Scientific Abstract Presentations: Research & Technology Session 4 Friday, September 27 Fri, Sep 27 10:30 a.m.-12:30 p.m. PDT

Purpose: Plastic and reconstructive surgery is one of the most competitive residency programs. According to the 2022 National Resident Matching Program (NRMP) data, applicants who matched into plastic surgery residency had the highest average total number (28.4) of research abstracts, presentations, and publications across all specialties. With other aspects of the application process (i.e., Step 1, preclinical grades, clinical grades) becoming pass/fail, higher expectations for research productivity when reviewing residency applications are a potential outcome. Thus, this study sought to characterize the value of research and different types of research publications in plastic surgery residency applications.

Methods: A Qualtrics survey was distributed to the American Council of Academic Plastic Surgeons (ACAPS) email listserv in September and November of 2023. Questions asked about study type, number of publications, authorship level, research presentations, research years, and factors contributing to publication value. Factors included research topic, study type, significance of results, publication journal, senior author(s), authorship level, and collaboration/multidisciplinary. The respective values of four components of residency applications (clinical/academic, letters of recommendation, research, and background) were also compared.

Results: Complete responses totaled 75. 52% of respondents were associated with top 40 NIH-funded medical schools, and 61% did clinical research. Chairs/chiefs comprised 19%, program directors/assistant program directors 32%, and residents 21%. For residency application scoring, on average, research received 17% weight, letters of recommendation 34%, clinical/academic 28%, and background 22%. Beyond a median of 10 (IQR: 5-15) total publications, or 5 (IQR: 3-9) first-author publications, respondents reported that additional publications would add minimal value to a residency application. 48% of respondents selected the applicant's authorship level as the most important consideration in determining publication value. For ranking of first-author publications, highest or high value ratings were assigned 92% for prospective cohort studies, 77% for basic science/translational studies, 67% for systematic reviews/meta-analyses, 60% for retrospective chart reviews, 49% for surveys, 20% for case reports, and 5% for non-peer reviewed papers. Assigned values to second-author and middle-author publications were 71% (IQR: 60-80) and 51% (IQR: 40-69) the value of a first-author publication, respectively. However, first-author podiums and posters were worth 75% (IQR: 61-90) and 55% (IQR: 40-70), respectively. A submitted but not yet accepted first-author publication was considered to have half the value of a first-author published paper. Compared to first-author publications in a plastic surgery journal, first-author publications in other surgical specialty and medical journals with the same impact factor were considered to have similar value: 100% (IQR: 86-100) and 95% (81-100), respectively. When asked about two applicants (one who had taken a research year and one who had not) with 8 similar publications, 58% of respondents said they would view the applicant who had not taken a research year more favorably. 31% said they would view both applicants similarly.

Conclusions: Our findings suggest that research may be worth almost one fifth of plastic surgery residency applications. The value of an applicant's research publications varies with study type and applicant authorship level. These data may facilitate residency application review and guide medical student research endeavors.

Purpose: One common complication following mastectomy is skin necrosis (1). At our institution, we have begun administering topical tacrolimus to patients at high risk for the development of this complication. Clinically, topical tacrolimus is typically applied twice daily (BID) (2). The purpose of this study was to investigate the effect of different topical ointment dose regimens on the rate of skin flap necrosis in our rodent model.

Methods: Thirty-nine Sprague-Dawley rats were randomized to receive a 0.2g application of topical tacrolimus once daily (QD), BID, or once daily with a second application of 0.2g of topical nitroglycerin. Following one week of pre-treatment, a cranially based dorsal skin flap measuring 3×10cm was raised and reinset. Treatment continued for 7 days post-operatively, followed by sacrifice. Surface area of healthy, reversibly ischemic and full thickness necrotic skin was measured using Fiji software and tissue samples were analyzed by a trained pathologist under blinded conditions.

Results: The average necrotic area of the QD, BID and combined topical tacrolimus and topical nitroglycerin cohorts was 22.1%, 21.9% and 19.7%, respectively. Rates of healthy, ischemic and necrotic tissue were not statistically significant between any group (all p-values >0.05). Samples were indistinguishable on histologic analysis.

Conclusions: Our study on an ischemic rodent model identified QD dosing to be equivalent to more frequent ointment applications. Given the advent of topical tacrolimus use in mastectomy patients to reduce flap necrosis, and that simpler treatment regimens portend to greater patient compliance and decreased healthcare costs, our findings warrant further investigation.

1. Nykiel M, Sayid Z, Wong R, Lee GK. Management of Mastectomy Skin Flap Necrosis in Autologous Breast Reconstruction. Annals of Plastic Surgery. 2014;72(Supplement 1):S31-S34. doi:10.1097/SAP.0000000000000174
2. Keaney TC, Bhutani T, Sivanesan P, et al. Open-label, pilot study examining sequential therapy with oral tacrolimus and topical tacrolimus for severe atopic dermatitis. Journal of the American Academy of Dermatology. 2012;67(4):636-641. doi:10.1016/j.jaad.2011.10.033

Purpose

Plastic surgery fellowship training programs are typically conducted at medical centers with existing integrated plastic surgery residency programs (1). Establishing a fellowship can introduce resident concerns about their training in respect to caseload, educational opportunities, and preparation for future surgical skill. Although several studies in other surgical subspecialties have shown that the caseload of residents does not decrease with the presence of fellows, the authors of one such study hypothesized that residents may be less likely to be the "first assist" in their cases due to the accepted hierarchy of fellows and residents (2-4). This may cause residents to feel that fellows are encroaching on their educational opportunities. In this study, we surveyed integrated plastic surgery residents to better understand how a fellow's presence impacts the work-related dynamics of plastic surgery trainee education and may be different from a resident's perspective of their impact.

Methods

Following approval and sponsorship from the American Council of Academic Plastic Surgeons, a 32-question survey was sent to coordinators at all integrated plastic surgery programs in the United States for resident completion. Questions were presented in a Likert scale format, with responses varying from very negative (1) to very positive (5). Survey responses from residents with (RWF) and without fellows (RWO) were compared using the Student's T-test.

Results

There were 83 respondents representing all PGY levels, with 60.2% working alongside fellows in their programs. RWF were significantly more inclined towards pursuing a subspecialty fellowship (76.0% vs. 45.4%, p=0.0046). More than half of RWF somewhat or strongly agreed that training with fellows increased their interest in those subspecialties (51.1%). However, RWF were more likely to view fellows as negatively impacting their opportunities to practice in those subspecialties after residency (26.67% versus 5.26%, p=0.002).

