Scientific Abstract Presentations: Practice Management Session 2 Friday, September 27 Fri, Sep 27 10:30 a.m.-12:30 p.m. PDT

Introduction Laceration injuries are a common presenting complaint to emergency departments (EDs), comprising 5.2-8.2% of ED visits in the United States annually (1). However, guidelines on which wounds warrant consulting a specialized surgical service are not standardized. Moreover, these specialists are not always available. A nationwide survey of ED directors revealed the greatest difficulties in ensuring adequate plastic and reconstructive surgery on-call coverage (2). The No Surprises Act (NSA), implemented in January 2022 to prevent surprise medical billing, may exacerbate the gap between on-call specialist demand and coverage (3). In this study, we aim to understand criteria for plastic surgery consults and evaluate the effect of the NSA on institutional practices of emergent laceration repairs.

Methods This was a cross-sectional survey study of Plastic & Reconstructive Surgery and Emergency Medicine residency and fellowship program leadership. Program directors of training programs at the 50 largest hospitals in the United States were invited via Qualtrics XM (Seattle, WA) to complete the survey.

Results 25/46 (54.3%) of PRS programs and 24/45 (53.3%) EM programs responded. 60% of surveyed institutions have published guidelines on which service closes ED lacerations, based on factors such as location (77.3%), complexity (66.7%), size of the wound (53.3%), and age of the patient (20.0%). Eyelids are the most frequently consulted-on area (87.5%), followed by the lips (45.8%), ears (41.7%), and nose (41.7%). 88% of institutions honor patient requests for PRS repair, and 72% have PRS residents close by default. Of surveyed EM leadership, 39.1% reported lack of ED provider time as a factor in consulting PRS, although 91.7% disagreed that calling a PRS consult decreases the patient's overall length of stay. Three PRS programs (12%) reported difficulties with ED coverage since the implementation of the NSA.

Conclusion Despite the absence of standardized guidelines, both clinical and situational factors contribute to the decision to consult a surgical specialist for repair of a laceration in the ED. Wounds that are complex or located in the head and neck region more often necessitate a PRS consult. Patient request and lack of ED provider time also contribute to an emergency physician's decision to consult PRS. The introduction of the NSA, although not significantly altering ED practices yet, poses future challenges for specialist coverage. These policy changes highlight a need to increase the number of providers who can provide laceration repair in the ED, thereby allowing emergency physicians to attend to other waiting patients and elevating the satisfaction, safety, and welfare of all patients in the ED.

References 1) Singer AJ, Thode HC Jr, Hollander JE. National trends in ED lacerations between 1992 and 2002. Am J Emerg Med. 2006;24(2):183-188. doi:10.1016/j.ajem.2005.08.021

2) Rao MB, Lerro C, Gross CP. The shortage of on-call surgical specialist coverage: a national survey of emergency department directors. Acad Emerg Med. 2010;17(12):1374-1382. doi:10.1111/j.1553-2712.2010.00927.x

3) Zbar RIS, Zbar D, Canady JW. Downstream Impact for Plastic Surgeons in the United States from the "No Surprises Act". Plast Reconstr Surg Glob Open. 2022;10(3):e4202. Published 2022 Mar 18. doi:10.1097/GOX.0000000000004202

Introduction In recent years, there has been an encouraging amount of plastic surgery literature published regarding the benefits of reducing opioid use and the best strategies to responsibly treat patient's postoperative pain. However, there are still many plastic surgeons who hesitate to initiate this directive. While non-surgical fields have seen a significant decrease in opiate prescriptions, surgical specialties continue to provide a large excess of narcotics, increasing the risk for abuse. We present a practice modification designed to reduce the number of opiates prescribed and highlight the steps needed to implement a new prescribing algorithm.

Methods In October of 2023 we implemented a new pain management algorithm for patients undergoing reconstructive, aesthetic, or revision breast surgery. In the pre-intervention group, patients received 30 pills of postoperative opiates and recorded their consumption using take-home logs. Following the intervention, patients were given a maximum of 10 pills. To guide our new prescribing practice, we relied on pill consumption analysis from our pre-intervention cohort. Data was prospectively collected on postoperative analgesic use per procedure. We compared the differences between pre-and post-intervention groups using Student's t-test to analyze the number of opiates prescribed, amount consumed, and number of days used. The incidence of patients who used non-opioid analgesics and required refills were compared using Fisher's exact test. All statistical analysis were performed with SPSSv24.0 (p<0.05 considered statistically significant).

Results 41 survey responses were included in our pre-intervention cohort and 10 in our post-intervention cohort. A median of 5.5 pills was consumed by patients who received implant and tissue expander procedures, 4.75 pills were consumed by patients who underwent pedicled flaps, 12 pills for fat grafting, 5 pills for breast reduction, and 12.5 pills for gender affirming mastectomies. Prior to the opioid intervention, patients received 30 pills of opiate analgesic postoperatively, and consumed a median of 6 pills. Following the intervention, patients received a median of 7 pills, which was a significant reduction (p<0.000) and consumed a similar number of opiates (5.5 pills, p=0.398). Patients in both cohorts would consume pills for a median of 4 days postoperatively. In the pre-intervention group, patients had a median of 24 unused pills. This was significantly reduced to 0.5 unused pills in the post-intervention cohort (p<0.000). Refill requirements and analgesic use by the two groups was not significantly different (p=0.063 & p=0.545).

Conclusion We have shown it is possible to implement a new opioid prescribing algorithm in plastic surgery. Our opiate intervention significantly diminished opiate excess, reducing the risk for abuse, without significantly increasing patient's need for refills or non-opiate analgesics. With growing research demonstrating the benefits of regulating prescriptions and the best ways to implement change, surgeons can feel confident to just say yes to this meaningful reform.

