Scientific Abstract Presentations: Practice Management Session 1 Thursday, September 26 Thu, Sep 26 1:00-2:30 p.m. PDT

Background: The transition of plastic surgery divisions to departments has been a gradual process compared to peer surgical specialties. We hypothesize that intra-institution metrics between plastic surgery units and other peer surgical subspecialties at that same academic medical institution are a major determinant of division or department status. Here we examine characteristics that define plastic surgery departments and identify the predictors of departmental status. Methods: Data were collected from institutional websites of academic plastic surgery units with integrated and/or independent residency programs as well the units of cardiothoracic surgery, urology, and otolaryngology at the same institution. Multivariable logistic regression was performed to determine program characteristics that were most associated with departmental status. Results: Plastic surgery departments tended to have older integrated residency programs (p<0.01) and more full-time faculty (p=0.026), research factulty (p=0.026), and residents (p=0.010). Through multivariable analysis, the presence of a department of cardiothoracic surgery (OR 1.30, p<0.01), the ratio of plastic surgery to otolaryngology faculty (OR 1.26, p<0.01), the number of years a unit has had an integrated residency program (OR 1.01, p<0.01), and the number of research faculty (OR 1.07, p=0.029) were independently associated with departmental status. Conclusions: Attaining departmental status at an academic institution allows a specialty to chart its own course with greater financial and administrative autonomy. Identifying the characteristics of plastic surgery departments can help divisions recognize their relative strengths and weaknesses when considering a possible transition to departmental status.

Introduction The landscape of plastic surgery residency training in Nigeria, in comparison with other countries, presents a unique mix of challenges and advancements. This study aims to assess the current state of plastic surgery training from the perspective of educators, identifying critical areas for improvement and offering recommendations for future development.

Methods A 25-question survey was distributed on the online plastic surgery resident/educator's forum in Nigeria using Google Forms. The survey collected detailed responses on demographics, institutional affiliations, training scope, surgical volume, training experience, satisfaction levels, challenges faced, and recommendations for improvement.

Results Out of 171, 37 educators responded to the survey (response rate = 21.6%). The educators were between 38 and 60 years old, predominantly male (82.9%), and were chiefly affiliated with tertiary institutions (91.4%). Most educators focused their practice on reconstructive surgery (75%) compared to aesthetic surgery (25%). The duration of experience in training residents ranged widely from 1 to 26 years. When discussing work conditions, most were neutral (54.3%) or happy (25.7%). Only 31.4% of educators found time spent with residents in operation theatre adequate. However, for time spent in the clinic, 51.4% found it adequate. 77.1% of educators believed residents lacked core competencies, specifically aesthetic surgery and microsurgery. Challenges identified included lack of essential surgical equipment, insufficient theatre space, high cost of medical bills affecting patient turnout, and inadequate exposure of residents to advanced surgical techniques. Educators highlight the need for increased collaboration with established centers globally, enhanced governmental support for resources, and the establishment of exchange programs, hands-on workshops, and simulations.

Conclusions The findings underscore the critical need for systemic improvements in plastic surgery training in Nigeria. Educators emphasize the importance of substantial investment in surgical equipment and integrating aesthetic surgery and microsurgery into educational curricula. Additionally, they recommend enhancing global collaboration with initiatives like Surgeons in Humanitarian Alliance for Reconstructive, Research and Education (SHARE) to bridge existing deficiencies and meet future demands in plastic surgery education.

Purpose: Understanding public misconceptions about plastic surgery can inform plastic surgeons of their patients' and non-plastic surgeon colleagues' knowledge gaps about the field. This deepened understanding can help lay the framework for better education, communication, and patient care and represents an essential step in optimizing patient satisfaction and health outcomes. The objective of this study was to leverage crowdsourcing methods to investigate the extent to which laypersons agree with common plastic surgery "urban myths."

Methods: A Likert scale-based survey of ten popular plastic surgery myths was distributed via Amazon Mechanical Turk between November and December 2023. Descriptive analyses and multinomial logistical regressions were performed to assess the strength of the associations between gender, age group, prior plastic surgery experience, and role as a health care professional and responses to the statements in the survey.