Among RWF, 88% spend over 25% of their time in the operating room (OR) with fellows. Regarding case selection, 42.3% felt that fellows usually have first pick over residents. No significant differences were found between the RWF and RWO cohorts in opinions on fellows' impact on desired case volume (p=0.777), case complexity (p=0.338), or autonomy in the OR (p=0.757). Among RWF, 61.70% indicated that fellows have a somewhat or very positive effect on the learning environment in the OR.

Responses differed significantly (p=0.025) on whether fellows make inpatient volume more manageable, with 60.87% of RWF somewhat or strongly disagreeing, compared to 36.85% of RWO.

When comparing responses by PGY level, only opinions regarding whether fellows make inpatient volume more manageable differed significantly, with residents at higher PGY levels being less likely to agree.

Conclusion

This study reveals nuanced perceptions among integrated plastic surgery residents regarding the impact of fellows on their training. The findings may offer program directors insights into the resident perspective when considering establishing a fellowship program. This information is also beneficial for prospective residency applicants, informing their expectations of the training environment they may enter.

References

1. Plastic surgery fellowship and training directory. Plastic Surgery Fellowship and Training. https://www1.plasticsurgery.org/globaltraining/. Accessed December 3, 2021.

2. P.T. Hallowell, M.I. Dahman, J.B. Stokes, D.J. LaPar, B.D. Schirmer. Minimally invasive surgery fellowship does not adversely affect general surgery resident case volume: a decade of experience. Am J Surg, 205 (3) (2013), pp. 307-311

3. Z. Chaudhry, C.M. Tarnay Assessing resident surgical volume before and after initiation of a female pelvic medicine and reconstructive surgery fellowship J Surg Educ, 74 (3) (2017), pp. 450- 454

4. S.Y. Jiang, K.D. Carlock, S.T. Campbell, et al. The impact of subspecialty fellows on orthopaedic resident surgical experience: a multicenter study of 51,111 cases J Am Acad Orthop Surg, 29 (6) (2021), pp. 263-270

Purpose: Plastic surgeons may have entered residency intending to attain additional fellowship training in a specific subspecialty– nature, or their choice for future subspecialty may have been impacted by their experiences at their residency program– nurture. This study explores the relationship between the specialization of faculty members within an integrated plastic surgery residency program and its graduates' future career paths.

Methods: A retrospective study identified the number of graduates from integrated plastic and reconstructive surgery residency programs in the United States (2015-2022) with regard to their first job or fellowship type. Data concerning graduates pursuing fellowship were then stratified based on the subspecialty and the presence or lack thereof of faculty members of that same subspecialty type from their residency program. Data was collected from residency programs' websites, and residency coordinators were contacted via email as needed. Data were categorized based on unique surgical specialties into: Aesthetic, Burn, Craniofacial, Gender Affirmation, Hand, and Microsurgery. For analysis, data were grouped into one of four categories: programs with faculty members of the specific subspecialty and graduates who pursued the same fellowship, programs with faculty members of the specific subspecialty and graduates who did not pursue the same fellowship, programs without faculty members of a specific subspecialty with graduates who pursued the fellowship, and programs without faculty members of the specific subspecialty and no graduates who pursued that fellowship.

Results: In total, 865 residents from 56 institutions were included in our study. There were 423 residents who completed an aesthetic fellowship, 175 for microsurgery fellowship, 86 for craniofacial fellowship, nine residents for burn fellowship, 166 for hand fellowship, and six residents completed a gender affirmation fellowship. The odds ratios were calculated to determine if the exposure to a subspecialty faculty member increased the odds of residents pursuing fellowship training in the same specialty. The results demonstrated the following odds: Aesthetic (OR 2.1, 95% CI: 0.08-51.1), Burn (OR 2.1, 95% CI: 0.37-11.5), Craniofacial (OR 0.8, 95% CI: 0.14-4.62), Gender Affirmation (OR 5.6, 95% CI: 0.58-53.9), Hand (OR 1.7, 95% CI: 0.06-45.5), Microsurgery (OR 0.52, 95% CI: 0.03-10.5). For all subspecialties combined (OR 4.34, 95% CI: 2.59-7.41, p < 0.0001).

Conclusion: Individual subspecialties had varying results on faculty influence, but when considering all subspecialties combined, the exposure of residents to subspecialized faculty members was associated with an increased odds that their career choice was in the faculty's same field. This supports the idea that mentorship by faculty and residency programs plays a nurturing role in residents' career determination.

Introduction: Postoperative drains are used widely in plastic surgery (PS) and can help prevent several postoperative complications, such as infection and hematoma. Patients tasked with manual record-keeping of drain output and drain care at home tend to experience increased anxiety. Providers also encounter frequent drain-related outpatient communication, as well as inaccurate output measurements, due to the lack of an easy-to-use drain management system.

Methods: Single-institution data from the PS Clinical Advice Services (CAS) help line was queried over a six-month period. Providers were surveyed on the frequency and nature of drain-related outpatient communication, as well as their experiences related to drain care management in the acute care setting. Survey data was analyzed and was then used to design a mobile application for electronic drain monitoring that facilitates drain care for patients, as well as remotely for providers.

Results: Over six months, 163 patients contacted CAS 223 times. 15% of calls were drain-related. 74% were escalated to the on-call resident, compared to 10% for drain-unrelated calls. Providers perceived that 58% of calls were potentially preventable. Providers estimated that 25% of patients forget to bring manual drain logs to clinic and, 21% of the time, providers are concerned about inaccurate record-keeping. 90% of providers agree that an electronic system would resolve such issues. A mobile application was then created, featuring a patient-friendly interface for record-keeping and easy-to-interpret 24-hour measurements for providers planning drain removal. Push notifications remind patients to empty their drains and a "frequently asked questions" section allows patients to triage drain-related issues at home.

Conclusions: Post-operative drain care is challenging for both patients and providers, leading to excessive outpatient communication that is potentially preventable. The advent of a drain management mobile application is intended to reduce providers' burdens related to drain management, as well as to reduce patient anxiety related to drain care at home. Further data will determine if electronic drain monitoring improves provider and patient satisfaction.

Background: Millions of patients worldwide are affected annually by surgical site infections (SSIs). Factors contributing to SSIs can be categorized into patient-related and intervention-related (surgical) aspects. One method of reducing SSI risk involves employing antibacterial substances on medical equipment, such as surgical sutures impregnated with triclosan. Triclosan is an antimicrobial agent added to products such as soap and toothpaste to reduce bacterial contamination. [1,2] While there are studies in the general surgery literature on these sutures showing SSI reduction, a limited number of studies exist on the use of antimicrobial sutures (AMS) in plastic surgery operations. [3-5] This study aims to determine whether AMS in plastic surgery operations affects the incidence of SSIs and wound healing complications.