Introduction.
Understanding reimbursement trends is crucial to maintaining a sustainable practice, particularly in craniofacial trauma. However, there is limited literature on reimbursement trends for craniofacial trauma services. The purpose of this study is to evaluate trends in physician fees (PF) and facility pricing (FP) within the past two decades.

Methods. National reimbursement data from 2007 to 2023 was obtained through the Medicare Physician Fee Schedule Look-Up (MPFS) tool provided by the Center for Medicare & Medicaid Services (CMS). Craniofacial trauma surgeries of interest were identified through Current Procedural Terminology (CPT) codes.

The following values were queried from MPFS under the National Payment Amount which includes relative value units for work, practice expense, and malpractice. Geographic Practice Cost Indices were set at 1.000 to account for national payment values. Conversion factors were directly obtained by contacting CMS. PF calculations were conducted using the established physician fee reimbursement equation [2].

Medicare facility pricing set at the National Payment Amount for craniofacial trauma were also obtained. Both PF and RP were adjusted for inflation using the Bureau of Labor Statistics Consumer Price Index [3]. Subsequent percentage change (PC) and year-over-year (YOY) analyses were conducted.

Results. Fifty-eight CPT codes were identified. YOY illustrated a decreasing pattern in reimbursements from 2007-2023. Interestingly, YOY demonstrated fluctuations within facility pricing and physician fee reimbursement, in tandem with significant changes occurring during the Global Financial Crisis of 2007-2008 and the SARS-CoV-2 pandemic of 2019.

Overall, PF reimbursements decreased by an average of 9.3% by 2023 compared to 2007. 21 (36%) craniofacial CPT codes experienced an average net increase of 10.2% while 37 (64%) craniofacial CPT codes experienced an average net decrease of 20.3% in Medicare reimbursement in 2023 compared to 2007. CPT 21240 (Reconstruction of jaw joint) had the highest decrease (-43.78%). CPT 21480 (Reset dislocated jaw) had the highest increase (14.6%).

FP reimbursements decreased by an average of 14.6% by 2023 compared to 2007. Three (5%) craniofacial CPT codes experienced an average net increase of approximately 11.5% while 55 (95%) craniofacial CPT codes experienced an average net decrease of 17.9% in Medicare reimbursement for facility pricing in 2023 compared to 2007. CPT 21490 (Open treatment of temporomandibular dislocation with interdental wire fixation) had the highest decrease (-32.2%) while CPT 21452 (Percutaneous treatment of mandibular fracture, with external fixation) had the highest increase (26.47%).

Conclusion. Overall, physician fee and facility pricing reimbursement demonstrated a down-trending pattern from 2007-2023, approximately 9.3% and 14.6%, respectively, with variable fluctuations at certain periods possibly due to significant economic changes.

References 1. Teven CM, Gupta N, Yu JW, Abujbarah S, Chow NA, Casey WJ 3rd, Rebecca AM. Analysis of 20-Year Trends in Medicare Reimbursement for Reconstructive Microsurgery. J Reconstr Microsurg. 2021 Oct;37(8):662-670. doi: 10.1055/s-0041-1724128. Epub 2021 Feb 25. PMID: 33634443.

2. Seidenwurm DJ, Burleson JH. The medicare conversion factor. AJNR Am J Neuroradiol. 2014 Feb;35(2):242-3. doi: 10.3174/ajnr.A3674. Epub 2013 Jul 18. PMID: 23868163; PMCID: PMC7965749.

3. Bureau of Labor Statistics, United States. Consumer Price Index. 2024. https://data.bls.gov/cgi-bin/surveymost

Introduction

Plastic surgery residency training in Nigeria has evolved considerably over the last decade but still faces unique challenges. These include limited awareness among the public and healthcare professionals about plastic surgery, a need for more specialized training, and a slow integration of aesthetic surgery into mainstream practice. This study aims to evaluate the perspectives of plastic surgery residents in Nigeria regarding the current state of their training programs, experiences, and overall satisfaction, with an emphasis on identifying areas for improvement.

Methods A survey with 30 questions was distributed on the online plastic surgery resident/trainers forum in Nigeria using Google Forms. The questionnaire sought detailed information on demographics, training, confidence levels in performing various surgeries, academic involvement, satisfaction with the training environment, and suggestions for enhancing the training framework.

Results Of 102 residents, 24 responded to our survey (response rate = 23.5%). 66.7% of residents were male, with an age range of 31-52. Most residents were in their third year of senior registrar training (41.7%). Confidence levels in performing specific surgeries varied, with a notable majority expressing confidence in tendon and nerve reconstructions (54.2%) and flaps for hand reconstruction (66.7%) but less so in microsurgery, with 29.2% of respondents having no experience and 45.8% having only 1-5 human cases. For aesthetic surgeries, a significant 41.7% deemed their training grossly inadequate or inadequate. Academic involvement was limited, with many residents never having authored a paper (41.7%) or presented at conferences (58.3%). Dissatisfaction was reported in workplace treatment (45.8%) and research exposure (50%). A higher satisfaction rate (54.2%) was reported regarding time spent with trainers in clinical settings. The suggestions for improvement focused on enhanced surgical participation, increased research motivation, and the need for structured training modules and adequate resources.

Conclusions The study highlights the residents' perspective on plastic surgery training in Nigeria, with deficiencies in specific core competencies and research opportunities. Respondents advocated for a multifaceted reform approach, including providing more educational resources, opportunities for foreign training, and establishing specialized hospitals. Addressing these concerns is critical for enhancing the quality and effectiveness of plastic surgery training in Nigeria, ultimately leading to better patient care and surgical outcomes.