Results: Two thousand survey responses were included. The average age of respondents was 37.4 ± 10.5 years (range: 18–79 years). Nine hundred forty-nine (47%) and 1031 (52%) respondents identified as female and male, respectively; 20 (1%) respondents identified as non-binary or other. Most respondents did not have a prior plastic surgery procedure (n = 1449, 72%) or a prior plastic surgery consultation (n = 1361, 68%). There were 617 respondents (31%) who reported working or training in health care. Over half of respondents (52.7%) believed that plastic surgery is almost always cosmetic. Over a quarter of respondents were unsure (25.8%) or disagreed (12.6%) that plastic surgeons perform emergency and trauma surgeries. Many respondents (40.0%) believed that wearing underwire bras causes breast cancer, and 40.7% of respondents believe that hand dominance is associated with an ipsilateral larger breast. Respondents who were male or younger than 35 were significantly more likely to believe in inaccurate myths. Health care workers had higher odds of agreeing that plastic surgery uses plastic (OR=2.49 [95% CI: 1.82–3.41]; p<0.001) and that plastic surgery is almost always cosmetic (OR=1.85 [1.32–2.61]; p<0.001). Participants who underwent a plastic surgery procedure or consultation were generally more likely to agree with the listed myths.

Conclusion: This study suggests that the public and non-plastic surgeon healthcare workers have a limited understanding of the scope and practice of plastic surgeons. A multi-pronged approach to increase awareness about the field and dispel certain myths will be an instrumental step in bettering patient care. For example, it will be important to educate health-care staff and doctors in different specialties about the field. Providing compassionate patient-physician communication and creating patient-centered educational resources can also help dispel misconceptions about the field and conditions treated by plastic surgeons, thereby optimizing patient health outcomes and satisfaction.

Introduction The transition from in-person to virtual interviews during the COVID-19 pandemic transformed the residency application process. Recognizing the gradual return to in-person interviews and the historical presence of gender disparities within medical fields, the present study sought to evaluate how interview modality influences the success rates of applicants to Plastic and Reconstructive Surgery (PRS) residency programs, with a focus on gender and applicant characteristics.

Methods Data on PRS residency applicants to a single integrated Plastic and Reconstructive Surgery program from 2017 to 2021 (four application cycles) were obtained from the Electronic Residency Application Service (ERAS), National Residency Matching Program databases, and public online sources. The dataset included demographics (gender, race, orphan status), academic and professional qualifications (research year participation, Alpha Omega Alpha [AOA] and Gold Humanism Honor Society [GHHS] memberships, USMLE Step 1 and 2 scores, reapplicant status, type of medical graduate, additional degrees), interview modality (virtual or in-person), and match results. Specifically, interviews in the 2017/18, 2018/19, and 2019/20 cycles were in-person and those that took place in the 2020/21 application cycle were virtual. Data analysis included univariate regression with chi-squared test and multivariate logistic regression to assess the impact of virtual interviews on match success across genders and other factors.

Results A total of 1298 applicants (573 females, 724 males, 1 uncategorized) were included in the analysis; 985 (75.9%) underwent in-person interviews, and 313 (24.1%) had virtual interviews. There was a predominance of males with in-person interviews (58.2%) and females with virtual interviews (51.6%) (p = 0.002). The overall match success rate was 63.5%, with virtual interviews having a lower match rate (56.9%) compared to in-person (65.5%) (p = 0.004). Gender analysis revealed that female applicants had a higher overall match rate (67.2%) than males (60.5%) (p = 0.008). Notably, females had 1.38 times higher odds of matching with virtual interviews (p = 0.006). Specifically, the majority of successful matches with in-person interviews were male (56.3%), and with virtual interviews were female (57.9%) (p = 0.001). Gender was not a significant determinant in match rates when considering other characteristics (p = 0.213). Race played a crucial role (p = 0.011), with Asian, Hispanic, and other race categories associated with lower match success (p = 0.004, p = 0.049, p = 0.045). Participation in a research year was positively correlated with match success (p < 0.001). Being a previous graduate at the time of application (as opposed to being a senior medical student at the time of application) had a negative correlation (p < 0.001). Reapplicant status had no significant impact (p = 0.213, p = 0.650).

Conclusion Virtual interviews for PRS residencies led to lower overall match rates compared to in-person interviews, although female applicants experienced a relative benefit. Applicant success was additionally influenced by personal and career-related factors, such as race and research activity. These findings underscore the need for comprehensive and equitable residency selection processes.

