A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

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.

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.

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.

Machine learning analysis of online patient questions regarding breast reconstruction.

BACKGROUND: Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction. METHODS: Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers. RESULTS: 522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?" CONCLUSIONS: Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

Assessment of Microsurgery Simulation Course Access in Plastic Surgery Training Programs.

BACKGROUND: Microsurgery requires complex skill development with a steep learning curve for plastic surgery trainees. Flap dissection courses and simulation exercises are useful to acquire these skills. This study aims to assess plastic surgery training programs' access to and interest in microsurgical courses. METHODS: A survey was distributed to plastic surgery residency and microsurgery fellowship program directors (PDs). The survey collected program demographics and attendance of trainees at structured microsurgical skills or flap dissection courses. We assessed if PDs thought trainees would benefit from instructional courses. RESULTS: There were 44 residency PD responses (44/105, 41.9%, 36 integrated, 8 independent), and 16 fellowship PD responses (16/42, 38.1%). For residency PDs, 54.5% (24/44) sent residents to flap courses, and 95% (19/20) of remaining PDs felt residents would benefit from attending. In addition, 59.1% of programs (26/44) sent residents to microsurgical skills courses, and 83.3% (15/18) of remaining PDs felt residents would benefit from attending. When examining fellowship PDs, 31.2% of programs (5/16) sent fellows to flap dissection courses and 10/11 of remaining PDs felt fellows would benefit from attending a course (90.1%). Half of programs (8/16) sent fellows to microsurgical skills courses, and 7/8 remaining PDs felt fellows would benefit from attending (87.5%). CONCLUSION: Only half of the plastic surgery trainees have access to microsurgical skills and flap dissection courses. The majority of residency and fellowship PDs feel that training courses are valuable. Expanding access to these courses could provide a significant benefit to microsurgical education in plastic surgery training.

Efficacy of Prophylactic Postoperative Antibiotics in Tissue Expander-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Conflicting evidence exists regarding the utility of prophylactic postoperative antibiotics in tissue expander (TE)-based breast reconstruction. This study evaluated the risk of surgical-site infection between patients receiving 24 hours of perioperative antibiotics alone versus prolonged postoperative antibiotics within a propensity score-matched cohort. METHODS: Patients undergoing TE-based breast reconstruction receiving 24 hours of perioperative antibiotics alone were propensity score-matched 1:3 to patients receiving postoperative antibiotics based on demographics, comorbidities, and treatment factors. Incidence of surgical-site infection was compared based on duration of antibiotic prophylaxis. RESULTS: Of a total of 431 patients undergoing TE-based breast reconstruction, postoperative antibiotics were prescribed in 77.2%. Within this cohort, 348 were included for propensity matching (no antibiotics, 87 patients; antibiotics, 261 patients). After propensity score matching, there was no significant difference in incidence of infection requiring intravenous (no antibiotics, 6.9%; antibiotics, 4.6%; P = 0.35) or oral antibiotics (no antibiotics, 11.5%; antibiotics, 16.1%; P = 0.16). In addition, rates of unplanned reoperation ( P = 0.88) and 30-day readmission ( P = 0.19) were similar. After multivariate adjustment, prescription of postoperative antibiotics was not associated with a reduction in surgical-site infection (OR, 0.5; 95% CI, -0.3 to 1.3; P = 0.23). CONCLUSIONS: Within a propensity score-matched cohort accounting for patient comorbidities and receipt of adjuvant therapies, prescription of postoperative antibiotics after TE-based breast reconstruction conferred no improvement in rates of TE infection, reoperation, or unplanned health care use. These data underscore the need for multicenter randomized trials on the utility of antibiotic prophylaxis in TE-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

Defining Predictors of Future Academic Productivity in Plastic Surgery Residency.