Introduction: Overuse of the operating room (OR) leads to increased costs, potential exposure to nosocomial infections due to extended stays, resource constraints, and considerable psychological impacts on patients.(1) More simple procedures can be done safely in an outpatient setting, saving both time and resources.(2) The Minor Procedures Clinic at San Francisco's only public and safety-net county hospital serves a patient population who is uninsured, underinsured, or belongs to lower-income demographics. The purpose of this study is to describe our experience with the Minor Procedures Clinic, to report outcomes following these procedures, and to encourage other hospital centers to develop independent procedural clinics such as ours.

Methods: A retrospective review was conducted of all patients presenting to the Minor Procedures Clinic at San Francisco's safety-net hospital from May 2022 to June 2023. Demographic data, location of procedure, and outcomes were obtained. Means and standard deviations were reported.

Results: The Minor Procedures Clinic is open two days a week and specializes in the evaluation and management of soft tissue foreign bodies and masses, including lipomas and cysts. Patients can drop in during open hours or be referred by their provider to be evaluated. Multiple procedures are offered, including medically necessary foreign body and soft tissue removal. Plastic surgery residents assess the patient's suitability for clinic procedures under local anesthesia and the need for additional imaging for mass evaluation through an initial medical history and physical exam. Caution is exercised in the face, breast, and axilla due to complex anatomy and aesthetics. Once the necessary workup is complete, written consent is obtained and the procedure is performed. The patient is provided with postoperative instructions and seen again by residents at a two-week postoperative appointment for wound check, suture removal if indicated, and pathology review.

67 patients were seen. The mean age was 49.6 ± 13.2 years, 53.7% were males, and 46.3% were females. The mean Body Mass Index (BMI) was 27.9 ± 5.0 kg/m^2. The primary language spoken was English (53.7%), followed by Cantonese (17.9%) and Spanish (14.9%). 44.8% were employed and 83.6% were covered by Medi-Cal. Substance use included methamphetamine (7.5%), alcohol (6.0%), cocaine (4.5%), and fentanyl (1.5%). The most common locations for procedures were the back (19.4%), scalp (13.4%), chest (9.0%), and buttock (9.0%). There was a 1.5% (n=1, hematoma) complication rate.

Conclusion: The Minor Procedures Clinic model offers a refreshing departure from the norm in healthcare management. Its design presents benefits including reduced hospitalizations, fiscal efficiency, and a robust patient-centric focus. Such an innovative approach, when juxtaposed against the backdrop of more conventional inpatient care systems, underscores the transformative potential and value of this healthcare paradigm.

References: 1. Aust H, Eberhart L, Sturm T, Schuster M, Nestoriuc Y, Brehm F, Rüsch D. A cross-sectional study on preoperative anxiety in adults. J Psychosom Res. 2018 Aug;111:133-139. 2. Mull HJ, Rosen AK, Charns MP, Itani KMF, Rivard PE. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. J Patient Saf. 2021 Apr 1;17(3):e177-e185.

Background: In plastic surgery, artificial intelligence (AI) has been used for a variety of tasks: postoperative free flap monitoring, simulating surgical outcomes, understanding pre-operative risk for complications, and creating individualized treatment plans.1 Many subdisciplines of AI exist, including machine learning, natural language processing (NLP), deep learning, and facial recognition.1 Billing constitutes a majority of the healthcare administrative expenses in the U.S., with incorrect coding alone accounting for up to 50% of the improper payment rate in surgical fields, reported from the Centers for Medicare and Medicaid Services Comprehensive Error Rate Testing in 2022. Given these challenges, incorporation of AI presents an opportunity to streamline the billing process.2 NLP and machine learning have garnered high interest due to their ability to generate current procedural terminology (CPT) codes from clinical documentation notes made of unstructured text in the electronic medical records (EMR).3-5

Purpose: This paper aims to explore the integration of artificial intelligence, specifically with natural language processing and machine learning, to enhance patient care and outcomes and improve administrative workflows within plastic surgery.

Results: AI has been used to interpret clinical documentation notes and assign ICD-10 and CPT codes with high accuracy compared to medical billing personnel, recognize instances of incorrect billing, and assist with prior authorizations approvals. Automated medical billing companies such as Nym Health (New York, NY) and CodaMetrix (Boston, MA) as well as literature using machine learning and NLP models have demonstrated the ability to interpret CPT codes from clinical documentation. Insurance companies such as Blue Cross Blue Shield of Massachusetts have piloted prior authorization approvals using AI. AI implementation holds potential to enhance billing practices and maximize healthcare revenue as practicing physicians.

Conclusion: The broad capability of AI to develop accurate, efficient billing codes can improve revenue capture, reduce labor costs associated with manual coding, and increase the speed and efficiency of the billing workflow for all medical fields, and specifically in plastic surgery. Implementation of AI to improve billing as well as patient care can enhance a surgical practice.

1. Knoops PGM, Papaioannou A, Borghi A, et al. A machine learning framework for automated diagnosis and computer-assisted planning in plastic and reconstructive surgery. Sci Rep. Sep 19 2019;9(1):13597. doi:10.1038/s41598-019-49506-1
2. Services CfMaM. Medicare Fee-for-Service Supplemental Improper Payment Data. 2022.
3. Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA. Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System. Jama. Feb 20 2018;319(7):691-697. doi:10.1001/jama.2017.19148
4. Kim JS, Vivas A, Arvind V, et al. Can Natural Language Processing and Artificial Intelligence Automate The Generation of Billing Codes From Operative Note Dictations? Global Spine J. Sep 2023;13(7):1946-1955. doi:10.1177/21925682211062831
5. Friedman C, Shagina L, Lussier Y, Hripcsak G. Automated encoding of clinical documents based on natural language processing. J Am Med Inform Assoc. Sep-Oct 2004;11(5):392-402. doi:10.1197/jamia.M1552

Background: Research is a critical component of academic medicine that may not be prioritized in centers with high clinical volumes. The benefits of research expansion go beyond notoriety and industry partnerships, expanding into resident training and preparation of the next generation of physician-scientists. Improving a division or department's research portfolio requires a commitment to re-organizing structure, personnel, resources and a dedication to innovative funding models. To improve research productivity and quality, our group placed several initiatives into motion beginning in August 2017 that we have outlined and evaluated in the present study. Some of these initiatives included restructuring leadership, resourcing both bench and clinical outcomes research, providing initial funding directly from clinical profits and rewarding research fiscally.