Background: Implants and tissue expanders (TEs) are used in all types of breast procedures. In the traditional ordering model, plastic surgeons will typically request 3-4 different implant and TE sizes per procedure with accompanying sizers and extras - yielding a range of 15-32 items - after which unused stock is sent back to the manufacturer. To date, no study has investigated the costs of transporting materials in any surgical field. This study aims to quantify the economic impact of shipping implants and TEs for use in breast augmentations and reconstructions.

Methods: Shipping courier websites were queried to establish average weight-based charges for overnight, two-day, and ground shipping. Four implant models - unilateral/bilateral lightweight and unilateral/bilateral heavyweight - as well as a TE model were created to determine forward and return shipping rates per case when 3 or 4 sizes were ordered. The 2020 ASPS statistics data were then used to calculate total costs in scenarios where multiple implant and TE sizes were ordered with various shipping options (1).

Results: In the most expensive scenario where 4 sizes were ordered with overnight shipping for all cases, the maximum possible total for implant and TE shipping in 2020 was $200,691,882.37. Conversely, ordering 3 sizes using ground shipping yielded a minimum possible total of $25,369,050.97, saving $175,322,831.40 (87.4%). Compared to the maximum, choosing ground shipping for 4 sizes saved $164,761,561.49 (82.1%), while ordering 3 sizes using overnight shipping saved $58,990,876.94 (29.4%).

Conclusion: Implant and TE shipping costs are extremely significant, totaling tens or hundreds of millions of dollars depending on the type of shipping and the number of sizes ordered. These excessive costs are handed down to the healthcare system, physician practices, and ultimately, the patient, which can increase financial toxicity. While this study has its limitations as a model, it may encourage the use of more cost-efficient methods, such as opting for ground shipping, ordering less sizes, or using a consignment system, to decrease overall waste.

1. 2020 Plastic Surgery Statistics Report. American Society of Plastic Surgeons. Accessed May 2023. https://www.plasticsurgery.org/ documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf

Background: Integrated plastic surgery residency is one of the most competitive specialties for medical students to match into. Osteopathic graduates account for only 1.02% of current integrated plastic surgery trainees. This study was performed to explore osteopathic medical students' perception of plastic surgery and identify methods that our national societies can utilize to foster interest and exposure to the specialty. Methods: An anonymous survey was distributed to Student Affairs directors of all 43 osteopathic medical schools. Student Affairs directors were asked to forward the survey to their respective student bodies. The survey consisted of 35 questions, inquiring about student demographics, exposure and barriers to surgical education opportunities, and overall perception of plastic surgery. Results: We received 252 responses from seven osteopathic medical schools. 25.4% of respondents reported exposure to plastic surgery prior to medical school and 29.6% reported exposure to plastic surgery during medical school. 87.4% of students believe that exposure is lacking at their medical school. 82.5% of respondents identified a surgery interest group at their medical school, but only 5.9% were able to identify a plastic surgery interest group at their school. 74.2% of students interested in pursuing away rotations or sub-internships for surgical specialties experienced barriers arranging these experiences, and 92.6% of students interested in away rotations or sub-internships specifically for plastic surgery experienced barriers. Conclusion: Osteopathic students encounter barriers when seeking exposure to plastic surgery during their medical education. Osteopathic students may benefit from mentorship opportunities directed to improve medical student exposure to plastic surgery. These programs include the mentorship programs of the American Council of Educators in Plastic Surgery (ACEPS) and attendance at the virtual Medical Students Day hosted by the American Society of Plastic Surgeons (ASPS). Early exposure and increased opportunities for away rotations may encourage more osteopathic medical students to pursue plastic surgery.

Purpose Face transplantation is a relatively novel procedure that is highly sensationalized in the media, drawing significant public attention and fascination. As a result, alongside informational sources, much of the online material on face transplantation is encompassed by news stories and tabloids on patients who have undergone the procedure. Thus, the purpose of this study, is to provide a quantitative assessment of the content and readability of online materials that prospective patients or the public encounter regarding face transplantation.

