Scientific Abstract Presentations: Practice Management Session 4 Saturday, September 28 Sat, Sep 28 10:30 a.m.-12:30 p.m. PDT

Purpose Acute Respiratory Distress Syndrome (ARDS) is a common complication among mechanically ventilated adult burn patients; however, the risk factors associated with its development are not well understood. Acute kidney injury and burn severity may predict ARDS, while the role of inhalation injury is still debated. Conflicting evidence exists regarding ARDS as an independent predictor of poor hospital outcomes. Given that prior studies are limited by small sample size or single institutional data, the purpose of this study is to identify risk factors for ARDS in mechanically ventilated adult burn patients and characterize the impact of ARDS on hospital course using multi-institutional data. Methods The National Trauma Data Bank (NTDB) was queried for patients >=18 years with ICD-9 or ICD-10 codes corresponding to burn injury from 2007-2016. Hospitalized patients with at least 48 hours of mechanical ventilation were included. Demographics, medical comorbidities, total body surface area (TBSA), injury severity score (ISS), initial Emergency Department (ED) vital signs, length of stay, and in-hospital mortality were collected. Chi-squared test, Wilcoxon rank sum test, unpaired t-test, and univariate and multivariate logistic regression were used to identify risk factors for ARDS. Propensity score matched analysis at a 1:5 ratio was used to determine the impact of ARDS on hospital course.
Results This sample included 13928 patients, of which 1437 (10.3%) developed ARDS. The average age for ARDS patients was 50 (standard deviation [SD]:17) which was older than non-ARDS patients (48 [SD:18], p<0.001). The median (interquartile range [IQR]) ISS for ARDS patients was also greater than non-ARDS patients (18 [9-26] vs. 10 [4-25], p<0.001). ARDS patients had a higher incidence of inhalation injury (198 [14%] vs. 1188 [10%], p<0.001) and burns covering more than 20% TBSA (464 [32%] vs. 2986 [24%], p<0.001) compared with the non-ARDS cohort. On multivariate logistic regression after controlling for age and sex, hypotension in the ED (adjusted odds ratio [aOR]: 1.83, 95% confidence interval [CI]: 1.29-2.54, p<0.001), alcohol use disorder (aOR: 1.82, 95%CI: 1.39-2.36, p<0.001), and inhalation injury (aOR: 1.57, 95%CI: 1.04-2.29, p=0.026) were most strongly associated with ARDS. TBSA and ISS also increased the risk of developing ARDS (aOR:1.07, 95% CI:1.02-1.12, p=0,007; aOR:1.02, 95% CI: 1.02-1.03, p<0.001). After propensity score matching controlling for age, ISS, TBSA, inhalation injury, alcohol use disorder, and admission year, ARDS patients had a significantly longer median (IQR) length of stay (32 [15-53] vs. 22 [7-33], p<0.001). In-hospital mortality was also significantly higher in the ARDS cohort (295 [37%] vs. 668 [25%], p<0.001). Conclusion This study confirms that both TBSA and inhalation injury are associated with ARDS development. Injury severity, hypotension in the ED, and alcohol use disorder were identified as novel risk factors for ARDS after burns. Furthermore, ARDS is independently associated with worse hospital outcomes including length of stay and mortality. These findings highlight the impact of patient and injury characteristics on developing ARDS and support the consideration of ARDS when estimating mortality risk in burn patients.

INTRODUCTION: Since their release, large language models (LLMs) have shown promise in providing accurate medical knowledge. The medical community is actively exploring the potential applications of these LLMs to determine how to best leverage their capabilities. One potential application is as a patient resource. The purpose of this study is to evaluate and compare the ability of OpenAI's ChatGPT-3.5, ChatGPT-4, and Google's Gemini in providing postoperative care recommendations to patients who underwent cosmetic plastic surgery.

METHODS: Each LLM was presented with 32 questions addressing common patient concerns after liposuction, breast augmentation, abdominoplasty, mastopexy, and blepharoplasty. The understandability and actionability of responses were determined using the Patient Education Materials Assessment Tool (PEMAT). The Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease Score (FRES) were calculated to assess the readability of responses. Additionally, medical accuracy was evaluated with a 5-point Likert scale. Response metrics were analyzed with ANOVA and Tukey's post-hoc analysis to compare model performance.

RESULTS: ChatGPT-4 demonstrated the highest accuracy of 81.3% with an average Likert score (LS) of 4.1 ±0.88, compared to ChatGPT-3.5 at 78% (LS 4.1±0.93) and Gemini at 75% (LS 4.1±0.91); however, there was no statistically significant difference in Likert scores (p-value=0.85). No significant difference was found either for PEMAT actionability scores (p=0.83), where ChatGPT-3.5, ChatGPT-4, and Gemini scored averages of 57.5%, 59.0%, and 58.0%, respectively. ChatGPT-3.5 responses averaged an 88.3±2.7% understandability score, which was statistically different from ChatGPT-4 (85.0±4.9%, p-value<0.01) and Gemini (91.0±3.0%, p-value=0.01); both ChatGPT-4 and Gemini were also statistically different from each other (p-value<0.01). Gemini averaged significantly lower FKGL (10.9±2.0) than ChatGPT-3.5 (12.9±1.0) and ChatGPT-4 (13.6±1.3). This translated to higher FRES for Gemini (43.7±10.2), which was significantly higher than ChatGPT-3.5 (33.7±6.8) and ChatGPT-4 (33.7±6.2) with p-value<0.01.

CONCLUSION: Our study has provided valuable insights into the efficacy of LLMs in delivering postoperative care recommendations to patients who underwent cosmetic plastic surgery. While ChatGPT-4 exhibited higher accuracy and clarity in its responses, ChatGPT-3.5 and Gemini were notably more understandable. However, all three models demonstrated shortcomings in providing actionable and concise guidance, necessitating the continued involvement of surgeons for follow-up care. Although LLMs have demonstrated their potential as adjunctive tools in postoperative patient care, further refinement and research are imperative to enable their evolution into comprehensive standalone resources.