Methods: Internal reviews of hiring records, research publications, grant allocations, and interviews with key personnel were carried out to generate a road map of the initiatives set in place to re-design and further develop our research department. Student's t-tests were used to compare means from 2010-2017 to those from 2018-2022. Average impact factor was calculated by averaging journal impact factors for all publications from the department each year, excluding any publications with greater than five times the raw average, and creating a corrected average that most accurately represents the work carried out by the department that year. Impact factors were obtained using the Journal Citation Reports database from Clarivate. Rankings of top plastic surgery journals were pooled from Google Scholar.

Results: Overall publication output increased from 11 in 2010 to 63 in 2023. Prior to our restructuring initiatives (2010-2017) the department published an average of 9 articles annually which increased to an average of 42 articles since that time (p<0.01). Average impact increased from 0 in 2010 to 4.02 in 2022 with the number of publications in top 10 plastic surgery journals following a similar trajectory with 1 publication in 2010 and 31 in 2023. Following an initial one-million-dollar investment to create an institutionally directed fund in 2018, the department leveraged its research to earn $3 million in endowments, $1.25 million in private industry partnerships, and $7.9 in Department of Defense and NIH funding. The diversity of research produced in the department significantly increased from a mean of 4.1 different study designs represented in publications from 2010-2017 to 9.2 between 2018 and 2022 (p<0.001).

Conclusion: Initiatives as noted above have led to remarkable growth in research output. This road map needs to be deliberate and prioritized. We believe these results are generalizable and that organizational structuring as carried out in our institution can reap benefits across the academic plastic surgery community.

Purpose: Patients interested in facial rejuvenation may be treated with a variety of minimally invasive and surgical treatments. The extent to which patients participate in the shared decision-making process is highly variable in plastic surgery practices. Selecting a treatment is often complex and needs to account for variables such as physical characteristics, medical co-morbidities, patient expectations, downtime tolerance, and budget. Anecdotal reports suggest that patients find education from plastic surgeons is inadequate during the consultation process, leading them to search the internet. Web-based information is unable to replicate clinical judgment and may lead to incorrect conclusions. Investigation to evaluate the information reaching patients in a clinical setting is needed to aid in determining areas where shared decision-making can be improved.

Methods: To facilitate shared decision-making, it is necessary to study the patients' point of view, determine which aspects of planning discussions are felt to be neglected, and identify opportunities to improve the therapeutic alliance between surgeon and patient. To fulfill these objectives, we performed a mixed methods study that employed validated clinical facial aging scales in conjunction with semi-structured interviews from a sample of patients who presented for facial rejuvenation consultation.

Results: Forty participants [four men (10%) and thirty-six women (90%); mean age, 52 years (range, 37 to 84 years)] underwent facial rejuvenation procedures. Scores from the facial aging scales showed a high correlation to the level of invasiveness of the recommended procedure(s) with a Pearson coefficient of 0.79. When patient downtime was discussed in conjunction with the expected impact of procedures, the interviews revealed a high degree of shared decision-making and satisfaction. Patients who reported limited discussion of recovery time and expectations had the lowest perception of shared decision-making.

Conclusions: Plastic surgeons must help patients select facial rejuvenation treatment plans that align with the patients' preferences for significant impact, recovery period, risks, and cost as they use this information to assist in their procedure choice. Areas of greatest impact for shared decision-making include details around physical and social downtime, and discussion around realistic expectations.

Purpose: This study aimed to analyze factors contributing to plastic surgery faculty involvement in diversity, equity, and inclusion (DEI) committees across the United States.

Methods: A retrospective review of ACGME plastic surgery residency program websites was conducted by three independent reviewers of different ethnicities and genders. Program size, program type (integrated vs. independent), perceptible representation in leadership, and plastic surgery faculty presence on an institutional diversity committee were collected from program websites. Perceptible representation in leadership was defined as a program director or assistant program director that the reviewers determined as representative of an expansion of plastic surgery diversity. Discrepancies between reviewer determination of perceptible representation were consolidated and inter-rater reliability was performed between the three reviewers. Statistical analysis was performed on R Studio 4.2.1.

Results: Upon review, 82 ACGME certified plastic surgery residency programs were identified, of which 59 (71.9%) programs were integrated and 23 (28.1%) programs were combined (independent and integrated). When comparing these integrated programs with the combined programs, there was a significant difference in plastic surgery participation in institutional DEI committees (30.5% vs. 69.6%; p=0.0003). Additionally when comparing between programs with and without perceptible representation, there was a significant difference in plastic surgeon participation in institutional DEI committees (22.2% vs. 4.3%; p=0.034). Univariate logistic regression further confirmed combined programs (p=0.005, OR=8.17) and the presence of perceptible representation (p=0.03, OR=6.29) as significant contributors to the presence of a plastic surgeon on the institutional DEI committee. When combined into a multivariate logistic regression, these variables remained statistically significant.