Methods In February 2024, an exhaustive search of "face transplantation" and related terms was performed on Google, reviewing over 180 search results. Sites were categorized under three groups: informational sites from established face transplant centers, informational sites from third party sources (e.g. Wikipedia), and news article/tabloid sites. Each site was assessed for readability using 15 different standardized readability assessment scales including the Flesche Reading Ease (FRE), Coleman Liau Index (CLI), Automated Readability Index (ARI), and Dale-Chall Readability Score (DCRS) among others. The quality of each site was assessed utilizing the JAMA Benchmark Criteria.¹ One-way ANOVA with post-hoc Tukey's multiple comparisons test was used to compare average scores of each metric.

Results From the search results 20 sites from face transplant programs were identified, 22 sites from third-party informational sources, and 36 news articles/tabloids. While face transplant program sites and third-party informative sites had overall similar readability scores across all scales, news sources had significantly greater FRE scores (57.11 vs 44.96; p=0.017), lower CLI (10.80 vs 13.85; p<0.001), lower ARI (9.718 vs 11.66; p=0.032), and lower DCRS (5.746 vs 6.975; p=0.007) relative to face transplant program cites- all reflecting easier/lower grade level of reading in news sources. There was a significant difference between all categories for the JAMA Benchmark Criteria with face transplant programs demonstrating the lowest average score, followed by third-party sites, and news sources encompassing the highest score (2.05 vs 2.91 vs 3.67; p<0.001).

Conclusion Our analysis ultimately revealed that news source sites about face transplantation not only provide their content at a significantly lower grade/reading level, making it much more accessible and understandable to the general public, but also are overall more reliable and transparent in their authorship, sources, disclosures, and publishing dates (four criteria of JAMA Benchmark). This is a potential concerning finding because prospective patients and the public will seek out these readily accessible, understandable, and more abundant news sites as their primary sources of information when often they are authored by non-clinicians that lack the depth of face transplantation knowledge a face transplant program or reputable third-party resource sites possess. Thus, face transplant programs should update their websites to ensure greater transparency and accessibility of the information provided to the public.

1. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor--Let the reader and viewer beware. Jama. Apr 16 1997;277(15):1244-5.

PURPOSE The complexities in approaching breast reconstruction necessitates shared decision-making in order to balance patient preferences, needs, and medical limitations. The quality of patient-centered care can account for significant differences in immediate breast reconstruction rates (1, 2). Language discordance may impede this process.

Literature on translation validation and content readability have demonstrated the importance of resource accessibility for informed patient decisions (3). However, the influence of language barriers during patient-provider communication lacks research. This study systematically examines the influence of language discordance on breast reconstruction surgical decision-making and outcomes.

METHODS A systematic review was performed using PubMed, Scopus, CINAHL, and Medline - Ovid within 10 years of the search date of June 2023. Original studies on patient-provider language differences and breast reconstruction decisions or outcomes were included. Non-English studies, case reports, and articles validating translated materials or content readability were excluded. Articles that met the inclusion criteria were evaluated for risk of bias. Patient data was dichotomized into English and Non-English speaking groups, representing the absence and presence of language discordance respectively. Further statistical analysis was conducted through the Cochrane RevMan Web program with a Cochrane-Mantel-Haenszel Estimate forest plot. Included studies were also qualitatively analyzed.

RESULTS Six of the final 8 included studies found that fewer Non-English speaking mastectomy patients underwent breast reconstruction. Of which, 3 of the studies were statistically significant (P< 0.05). However, the significance did not remain following odds ratio analysis of breast reconstruction rates between English and Non-English speaking patients in the pooled data. Overall, Non-English speakers were 43% (odds ratio: 0.57) less likely to undergo breast reconstruction than English speakers (95% CI, 0.55 - 0.65). The lack of statistical significance may be attributed to high heterogeneity (I2 = 91%) and limitations in quality of data.

CONCLUSION Non-English speaking patients were less likely to undergo breast reconstruction than English patients, suggesting that language discordance acts as a disparity in elective surgical experiences. However, a qualitative review of articles that did not demonstrate a significant difference in reconstruction rates cited their robust translation services as a critical mitigating factor. Further studies on protective factors such as interpreters and culturally-competent approaches are warranted to address the potential for language discordance to impede shared decision-making.