Purpose: Patient education is a critical aspect of Plastic and Reconstructive Surgery. Proper patient understanding is critical to mitigate anxiety and improve post-op care. However, patient education can be time consuming and difficult, especially if the patient has low health literacy. This can disproportionately impact patients from low socioeconomic status. A potential solution to these barriers is surgical education videos. Educational videos can provide patients with a reference for surgical education and post-op care. This project has two goals. Our first goal is to determine health literacy's role in patient satisfaction with pre-operative education and if there is a need to improve it. Our second goal it to determine the role of patient education videos in a pre-operative setting.

Methods: To address our first aim, we administered an amazon MTurk survey to individuals that had a prior surgery. The survey comprised of 5 questions from the HLS-EU-Q47 (a validated health literacy metric) and one question to rate participant satisfaction with pre-operative education (range 0-100). To address our second aim, we showed patients at our institution videos explaining their upcoming surgery. Videos were shown after the patient had their initial consult with the surgeon, which included pre-operative education. Videos were created by Understand.com and are pre-approved by ASPS. Videos shown included abdominoplasty, breast augmentation, mastopexy, and lower face lift. Before the video, patients were given a survey of three questions from HLS-EU-Q47 and one question to assess their satisfaction with their pre-operative education. After the video, patients were given a survey to determine if understanding and anxiety improved.

Results: 39 participants filled out our MTurk survey. Our cohort mean age was 48.3 years and comprised of 23 females and 16 males. The mean health literacy score was 66.3/100. The mean satisfaction with pre-operative education was 78.3/100. Pearson correlation analysis demonstrated a significantly, strong positive relationship between health literacy and pre-operative education satisfaction, R=.74, p=6.8X10-8. At our institution, 6 patients were enrolled for pre-operative video education. Ages ranged from 25-65 and all patients were female. Mean health literacy was 94.3/100. Mean pre-video reported satisfaction with surgical education was 85.6/100. After the video, all participants reported improved understanding of their upcoming procedure. 3/6 (50%) reported improvement in anxiety surrounding the upcoming procedure. Lastly, all participants reported the video was beneficial and recommend others to watch it.

Conclusion: There is opportunity to improve patient education in Plastic and Reconstructive Surgery. Videos provide a unique opportunity that require minimal work on the physician end, while providing patients with an educational source they can continuously watch. People with lower health literacy had lower reported satisfaction with pre-operative education, demonstrating a health literacy gap that must be addressed. Despite a high level of health literacy and perceived pre-operative understanding, our patients had substantial improvement in understanding and anxiety from educational videos. This further demonstrates that videos can help patients of all health literacy levels understand their upcoming procedure, improving patient experiences and outcomes. This will improve access for all. We are continually enrolling patients at our institution.

Introduction: Pregnant surgeons, including trainees, are more likely to have major pregnancy complications, including preterm labor, intrauterine growth restriction, and miscarriage, compared to non-surgeons. Obstetric complication rates for surgeons are significantly higher than the general US population (82% vs 15%), with one 2019 study showing a 56% obstetric complication rate in plastic and reconstructive surgery residents.1 As women comprise an increasingly larger proportion of surgical trainee positions, careful and deliberate consideration of policies that promote a safe pregnancy in this population is a necessity. This study aimed to determine the current practices of surgical residency programs regarding existing policies around pregnant trainees and to define accommodation guidelines for pregnant trainees to improve the health and safety of both mother and fetus.

Methods: An internally validated 20-question survey was emailed to program directors and coordinators of surgical training programs in the United States, including plastic and reconstructive surgery, otolaryngology-head & neck surgery, vascular surgery, and general surgery programs. The survey comprised questions about programs' experience with pregnant trainees, whether a perinatal policy exists, and specific accommodations they make to protect pregnant trainees. The survey additionally included an open response section for additional comments. The survey was issued in November and December 2022, and data were collected until January 2023.

Results: Surveys were emailed to 608 surgical programs; the response rate was 23.5% (n= 143), including 20 plastic and reconstructive surgery programs. When asked if their program has a policy for pregnant trainees, 84.4% responded yes. 60.3% of programs report providing protected time off for miscarriages. However, only 36.9% provide information to pregnant trainees regarding workplace exposures that pose a risk of fetal anomaly or miscarriage. Regarding accommodation for surgical trainees, only 47.1% incorporate rest breaks for pregnant trainees, and 20% protect the number of hours a pregnant trainee operates per week. 24.2% of programs adjust overnight shifts or call schedules for pregnant trainees, and of those that adjust call shifts, 20% require pregnant trainees to "make up" these missed call shifts. Less than half (40%) of programs have a contingency plan in place for non-child-bearing residents who take on the work of their colleagues during pregnancy or postpartum. Many of the open responses on the survey mentioned how difficult it can be to accommodate pregnant surgeons while also not overburdening their non-childbearing colleagues. Additional responses were encouraged by the timeliness of the survey, as they are currently revamping their institutional perinatal policies.

Conclusion: While a majority of training programs report a pregnancy policy, most of these policies appear to be severely deficient in addressing the aspects of surgical training that place both fetus and mother at risk of complications. This data indicates a need for standardized, safe pregnancy protocols to recruit and retain women into surgical specialties and protect the childbearing trainee and her unborn child.

1. Bourne DA, Chen W, Schilling BK, Littleton EB, Washington KM, De La Cruz C. The Impact of Plastic Surgery Training on Family Planning and Prenatal Health. Plast Reconstr Surg. 2019;144(5):1227-1236.

Introduction: Neonates born with myelomeningocele (MMC) may require transfer from their place of delivery to a specialized institution for surgical repair. This study aims to investigate the of impact interfacility transfer on neonates undergoing myelomeningocele (MMC) repair.

Methods: All MMC repair cases from 2015-2021 were extracted from the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Transferred and non-transferred cohorts were compared for associations between transfer status and post-operative complications. Stepwise regression was completed to identify predictors of adverse outcomes.