Conclusions: This study identified combined programs and the presence of perceptible representation as predictors of plastic surgeon participation in DEI committees. The methods by which this information was collected highlight the need for quantifiable and publicly accessible data enumerating program demographics.

Purpose: The incarcerated patient population is underserved and understudied. The primary objective of this systematic review examining a national medical malpractice database is to identify the deficits in surgical care from the perspective of incarcerated patients and the secondary objective is to propose interventions to improve their surgical care.

Methods and Materials: Our systematic review of the Thomson Reuters Westlaw legal database included all medical malpractice cases from January 2017 to January 2022 with a prisoner or prisoner representative as the plaintiff, a physician named as one of the defendant(s), and a surgical procedure. Cases that were still ongoing at the time of data collection or cases settled before litigation were excluded. We recorded plaintiff allegations against defendants, the timing of allegations in the surgical care spectrum (preoperative, intraoperative, and postoperative), legal and geographic data, and patient sex.

Results: A total of 634 malpractice cases were included. Most malpractice allegations involved surgical care in the postoperative period (51.6%), followed by the preoperative (39.0%), and intraoperative (8.0%) periods. Chi-squared analysis revealed a significant difference in the timing of the surgical care allegation across different allegation types (P < 0.001). The most common allegation was delays in evaluation (22.2%), followed by failure to manage complications appropriately (21.0%), incorrect treatment (17.4%), and procedural or technical error (7.6%). The least common allegations were abandonment (0.8%) and wrong site surgery (0.2%). California (18.0%), Pennsylvania (7.4%), and Illinois (6.2%) are the states with the highest number of malpractice lawsuits by incarcerated patients. The legal verdict favored physicians in 97.8% of cases. Ninety-seven percent of incarcerated patients were male.

Conclusion: Most malpractice allegations by incarcerated patients involve surgical care in the postoperative and preoperative periods. Patients often cited delays in evaluation or failure to manage complications appropriately as motivating factors for their lawsuits. Plastic surgeons may improve surgical care for incarcerated patients by working with local prisons to optimize channels of communication between the hospital and prison, improve the timeliness of preoperative evaluation, and establish follow-up protocols to ensure appropriate care during an incarcerated patient's postoperative course.

Purpose: In 2021, the United States Food and Drug Administration (FDA) took several actions to improve communication of the risks associated with breast implants and breast implant surgery to help patients make informed decision. New labeling, a checklist, and updated rupture screening recommendations for breast implants were issued. Prior studies have demonstrated its influence on public perception of breast implants. Plastic surgeons are important stakeholders in breast implant safety and utility; therefore, their perspectives on improving implant labeling and risk communication should be investigated. Our secondary aim was to review each of these components and their impact on current practice patterns.

Methods: An anonymous, voluntary survey was distributed to a cohort of 4,352 active American Society of Plastic Surgeons (ASPS) members in September 2023. The cross-sectional survey included 27 multiple-choice questions to evaluate respondents' attitudes on the black box warning, informed decision checklist, and updated rupture screening recommendations. Respondents were asked to provide their opinion of the statement based on a 5-point Likert scale (i.e. not applicable, neutral, disagree, agree, strongly disagree, and strongly agree). Respondent demographics, including age and years in practice were collected. Preferences for implant shell, shape, and fill type were also documented.

Results: A total of 591 respondents who were demographically representative of active ASPS members responded to the survey (13.6% response rate). 98% of respondents performed breast implant procedures. More than half were between the ages of 45 to 64 (58%) and had been in practice for more than 20 years (52%). 71% of respondents felt that the rupture screening recommendations were appropriate. However, the majority (57%) stated the informed decision checklist did not have a positive impact on workflow; 66% were also neutral or disagreed with the reported incidence rates related to complications and cancer risk. A greater number (47%) of respondents did not find the black box warning to improve their patients' understanding of the risks and benefits. 47% of respondents also believed these requirements, in combination, did not improve the overall patient experience with implants.

Conclusions: The recent changes to breast implant labeling and distribution have been a subject of discussion with research focused on understanding the patient's standpoint. Overall, respondents in our study believed patients should be provided risk information associated with implants and had positive opinions of many of the changes. Most surgeons felt the updated rupture screening recommendations to be appropriate and may increase compliance. However, respondents were not as optimistic toward the impact of the black box warning and patient decision checklist on clinical practice.

Purpose: In an effort to improve post-operative outcomes and optimize patient recovery, Enhanced Recovery After Surgery (ERAS) protocols have gained popularity.[1] The objective of this systematic review was to assess the reporting and methodological quality of plastic surgery ERAS studies.

Methods: All plastic surgery ERAS studies, published between January 2021 to November 2023 were assessed for reporting quality, and those published between January 2020 to November 2023 were assessed for methodological quality. Time-periods were selected based on publication dates of The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist[2] (reporting quality) and Recommendations from the ERAS® Society for the development of ERAS guidelines[1] (methodological quality). The primary outcome was reporting quality (The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist[1] (40 points)). Secondary outcomes included methodological quality. For Autologous Breast Reconstruction and Head and Neck (H&N) studies, methodological quality was assessed through the appraisal of adherence to ERAS® Society guidelines.[3, 4] The methodological quality of other sub-specialty ERAS studies was appraised through adherence to Recommendations from the ERAS® Society for the development of ERAS guidelines[1] (9 points).