REFERENCES 1.) Myckatyn TM, Parikh RP, Lee C, Politi MC. Challenges and Solutions for the Implementation of Shared Decision-making in Breast Reconstruction. Plast Reconstr Surg Glob Open. 2020 Feb 6;8(2):e2645. doi: 10.1097/GOX.0000000000002645. PMID: 32309090; PMCID: PMC7159965. 2.) Frisell A, Lagergren J, de Boniface J. National study of the impact of patient information and involvement in decision-making on immediate breast reconstruction rates. Br J Surg. 2016;103(12):1640-1648. doi:10.1002/bjs.10286 3.) Villa Camacho JC, Pena MA, Flores EJ, et al. Addressing Linguistic Barriers to Care: Evaluation of Breast Cancer Online Patient Educational Materials for Spanish-Speaking Patients. J Am Coll Radiol. 2021;18(7):919-926. doi:10.1016/j.jacr.2021.02.001

BACKGROUND: Hyperbaric oxygen therapy (HBOT) can promote viability in ischemic tissue. It is considered medically necessary for acute graft and flap compromise by most insurance policies but, in practice, it is inconsistently covered. Physicians have reported challenges with denied claims for HBOT resulting in unexpected costs for patients.

PURPOSE: This cross-sectional analysis aimed to review HBOT insurance policies, highlight minimum documentation standards, and suggest practical approaches when submitting claims for HBOT reimbursement.

METHODS: Using previously described methods, we collected insurance policies on HBOT from 60 health insurers and conducted a dual, blind extraction of documentation policies, prior and continuing authorization requirements, and treatment guidelines.[1] We compiled these data into an insurance reimbursement algorithm to assist prescribing physicians.

RESULTS: Of the 60 insurance providers initially identified, 53 (88.3%) had policies on HBOT. While most (83.6%) covered HBOT to varying extents, three (5.7%) considered HBOT investigational, and one (1.9%) explicitly denied coverage. Only 15 insurers (28.3%) defined graft or flap "compromise" in their policies. Most definitions relied on clinical suspicion of hypoxia, ischemia, or necrosis. Four policies required quantitative evidence of hypoxia using transcutaneous oximetry testing (TcPO2). Of insurers with HBOT policies, 25 (47.2%) required prior authorization, and most required continuing authorization after a dedicated number of HBOT sessions (Median 20, Min 12, IQR 18). Minimum acceptable pressure thresholds ranged from 1 atmosphere absolute (ATA) (n=15, 35.7%) to 1.9 ATA (n=2, 4.8%), and seven policies mandated twice daily HBOT at 2.0 to 2.5 ATA for 90 to 120 minutes. Less than half of insurers (n=22, 41.5%) outlined documentation requirements for HBOT reimbursement. The most requested documentation items were medical records (n=19, 86.4%), signs of healing (n=12, 54.5%), images (n=10, 45.5%), treatment goals (n=8, 36.4%), and dive parameters (n=5, 22.7%). Detailed records required the patient's diagnosis, type of graft or flap, surgeon's name, exclusion of mechanical etiologies for flap compromise, and any attempted conservative therapies. Twelve policies (54.5%) required that progress notes include "measurable" signs of healing, three of which recommended serial TcPO2 testing.

CONCLUSIONS: Most insured Americans are eligible for at least 12 sessions (6 days) of HBOT at 2.0 to 2.5 ATA for 90 to 120 min. Plastic surgeons wishing to refer patients for HBOT may improve the likelihood of claim coverage by seeking prior authorization, maintaining detailed patient records, and using objective measures of graft or flap viability. These details are outlined in our HBOT prescribing and documentation algorithm.

REFERENCES: 1. Ngaage LM, Knighton BJ, Benzel CA, et al. A Review of Insurance Coverage of Gender-Affirming Genital Surgery. Plast Reconstr Surg. 2020;145(3):803.

Introduction: Recent studies on plastic surgery expenditures have simultaneously revealed trends of both increasing charges to patients alongside decreasing reimbursements for providers (1,2). This is particularly true for government insurers like Medicare (3,4). However, there remains a lack of understanding related to the causes and implications of how expenditures, payer type distribution, and reimbursement rates in plastic surgery have changed. The purpose of this study is to investigate payer trends for ambulatory plastic surgery visits to better understand noted changes in spending patterns, payer type mix, and reimbursements rates over the past two decades.