Methods: A cohort of patients who underwent breast reduction, mastopexy, panniculectomy, or abdominoplasty by plastic surgeons at an academic institution and received incision closure with AMS from July 2017 to 2021 were compared with an equal number of patients from this period who underwent these same operations and received incision closure with standard sutures (SS). Patients under age 18 or who had no follow-up data available were excluded. Demographics, comorbidities, and the postoperative course were reviewed. The primary outcome variables were wound issue (e.g., dehiscence/healing issue/wound), suture abscess, spitting suture, hyperpigmentation, hypopigmentation, skin necrosis, seroma, keloid scar, post-operative wound infection requiring antibiotics, hematoma. For univariate comparison, a 2-sample test of proportions was used.

Results: No infections requiring hospital admission or reoperation were observed. When comparing all patient complications using AMS or SS for all procedures, a higher proportion of patients were prescribed oral antibiotics post-operatively for infection in the AMS cohort (p=0.030). When stratifying patients by surgical site and comparing the suture cohorts, a higher proportion of breast cases in the AMS cohort had wound issues (p=0.014), and a higher proportion of abdominal cases in the AMS cohort were prescribed post-operative oral antibiotics for infection (p=0.009).

A single surgeon analysis was performed for the surgeon who used AMS in the largest number of cases. There were no significant differences between suture cohorts in the sub-group analysis. Stratifying patients by surgical site and comparing suture cohorts revealed abdominal cases in the AMS cohort had a higher proportion of post-operative antibiotic prescriptions for infection (p=0.0217).

Co-morbidities and patient habits were explored to identify risk factors for infectious complications. A higher proportion of marijuana users received post-operative antibiotic prescriptions for infection compared to non-marijuana users (p=0.036).

Conclusions: The use of AMS in plastic surgery operations of the breast or abdomen did not make a significant difference in rates of wound healing problems or infections, except for an increased incidence of breast healing issues in the AMS cohort (seen only in the all-surgeon group but then attenuated in the sub-group analysis). Limitations include a small sample size and documentation differences between surgeons, potentially affecting the ability to determine the true rate of complications. Additionally, marijuana may possess a mechanism for the development of post-operative wound infection. Future research is needed to determine if there is a difference in edible versus inhaled marijuana use.

References:

1. Ahmed, I., et al., The use of triclosan-coated sutures to prevent surgical site infections: a systematic review and meta-analysis of the literature. BMJ Open, 2019. 9(9): p. e029727.
2. Alexiou, K., et al., A prospective randomised trial of isolated pathogens of surgical site infections (SSI). Ann Med Surg (Lond), 2017. 21: p. 25-29.
3. Deliaert, A.E., et al., The effect of triclosan-coated sutures in wound healing. A double blind randomised prospective pilot study. J Plast Reconstr Aesthet Surg, 2009. 62(6): p. 771-3.
4. Guo, J., et al., Efficacy of triclosan-coated sutures for reducing risk of surgical site infection in adults: a meta-analysis of randomized clinical trials. J Surg Res, 2016. 201(1): p. 105-17.
5. Laas, E., et al., Antibacterial-coated suture in reducing surgical site infection in breast surgery: a prospective study. Int J Breast Cancer, 2012. 2012: p. 819578.

Three-dimensional printing (3DP) has been used in many surgical specialties for virtual surgical planning. A medical image is fed into modeling software, converted to a print file, and then printed from a variety of materials, usually soft or hard plastic. The result is a three-dimensional model of the original image that can be used to guide preoperative and intraoperative decision making. This technology is not currently used commonly for virtual surgical planning in microsurgery.

Virtual and 3D surgical planning strategies in head and neck reconstructive surgery have been shown to result in overall decreased intraoperative decision making, decreased procedure times, and improved microvascular ischemic time in free flaps. In microsurgery, CT-angiography is often used as a proxy to virtual surgical planning to identify major vessels capable of supporting axial flaps. Actual anatomy may differ from the CT-generated images, due to patient volume characteristic, timing of contrast, and operator ability, necessitating a change in intraoperative decision making. 3DP provides a unique opportunity to create accurate 3D replicas of abdominal vasculature for use in surgical planning. These replicas allow for the surgeons to analyze spatial relationships between various anatomical landmarks in ways that purely CTA surgical planning does not. In 2022 Ogunleye et. al demonstrated that 58 breast free flaps performed using 3D printed models as guidelines had no changes in intraoperative decision making, compared to a 24.1% change in operations using standard CTA for surgical planning (1). In addition, 3DP could play a role in mapping nerves in three-dimensional space allowing the surgeon to identify intraoperative landmarks for nerve preservation. 3DP and other methods of virtual surgical planning have already been used in skull base surgery and oral maxillofacial surgery to identify intraoperative landmarks for the purpose of nerve preservation with good success (2-4).

3DP has significant future applications in microsurgery. Implementation of 3DP could reduce intraoperative changes to preoperative plan, decrease overall procedure time, and assist in preserving sensation for patients.

References

1. Ogunleye et. al, The utility of three-dimensional models in complex microsurgical restruction. Archives of Plastic Surgery, 03-22-2022.
2. Hermann et. al, A novel approach to nerve preservation during segmental resection of mandible utilizing virtual surgical planning (VSP): A Case Series
3. Cung et. Al, Preservation of Infraorbital Nerve in Orbital Floor and Maxillary Defect Reconstruction With Patient-Specific Three-Dimensional Implant: A Case Report. Ophthalmic Plastic and Reconstructive Surgery. 38(5):p e136-e141, September/October 2022.
4. Hsu et. al. Computer-Aided Three-Dimensional Virtual Surgical Planning in Complex Skull Base Reconstruction for Sphenoid Wing Dysplasia in Neurofibromatosis Type 1. Journal of Craniofacial Surgery. 32(7):p 2539-2541, October 2021.

Background: Integrated plastic surgery (IPS) is one of the most competitive residency programs in the U.S. In the 2020 cycle, there were only 82 IPS programs that offered 180 training positions, while similarly competitive specialties such as neurological surgery had 118 programs with 232 positions available. [1]. Historically, matched applicants in IPS have reported one of the highest means of publications, research experiences, and USMLE Step 2 scores compared to their colleagues applying to other competitive specialties [2-3]. The COVID-19 pandemic had a significant impact on the IPS residency match, causing rotations to be suspended, and necessitating a shift from in-person to virtual interviews. This study seeks to evaluate whether the "home effect" persisted in the most recent match cycles and whether medical school ranking and geographical distribution have any bearing on match patterns to integrated plastic surgery in the three year pre and post-COVID periods.