Results: Fifty studies were included (Breast Reconstruction: 29, 58%; H&N: 7, 14%; Craniofacial: 7, 14%; Aesthetic: 5, 10%; Other: 3, 6%). Mean reporting quality was 22.6/40 (56.5%; SD: 4.7). ERAS protocol elements least adhered to included: patient warming strategy (8/50, 16%), post-operative analgesia/anti-emetic plans (14/50, 28%), and post-discharge outcome tracking (14/50, 28%). Evaluation of the methodological quality of Autologous Breast Reconstruction studies revealed mean compliance of 8.0/18 (44.4%, SD: 3.5). Least complied with elements included: preoperative CTA (4/23, 17.4%), intra-operative warming (6/23, 26.1%), and post-operative wound management (2/23, 8.7%). For H&N studies, average compliance was 9.2/24 (38.3%, SD: 5.2). Least complied with elements included: pre-anesthesia pain medications (1/7, 14.3%), post-operative wound care (0/7, 0%) and post-operative pulmonary therapy (1/7, 14.3%). Least complied with elements for other sub-specialties included: multidisciplinary ERAS development (3/16, 18.8%), and evaluation plans (3/16, 18.8%).

Conclusions: ERAS studies in plastic surgery are variable, with overall low reporting and methodological quality. Plastic surgeons should critically appraise ERAS protocols before adopting them to their practice.

1. Brindle M, Nelson G, Lobo DN, Ljungqvist O, Gustafsson UO (2020) Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open 4:157–163
2. Elias KM, Stone AB, McGinigle K, et al (2019) The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies. World J Surg 43:1–8
3. Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O (2017) Consensus review of optimal perioperative care in breast reconstruction: Enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg 139:1056e–1071e
4. Dort JC, Farwell DG, Findlay M, et al (2017) Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngology–Head & Neck Surgery 143:292–303

Background/Purpose: Many factors can influence a successful match into a plastic surgery (PS) residency program. Programs are more likely to match students from their affiliated medical school, state, and region(1). In addition, students that attend medical schools not affiliated with a PS residency program report fewer opportunities for exposure to PS education. This study aims to explore the importance of the residency program size and its influence on matching medical students from schools without a home residency program.

Methods: Using the AAMC Residency Explorer Tool, all U.S. integrated and independent PS residency programs were identified. For each program, the number of residency spots offered per year, and the change in residency spots over the past six years, was recorded. For each current resident, the medical school attended by the resident and the affiliation of that medical school with an integrated PS residency program was documented. The number of residency positions offered by each program and the origin of residents from home (HP) versus non-home (NHP) programs were summarized using descriptive statistics. The association between number of residency positions offered and HP versus NHP were assessed using one-way ANOVA.

Results: Our analysis included 89 US integrated PS residencies. The average number of residency spots was 2.24 per year (1-5). The largest subset of PS residencies have two spots for incoming residents each year, which was the case at 38 (42.7%) of programs. The next most frequent number of spots at programs in descending order were 1 at 19 (21.3%) programs, 3 at 16 (18%) programs, 4 at 10 (11.2%) programs, and 5 at 1 (1.1%) of programs. Additionally, 26 (31%) of PS integrated residencies also have an independent residency program. Analysis showed no significant association between the number of residency spots per year and having both types of residencies versus just an integrated program (p-value=0.295). We found no statistically significant association between the number of residency spots at a program and if residents were from a school with HP or NHP (p-value<0.05).

Conclusion: This study provides an overview of factors that could connect the number of residency spots at a program and their likelihood of coming from a medical school with or without a home plastic surgery training program. Our results indicate that there was no association between either having both an integrated and independent residency or the availability of a PS residency at the residents' medical school with the number of residency spots. Therefore, applicants coming from schools without home programs can focus on the quality of training, rather than the availability of positions when determining which programs they should apply to for residency.   References: 1. Asadourian PA, Murphy AI, Marano AA, Rohde CH, Wu JK. Home Field Advantage: Assessing the Geographic Trends of the Plastic Surgery Residency Match during the COVID-19 Pandemic. J Surg Educ. 2021;78(6):1923-1929. doi:10.1016/j.jsurg.2021.06.002 2. Sasson DC, Shah ND, Yuksel SS, Applebaum SA, Gosain AK. Improving Medical Student Recruitment into Plastic Surgery: A Survey of Orphaned Medical Students. J Surg Educ. 2022;79(1):139-146. doi:10.1016/j.jsurg.2021.08.009

Purpose: Prenatal myelomeningocele (MMC) repair offers significant benefits over traditional postnatal repair, as demonstrated by the MOMS trial [1]. We characterized the current status of practice and specialist involvement in prenatal and postnatal MMC repair. Methods: The top 50 US News Children's Hospitals for Neonatology and Neurology & Neurosurgery were queried, resulting in 67 unique hospitals. Specialties involved in MMC repair were extracted via hospital websites and surveys. Results: Among the 58 hospitals that offered either prenatal or postnatal MMC repair, 40 offered postnatal repair only, 18 offered both, and 7 prenatal teams included fellowship-trained fetal surgeons. Of the 40 offering postnatal repair only, neurosurgeons (n=38), orthopedic surgeons (n=34), and urologists (n=33) were most often included. Of the 18 hospitals with prenatal repair, neurosurgeons were involved most (n=18), followed by maternal-fetal-medicine (MFM) specialists (n=14). Pediatric and fetal surgeons were more likely to be involved in prenatal teams (p=0.011, p=0.035, respectively). MFM and orthopedic surgeon involvement did not differ significantly between prenatal and postnatal teams. The teams led by fetal surgeons always included neurosurgeons (n=7) and maternal-fetal medicine specialists (n=7) and were least likely to include plastic surgeons (n=1). Conclusion: These data emphasize the delayed adaptation of fetal repair despite its demonstrated benefits 12 years ago in the MOMS trial. Further research is warranted to explore the reasons for delayed adoption of fetal repair and lack of fellowship-trained fetal surgeons in order to ultimately optimize MMC treatment.

