases in search volume and above-the-shoulder procedures. CONCLUSIONS: Public interest in above-the-shoulder surgical procedures statistically significantly increased following February 2020 compared with below-the-shoulder procedures. Continued examination of specific procedure trends and determining correlations with more accurate procedural datasets will provide increased insight into consumers' mindsets and to what extent video conferencing plays a role in the public's interest in pursuing aesthetic surgery.

Perineal Reconstruction With the Profunda Artery Perforator Flap.

BACKGROUND: Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction. METHODS: A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications. RESULTS: Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients. CONCLUSIONS: The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast.

INTRODUCTION: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. METHODS: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. RESULTS: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). CONCLUSIONS: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.