Methods: Data were collected from a total of 86 IPS residency programs, excluding those offering solely the independent pathway, lacking sufficient information on residents' PGY, or featuring less than a 6-year dataset. Data encompassed the following variables: name, medical school, year of residency training, entry year to the residency program, plastic surgery pathway, medical school research ranking, matriculation year to medical school, medical school regional and state locations. Collection methods included residency program websites, supplemented by information from programs' Instagram pages and residents' Linkedin profiles where program websites lacked data. Matriculation year to medical school determined the medical school research ranking of each resident, utilizing U.S. News & World Report's Rankings spanning 2013-2019. Historical data inaccessible via U.S. News & World Report were retrieved from the Internet Archive's Wayback Machine.

Results: In our analysis of 1,180 integrated plastic surgery resident profiles from 2018 to 2023, we found that the percentage of successful applicants from affiliated home medical schools increased from 16.9% to 19% in the pre- and post-pandemic eras, but this difference was statistically insignificant (p > 0.05). Resident percentages from affiliated medical schools increased from 15% in 2020 to 23% in 2021, with marginal insignificance (p = 0.052). However, in 2022, there was a significant 9% decrease compared to 2021 (p = 0.041). In the pre-COVID era, 13.47% of applicants were from Top-10 research-ranked medical schools, compared to 13.96% post-COVID. Applicants from medical schools ranked between 11-20 slightly decreased by 1.98% post-COVID. Medical schools ranked above 20 were represented by the majority of applicants in both pre- and post-COVID cycles, with 48.57% and 50.31%, respectively. The percentage of applicants from unranked medical schools was consistent in the two groups at around 25%. Our analysis did not reveal a significant association between an applicant's medical school USNWR research ranking and their likelihood of matching at an integrated plastic surgery residency program (p > 0.05). Regarding regional trends, the percentage of applicants attending medical schools in the Northeast who matched with their home integrated plastic surgery program increased from 29.4% to 35% post-pandemic. In contrast, there was a 7% decrease for applicants from the South matching with their home program in the post-pandemic era. Importantly, no significant association was observed between the geographic region of medical schools and the integrated plastic surgery programs to which applicants matched (p > 0.05).

Conclusions: Our analysis suggests that the rise in medical students matching into their home integrated plastic surgery programs from pre- to post-COVID was statistically insignificant. Furthermore, our research indicates that match rates in integrated plastic surgery residencies are not significantly influenced by applicants' medical school rankings or geographic regions. The smooth transition to virtual interviews, coupled with the adaptability demonstrated in the face of fluctuations, underscores the commitment of residency programs to providing all applicants with a fair chance of acceptance. The statistical insignificance in key metrics speaks to the successful navigation of challenges, ensuring the continued excellence and fairness of the integrated plastic surgery residency selection process.

References 1. Asserson, D. B., et al. (2022). "A 5-Year Analysis of the Integrated Plastic Surgery Residency Match: The Most Competitive Specialty?" J Surg Res 277: 303-309. 2. Mehta, K., et al. (2019). "Matching into Integrated Plastic Surgery: The Value of Research Fellowships." Plast Reconstr Surg 143(2): 640-645. 3. Schultz, K. P., et al. (2020). "Integrated Plastic Surgery Applicant Review: Important Factors and Selection Criteria." Plast Reconstr Surg Glob Open 8(7)

Background: In recent years, there has been a marked increase in interest in global health, particularly in the realm of global surgery (1). Many studies are performed by physicians in high-income countries rather than those in low/middle income countries (LMICs) where many initiatives are actually implemented (2). This geographical imbalance highlights the pressing need for greater involvement of LMIC surgeons to lead locally based research efforts. For this to be realized, there must be a concerted effort to provide formal research training (3). Surgeons in Humanitarian Alliance for Research and Education (SHARE) is an innovative Plastic Surgery Foundation-based program that enhances collaboration between reconstructive surgeons in the US and Sub-Saharan Africa. This study describes the development and results of SHARE's pilot program on research development as an adjunct to the clinical curriculum.

Methods: The SHARE Research Club was designed to provide opportunities for LMIC Fellows to share research ideas, learn research methodology, and develop scientific writing skills. An initial needs assessment survey was distributed to assess need and desire for research training. Through the two-year fellowship program, bi-monthly virtual research sessions were held to provide Fellows with this training. Research micro-grants applications up to $2000 were also available to Fellows. A Berlin test with 15 multiple choice questions was administered at the start and end of the program to assess understanding of research methods (4). Paired and unpaired t-tests were conducted to evaluate statistical significance (p-value < 0.05) of the difference in pre-and post-test scores. Secondary outcomes included research productivity in terms of micro-grants awarded, publications, and abstract presentations.

Results: There was a total of 31 Fellows in the 2020-2022 cohort. Thirteen Fellows completed the initial survey, with 92.3% demonstrating interest in conducting research. Some of the most commonly sought skills were: choosing a research question (mean score 84.6%), designing a study (84.6%), data collection and analysis (92.3%). Nine Fellows completed the pre-test, 5 completed the post-test, with 4 of those completing both. The mean pre-test score was 5.7/15 and the mean post-test score was 8.0/15 with a mean improvement of 2.3 (p=0.095). The mean difference for the 4 Fellows who completed both tests was an improvement of 0.25 (p=0.89). Five of 17 Fellows (29%) were awarded micro-grants from PSF, and fellows produced a total of 5 peer-reviewed publications.

Conclusion: This pilot program within SHARE demonstrates the initial efforts made to successfully integrate formal research training for surgeons in LMICs to bridge the research gap. The results of the program show an increase in research knowledge and productivity among the Fellows. While the Berlin test results were underpowered to detect significance, the overall progress indicates a positive trajectory in building research capacity in LMICs.

1. Johnston PF, Scholer A, Bailey JA, Peck GL, Aziz S, Sifri ZC. Exploring residents' interest and career aspirations in global surgery. J Surg Res. 2018;228:112-117. doi:10.1016/j.jss.2018.02.056
2. Francis P, Chu K, Isiagi M, Fieggen G, Gordon C, Maswime S. Developing a Pipeline of African Global Surgery Scholars. S Afr Med J. 2023;113(7):10-11. doi:10.7196/SAMJ.2023.v113i7.1104
3. Frimpong-Boateng K, Edwin F. Surgical leadership in Africa – challenges and opportunities. Innov Surg Sci. 2019;4(2):59-64. doi:10.1515/iss-2018-0036
4. Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R. Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine. BMJ. 2002;325(7376):1338-1341. doi:10.1136/bmj.325.7376.1338

Purpose: Single-use medical devices commonly used in plastic surgery procedures can contribute to medical waste and increased costs. Reprocessing of medical devices may reduce cost and environmental impact. However, the landscape of new devices approved for reprocessing in plastic surgery is less known. This study comprehensively identifies the reprocessing capabilities of newly FDA-approved devices used in plastic surgery procedures.