Results: From 2015-2021, 1672 MMC repairs were identified, 753 of which were transferred from an outside facility. Transferred patients were significantly more likely to be born vaginally (27.2% vs 18.9%, p<0.001), born premature (20.6% vs 15.3%; p=0.005), and born with low birth weight (16.7% vs 12.6%; p=0.017). Transferred patients were more often classified as ASA III (65.9% vs 61.0%; p=0.032). Transferred patients were more frequently declared an emergent (30.0% vs 19.2%; p<0.001) and an urgent case (37.3% vs 24.9%; p<0.001). Post-operatively, transferred patients were significantly more likely to experience cardiac arrest (0.9% vs 0.2%; p=0.026), require supplemental oxygen at discharge (9.56% vs 4.79%; p<0.001), and die over a week after surgery (n=13 vs n=3; p= 0.016).

Conclusion: Patients with MMC who are transferred in the immediate post-natal period for surgical repair may have worse postoperative outcomes. Every attempt should be made to diagnose MMC pre-natally, so that delivery can occur at an institution equipped to surgically manage these patients.

Introduction: We introduce a pre-operative surgical pause called the "Professional Time Out" (PTO). It emphasizes the common goal of respect for the wellbeing of the patient and entire healthcare team, as well as the importance of clearly communicating any operating room (OR) issues at an appropriate time. This study aims to assess the impact of the PTO on team performance, psychological safety, and patient care at our institution.

Methods: In this pilot before-and-after survey study at a single tertiary academic center, six attending surgeons (plastic surgery, general surgery, and otolaryngology) were trained in the PTO intervention. Surgical staff were given voluntary surveys to assess endpoints first during pre-intervention phase, then during post-intervention phase (each 3 months long). Staff included attending surgeons/anesthesiologists, surgical/anesthesia residents, medical students, anesthesia nurses, scrub nurses, and surgical technologists. Primary endpoints included professionalism, collaboration, patient care and verbalization of unprofessional behavior (UB). Secondary endpoints included opinion-sharing, involvement, and ratings of case involvement/case flow/case efficiency. Five endpoints were specifically classified as empowerment metrics: opinion-sharing, involvement, verbalization of UB, reporting UB to a colleague, and reporting UB to a superior. Case flow/case efficiency/case involvement were evaluated on 1-10 scale (scalar variables), all other endpoints were rated on 5-point Likert scale from strongly agree to strongly disagree (nominal variables). Endpoints were compared between pre-intervention and post-intervention groups.

Results: 333 survey responses were collected; 180 in the pre-intervention phase, 153 in the post-intervention phase. Pre- and post-intervention groups had similar gender demographics (p=0.499). After PTO implementation, there was significant improvement in 4/4 primary endpoints (professionalism (p<0.001), collaboration (p<0.001), patient care (p=0.010), verbalization of UB (<0.001)) and 5/8 secondary endpoints (opinion-sharing (p<0.001), involvement (p<0.001), verbalization of UB (p<0.001), reporting UB to colleague (p<0.001), and reporting UB to superior (p=0.007)). Even the secondary endpoints without significant change (case flow/case efficiency/case involvement) trended towards improvement with higher mean responses after PTO implementation. We compared responses by role in the five empowerment metrics for three rungs on the hierarchical ladder: medical student, scrub nurse, and surgical attending. Pre-intervention empowerment metric responses were lowest for medical students; on the 1-5 Likert scale, baseline median values fell between 3-4 for medical students, 4-5 for scrub nurses, and 5 for attendings. After PTO implementation, there was significant improvement in 5/5 metrics for medical students, 3/5 metrics for scrub nurse, and no metrics for attendings (already at maximum baseline). When asked about opinion of the PTO, 95.4% of survey respondents felt it was either properly instituted at this time (52.3%) or needed and overdue (43.1%).

Conclusion: Our data show significant improvement in team members' perception of professionalism, collaboration, opinion-sharing, involvement, patient care, verbalizing and reporting UB with implementation of the PTO. Improvement was notable in all empowerment metrics for the medical students, who are traditionally lowest in the hierarchy compared to scrub nurses and surgical attendings. This pre-operative pause is a simple, concise, cost-free way to prime the surgical team for professional, open communication. It has the potential to positively impact OR dynamics and patient outcomes.

Introduction:
The Competency-Based, Time Variable (CBTV) model for graduate medical education emphasizes performance and skill mastery, rather than time-based benchmarks. In the upcoming year, residents from CBTV programs will begin applying to fellowship, with some graduating in 5 years of clinical training. This study aims to understand the perception of CBTV applicants from the perspective of fellowship program directors.

Methods: An anonymous online survey invitation was sent to fellowship program directors in hand surgery, aesthetic surgery, microsurgery, craniofacial surgery, and gender affirmation surgery. The asked participants to rank the relative importance of various factors for CTBV applicants versus applicants from traditional 6-year plastic surgery training programs.

Results: A total of 195 eligible participants were identified, of which 49 (25.1%) responded. 12 (25.5%) of respondents indicated that they would view a 5-year CBTV applicant favorably, 14 (29.7%) would view a 5- year CBTV applicant unfavorably, and the remaining 23 (46.9%) stated that graduation in 5 clinical years would not affect their view of an applicant. Compared to traditional applicants, 60% of respondents rated letters of recommendation of greater importance when considering CBTV applicants, and 46% rated residency program reputation of greater importance when considering CBTV applicants. In-service exam scores, dedicated research experiences, and number of publications were on average rated equally as important in both groups.

Conclusion: Fellowship directors have varied views on 5-year CBTV applicants. Fellowship program directors place greater importance on letters of recommendation and residency program reputation when evaluating competency-based applicants.

Purpose Plastic surgery remains the most competitive specialty in the Match. Efforts have been made to improve outcomes for applicants who are underrepresented in medicine (URiM) and those without home plastic surgery programs. The effect of preference signaling and virtual versus in-person interviews on URiM applicants remains unclear. This study seeks to understand the values and experiences of URiM students in the 2023-2024 plastic surgery Match.