[1] Adzick, N. S., Thom, E. A., Spong, C. Y., Brock, et al. (2011). A randomized trial of prenatal versus postnatal repair of myelomeningocele. The New England journal of medicine, 364, 993–1004. https://doi.org/10.1056/NEJMoa1014379

Introduction Alternative payment models (APMs) offer alternatives to the traditional fee-for-service (FFS) model and are designed to promote high-value care by linking cost and quality. The transition toward APMs among insurers will influence the mechanisms, quality, and grading of plastic surgery care. To date, patient knowledge of APMs in surgery has not been investigated, but it will inevitably shape surgical care delivery once implemented. This study aims to assess plastic surgery patients' self-reported knowledge of APMs, determine the attributes of providers and institutions that patients prioritize, and evaluate how brief education on payment models alters patient values.

Methods Study participants 18 or older who underwent a plastic surgery procedure from 2013-2023 were identified through an institutional database. Eligible participants were emailed a survey via REDCap to gather demographic information, baseline knowledge of APMs, and attitudes toward provider and institution attributes. Then, a brief educational excerpt on payment models was provided and was followed by an identical post-education survey.

Results 2,331 patients were contacted for participation, of whom 264 completed all surveys (11.3%). Most respondents had limited self-reported knowledge of payment models, with the greatest proportion endorsing awareness of basic principles of FFS reimbursement (17.1%) compared to APMs (7.6%), Accountable Care Organizations (7.1%), and bundled payment models (4.6%). Self-reported knowledge did not differ significantly upon sub-analysis of age, gender, education, income, insurance, deductible, or surgery type (p>0.05).

Before education on payment models, most respondents valued patient testimonials (76%), online ratings (62%), hospital/university affiliation (87%), transparent procedure cost breakdown (70%), and revision costs (69%). Most preferred providers with better outcomes and fewer re-operations despite out-of-pocket expenses (63%) and wanted detailed procedure explanations (98%), information on complication rates (98%), and all possible implant/technique offerings (83%). A minority of respondents valued the surgeon's social media/search engine presence (28%) and an explanation of their surgeon's compensation model (30%). Few respondents wanted the most expensive device despite out-of-pocket payment (27%) and thought that knowing about revision cost breakdown (38%) or FFS compensation (20%) would influence provider selection.

After education, respondents cared more about surgery cost (29% to 47%; p<0.001), complication rate (73% to 87%; p<0.001), revision policy/costs (48% to 70%, p<0.001), surgeon's compensation model (18% to 46%, p<0.001), and explanation of their surgeon's compensation (30% to 44%; p=0.02). They grew more hesitant to undergo surgery with APM-paid surgeons (13% to 38%, p=0.023), and fewer supported incentivizing physicians to minimize cost while maintaining outcomes (64% to 53%, p=0.006).

Conclusions Plastic surgery patients have limited baseline knowledge of healthcare payment models. Upon education, patients tend to care more about transparency regarding costs, complications, and compensation models, with greater hesitancy regarding payment models that incentivize cost minimization. Understanding patient decision-making priorities and perspectives will help calibrate models to ensure the delivery of high-value care without compromising patient confidence.

Background: Initially envisioned as support for primary care physicians, advanced practice providers (APPs) have experienced dramatic growth in both nonsurgical and surgical fields. Within surgical practices, APPs function as autonomous providers alongside surgeons to enhance continuity of care and improve efficiency. APPs are especially valuable in the field of plastic surgery due to the frequency of staged procedures, complex perioperative care, and broad scope of practice. Several surgical specialties have explored the impact of APPs, revealing increased surgical volume and reduced wait times. Literature specific to plastic surgery, however, is limited. Our study aims to evaluate the impact of increased APP utilization on surgical productivity in one of the largest pediatric plastic surgery divisions in the United States.

Methods: A retrospective review was conducted for the division of plastic surgery at our institution from October 2012 to September 2023. Data was extracted from the annual Surgery Department Executive Committee (SDEC) reports, an institutional tool designed to assess provider and divisional productivity. The number of clinic encounters, providers, and operating room (OR) cases were collected for each fiscal year (FY). The surgical conversion rate was calculated as the number of clinic visits to OR cases per provider. Descriptive analyses were performed to describe productivity trends.

Results: Over the last decade, there has been an upward trend in the ratio of clinic patients evaluated by APPs compared to MDs. In 2013, APPs completed 1 encounter for every 5 completed by MDs per provider. Since 2020, APPs have consistently matched or exceeded the number of clinic patients seen by MDs per provider. The COVID-19 pandemic generated a period of instability with clinical delays and a backlog of surgical cases. As normal operations resumed, surgical volume increased substantially despite a stable number of surgeons. In 2023, the division performed 2,047 OR cases, surpassing pre-COVID levels. The MD surgical conversion rate has also grown, increasing from 0.19 (1 OR case per 5.3 clinic encounters) in 2018 to 0.26 (1 OR case per 3.8 clinic encounters) in 2023.

Conclusions: The enhanced utilization of APPs in the division of plastic surgery has optimized our patient care model, increasing procedural productivity for surgeons without compromising clinic volume. In the setting of an academic institution, this helps optimize workload distribution, and provides stability in a dynamic work environment. For surgical residents, this may result in increased educational experiences and additional opportunities for evaluation.

Purpose: Physician assistants (PAs) play a vital role in the United States healthcare system, particularly amid the persistent surgeon shortage and escalating healthcare demands (1, 2). We aim to characterize the current cohort of PAs in plastic surgery by comparing them to PAs in all other specialties.

Methods: A cross-sectional analysis of the 2022 National Commission on Certification of PAs dataset was used to compare demographic and practice characteristics of PAs in plastic surgery with those in all other specialties. Analysis included descriptive and bivariate statistics.