Methods: Surgical medical devices and their design features were identified using the publicly-available FDA Releasable 510(k) Database from January 2018 to April 2023 using the product codes laparoscopic instruments (GCJ), electrosurgical instruments (GEI), powered laser surgical instruments (GEX), and fat-reducing low-level laser (OLI). Only devices indicated as posing a high risk for infection in the FDA's Reprocessing Final Guidance Appendix E were required to include reprocessing validation information. Reprocessing capability was defined as inclusion of approved reprocessing procedures in device summaries. Single-use devices were those that included any single-use components and could not be reprocessed. Costs were obtained from medical device company websites. Common surgical tools were identified for the most common plastic and reconstructive surgery procedures.

Results:

There were 638 510(k) premarket applications for surgical devices between 2018-2023, representing 3.8% (638/16723) of total applications. While laparoscopic techniques are uncommon in plastic surgery, 56% of laparoscopic devices and 38% of camera systems possessed reprocessing capabilities, representing the highest percentage of devices with reprocessing capabilities investigated. Among GEI devices, 7 (50%) laparoscopic devices and accessories and 5 (50%) cables/cord devices had reprocessing capabilities, making them the highest reprocessing categories. The most common reconstructive surgery is tumor removal and involves the use of such imaging modalities as well as specimen retrieval. Other commonly performed reconstructive procedures, including laceration repair and scar revision, involve the use of electrodes and tissue ablation which have the least reprocessing capabilities for GEI instruments, with 1 (9%) and 1 (5%) reprocessing devices, respectively.

For GEX and OLI devices, 1 (25%) UV-phototherapy device and 9 (16%) hair removal devices had reprocessing capabilities, making them the highest reprocessing categories. Despite laser resurfacing being the highest cosmetic procedure, laser filters and vein treatment had the least reprocessing capabilities, with 0 (0%) for both categories.

The average cost of GEI single-use devices ($11314, $8551) was slightly less than their reprocessed counterparts ($16052, $16134). The average cost of GEX and OLI single-use devices ($35860) was greater than their reprocessed counterparts ($26013). Reprocessing capabilities are lacking in medical devices used in the most commonly performed aesthetic and reconstructive surgery procedures.

Conclusions: The majority of reprocessing capabilities are focused on devices used outside of plastic surgery, including cameras and laparoscopes. Future efforts to build reprocessing capabilities in plastic surgery specific devices are therefore warranted. Surgical instruments have the least reprocessing potential, which is concerning given their use in common aesthetic and reconstructive surgeries. Plastic surgeons can consider vendors who incorporate reprocessing to reduce their utilization of single-use devices. Manufacturers should focus reprocessing and design efforts on device categories that currently lack reprocessing capabilities.

Purpose: ChatGPT is an Artificial Intelligence (AI) tool that has potential utility in academic medicine, including assisting with research and literature review. However, concern has been raised regarding AI's ability to provide accurate literature review in academic medicine. This paper aims to assess the accuracy of plastic and reconstructive surgery (PRS) references provided by ChatGPT 3.5 and ChatGPT 4.0 to determine the viability of their use in academic medicine.

Methods: Twenty test queries in five different disciplines of PRS (Aesthetic, Breast reconstruction, Craniofacial, General Reconstruction, and Burn) were generated. Queries were submitted to both ChatGPT 3.5 and 4.0, and references were produced on these individual topics. The references produced by ChatGPT were then verified for authenticity utilizing the following: Pubmed, Google Scholar, Scopus, and Google. The articles were deemed true if the correct title, author, and Digital Object Identifier (DOI) were provided by ChatGPT, or false if the article was either not found, or if title, authors, or DOI were only partially matched to an existing article.

Results: The 20 queries yielded a total of 172 references from both ChatGPT 3.5 and 4.0. ChatGPT 3.5 delivered 146 references, with a median of 7 references per question. A median of 5 references per query were categorized as true and 2.5 were false. Of the 146 total references, 57 (39.0%) were classified as false. Subgroup analysis revealed no statistically significant difference among the different plastic surgery disciplines (Kruskal-Wallis' test, p = 0.124). ChatGPT 4.0 generated 26 references, with a median of 1 reference per query. While about half of these references (11) were peer-reviewed articles or book chapters, many were websites from medical centers or commercial medical groups. A Fisher's test revealed that ChatGPT 3.5 was significantly worse at providing accurate references than ChatGPT 4.0 (p = 0.0002). ChatGPT 3.5 also generated significantly more references than ChatGPT 4.0 (p < 0.0001).

Conclusion: ChatGPT 3.5 generates significantly more inaccurate references in response to clinical PRS queries than ChatGPT 4.0. This limitation is an important consideration for researchers attempting to employ AI in the literature review phases of their research. While ChatGPT 3.5 responded to test queries with a list of 6 to 8 references, ChatGPT 4.0 tended to provide more conversational, paragraph-style answers that encouraged readers to learn more utilizing the 1-3 references it provided. This tendency for ChatGPT 4.0 to provide more patient-centered responses with fewer references may reflect advancements in complexity and user-friendliness, and indicates a need for further study into the optimal phrasing of questions to yield more valuable references for a literature review. This shift in response style from 3.5 to 4.0 also illuminates ways in which patients could use this technology to learn more about their clinical conditions. AI has the potential to play a helpful role in scientific writing, though future study is warranted to navigate its limitations.

Background: Plastic surgeons' presence on social media was as high as 61.9% in a recent ASPS survey, with Instagram being one of the primary tools used to reach a more expansive audience (1). Patients also routinely use these platforms to educate themselves, review before-and after-photographs, and discuss their experiences (2). Social media is utilized professionally as an emerging practice paradigm, but recent policy changes have negatively impacted surgeon users, resulting in "shadow-bans" or decreased visibility of surgeon accounts. This is the first known study to investigate awareness of plastic surgeons regarding Instagram's community guidelines and characterize the adverse effects of emerging policies on user experience and practice.

Methods: In February 2024, an IRB-approved survey was disseminated among plastic surgeons active on Instagram. The survey included questions about perceived shadow-banning, page utilization practices, observed decreases in account reach, and assessments of knowledge regarding permissible content. Univariate analysis incorporated t-tests and chi-squared tests, with comparisons based on board certification status and the presence of a secondary page to mitigate shadow-bans or page deletion. Statistical significance was established at p <0.05.

