Preclinical Performance of the Combined Application of Two Robotic Systems in Microsurgery: A Two-center Study.

Background: Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial. Methods: Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score. Results: All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants. Conclusions: The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction.

BACKGROUND: Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction. METHODS: Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed. RESULTS: 122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001). CONCLUSIONS: Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study.

BACKGROUND: Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. STUDY DESIGN: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. RESULTS: The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. CONCLUSION: The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Surgical management of breast fat necrosis: Multi-institutional data analysis of early outcomes and risk factors for complications.

BACKGROUND: Breast fat necrosis (BFN) is a non-cancerous condition affecting the adipose tissue. Despite incidence rates of up to 25% after breast surgery, little is known about risk factors and postoperative outcomes following the surgical treatment of BFN. METHODS: The National Surgical Quality Improvement Program of the American College of Surgeons (2008-2021) was queried to identify female patients diagnosed with and surgically treated for BFN. Outcomes of interest included 30-day surgical and medical complications, reoperation, and readmission. We performed confounder-adjusted multivariable analyses to determine risk factors. RESULTS: The study population included 1179 female patients (mean age: 55.8 ± 13.8 years), of whom 96% (n = 1130) underwent direct excision and 4.2% (n = 49) received debridement of necrotic tissue. The majority of cases were operated on by general surgeons (n = 867; 74%) in the outpatient setting (n = 1107; 94%). Overall, 74 patients (6.3%) experienced postoperative adverse events, most of which were surgical complications (n = 43; 3.7%). Twenty-one (1.8%) women had to return to operating room, while readmission was reported in 18 (1.5%) cases. Adverse events were significantly more likely to occur in patients with chronic heart failure (p = 0.002) and higher wound classes (p = 0.033). CONCLUSION: Complication rates following the surgical management of BFN were found to be relatively high and seen to correlate with the setting. We identified chronic heart failure and wound contamination as risk factors for complication occurrence. These evidence-based insights may sensitize surgeons to critically balance patients' eligibility for BFN surgery and refine perioperative algorithms.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis.

BACKGROUND: A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS: We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS: A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION: At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Visual representation of diversity in online patient education materials for reduction mammaplasty.

Online patient education materials play an important role in plastic surgery, and surgeons should ensure that materials accurately reflect their patient population. This study compared the skin tone of images in online materials from the American Society of Plastic Surgeons (ASPS), academic plastic surgery programs, and private groups to the demographics of the United States (US) reduction mammaplasty population. Images within patient education materials and embedded photo galleries were assessed and skin tones were categorized using the Fitzpatrick Skin Scale (FSS). Two reviewers evaluated 616 images. Scores of 1-3 were categorized as White, while scores of 4-6 were classified as non-White. The proportion of images categorized as White and non-White were compared to the demographics of the reduction mammaplasty population in the US. Of 616 images, 82% were classified as White, while 18% were non-White. This distribution differed significantly from the racial demographic distribution of patients undergoing reduction mammaplasty in the US in 2020, where 48% identified as White and 52% as non-White (p < 0.001). There was also a statistically significant difference in the distribution of FSS scores between the materials from the ASPS, academic programs, and private surgeon groups, with private groups having a lower percentage of non-White images (p = 0.028). These findings suggest that implicit bias may impact the creation of patient education materials for reduction mammaplasty and highlights the need for improvement in distributing patient education materials that accurately represent the diverse reduction mammaplasty population.

Replacement of Shaped Textured Implants with Round Smooth Implants in Breast Reconstruction: Long Term Patient- and Surgeon- Reported Outcomes.