Methods: We utilized the Medical Expenditure Panel Survey (MEPS), a dataset of national surveys of patients and providers on attendant healthcare usage and expenditures. During the study period (2002-2021), we calculated the yearly average amount of money charged and paid per visit, the distribution of payer type expenditures (i.e., government insurance, private insurance, out-of-pocket), and the mean percentage discount per visit. This refers to the percent of total charges not reimbursed. Dollar amounts were inflation-adjusted to 2021 estimates.

Results: 792 ambulatory visits were identified from 2002 – 2021. The mean dollar amount paid per visit increased generally over time, particularly in the second decade, ranging from $2,021 (2013) to $8,023 (2021) (Fig. 1). Approximately 5.2% of expenditures were paid through Medicaid, 12.5% through Medicare, 56.0% through private insurance, 16.2% out-of-pocket, and 10.1% through other means. The proportion of expenditures paid through private insurance increased gradually to a high of 82.8% (2021), while the proportion of Medicaid, Medicare, and out-of-pocket expenditures remained relatively steady (Fig. 2). The mean percentage discount generally increased over the study period, ranging from 40.7% (2002, 2005) to 68.5% (2015) (Fig. 3).

Conclusions: Healthcare spending by patients and insurers for outpatient plastic surgery visits has increased since 2001. The majority of these expenditures were paid through private insurers. The data also shows that payer mix trends have fluctuated and reimbursements have decreased in the previous two decades. Further investigation is key to elucidating the causes of these changes and their potential implications for patients, providers, and health systems, particularly as it relates to access to equitable care.

References 1. Billig JI, Chen JS, Lu YT, Chung KC, Sears ED. The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures. Plast Reconstr Surg. 2020;145(6):1541-1551. doi:10.1097/PRS.0000000000006847 2. Kim YJ, Chung KC. Insurance Reimbursement in Plastic Surgery. Plast Reconstr Surg. 2021;147(4):995-1003. doi:10.1097/PRS.0000000000007761 3. Gong JH, Bai G, Vervoort D, Eltorai AEM, Giladi AM, Long C. Decreasing Medicare Utilization, Reimbursement, and Reimbursement-to-Charge Ratio of Reconstructive Plastic Surgery Procedures: 2010 to 2019. Ann Plast Surg. 2022;88(5):549-554. doi:10.1097/SAP.0000000000002990 4. Kandi LA, Jarvis TL, Shrout M, et al. Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma. J Craniofac Surg. 2023;34(1):247-249. doi:10.1097/SCS.0000000000008840

Introduction: High risk patients undergoing vascular procedures often receive plastic surgery directed closure of surgical wounds. Although many different strategies exist for wound closure, sartorius flap closure remains a mainstay method, due to the versatility and reliability of the muscle flap for sufficient tissue support. Despite this, plastic surgeons may sometimes need to rely on alternative methods such as rectus flaps (rectus femoris, rectus abdominus) or complex closures due to the unsuitability or unavailability of sartorius flaps from prior operation. Here, we investigate the context for usage of alternative closure methods and compare the postoperative outcomes of these closure methods for groin incisions.

Methods: Data from the electronic health record was pulled for all procedures involving both vascular and plastic surgeons over a 7 year time period (2014-2020). Cases were manually reviewed for those describing groin closure. A variety of demographics and clinical characteristics were collected. The context and type of the closure (re-do vs. novel closure) was determined through chart review. Cases with more than 1 closure method detailed were excluded from further analysis. Postoperative complications and return to operating room (OR) rates were recorded. Data was compiled and logistic regression was used to derive correlations.

Results: Our complete cohort consisted of 283 unique patients and 419 procedures. This consisted of 345 sartorius flaps, 48 complex closures, 16 rectus femoris flaps, and 10 rectus abdominus flaps. Preoperative health was similar amongst all closure methods groups with a median ASA score of 3 (min=2; max=5). Rectus femoris and abdominus flaps were most commonly utilized in the context of a re-do procedure (70%; 75%) as opposed to complex closures (27.1%) and sartorius flaps (26.4%). Rectus abdominus flaps saw the highest overall complication rate (40.0%) followed by complex closure (39.1%), rectus femoris flaps (37.5%) and sartorius flaps (25.8%). A similar trend was present with return to OR rates (31.3% rectus femoris, 29.1% complex closure, 20.0% rectus abdominus, 12.8% sartorius). Of all postoperative complications included in review, wound breakdown, lymphocele, and hematomas were the only 3 significantly associated with return to OR (p<0.01). Rectus femoris and abdominus flaps saw comparable rates of wound breakdown (18.8%; 10.0%) to sartorius flaps (16.8%) and all three had lower breakdown rates than complex closure (29.1%). Hematoma and lymphocele rates were similar amongst all 3 groups (+/-5%).