Results: The survey consisted of 107 responses (88 board-certified plastic surgeons, 19 without board-certification); most respondents (72.90%) reported 1,001-50,000 followers. Respondents with a second Instagram page (30.80%) were statistically more likely to note decreased visibility over the last year (96.97% vs 79.73%, p=0.02), more likely to make a broadcast channel (12.10% vs 0%, p=0.002), and believe they have been shadow-banned (87.80% vs 59.50%, p=0.01). Respondents demonstrated knowledge gaps in posting policies, such as being unaware that the current guidelines prohibit posting breasts, even with nipple covers. Most respondents (98.13%) reported that Meta's community posting content policies are not clear enough and board-certified plastic surgeons had significantly more knowledge on how to check if they were in violation of community guidelines (80.68% vs 57.89%, p=0.033).

Conclusions: Plastic surgeons and Instagram have the potential for mutual beneficial relationships, yet recent content policies have limited the platform's effectiveness for practice. This study identified critical knowledge gaps in the community content posting policies, potentially contributing to increased rates of shadow-banning and subsequent frustrations with the platform. Board-certified plastic surgeons have greater understanding on how to determine their account status, and are potential resources as key opinion leaders, ambassadors, and educators for the emerging generation of users on the platform. Potential education points for a social media curriculum identified from this study includes posting policies, shadow-banned hashtags (many of which are related to the plastic surgery industry ie. #cancer, #thighs), and common misconceptions such as the benefits of a secondary Instagram page. Future directions include currently ongoing surveys to better inform inter-organizational discussions with Meta and social media platforms to facilitate positive and productive mutual outcomes.

References: 1. Economides JM, Fan KL, Pittman TA. An Analysis of Plastic Surgeons' Social Media Use and Perceptions. Aesthet Surg J. 2019;39(7):794-802. 2. Thawanyarat K, Hinson C, Gomez DA, Rowley MA, Navarro Y, Venditto CM. Content and Engagement Among Plastic Surgeons on Instagram. Aesthet Surg J Open Forum. 2023;5:ojac096.

Introduction: In response to the opioid crisis in the United States, there has been a growing interest in alternative pain management strategies. This retrospective study investigates the efficacy of suprazygomatic maxillary nerve blocks (SZM) in patients undergoing rhinoplasty or functional septorhinoplasty to find an optimal approach to postoperative pain management.

Methods: A multicenter retrospective analysis was conducted on patients who underwent functional nasal surgery and rhinoplasty at an adult and children's hospital between April 2021 and January 2024. The study evaluated the impact of SZM on intraoperative anesthetic and opioid use, postoperative pain as a proxy of PACU time to analgesia, and PACU length. All opioids were converted into morphine milligram equivalents (MME's). T-tests and Mann-Whitney U tests were conducted to assess the data.

Results: A total of 59 patients underwent rhinoplasty or septorhinoplasty. Twenty patients received a SZM before undergoing the procedure. The average age at the time of procedure was 28 (range 16-82). SZM significantly reduced the amount of intraoperative MME's used (p = 0.03), including hydromorphone (p=0.02). The use of SZM also significantly reduced post-anesthesia PACU stay (p = 0.003).

Conclusions: Suprazygomatic maxillary nerve blocks provide a viable alternative to traditional opioid-based analgesia in nasal surgery. It is associated with decreased intraoperative opioid use and PACU stay. This study supports the shift towards optimizing pain management protocols in response to the opioid epidemic, prioritizing patient safety and recovery.

Background: Novel microsurgical techniques are redefining the field of reconstructive surgery, necessitating further incorporation of microsurgical training into the residency curriculum. Currently, the level of microsurgical exposure in plastic surgery residency is limited, especially in the operative setting. The steep learning curve for junior trainees is yet another barrier to developing proficient microsurgical skills. The advent of the microsurgical robot offers a promising solution, improving visualization, precision, and overall ease of operation for trainees in both practice and operative settings. We aim to understand the potential role of the microsurgery robot as an effective teaching tool for plastic surgery trainees.

Methods: Plastic surgery faculty and trainees at a single residency program participated in a two-day demonstration of the microsurgical robot, which entailed twenty-minute, hands-on practice sessions. Using the robot, participants were asked to create one anastomosis on a 2mm synthetic vessel, with the instructor coaching as needed. The instructor then graded participants on the quality of anastomosis using a modified MARS10 scale; suture and knot quality were assessed, but patency of anastomosis was not. Participants were then surveyed regarding their perceived skill level while using the robot, their opinions on routine use of the robot, and their perspectives on incorporating the robot into the training curriculum.

Results: There were 16 study participants, including eight trainees and eight faculty. Approximately 87.5% of faculty reported that using the robot was "very easy" or "somewhat easy," compared to 50% for trainees. None of the faculty or trainees believed the robot allowed them to create an anastomosis faster than when using the traditional microscope setup. Similarly, none of the faculty felt the robot allowed them to more effectively assist as a second surgeon, while 25% of trainees did believe so. When graded on the quality of anastomosis, faculty members scored 89.1% ± 10.4%, while trainees scored 88.3% ± 9.7%. With respect to including the robot in an educational setting, half of the faculty believed the robot could allow trainees to more effectively assist as a second surgeon in the operative setting. However, with regards to one-on-one teaching, only 25% of faculty preferred teaching trainees with the robot in a practice setting, and only 12.5% preferred the robot to teach in an operative setting. Finally, 75% of faculty agreed that including the microsurgery robot would help trainees build skills more than the microscope, and 100% of trainees agreed with this statement.

Conclusions: Trainees were less confident in using the robot than faculty were, but trainees still performed nearly as well as experienced faculty when graded by the instructor. Faculty members did not believe that the robot would allow trainees to assist more effectively in the operating room and were overall reluctant about using the robot to teach trainees. In contrast, trainees were more enthusiastic about incorporating the microsurgical robot into their training curriculum than the faculty were. This was despite the fact that trainees believed the robot to be more difficult to use than the traditional microscope setup.

Purpose Hypertrophic scaring (HTS) is an abnormal process of wound healing that results in excessive scar tissue formation. Following cutaneous injury, healing tissue that is subject to tension is more prone to develop HTS. Chronic inflammation and dysregulated extracellular matrix formation have been proposed to mediate the process of HTS. In order to better understand HTS formation, our lab previously developed a murine model that mimics human-like HTS by applying mechanical strain across an incisional wound (Aarabi et al. 2007). Since the advent of the model, significant changes have been made to improve the HTS protocol to make it simple, standardizable, and replicable. Further, our previous understanding of HTS formation is limited to long term time points after the scar has already formed. Here, we present a detailed protocol and chronological progression of wounds for the human-like HTS in mice.