Materials and Methods Two anonymously recorded surveys were sent before and after interviews to all applicants at four plastic surgery programs during the 2023-2024 plastic surgery application cycle. Inclusion criteria were racial minorities, gender minorities, first-generation college students, and those without home programs. The pre-interview survey assessed awareness and utilization of URiM resources and the decision-making process of selecting sub-internships and assigning preference signals. The post-interview survey sought to assess the virtual/in-person interview experience and equity of the interview process. Descriptive and bivariate analysis was conducted with Fisher's exact test in R version 4.3.0.

Results There were 79 and 44 complete responses for the pre-interview and post-interview survey respectively. Over half of URiM applicants were dual applicants to non-plastic surgery specialties. Operative autonomy (78.5% vs. 75.9%), operative volume (78.5% vs. 77.2%), and alignment with career interests (74.7% vs. 81.0%) were top program qualities considered when selecting sub-internships and assigning preference signals respectively. Emphasis on DEI (55.7% vs. 58.2%) and minority representation (55.7% vs. 58.2%) were moderately important. Program websites (97.5%) and social media accounts (84.8%) were highly utilized resources when considering preference signaling and crafting signal statements but were found to be lacking in specificity and useful or updated information (37.7% vs. 34.3%).

Applicants received an average of 12.7 total interviews, 2.3 of which aligned with preference signals. 72.7% of applicants do not believe preference signaling contributes to improving equity in the Match, but 86.4% would recommend continuing the program. 88.6% of applicants attended both virtual and in-person interviews. While virtual interviews provided less financial strain, improved ease of scheduling, and increased ability to participate in more interviews (all p<0.001) compared to in-person, most applicants (77.3%) preferred in-person interviews and believe that virtual interviews are disadvantageous. Applicants find that in-person interviews provided significant advantages in showcasing an application holistically, understanding the program culture, interacting with faculty and residents, and assessing fit into a program (all p<0.001). 61.4% of applicants do not believe that interviews are distributed fairly and believe there should be an interview cap.

Conclusions Providing specific and updated information on program websites and social media content will better inform underrepresented applicants for choosing sub-internships and preference signaling. Despite financial constraints, in-person interviews were the preferred form of interviewing compared to virtual interviews as it allowed for better comprehensive exposure of the applicant to the program and vice versa. Interview caps and travel scholarships for interviews may be considered as future interventions to improve equity in the plastic surgery Match.

Background: Most hospital regulated medical waste (RMW) originates from operating rooms (1, 2) Operating room (OR) waste reduction efforts including intentional instrument selection and reprocessing of single-use medical devices can be cost-effective in surgical settings (3). In plastic surgery, various environmentally sustainable interventions have been implemented (4). This study sought to quantify the type and amount of waste in common plastic surgery procedures and determine factors to improve efficiency.

Methods: A prospective observational study quantifying OR waste and cost was performed at two sites - a tertiary hospital (HOS) and an ambulatory surgical center (ASC) - in the same healthcare system from June 2023 to February 2024. Any item that was opened and went unused, defined as not touching the surgeons' hand or the patient, was classified as "waste." Patient demographics, procedure type, operative time, surgical and nursing team composition, RMW weight and cost was collected. Univariate analysis was performed to identify predictors of OR waste production.

Results: A total of 12 abdominoplasty and 22 reduction mammoplasty were included. Most procedures were performed at the HOS in older patients compared to the ASC (p= 0.05 and p=0.04, respectively). The combined median procedure cost of both abdominoplasty and reduction mammoplasty ($724.50 [$623.25, $1,275.50] vs. $598.00 [$531, $793.25],p=0.03) and weight of blue wrap used to cover sterile instruments (334.50 g [294.25 g, 359.25 g] vs. 251.50 g [245.25 g, 268.75 g], p<0.0001) were greater at ASC compared to HOS. Cases with traveling OR staff had a significantly higher median procedure cost than those with permanent OR staff ($749.00 [$598.00, $1,038.25] vs. $610.50 [$465.25, $756.50], p=0.04).

Conclusion: These findings suggest areas for potential improvements, especially at the ASC where median procedure costs and weight of sterile blue wrap are increased compared to HOS. Cases with traveling OR staff were found to have greater median procedure costs but not due to increased waste costs. Continued investigation may elucidate factors contributing to inefficiencies in common plastic surgery procedures.

References:

(1) Bravo D, Thiel C, Bello R, Moses A, Paksima N, Melamed E. What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve [published online ahead of print, 2022 Apr 29]. Hand (N Y). 2022;15589447221084011. doi:10.1177/15589447221084011 (2) Zygourakis CC, Yoon S, Valencia V, et al. Operating room waste: disposable supply utilization in neurosurgical procedures. J Neurosurg. 2017;126(2):620-625. doi:10.3171/2016.2.JNS152442 (3) Albert MG, Rothkopf DM. Operating room waste reduction in plastic and hand surgery. Plast Surg (Oakv). 2015;23(4):235-238. doi:10.4172/plastic-surgery.1000941 (4) Wood BC, Konchan S, Gay S, Rath S, Deshpande V, Knowles M. Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains. Ann Plast Surg. 2021;86(6S Suppl 5):S635-S639. doi:10.1097/SAP.0000000000002913

INTRODUCCIÓN:

Gunshot wounds are now a worldwide public health problem. In the past 15 years wounds caused by weapons of this type have undergone a major increase (1). Statistics show that in 2014 20,010 homicides were recorded in Mexico (11,514 of which were caused by firearm projectiles), i.e., a proportion of 16 per 100,000 inhabitants at national level (2). It's clear that differences exist between different Federal districts in our country, and that these should be considered. According to the latest INEG data, in 2014, the state of Nuevo León has remained among the first 12 regions over the years. After the report of the Attorney General's Office of the State of Nuevo León was released, the month of October of this year concluded with 118 homicides, adding a total of 1,150 cases so far in 2023 (3). Firearm projectiles cause damage by tissue disruption, leading to hemorrhages and infections. The amount of kinetic energy transferred from a projectile to the surrounding tissues, internal organs and structures which are damaged directly, as well as the final location of the projectile, all determine the severity of gunshot wounds. It is vitally important that doctors and health institutions are expert in external, internal and terminal ballistics associated with clinical symptoms to manage these types of catastrophic injuries.