BACKGROUND: The number of patients undergoing exchange of textured implants for smooth devices has greatly increased due to concern over BIA-ALCL. The authors examine long-term patient- and surgeon-reported outcomes in terms of aesthetics, comfort, and complications. METHODS: Patients who underwent reconstruction with shaped, textured implants replaced with round, smooth implants between 1994-2022 with a minimum follow-up of 1 year were included. Patient-reported outcomes were collected using the BREAST-Q Reconstruction Module as well as a survey evaluating aesthetics and comfort. Surgeon-reported outcomes included evaluation of aesthetics and capsular contracture. RESULTS: 530 patients were reviewed, and 307 patients were included. Pairwise comparison of BREAST-Q data demonstrated psychosocial well-being (72.68 to 76.45; p=0.0075) and physical well-being (78.79 to 81.88; p=0.0078) significantly increased. Overall breast satisfaction (61.94 to 67.27; p=0.0082) and sexual well-being (53.89 to 57.98; p=0.0002) were also significantly higher in parallel with a clinically meaningful increase in BREAST-Q score of 5.33 and 4.09 points, respectively. Most patients felt they looked better (56.4%) or similar (27.3%) and were more comfortable (54.4%) or similar (39.4%) after the exchange procedure. The senior surgeon rated 40.1% of patients as a better aesthetic grade after replacement and 50.3% as the same. 36.8% of patients were rated as having a decrease in Baker capsular contracture grade. 2.9% of patients experienced a peri-operative complication and there were no reconstructive failures. CONCLUSION: Exchange of textured to smooth implants is safe, does not sacrifice aesthetic outcome, and provides a more comfortable and satisfactory outcome for patients with minimal complications.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Laparoscopic-Assisted Relocation of the Umbilicus With Umbilicoplasty in Complex Abdominal Wall Reconstruction.

Patients with complex abdominal wall pathology often present with significant distortion of their umbilicus. Ventral and umbilical hernias often create widening or protrusion of the umbilicus, while obesity and laxity of the skin and subcutaneous tissue of the abdominal wall further exacerbates the deformity. The primary goal of hernia repair is always reduction of the hernia with a tension-free repair; however, an important secondary goal is esthetic improvement of the abdominal wall. Often, in patients with complex hernia defects involving the umbilicus, there is discussion of not salvaging the umbilicus altogether. Although this certainly remains an option for many patients, we present a technique that would not only allow for hernia reduction under direct laparoscopic visualization but also an improved esthetic to the umbilicus.

Breast reconstruction after mastectomy in patients with obesity: a narrative review.

Background and Objective: Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. Methods: A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. Key Content and Findings: This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. Conclusions: The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

Head Computed Tomography Versus Maxillofacial Computed Tomography: An Evaluation of the Efficacy of Facial Imaging in the Detection of Facial Fractures.

Background: In an initial trauma evaluation, computed tomography of the head (CTH) is performed to assess for life-threatening intracranial injury. Given the high incidence of concomitant facial injuries, many facial fractures are diagnosed incidentally during this evaluation. Although maxillofacial CT (CTMF) is widely accepted as the most sensitive method for evaluating facial fractures, it is often excluded from the initial survey. Failure to obtain dedicated imaging can lead to increased costs related to a missed or delayed facial fracture diagnosis. Our study investigates the location and type of missed facial fractures on CTH by reviewing imaging data from patients who presented at a level 1 trauma center and underwent both CTH and CTMF. Methods: A retrospective review of all facial fractures diagnosed at a single institution from 2002 through 2016 was conducted. Inclusion criteria included adults aged 18 years or older who received CTH and then subsequent CTMF. Patients who had either CTH or CTMF only or combined CTH/CTMF were excluded. The facial fractures were further subdivided by location. Results: There were 501 patients with 1743 total facial fractures. CTH successfully identified 788 (45.21%) fractures, versus 1743 (100%) for CTMF. The most common fractures, in both cohorts, were nasal bone (15.7%) and orbital floor (12.8%) fractures. Using CTMF to identify missed fractures on CTH, significant differences were noted in the following locations: anterior table frontal sinus, medial/lateral pterygoid, maxillary sinus, lateral orbital wall, zygomatic arch, palate, and all types of mandible fractures excluding the mandibular condyle. Conclusions: CTH for initial trauma evaluation often misses facial fractures. CTH alone was only sufficient in detecting posterior frontal sinus, orbital (excluding lateral wall), and mandibular condyle fractures. In patients with suspected facial injury, dedicated imaging should be performed to detect the location and extent of injury because CTH inadequately identifies most facial fractures.