Methods Approximately 2cm long full-thickness incisions were made on the dorsa of 12 15-week-old C57/BL6 mice and were closed using monofilament nylon 5-0 sutures. Mechanical loading devices were made from 13mm palatal expanders and molded using X7 NiTi Three Jaw Pliers. On post-incision day 4, sutures were removed, and mechanical loading devices were placed over the wounds secured using Vetbond and Autoclip System surgical staples. Loading devices on 6 of the mice were expanded by 2mm every other day for 14 days total, thereby producing consistent tension across the wound (strain). The loading devices on 6 mice were not expanded and did not have tension across the wound (control). Scars were imaged at post-op day (POD) 4, 8, 14, and 18 to examine the progression of scar formation and analyzed using ImageJ.

Results The control, non-strain group had average scar widths of 0.73mm, 0.63mm, 0.54mm, and 0.42mm at POD 4, 8, 14, and 18, respectively. At POD 4, prior to the initiation of mechanical strain, the strain group had similar average scar widths compared to controls (0.58mm, p=0.250). However, after applying mechanical strain across the wound, scars were significantly thicker than controls and peaked in width at POD 8 with an average of 0.99mm (p=0.0450). Scar widths remained significantly greater than controls at POD 14 (0.95mm, p=0.0429) and POD 18 (0.78mm, p=0.0450).

Conclusion Since much remains unknown regarding the pathophysiology of HTS formation, it is imperative to create a reproducible murine model to investigate. Using our updated and refined human-like HTS murine model protocol, mechanical strain across a wound bed produced significantly larger scars at multiple time points. Scar formation seemed to plateau and then decrease over time but remained elevated compared to wounds with no strain across them. Understanding the progression of HTS formation can help direct both prevention and potential therapeutic interventions, especially in wound sites with high tension.

Introduction: The practice of evidence-based medicine in plastic surgery is essential to provide the optimal care to individual patients. Level of evidence (LOE) and number of citations are metrics used to gauge quality of research and impact within a field, respectively. The objective of this study was to determine an association between level of evidence and number of citations within recent articles published in Plastic and Reconstructive Surgery.

Methods: A review of original research articles published in Plastic and Reconstructive Surgery from January 2018 to June 2022 was performed to determine the relationship of level of evidence to number of times an article was cited. Level of evidence was identified through the PRS website, and number of citations identified via PubMed. Articles were further divided into sections of their corresponding topic (breast, cosmetic, experimental, hand/peripheral nerve, pediatric/craniofacial, and reconstructive). Excluded from the study were animal studies, cadaver studies, basic science studies, review articles, instructional course lectures, CME articles, editorials, and correspondence articles.

Results: 965 articles were reviewed since January 2018, of which 21 (2.2%) were articles assigned level I evidence. There were 147 (15.2%) level II articles, 360 (37.3%) level III articles, 377 (39.1%) level IV articles, and 60 (6.2%) level V articles. Average number of citations per article was 2.72, and average level of evidence of all included articles was 3.31. Breast articles had the greatest average number of citations (3.81) while experimental articles had the greatest average level of evidence (4.18). Breast articles also had the greatest percentage of level I articles (38.1%) compared to other types of articles. Level I articles had an average of 4.95 citations, which is significantly more than the average number of citations for level II, III, IV, and V articles, individually. These findings conclude that level I articles are more likely to be cited compared to levels II-V articles.

Conclusion: Our data shows that articles assigned level I evidence in Plastic and Reconstructive Surgery yield a higher number of citations compared to articles assigned lower levels of evidence. Breast research is generally higher quality and has a greater impact in the field of plastic surgery compared to other types of PRS research. Since higher LOE correlates with a greater impact, these findings should encourage investigators to publish level I evidence research in order to have the greatest effect on the field.

Purpose: Patients undergoing facial cosmetic surgery, such as rhinoplasty, genioplasty, otoplasty, and cervicoplasty, rely highly on surgeons' pre- and postoperative photos to both gain an understanding of expected postoperative results, and to develop their perception of a physician's surgical skill. The development of readily accessible generative artificial intelligence models (AI) now allows patients to enter a free-text prompt and a preoperative image, and generate a potential postoperative outcome. However, AI training models vary widely and may not have appropriate surgical photography in the model training set. This may lead to inaccurate image generation, and to patients having unrealistic expectations of surgery. The authors therefore sought to evaluate the quality of these generated images.

Methods: Image Generation: The authors developed a series of initial prompts for the generation of pre- and postoperative images for rhinoplasty, genioplasty, otoplasty, and cervicoplasty. ChatGPT was then used to serially refine the prompts, emphasizing surgically relevant details while excluding information that would vary between patients. Final prompts for each procedure were kept consistent, and fed into three unique combinations of generative adversarial networks (GANs) and other deep-learning frameworks, to produce 3 images per procedure. Image Evaluation: An 11-item assessment (scale 1-5) was generated using evaluation systems from other previously published relevant literature. Points of assessment included anatomical correctness, features of image realism, and relevance to the surgical procedure, among others. A panel of two fellowship-trained craniofacial surgeons, two board-certified general plastic surgeons, and two plastic surgery residents evaluated each image using the 11-item assessment, as well as via free text response. Results were characterized by ANOVA, Kruskal-Wallis H-test, and Mann-Whitney U-test when appropriate.

Results: Comparison of panelist responses showed no significant differences in scores on "Realism" metrics (F=2.85, p=0.07), indicating a consensus in anatomical accuracy, age simulation, color fidelity, and texture mapping. Significant variations, however, were found in the "Clinical Value" metrics of target feature recognition, postoperative result prediction, and surgical relevance (F=3.52, p=0.04). When comparing metrics, "Healing and Scarring Prediction" received significantly lower scores than "Size and Volume Accuracy" (p<0.001), "Color Fidelity" (p<0.001), and "Correct Simulation of Age" (p<0.001) (H=53.00, p<0.001). When comparing the AI models, there was no significant differences in "Realism" (F-value: 1.444, P-value: 0.269) and "Clinical Value" (F-value: 2.661, P-value: 0.114). Panelists reported that several images demonstrated the "uncanny valley" effect.

Conclusion: When using AI to generate images for facial surgery, there was no best-performing model. Evaluators agreed that the images did not score well on realism metrics, but disagreed on whether or not the images were clinically valuable. Some images reasonably depicted the aesthetic deformity and a realistic expected postoperative result, while many images failed to appropriately predict a reasonable surgical result, had inappropriate skin color or texture, or were just unrealistic enough to trigger the uncanny valley effect. Further development is needed to produce AI models that will allow the generation of appropriate pre- and postoperative imagery; the authors plan additional study including use of 'live' preoperative imagery, as well as comparison of AI-generated vs true-to-life results.