Methods:

We made a retrospective analysis utilizing the photographic database from the Plastic Surgery Department of all the patients admitted between March 1, 2023, and January 1, 2023, that suffered gunshot wounds and required some form of intervention.

Results:

A total of 51 cases were obtained, 28 of which presented facial wounds requiring intervention from the craniofacial clinic, 10 presenting hand wounds with multiple fractures and tissue exposure requiring intervention from the hand and microsurgery clinic (1 requiring coverage with a lateral arm flap), 13 patients presented forearm wounds requiring nerve or vascular repair (4 of whom also needed a flap for defect coverage), and finally, one patient with a foot wound and bone exposure requiring a reverse sural flap.

Discussion:

Given the high prevalence of drug cartel related violence in our area, it's common in our medical practice to treat patients with gunshot wounds. During our time as plastic surgery residents, we have attended a significant number of patients and performed numerous surgical procedures that undoubtedly contribute to our reconstructive skills. Emphasis is placed on the importance of having a hospital center with good resources and well-prepared medical professionals, as these patients require intensive care and procedures that require a third level hospital.

Bibliography:

(1) Sotelo Cruz N, Cordero Olivares A, Woller Vázquez R. Heridas por proyectil de arma de fuego en niños y adolescentes. Cir Cir. 2000;68:204-10.

(2) Franco Agudelo S. Momento y contexto de la violencia en Colom-bia. Rev Cub Salud Publica. 2003;29:18-36.

(3) Escalante-Gonzalbo F. Homicidios 2008-2009. La muerte tiene permiso. Nexos. 2011:397

Background/Purpose Postoperative monitoring is vital to allow successful salvage of free flaps when complications arise1. Flap monitoring is not always done by surgeons or those experienced in flap care1. Intensive, in-person in-service modules have demonstrated the ability to improve free flap monitoring knowledge and confidence among nursing staff2. A more succinct learning module that can be completed independently could potentially reach a much larger audience while remaining effective. We conducted a pilot study of an online learning module to improve nursing staff knowledge and confidence regarding free flap monitoring.

Methods and Materials A HealthStream module about how to monitor and care for free flaps for nurses was assigned to all nurses at a single site. Participants were asked to read a pamphlet and watch an 11-minute video. Participants completed a pre- and post-course survey and quiz to assess comfort level and knowledge, respectively, of free flap monitoring. Pre- and post-course test scores along with participant background information was collected and analyzed.

Results 59 nurses completed our HealthStream module with the pre- and post-course assessments. All nurses work in the PACU with 57 (96.6%) not currently working in the ICU. 39 (66.1%) of participants have been a nurse for at least 10 years, with 24 (40.7%) having been in the ICU for 1 year or less. 40 (67.8%) of the nurses not currently working in the ICU have previous ICU experience. 36 (61%) report taking care of a free flap patient while 22 (37.3%) have not, however, 15 (25.4%) have taken care of a flap patient in the past year while 43 (72.9%) have not. Pre-course comfort monitoring free flaps showed 18 (30.5%) neither comfortable or uncomfortable, 24 (40.6%) uncomfortable, and 16 (27.1%) comfortable. Post-comfort monitoring flaps showed 14 (23.7%) neither comfortable nor uncomfortable, 10 (17%) uncomfortable, and 31 (52.5%) comfortable. On regression, none of the background experience for years as a nurse, in the ICU, and recent or overall free flap monitoring experience was associated with pre-course comfort level (p-value>0.05). Mean quiz scores significantly increased following the module (49.58% vs 100%, p-value<0.001).

Conclusion Our module provides a quick and time-efficient module for improving comfort level of nurses with monitoring free flaps. Although our module should be applied to other institutions for generalizability, our results could indicate our module as a short module that could potentially increase salvage rates among free flaps that experience complications.

Background:: A 10 year experience with founding and operating multiple medspas will be presented. The advantages and disadvantages of owning and operating one or more medspas and their impact on any plastic surgery practice will be presented. Comparisons will be made between single location and multiple location medspa businesses.

Methods:: Over 10 years ago many services traditionally reserved for the plastic surgeons office were moved to separate and complimentary retail locations creating the "medspa cottage industry" for plastic surgeons. The goals of such a separatiion include; 1) Frequent visits of patients both old and new 2) Growth of ancillary services besides surgery. 3) Achieving complimentary "youthfull" results not attainable through surgery. 4) Separate potential profit center for plastic surgeons; including a new source for surgery patients.Results:: 10 years of medspa experience demonstrate that success is dependent many factors; some familiar to plastic surgeons and some less familiar such as: 1) Choosing the right location. 2) Managing the build out and furnishings 3) Choosing the menu of services 4) Finding/training staff 5) Choosing the technology 6) Choosing the right software infrastructure 7) Marketing 8) Selling surgery 9) Making a profit

Conclusion:: The pro's and con's of medspa ownership and their impact on plastic surgery practices will be outlined in detail. Success dependends on the type of plastic surgery practice, the retail business acumen of the plastic surgeon, and the primary goals of the medspa.

Purpose: The COVID-19 pandemic prompted the use of telemedicine to continue healthcare appointments while minimizing in-person contact. Subsequently, there was a rise in telemedicine utilization for pre- and post-operative appointments for upper and lower extremity surgery, with research highlighting adequate levels of patient and provider satisfaction. However, there have been only two studies investigating whether telemedicine appointments are equivalent to in-person appointments for assessing surgical candidacy in extremity surgery. We conducted a retrospective review comparing surgical decision-making during telemedicine consultations versus in-person consultations, and hypothesize that telemedicine consultations are equivalent to in-person consultations when determining if a patient would benefit from surgery.