Diversity in Plastic Surgery: Analysis of Representation of Sex and Ethnic Diversity in Plastic Surgery Residency Social Media Accounts.

BACKGROUND: Increasing health care diversity is critical to overcoming disparities. Plastic surgery has been working to improve diversity through various efforts, including social media movements like Diversify PRS and #ilooklikeasurgeon. Because residency programs' social media sites serve as a public symbol of the programs' values and can attract potential applicants, we sought to analyze such platforms for content highlighting sex and ethnic diversity. METHODS: Integrated plastic surgery residency programs during the 2020 to 2021 academic year were found on the American Council of Academic Plastic Surgeons website, and their associated social media accounts were identified. The authors reviewed each program's account for all posts published by November 8, 2021, for content promoting sex or ethnic diversity. Any hashtags related to diversity were also recorded. Nonparametric Mann-Whitney U and Kruskal-Wallis tests were used to compare percentages of total social media posts related to sex and ethnic diversity between programs (α = 0.05). RESULTS: Of 82 programs, 76 (92.7%) had active Instagram accounts, 29 (35.4%) had active Facebook accounts, and 29 (35.4%) had active Twitter accounts. Across all platforms, 19.0% of all posts were promoting sex diversity and 3.3% were promoting ethnic diversity. Of 4651 posts promoting sex diversity, 4067 (87.4%) highlighted women, 1017 (21.9%) featured all-women teams, 779 (16.7%) used sex diversity-related hashtags, and 300 (6.5%) included purposeful statements. Of 808 posts promoting ethnic diversity, 527 (65.2%) used ethnic diversity-related hashtags, 224 (27.7%) included purposeful statements, 199 (24.6%) mentioned ethnic background, and 36 (4.5%) used different skin-toned emojis. Programs did not vary in percentages of posts related to diversity by geographic region, ranking, accreditation length, or engagement rate. The percentage of posts promoting sex diversity was greater than that promoting ethnic diversity (P < 0.001). The most used diversity hashtag was #ilooklikeasurgeon. CONCLUSIONS: Despite the importance of increasing recruitment of trainees from diverse backgrounds to plastic surgery and the global reach of social media movements like #ilooklikeasurgeon, sex and ethnic diversity are still poorly promoted on residency social media accounts. Increasing such content is a simple yet powerful way to create a culture of inclusivity for all applicants.

A Social Media Analysis of Wellness Culture in Plastic Surgery Residency.

BACKGROUND: Burnout, "a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment", afflicts approximately one third of plastic surgery attending surgeons and residents. Burnout can be detrimental to resident training and patient outcomes. Therefore, cultivating wellness during residency is essential. In fact, the Accreditation Council for Graduate Medical Education requires residency programs to create learning and working environments that optimize faculty and resident wellness. With increasing social media use by plastic surgery residency programs, this study aimed to analyze their posts for wellness-related content. METHODS: Integrated plastic surgery residency programs were obtained from the American Council of Academic Plastic Surgeons Web site, and their associated social media accounts were identified. The authors reviewed all post images, captions, and comments made by the program's account, until July 3, 2021. Any hashtags relating to wellness were also recorded. RESULTS: Of 82 programs, 76 (92.7%) had active Instagram accounts, 31 (37.8%) had active Facebook accounts, and 30 (36.6%) had active Twitter accounts. Instagram had higher rates of engagement than Facebook and Twitter (P < 0.001). Across all platforms, the mean percent of total posts related to wellness was 18.87%. The most common wellness content showcased resident work-life balance (48.73%), followed by educational events incorporating wellness activities (27.61%), attention to physical health (17.71%), healthy work environments (5.29%), wellness-specific activities (3.25%), team building activities (2.40%), and images implying but not directly showing resident wellness (1.46%). Programs did not vary significantly in percentages of total posts related to wellness by geographic region, ranking, or accreditation length. In total, 1893 wellness-related hashtags were used on Instagram, 253 on Facebook, and 72 on Twitter. The most used wellness-related hashtag was #residentlife. Only 40.8% to 50.8% of posts using wellness hashtags met at least 1 wellness criterion. CONCLUSION: Despite the importance of burnout prevention during plastic surgery residency, less than a quarter of residency program social media content promote wellness. Social media can demonstrate how residency programs are incorporating wellness into their curricula, but whether residencies lack sufficient wellness initiatives or are not advertising such programming on their social media accounts remains to be studied.