Conclusions: This study suggests that rectus abdominus and femoris flap closure is superior to complex closure in cases where sartorius flaps have failed previously or cannot be used. Complication rates were similar to those in complex closures despite the majority of abdominus and femoris flaps being performed on re-do cases. These cases confer increased risk over novel closures due to the presence of scar tissue and previous vascular damage. Our results also reinforce current practice patterns that favor sartorius flaps for groin closure due to better performance endpoints (complication and return to OR rates).

Purpose The American Council of Educators in Plastic Surgery (ACEPS) is the leading organization invested in improving plastic surgery education and training, thereby influencing the future workforce of plastic surgery. With the formation of ACEPS' Diversity, Equity, and Inclusion (DEI) Committee in 2021, the landscape of abstracts submitted to ACEPS meetings may be changing, reflecting the social and professional shifts in inclusion. We sought to characterize differences in abstracts submitted versus accepted to the ACEPS meetings over a 6-year span in (1) author gender and (2) institutional affiliation.

Methods We retrospectively reviewed abstracts submitted to the 2018-2023 ACEPS annual meetings. Data included: acceptance status, reviewer scores (1=lowest, 5=highest), author lists, and institutional affiliations. We cross-referenced last authors' affiliated institution with the top-40 National Institutes of Health(NIH)-funded institutions. We used Gender API to designate first and last author genders. Parametric tests were performed to analyze continuous variables. Significance was p<0.05.

Results We analyzed 489 abstracts and found no difference in mean reviewer scores for submissions with women versus men first (3.06 vs. 3.02; 95%CI=(2.97-3.15) vs. (2.92-3.13); p=0.56) or last authors (3.13 vs. 3.02; 95%CI=(3.00-3.25 vs. 2.94-3.10); p=0.14). Overall, 50.4% of submissions had women first author and 21.3% as last. Women first author submissions increased from 42.1% (n=8) in 2018 to 53.9% (n=104) in 2023; last author increased from 15.8% (n=3) in 2018 to 23.3% (n=45) in 2023. The smallest proportion of women last author submissions (n=7, 9.2%) and podium acceptances (n=3, 11.5%) was observed in 2020; the largest was in 2021 (n=27, 31.0%; n=11, 42.3%) and remained visibly higher since its 2020 nadir. Across all 6 years, there was a similar proportion of submitted versus accepted last authors from a top-40 NIH-funded institution (61.11% vs. 65.04%).

Conclusions Representation of women first authors in abstract submissions/acceptances remained >50% in 2022 and 2023, suggesting ACEPS DEI Committee's successful efforts. However, representation of women last authors has yet to reach parity, a finding that may reflect the persistent landscape of fewer women as senior faculty. Last-author affiliation with a top-40 NIH-funded institution was not associated with greater acceptance rates. Achieving gender parity in senior authorship may take time as more women first authors enter academia, achieve senior faculty ranks, and become principal investigators. It is imperative to continue to support women academicians as they progress in their plastic surgery career.

Background: Internet search engines like Google make health information accessible to patients. Although internet searches may help patients educate themselves, they may provide extraneous information resulting in patients misdiagnosing themselves. As a result, patients may seek care for nonexistent conditions, leading to unnecessary tests, procedures, and treatments, thereby straining healthcare resources. This study seeks to elucidate the frequency of self-directed patient research and how it affects their new patient visit.

Methods: We prospectively administered an optional survey, via Epic, to all new patients two days before presenting to a hand surgeon at a single institution from July 2023 to December 2023. Survey questions included whether patients researched their condition, the search engine used, time spent researching, and search terms used. Following their new patient visit, billing and insurance data for the encounter were collected. Patients who did not complete the survey or had incomplete billing data were excluded. Patients who completed the survey and had a complete set of billing data were sorted into a correct or incorrect category based on the agreement between their self-researched key terms and billed diagnosis code (International Classification of Diseases-10 (ICD-10) code). Descriptive statistics were performed on demographic and survey data. Student's t-tests were performed to evaluate differences in means between the correct and incorrect agreement groups for the following variables: total visit time (determined by Current Procedural Terminology (CPT) code), total encounter charges, and physician work Relative Value Units (wRVUs).