Methods: A retrospective review of electronic medical records of new patients at a tertiary referral center seen by the senior surgeon (S.E.M.) between June 2020 and January 2023 was performed. EMR visit notes for all initial surgical consultations were reviewed, and data were extracted regarding patient demographics, reason for visit, diagnosis, and ultimate surgical decision at the conclusion of the visit. Records were divided into four surgical decision-making categories: 1) Yes-the patient was offered a surgical procedure; 2) No-the patient was not offered a surgical procedure; 3) Undecided-the provider and patient discussed one or more operations which may benefit the patient, but the patient requires further conservative management, diagnostic workup, or assessment by another provider; and 4) Declined-the patient was offered surgery, but declined. Fisher's exact tests were used to compare proportions of patients in each surgical decision-making category across both visit types.

Results: 391 out of 921 new patient records were reviewed. For patients with an in-person surgical consultation (n=130), 61 patients (47.3%) were categorized as "Yes", 41 patients (31.8%) were categorized as "No", 22 patients (17.1%) were categorized as "Undecided", and 5 patients (3.9%) were categorized as "Declined." For patients with a telemedicine surgical consultation (n=261), 101 patients (38.7%) were categorized as "Yes," 62 patients (23.8%) were categorized as "No," 91 patients (34.9%) were categorized as "Undecided," and 7 patients (2.7%) were categorized as "Declined." Fisher's exact test indicated a significant difference in spread of surgical decisions between in-person and telemedicine consultations (p = 0.002).

For patients with telemedicine surgical consultations, 81.2% of patients with an initial "Yes" categorization eventually underwent surgery. For patients with in-person surgical consultations, 82.0% of those with an initial "Yes" categorization eventually underwent surgery. These proportions were not significantly different per a Fisher's exact test (p = 0.669).

Conclusions: Among patients who were recommended for surgery at their initial consultation, the proportion of patients who eventually received surgery was equivalent between telemedicine and in-person consultations. This indicates that telemedicine consultations can accurately identify surgical candidates for upper and lower extremity surgery. In the telemedicine consultation group, the increased percentage of patients in the "Undecided" category represents the utility of telemedicine to reach a group of patients with very recent nerve injury, and discuss the complex algorithm for management before a definitive surgery would be offered.

Purpose: The Plastic Surgery Central Application (PSCA), designed to provide an equitable and streamlined application for both applicants and programs, was first designed in 2019, piloted in the 2020–21 application cycle, and is now in its fourth cycle in 2023–24. It has included preference signaling since the 2022–23 cycle, a feature in which applicants can send five "signals" to programs to express interest. We surveyed both PDs and applicants following the 2023 Match on their perceptions of PSCA versus Electronic Residency Application Service (ERAS).

Methods: Surveys were deployed to applicants from three integrated plastic surgery programs during the 2022–23 cycle and all PDs. Respondents were asked basic demographic information, which application system they preferred: PSCA or ERAS, how well they were able to highlight/evaluate different areas of the application, and about their experiences specifically with preference signaling.

Results: Forty-two (48%) program directors (PDs) and ninety-three (29%) applicants responded. Most PDs (72%) and applicants (59%) preferred PSCA, with only 18% and 27% preferring ERAS, respectively. The remainder had no preference. Ninety-three percent of applicants reported the cost savings of the PSCA were important. Most applicants (78%) and PDs (80%) were in favor or strongly in favor of the preference signaling program.

Conclusions: Most applicants and PDs prefer PSCA over ERAS. These data, in conjunction with the cost savings, suggest that the PSCA may be a better alternative for the integrated plastic surgery match. Future analyses of these application systems will help guide provide the best application for prospective residents.

Purpose Each year, plastic surgeons face an approximately 15 percent chance of being named in a malpractice lawsuit [1]. Although as a specialty, annual indemnity payments are relatively low, the risk for liability – and subsequent fear and apprehension – has been shown to negatively affect practice patterns and physician well-being [2]. In order to minimize risk of litigation and assuage these concerns, it is thus critical for practitioners to have a general understanding of the factors influencing plastic surgery malpractice lawsuits. Heretofore, however, assessments of these factors have been limited in scope or temporality with global reviews only extending to 2019. We therefore sought to create an updated characterization of litigation in plastic surgery.

Methods The Westlaw legal database was queried using a combination of Boolean and natural language searches to identify malpractice cases in the United States that were finalized between January 2015 and January 2024. Inclusion criteria included a plastic surgeon as a named defendant and a cause of action for professional malpractice or negligence. The data was analyzed using descriptive statistics, t-tests and Fisher's Exact tests (JMP, Version 17).

Results After screening for inclusion criteria, 268 cases were identified. Most plaintiffs were females (n=219, 81.7%). Reported age at time of the inciting incident ranged from 1 to 73 years old (average: 43.5). Additional defendants were named in 79.5 percent of cases, including surgical practices (61.6%), hospitals or surgical centers (24.6%), other surgeons (17.2%), anesthesia providers (6.0%), and medical device companies (2.2%). Residents were named in 8.6 percent of cases. Additional causes of action were included in 57.1 percent of cases, most frequently lack of informed consent (36.2%), loss of consortium (11.6%), and negligent hiring or supervision (10.4%). Most of the suits (n=178, 66.4%) arose from cosmetic procedures. The most common adverse outcomes reported were disfigurement (47.4%) and injury (27.2%). Eighteen suits were for patient death. Legal outcome was most frequently determined by jury verdict (n=141, 52.6%). Disposition by summary judgment and settlement occurred in 26.1 and 12.3 percent of cases, respectively. Overall, defense verdicts occurred in 198 cases (73.9%). Verdicts in favor of the patient, however, were more likely in cases involving patient death (p=0.004) and those with additional claims for lack of informed consent (p=0.03), loss of consortium (p=0.05) and wrongful death (p=0.03). When plaintiffs prevailed, awards ranged from $2,500 to $13,000,000 (median $462,500).