Purpose: Vascularized composite allograft (VCA) transplantation represents a promising avenue in plastic surgery. Ex-vivo machine perfusion (EVMP) has emerged as a technique to extend the viability of donor organs, including VCA grafts. However, EVMP protocols vary widely, leading to inconsistent outcomes. Further refinement in these protocols is necessary, but research on this topic is limited. We hypothesize that specific parameters during EVMP significantly impact perfusion outcomes. Methods: A meta-analysis of literature was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement. The search encompassed articles published before July 25, 2023. PubMed, Embase, and CENTRAL were screened using search terms "ex-vivo", "ex-situ", "machine" and "perfusion". Weight gain was chosen as an outcome measure, as it is an indicator of organ viability, endothelial injury, interstitial swelling, and microthrombosis. Extracted variables included perfused organ, warm and cold ischemia time before perfusion, perfusion duration, perfusate flow, pressure, temperature, perfusate composition (presence of cellular or acellular oxygen carrier, colloids, other supplements) and percent weight change. In correlation analysis, Pearson's correlation coefficient was computed and the results were reported as the beta coefficient (ß), correlation coefficient (R), and p-value (p). For continuous data, Student's t‐tests or analysis of variance (ANOVA) with or without Welch modification, followed by Tukey post‐hoc pairwise comparison, were performed as appropriate. Data analysis was conducted using IBM SPSS Statistics version 26.0.0.0. P values <.05 were considered statistically significant. Results: A total of 916 studies were retrieved. Forty-six papers were included. Red blood cell based perfusates resulted in significantly lower weight gain compared to acellular perfusates without oxygen carriers (11.3% vs. 27.0%, p<0.001). Hemoglobin based oxygen carriers resulted in significantly lower weight gain compared to acellular perfusates (16.5% vs. 27%, p=0.006). Normothermic perfusion led to the least weight gain (14.6%), significantly different from hypothermic (24.3%) and subnormothermic (25.0%) conditions (p<0.001), with no significant difference between hypothermic and subnormothermic groups (24.3% vs. 25.0%, p=0.952). Multivariable linear regression revealed negative correlation with hematocrit and weight gain (standardized beta coefficient=-0.642, p<0.05). Conclusion: This metanalysis shed light on several critical aspects influencing organ viability during ex-vivo perfusion. The ideal perfusate seems to consist of an oxygen carrier at normothermic temperatures. Perfusates can be supplemented with either hydroxyethyl starch, bovine serum albumin or human serum albumin without compromising outcomes. Warm ischemia time should be kept to a minimum, but cold ischemia time is permissible. Hematocrit within 12.5-32% can be successful. Flow rate should be kept between 0.075 and 0.25 mL/min/g per starting tissue weight. These findings offer opportunities for improving organ transplantation outcomes.

Introduction: In the realm of contemporary medical practices, social media has emerged as an integral tool for plastic surgeons, serving as a strategic platform for professionals to cultivate their practice's brand identity, engage prospective patients, and contribute to public education within the field (1). As social media usage has surged, heightened ethical concerns have arisen regarding its impact and implications. However, data on its impact on their private life, safety, and business is limited. Thus, this study aimed to assess the prevalence and characterize the types of harassment that plastic surgeons experience on social media.

Methods: This cross-sectional study involved a 30-question anonymous survey that was emailed to active members of the American Society of Plastic Surgeons (ASPS). The survey collected demographic data as well as social media usage, types of content, harassment experienced, and subsequent consequences. Analyses encompassed Chi-square test or Fisher's exact test for proportions with stratifications for gender, years in practice, race, length of time using accounts, followers, and type of content. Univariate analysis was performed to select variables included in the multivariate analysis for the outcome of any form of harassment.

Results: A total of 215/2093 ASPS members responded, with most being private practitioners (97%), male (67%), and white (81%). Instagram (95%) and Facebook (90%) were the most popular social media platforms utilized. Most respondents (57%) posted strictly professional content; most of whom identified as female (64.3% vs 44.3%, p=0.008). Most respondents (58%) reported at least one experience of online harassment, mainly fake reviews (40%) and threatening messages (26%). Harassment led to patient loss (24%) and legal issues (4%). Female respondents experienced sexual harassment at a higher rate compared to males (13% vs. 2%, P=0.004). Harassment was more strongly correlated with specific content, namely pre-and-post-operative patient photos.

Conclusion: Our study identified the most common forms of harassment, including fake negative reviews and threatening messages, emphasizing consequences such as patient loss and damage to professional partnerships. Furthermore, it underscores the presence of gender inequity that persists even in the realm of social media, as it pertains to sexual harassment, which has been observed across various medical specialties (2,3). By acknowledging the factors contributing to online harassment, practitioners can implement strategies to protect themselves while ensuring social media remains a constructive tool for professional growth and patient education. Future research should focus on exploring harassment prevalence among racially underrepresented in medicine (URiM) surgeons, a limitation of this study.

References: 1. Teven CM, Park JE, Song DH. Social Media and Consent: Are Patients Adequately Informed?. Plast Reconstr Surg. 2017;140(5):770e-771e. 2. Pendergrast TR, Jain S, Trueger NS, Gottlieb M, Woitowich NC, Arora VM. Prevalence of Personal Attacks and Sexual Harassment of Physicians on Social Media. JAMA Intern Med. 2021;181(4):550-552. 3. Woitowich NC, Arora VM, Pendergrast T, Gottlieb M, Trueger NS, Jain S. Gender Differences in Physician Use of Social Media for Professional Advancement. JAMA Netw Open. 2021;4(5):e219834.

Background

Chronic non-healing wounds significantly challenge healthcare, affecting patients' quality of life and function. The dynamics of the chronic wound microbiome, how it changes with time, and its influence on clinical outcomes are not well understood. This study aims to fill this gap by offering a detailed analysis of the microbiome in chronic wounds over time, paving the way for personalized, targeted topical antimicrobial treatments.

Methods Seven Type II diabetic wounds were sampled monthly during standard wound debridements for three months. Metagenomic sequencing and diversity indices (Shannon Index for alpha diversity and Bray-Curtis Dissimilarity for beta diversity) were used to analyze microbiome diversity and behavior over time. Patient factors including HgbA1c, wound size, wound care and systemic antibiotic treatment were recorded. Results Wounds enlarging over time exhibited increased biodiversity, suggesting a shift towards a more polymicrobial state that was more difficult to treat. Systemic antibiotic treatment led to increased biodiversity in two of four patients, highlighting antibiotics' limited impact on microbial diversity. Over time, all wounds maintained a high Bray-Curtis Index, indicating consistent microbial dissimilarity irrespective of healing status or treatments. Conclusion These findings reveal the dynamic, polymicrobial nature of chronic wound biofilms over time. Systemic antibiotics may increase biodiversity counter to their intention to decrease bacterial load highlighting the importance of antibiotic stewardship. This study helps to define the true complexity and constant changing of the chronic wound microbiome using state of the art technology.