Representation of Global Health Initiatives in Plastic Surgery Training: A Social Media Analysis.

INTRODUCTION: Over the last several years, various social media platforms have been used to increase collaboration, education, and research internationally. The purpose of this study was to evaluate how plastic surgery residency programs use social media to promote global surgery education, research, and collaboration. METHODS: A full list of active integrated residency programs was obtained from the American College of Academic Plastic Surgeons website. A total of 82 programs were identified. Instagram, Facebook, and Twitter were searched for active accounts. Only accounts dedicated to plastic surgery programs or had a significant amount of residency-related content were included. Inclusion criteria included posts relating to global health, global surgery, mission trips, international plastic surgery education, and global surgery research. Caption language was analyzed and classified as either "resident education in global surgery," "an individual's interest in global surgery," "research in global surgery," "visiting international professor," or "global collaboration." Image content was then assessed for "images with patients," "images with other surgeons/residents," "images of international location," a combination thereof, "other," or "none." RESULTS: Instagram was by far the most used by plastic surgery residency programs with a total of 76 programs having accounts compared with only 32 programs and 33 programs having Facebook and Twitter accounts, respectively. There was no significant difference in the proportional number of posts relating to global surgery across the 3 platforms (P = 0.1911). On all 3 social media platforms, the majority of posts fell into the category of "international collaboration" with 42.5%, 50.7%, and 48.8% on Instagram, Facebook, and Twitter, respectively. None of the caption categories examined showed a significantly different proportion of posts across the 3 platforms. Image analysis showed a significant difference in the proportional representation across the 3 platforms in the categories of "images with other surgeons/residents" (P = 0.0196) "images with patients" (P = 0.0082), combination (P = 0.0225), and other (P = 0.0114). CONCLUSIONS: Although social media offers programs an easy way to promote global surgery research, collaboration, and education with a wider audience, it is being underused for this purpose as evident by the relatively lower number of postings on each platform relating to this content.

Research Productivity of Integrated Plastic Surgery Residents: Does Reputation Matter?

INTRODUCTION: It is unknown whether the ranking of plastic surgery residency programs influences resident research output. This study aims to determine whether program reputation and other factors are associated with integrated plastic surgery resident academic productivity. MATERIALS AND METHODS: Programs were divided into four tiers based on Doximity reputation rankings. Residents from 2019 to 2020 were found through program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year to August 10, 2020. Variables included resident demographics and medical school, residency reputation ranking, geographic region, and medical school affiliation. 'High research output' was defined as having ≥75th percentile of publications adjusted by training year. RESULTS: In total, 921 residents in 80 programs were identified. The median (IQR) number of total publications and original articles was 3 (1-6) and 2 (0-4), respectively. On multivariable analysis, residents in top-20 ranked programs (OR = 2.31, 95% CI [1.55; 3.43], P < 0.001) or from programs associated with top-20 medical schools (OR = 1.61, 95% CI [1.08; 2.41], P = 0.020) were more likely to have higher research output. On the other hand, coming from a top-50 in research medical school (OR = 1.80, 95% CI [1.31; 2.47], P < 0.001) or being in a program affiliated with a top-20 medical school (OR = 2.52, 95% CI [1.69; 3.78], P < 0.001) were associated with higher original article output. Gender and geographic location were not associated with higher research output. CONCLUSIONS: Program reputation and affiliated medical school research rankings are associated with research productivity during integrated plastic surgery residency. Applicants with a particular interest in research careers may consider this as they apply to residency.

Interest in Plastic Surgery Residency: A Google Trends Analysis.