Conclusion Malpractice lawsuits can exact significant emotional and financial costs upon practitioners. Analysis of precedent helps identify patterns in litigation to highlight patient concerns and guide adjustments in practice to mitigate risk. Although likely under-representative of cases resolved by settlement, this data underlines the importance of shared decision making, the clear communication of reasonable postoperative expectations, and informed consent.

References 1. Boyd JB, Moon HK, Martin S, Mastrogiovanni DB. Plastic Surgery and the Malpractice Industry. Plast. Reconstr. Surg. 2021;147:239-247. 2. Remington AC, Schaffer A, Hespe GE, Yugar, CJ, Sherif R, Vercler CJ. Understanding Factors Associated with Paid Malpractice Claims in Plastic Surgery. Plast. Reconstr. Surg. 2024;153:644e-9e.

Introduction: Apart from treating a patient one of the most essential part of patient care is precise, thorough and accessible documentation of medical records, one element of this being operation notes.1,2 High quality operation notes ,as crucial parts of patient care, are means of communication among professionals, source of data for audits and researches, and a source of information in court.1,3,4 The Royal College of Surgeons of England (RCSEng) has produced a guideline in 2014 titled 'Good Surgical Practice', that outlines the minimum standards that need to be documented on operation notes.5 This study aims to assess the adherence of ALERT hospital plastic and reconstructive unit to these guidelines.

Objectives: To evaluate operation notes in the plastic and reconstructive unit of ALERT hospital against RCSEng 2014 standards, identify causes of incompleteness and suggest possible ways of improvement in the quality of operation notes.

Methods: The study is a cross sectional retrospective study conducted in plastic and reconstructive surgery unit of ALERT hospital, using stratified random sampling of 341operation notes written since April 2020, supplemented by survey questionnaire administered to 22 doctors to assess their experience and opinion regarding operation note standards.

Results: None of the RCSEng GSP 2014 standards were consistently documented. Only 3 standards were documented in more than 90% of operation notes. Most operation notes were written by residents. Participants of survey questionnaire believe that lack of quality of operation notes affects follow up and future interventions for patients. More than 95% of the respondents reported that they do not write all the standards consistently and most commonly attributed reasons are absence of formal education on the subject and operation note proforma incompleteness. The survey participants suggested introduction of formal teaching about operation note writing, update of the existing operation note proforma and educating the staff about the standards to improve the quality of operation notes.

Conclusion: Operation notes in plastic and reconstructive surgery unit of ALERT hospital are not up to standard per RCSEng GSP 2014 guideline. Formal education, update of existing operation note proforma, posting aide memoires in the operation theatres and clinical education of the staff about the standards are the proposed solutions to improve the quality of the operation notes.

1. Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med (Lond). Feb 2 2017;78(2):104-107. doi:10.12968/hmed.2017.78.2.104
2. Nicholson L. Setting the records straight: a study of hospital medical records undertaken by the Audit Commission. Records Management Journal. 1996;6(1):13-32. doi:10.1108/eb027083
3. Nyamulani N, Mulwafu W. The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study. Malawi Med J. Jun 2018;30(2):86-89. doi:10.4314/mmj.v30i2.6
4. Singh R, Chauhan R, Anwar S. Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study. J Eval Clin Pract. Jun 2012;18(3):578-80. doi:10.1111/j.1365-2753.2010.01626.x
5. England RCoSo. Good surgical practice. Royal College of Surgeons of England (RCS); 2014.

Purpose In addition to the over 8.7 million neurotoxin injections performed by licensed practitioners in 2022, an increasing number of individuals are turning to the black market for unregulated DIY Botox.[1,2] In light of the potential safety consequences and the demonstrable role of direct-to-consumer advertisements in neurotoxin popularity, increased attention has been directed towards enhanced regulation of DTC advertisements.[3] In November 2023, the U.S. Food and Drug Administration (FDA) published a final rule amending the regulations for DTC television advertisements of prescription drugs. Although the rule mandates "consumer-friendly language" and concurrent presentation of the Major Statement's audio information in text, it fails to specify a required reading level.[4] Given concerns for persistent patient misinformation in the absence of a restricted standard, this study sought to analyze current DTC advertisements for botulinum toxins to evaluate current readability and comprehensibility.

Methods A natural language search of YouTube was conducted in November 2023 to identify DTC advertisements for botulinum toxins. Advertisements produced after January 2015 from three companies – Botox Cosmetic, Jeuveau, and Xeomin – were included for analysis. Commercials directed toward non-cosmetic use were excluded. A single author (K.S.) produced written scripts including the dialogue and text for each commercial. Each was analyzed using validated metrics to assess readability and understandability including the Coleman-Liau, Flesh-Kinkaid, Gunning Fog, SMOG, and Fry instruments using Readability Studio Professional Edition, Version 2020 (Oleander Software,Ltd, Vandalia, Ohio). The maximum required reading speed for the text was also calculated.

Results Fourteen commercials were identified. DTC advertisements had a mean reading grade level of 8, 11, and 12 based on the Gunning Fog, Smog, and Coleman-Liau metrics, respectively. Despite short sentences, on average, 16 percent of the accompanying text consisted of complex words, which increased overall reading difficulty. Twenty-five percent of the text consisted of unfamiliar words. The average speed required to read all on-screen text was 817 words per minute.

Conclusion Both the auditory and text components of direct-to-consumer advertisements for botulinum toxins are written at an elevated reading level that is inappropriate for the general population per informed consent guidelines. As the FDA's final rule fails to require a specific reading level and the cushioning effect of learned intermediaries is increasingly tested with black market products, users remain at heightened risk for misinformation of the products' potential complications.