Background: Research is a valued component of applications to plastic surgery residency. No prior studies have explored factors associated with increased resident research productivity. This study aims to compare the academic productivity levels of plastic surgery residency graduates based on their pre- and postresidency experiences. Methods: Residents graduating in 2019 and 2020 were identified from integrated programs. Metrics collected included the number of publications in medical school and residency. Descriptive statistics were completed along with linear regressions to evaluate the impact of these on academic productivity. Results: A total of 221 residents from the classes of 2019 and 2020 were included. Most residents completed fellowship (75.9%) although less than half went on to academic practice (42.3%). Approximately one in five residents obtained secondary degrees (17.4%). Subjects averaged 3.15 (N = 208, SD = 4.51) publications while in medical school and 8.1 publications during residency (N = 209, SD = 10.0). For h-index calculated at the end of residency, having dedicated medical school research time was the only statistically significant factor (coefficient = 2.96, P = 0.002). Conclusions: Plastic surgery residents published more often as first authors and overall during residency than medical school, indicating increased research involvement and leadership. The present study builds upon prior studies by confirming the importance of dedicated medical school research time and its lasting impact. Understanding the associations of academic factors with increased research productivity in residency is relevant for both applicants and programs evaluating residency candidates.

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.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction.

BACKGROUND: Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS: We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS: We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 1.15, p < 0.001) and operative time (ß - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS: Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

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.

Trends in Patient-Reported Outcomes Reporting in Breast Reconstruction: A Scoping Literature Review.

INTRODUCTION: Patient-reported outcomes (PROs) provide essential information in reconstructive surgery, where interventions center on patients' functional and aesthetic goals. Although multiple patient-reported outcome measures (PROMs) have been validated for breast reconstruction since 2009, no studies have assessed recent frequency and consistency in use. This study aims to characterize recent trends in inclusion of PROs in recent breast reconstruction literature. METHODS: Articles published between 2015 and 2021 pertaining to autologous and/or prosthetic breast reconstruction in Annals of Plastic Surgery and Journal of Plastic and Reconstructive Surgery were considered in a scoping review. Original breast reconstruction articles were reviewed for use of PROMs and characteristics of administration in accordance with PRISMA-Scr guidelines. Previously defined scoping review criteria were considered, including PROM used, timeline of collection, and topics addressed, with trends in frequency and consistency of usage assessed over the designated period. RESULTS: Of the 877 articles reviewed and 232 articles included, 24.6% reported using any PROM. The majority used BREAST-Q (n = 42, 73.7%), with the remainder being institutional surveys or previously validated questionnaires. Patient-reported outcomes were most often collected retrospectively (n = 20, 64.9%) and postoperatively (n = 33, 57.9%). The average time point of postoperative survey administration was 16.03 months (SD, 19.185 months). χ2 Analysis revealed no significant association between the numbers of articles, including PROMs and the year (P = 0.1047). CONCLUSIONS: This study demonstrates that only one-fourth of breast reconstruction articles report the use of PROMs with no interval increase over recent years. Patient-reported outcome measures were predominantly used retrospectively and postoperatively with notable variation in timing of administration. The findings highlight the need for improved frequency and consistency of PROM collection and reporting, as well as for further exploration into barriers and facilitators of PROM use.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery.

BACKGROUND: After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS: PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS: The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS: Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Early Simultaneous Cross Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis after Tumor Resection.

We describe a new approach for facial reanimation after skull base tumor resection with known facial nerve sacrifice, involving simultaneous masseter nerve transfer with selective cross facial nerve grafting (CFNG) within days after tumor surgery. This preliminary study compared outcomes of this approach versus a staged procedure involving a masseter nerve "babysitter" performed in a delayed timeline. Methods: Patients undergoing masseter nerve transfer and CFNG for facial paralysis after skull base tumor resection were consented to participate in video interviews. Facial Clinimetric Evaluation (FaCE) Scale (0-100) patient-reported outcome, eFACE, and Facial Grading Scale scores were compared. Results: Nine patients had unilateral facial paralysis from resection of a schwannoma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days after resection), whereas four underwent two-stage reanimation including a babysitter procedure (mean 218 days after resection). Postoperative FaCE scale and Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative mean eFACE scores were similar for both groups for smile (early: 71.5 versus delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7 versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group (76.4 versus 91.1; P = 0.04). Conclusions: Early simultaneous masseter nerve transfer and CFNG provides reanimated movement sooner and in fewer stages than a staged approach in a delayed timeline. The early technique appears to result in similar clinician- and patient-reported outcomes compared with delayed procedures; however, in this preliminary study, the early approach was associated with greater synkinesis, meriting further investigation.