Results: The survey was sent to 266 patients, and we received 76 responses (response rate 28.5%). 28 patients were excluded for the following reasons: three did not attend their visit, 22 did not completely fill out the survey, and three had incomplete billing data. 48 patients were included in the study. The average age of the included participants was 60.75 years (SD 15.8 years). Of the 48 patients who responded to the survey, 39 (81.3%) reported researching their condition before their appointment. Google was the most common search engine (n = 32, 82.1%). Most patients who performed research on their condition were incorrect about their diagnosis (n=22, 57%). The average time per appointment was significantly longer for incorrect patients (35.7 minutes) compared to correct patients (28.8 minutes) (p < .05). Similarly, the average total charges for the encounter were higher for incorrect patients ($450.86) than for correct patients ($379.69); however, this difference was not statistically significant (p > .05). Likewise, total physician work RVUs for the encounter were greater for incorrect patients (2.28) compared to correct patients (1.91); although, this difference also was not statistically significant (p > .05).

Discussion: The majority of respondents (81.3%) engaged in self-directed research on their condition prior to their new patient visit. However, pre-appointment research does not typically result in accurate self-diagnosis, as 57% of patients who researched their condition had incorrect diagnoses. Patients with incorrect self-diagnoses experienced longer appointment durations. The added time may be due to additional provider discussion time explaining why the patient's pre-conceived diagnosis is not their actual diagnosis.

Purpose: Plastic surgeons should be educated about market players that impact patient access and reimbursement of surgical services. Centers for Medicare and Medicaid Services (CMS) reimbursement for plastic surgery procedures have not kept pace with inflation. Furthermore, CMS reimbursement is often used as a lower bound for reimbursement from private payers. We quantitatively and qualitatively describe the American Medical Association Relative Value Scale Update Committee (RUC) process, which influences plastic surgery reimbursement rates through RUC recommendations to CMS. We also describe the CMS rulemaking process to understand how CMS considers RUC recommendations about plastic surgery services.

Methods and Materials: Between CPT years 2015 and 2024, RUC made recommendations to CMS for 38 plastic surgery procedure codes. We collected available RUC data for 33 CPT codes, including American Society of Plastic Surgeons (ASPS) recommendations, physician surveys, and final recommendations. We utilized the federal Physician Fee Schedule rules to track CMS's consideration of RUC recommendations, including proposed adjustments, public comments, and their final decision.

Results: RUC agreed with ASPS recommendations for 88% (29/33) of codes. While reviewing codes, RUC considered "compelling evidence" to include reorganization into new code families (9 codes), flawed/outdated methodology (7), change in patient population (4), and miscoding (6). RUC conducted surveys for 25 codes, resulting in an average response rate of 4.4±2.0%. Work Relative Value Units (wRVUs) were recommended at or below the 25th percentile for 88% (22/25) of codes and were influenced by other code valuations for 56% (14/25) of codes. Regarding practice expenses, RUC's median recommended change in total cost of service per code was a $9.63 decrease for facility payments (ranging from $201 decrease to $19.32 increase) and a $28.09 increase for non-facility payments (ranging from $168.24 decrease to $134.90 increase).

In 87% (7/8) of codes where RUC recommended an increase in the wRVU, CMS decided to either lessen that increase, not change from the prior calendar year (CY), or issue a net decrease from the prior CY. In 100% (3/3) of codes where RUC recommended a decrease in wRVU, CMS decided to decrease reimbursement even further. On rare occasions, CMS considered methodologic concerns compelling enough to reverse their decisions. For new code proposals, CMS agreed with RUC recommendations 100% (8/8) of the time.

Conclusion: At the RUC level, we identified potential contributors to suboptimal valuation of codes including low survey response rates, recommending RVUs in the lowest quartile, and recommending decreases to service costs. Additionally, CMS frequently decreased RUC-recommended reimbursement values with the exception of new codes, which retained their recommended values. Fair reimbursement requires continuous strategic advocacy efforts by plastic surgery specialty societies and active participation from plastic surgeons in the RUC valuation and CMS rulemaking process.