References [1] American Society of Plastic Surgeons (2022). 2022 ASPS Procedural Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2022/plastic-surgery-statistics-report-2022.pdf. Accessed 26 February 2024.
[2] Brennan R, Wells JS, Van Hout M. "Saving face": an online study of the injecting use of DIY Botox and dermal filler kits. Plastic Surgery. 2018 Aug;26(3):154-9. [3] Mello S. Selling a super cosmeceutical: contextualizing risk in direct-to-consumer advertising of BOTOX® Cosmetic. Health, Risk & Society. 2012 June;14(4):385-98. [4] "Direct-to-Consumer Prescription Drug Advertisements: Presentation of the Major Statement in a Clear, Conspicuous, and Neutral Manner in Advertisements in Television and Radio Format" (CCN Final Rule) (88 FR 80958, November 21, 2023)

Background: Measures of quality in resident training in plastic and reconstructive surgery (PRS) programs are scarce and methodologically inconsistent [1, 2, 3, 4, 5]. Our research provides insights from current PRS trainees globally, mapping their training inputs, expected outputs, and recommendations for program improvements.

Methods: A global online survey was conducted among PRS residents across 67 countries to gauge their satisfaction with residency training, capturing crucial training inputs such as the number of surgeries attended and seminars they participated in. We also extracted residents' proposed recommendations for program improvement. We investigated the explanatory role of training inputs, demographics, hospital characteristics, and country income on resident satisfaction and graduate competence.

Results: The analysis incorporated data from 518 PRS residents. On average, residents attend 9.8 surgeries and 1.3 seminars per week. Simultaneously, there is a positive correlation between the perceived level of professional competency and training inputs, particularly seminars attended (p − value = 0.001). Male residents tend to report higher satisfaction (p−value =0.045) with their training (67%) compared with their female counterparts (58%), while those with family responsibilities also demonstrate slightly higher satisfaction levels.

Conclusions: Our analysis expands the evidence base regarding a "global hunger" for more comprehensive seminar-based and hands-on surgical training. Resident recommendations on program improvement reveal the need to address gaps particularly in aesthetic surgery training. The development of healthcare business models that allow for aesthetic procedures in training institutions is crucial in the promotion of aesthetic surgery training during residency. Policymakers, program directors, and stakeholders across the world can leverage these findings to formulate policies addressing the weaknesses of training programs.

References 1. Fernando A Herrera, Eric I Chang, Ahmed Suliman, Charles Y Tseng, and James P Bradley. Recent trends in resident career choices after plastic surgery training. Ann Plast Surg., 70(6):694–697, 2013. 2. River M Elliott, Keith D Baldwin, Abtin Foroohar, and Lawrence Scott Levin. The impact of residency and fellowship training on the practice of microsurgery by members of the american society for surgery of the hand. Ann Plast Surg., 69(4):451–458, 2012. 3. Mehool Patel. Changes to postgraduate medical education in the 21st century. Clin. Med., 16(4):311, 2016. 4. Brian C George, Jordan D Bohnen, Reed G Williams, Shari L Meyerson, Mary C Schuller, Michael J Clark, Andreas H Meier, Laura Torbeck, Samuel P Mandell, John T Mullen, et al. Readiness of us general surgery residents for independent practice. Ann. Surg., 266(4):582–594, 2017. 5. Samer G Mattar, Adnan A Alseidi, Daniel B Jones, D Rohan Jeyarajah, Lee L Swanstrom, Ralph W Aye, Steven D Wexner, Jos´e M Martinez, Sharona B Ross, Michael M Awad, et al. General surgery residency inadequately prepares trainees for fellowship: Results of a survey of fellowship program directors. Ann. Surg., 258(3):440–449, 2013.

Background: Private equity (PE) investments in plastic surgery have increased dramatically over the past several years. (1-4) However, the current literature offers limited insight into other financing strategies and attributes that can make plastic surgery practices attractive to potential investors. We aim to characterize the companies and investors involved in deals related to plastic surgery practices and to assess the financial performance of these investments.

Methods: We performed a retrospective review of deals related to plastic, reconstructive, and aesthetic surgery practices in the United States from Jan 2014 to Jan 2024 using Pitchbook, a financial database that contains public information on companies and investors. (5) Inclusion criteria were privately held companies with financial backing and companies that underwent an acquisition or merger, including chains, multidisciplinary practices, and ambulatory surgery centers. Exclusion criteria included companies without backing and publicly held companies as well as facial plastic surgery, oculoplastic surgery, dermatology, and medical spa practices without a plastic surgeon. Data were collected on types of investments, number of employees, years since founding, geographic region, city population, and last financing date and size. One-way ANOVA tests and chi-square tests were conducted, and significance level was set at p<0.05.

Results: Over the past 10 years, 136 plastic surgery practices were involved in 190 deals with 83 investors, totaling $1.2 billion. Nearly all were motivated by expansion; only one (0.7%) was triggered by bankruptcy. The most common financing strategies practices used were PE backing (n=50, 36.8%), debt financing (n=45, 33.1%), and corporate backing or acquisition (n=32, 23.5%). Practices that pursued debt financing were more likely to be founded recently than those that pursued corporate backing or acquisition (p=0.004). PE-backed deals were more likely to be larger than debt financing or corporate backing or acquisition deals (p=0.0004) with four notably large deals taking place in 2022 and 2023 ranging from $9 to $725 million.

Conclusion: While the majority of financing events are quite small and there is considerable variability in financing size within each year, there have been several large PE transactions in the past two years suggesting a changing investment landscape. Debt financing from well-known banking institutions may be critical to driving growth among younger practices. Plastic surgery practices looking to expand their footprint should be aware of all available financing strategies.

References: 1. Billig JI, Kotsis SV, Chung KC. Trends in Funding and Acquisition of Surgical Practices by Private Equity Firms in the US From 2000 to 2020. JAMA Surg. 2021;156(11):1066-1068. 2. Khetpal S, Lopez J, Steinbacher DM. Private Equity in Plastic Surgery: A Nine-Year Analysis. Plast Reconstr Surg. 2021;148(6):1088e-1090e. 3. Singer R. Private Equity and Plastic Surgery. Aesthet Surg J. Published online December 14, 2023. 4. Shaffrey EC, Attaluri PK, Wirth PJ, Rao VK. The Looming Future of Private Equity in Plastic Surgery. Aesthet Surg J. Published online December 27, 2023. 5. Pitchbook, Seattle, WA.