BACKGROUND: Since 2010, the number of programs and available positions for integrated plastic surgery residency has increased, yet the match rate remains one of the lowest of all specialties, and the applicant pool remains one of the most competitive. We sought to investigate whether this increased interest in integrated programs has translated to increased online search volume regarding plastic surgery residency. METHODS: Our study uses Google Trends, a powerful online tool that analyzes changes in Google search volume over time and across various regions, to study temporal and geographic trends in search interest for terms related to plastic surgery residency from July 2009 to 2020 in the United States. RESULTS: Terms related to plastic surgery research, step 1 and 2 scores, and residency interviews had the most search results, whereas terms related to away rotations and Alpha Omega Alpha had the least. "Independent plastic surgery track" had more total search results on Google than "integrated plastic surgery residency," and "plastic surgery fellowship" declined in search interest from July 2009 to March 2010. There was a rise in search volume for a plastic surgeon's salary and a fall in search volume for plastic surgery research between July 2009 and July 2020. However, other terms related to residency or residency applications showed no sustained trends over time. "Plastic surgery residency" was most searched in Pennsylvania, New York, Ohio, and Missouri, whereas "plastic surgeon salary" was most searched in Louisiana, Texas, Arizona, and Georgia. CONCLUSIONS: This Google Trends analysis showed discordance between the upward trend in integrated plastic surgery residency positions offered through the National Residency Match Program and relatively unchanging search interest in factors related to the plastic surgery residency application. However, interest in a plastic surgeon's salary has increased over time, but this is not specific to plastic surgery. Although online search tools can be of important predictive value, this study demonstrates that there are clearly other factors that influence medical students' interest in plastic surgery residency besides Internet research.

Are Opioids Out? Assessing Prescription Patterns in Plastic Surgery Using Medicare Part D Beneficiary Data.

INTRODUCTION: Since 1999, nearly 841,000 individuals have died from overdoses, 29% involving prescription opioids. Use of opioids for postoperative pain lacks evidence-based guidelines, and despite studies showing the efficacy of nonopioid agents in reducing postoperative morbidity, opioids are still routinely prescribed. However, multiple states are adopting prescription drug monitoring programs and prescription drug laws. The authors sought to investigate recent opioid prescription patterns among plastic surgeons. METHODS: This cross-sectional study used "Medicare Provider Utilization and Payment Data: Part D Prescriber" provided by the Centers for Medicare & Medicaid Services from 2016 to 2018. Entries were filtered to include plastic surgeons. Demographic variables included surgeon sex, geographic region and state, board certification status, and length of experience. The surgeon's practice was designated as academic, private, or both. Outcomes included total opioid claims, opioid prescriber rate, and days per claim. Kruskal-Wallis tests were used for statistical comparison (α = .05). RESULTS: From 2016 to 2018, plastic surgeons wrote 289,525 opioid prescriptions for 1,729,523 days (6.0 days per prescription), totaling $3,346,979.39. In 2018, 62.2% of plastic surgeons prescribed 0 to 10 opioids, 36.5% prescribed 11 to 50 opioids, and 1.3% prescribed more than 50. Furthermore, 99.5% of plastic surgeons prescribing opioids are practicing in metropolitan areas (rural-urban commuting area codes 1-3). Plastic surgeons who were male or were board certified had significantly lower opioid prescriber rates (P < 0.001). There were no significant variations in outcomes by length of surgeon experience. Geographic region was significantly associated with opioid prescription rates and days per claim, with Southern plastic surgeons having lower rates (P < 0.001) and those Northeastern ones prescribing shorter courses (P = 0.004). The number of opioid claims, days per claim, and opioid prescriber rates were all significantly lower in 2018 than in 2017 and 2016 (P < 0.001). CONCLUSIONS: Prescriptions written by plastic surgeons may have contributed to the opioid epidemic, but 2018 data suggest opioids are becoming less routine in postoperative pain control. Further studies are warranted to assess factors related to reduced and shorter opioid prescriptions by plastic surgeons in the South and Northeast, respectively. Such insight, if adopted into law and implemented into clinical practice, may help reduce the burden of the opioid epidemic.