Results: In 2022, 1.0% of PAs work in plastic surgery, and the number of PAs in this specialty nearly doubled from 2015 (n=647) to 2022 (n=1,186). Bivariate analysis among PAs in plastic surgery and those in other settings revealed several important attributes (all p<0.001); PAs providing care in plastic surgery were younger (median age, 36 vs. 39), identified as female (91.0% vs. 69.4%), resided in urban locations (97.6% vs. 92.5%), and performed a higher proportion of clinical procedures for most of their patients (66.5% vs. 33.9%). Furthermore, a statistically significant higher percentage of PAs in plastic surgery report high job satisfaction and are more likely to report no symptoms of professional burnout.

Conclusions: The expanding PA profession amid the scarcity of surgeons presents an ideal prospect for enhanced collaboration. In an era where surgeon burnout is increasingly common and PAs express a readiness to function independently at an advanced level, expanding a PA's role becomes desirable and imperative. This collaborative approach has the potential to address workforce challenges, elevate patient care, and enhance provider satisfaction.

References: 1. Seyidova N, Chen AD, Lee J, Alnaeem H, Grover R, Lin SJ. Advanced Practice Providers in Plastic Surgery. Plast Reconstr Surg. May 1 2021;147(5):862e-871e. doi:10.1097/prs.0000000000007877 2. IHS Markit Ltd. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. Washington, DC: AAMC; 2021.

Introduction: Despite the high cost of healthcare in the United States, published research has shown striking health disparities exist according to race, ethnicity, and household income, as well as other social determinants of health. More recently, health disparities have also been associated with living in a formerly redlined neighborhood. Redlining was the racially discriminatory practice by which the federal government classified neighborhoods for mortgage loan servicing using the 1940 Home Owners' Loan Corporation map. This study aims to investigate the association between historical redlining and adverse outcomes in plastic and reconstructive surgery (PRS) patients.

Methods: A retrospective cohort study was conducted utilizing data from patients who underwent a PRS procedure and subsequently experienced morbidity and/or mortality between January 2021 and October 2023 at a single academic institution in Rochester, NY. Patients' electronic medical records (EMR) were reviewed for demographic information, including 5-digit zip code, procedure underwent, and complication information. Patients' residential zip codes were overlaid on the 1940 Home Owners' Loan Corporation map of Rochester, NY and classified according to the federal government's classification at the time as: "Best," "Still Desirable," "Definitely Declining," and "Hazardous."

Descriptive statistics and ANOVA were performed to characterize average length of hospital stay, length of intensive care unit stay, and average number of complications experienced between the different groups.

Results: A total of 234 PRS patients were included in the study. A majority were female (60.3%), Caucasian (81.6%), or had private insurance at time of morbidity experienced (53.0%). Nine (3.8%) patients were found to reside in a zip code historically deemed "most desirable," 10 (4.3%) lived in a historically "still desirable" location, while 31 (13.2%) lived in an area deemed "definitely declining," and 5 (2.1%) lived in a historically "hazardous" zip code. All other patients (180, 76.9%) lived outside of the 1940 Home Owners' Loan Corporation map of Rochester, NY and therefore these neighborhoods' past redlining status could not be assessed. Length of hospital and ICU stay varied between these though not significantly (5.89, 11.00, 11.42, 5.6, vs 13.8, p-value=0.868) and (0.88, 0, 2.68, 0, vs 4.8, p-value=0.842) respectively from "most desired," "still desirable," "definitely declining," "hazardous" to outside city limits. The average number of complications also varied, but not significantly (2.44, 2.90, 2.68, 4.20, vs 2.68, p-value= 0.246).

Conclusion: While a significant difference was not found regarding hospital or, more narrowly, ICU length of stay or number of complications between formerly redlined neighborhoods in this study, there are trends that merit further investigation. Healthcare providers should always be cognizant of the potential influence of environmental factors on patient health and consider targeted interventions to mitigate disparities among vulnerable populations.

Background/Purpose: Gender-affirming surgeries, including but not limited to, breast augmentation and transmasculine chest reconstruction have been used to help improve the overall quality of life for transgender and non-binary individuals.(1) Due to the growing rate at which these procedures are being performed, it is important to assess the variables that may impact pre- and post-surgical requirements. One variable of increasing interest is marijuana use. Advancement in the legalization and use of marijuana within the United States necessitates clinical understanding of how it may affect perioperative management and outcomes. Cannabis is currently regarded as a gateway drug, specifically to opioids; thus introducing the idea that using it may increase the likelihood of an individual developing an opioid dependency.(2) Additionally, despite marijuana's ability to mediate pain and alleviate symptoms of nausea and vomiting studies have shown that cannabis use can potentiate tachycardia and arrhythmias.(3,4) This raises a concern for both the surgical and anesthesia teams regarding how THC may impact perioperative care. This study aims to evaluate the implications of cannabis use to provide evidence-based recommendations for preoperative counseling and postoperative care as it relates to plastic surgery patients.

Methods: In this study, we conducted a retrospective chart review on patients who underwent gender-affirming chest surgery at The Ohio State University affiliated medical centers from March 2022 to the present. Perioperative anesthesia requirements, surgical outcomes, and postoperative narcotic use was compared between patients who reported marijuana use and those who did not. Patient demographics, amount of anesthesia medications administered, and surgical complications were curated from patients' electronic medical records.

Results: Seventy-four cases with an average age of 27.8 were included in this preliminary data set. Three of these cases were excluded for a history of chronic opioid use. A fourth case was excluded due to a known history of illicit drug abuse. Of the remaining seventy cases, forty-one were identified as non-marijuana users while twenty-nine were self-reported cannabis users. Amongst non-users, 39% of patients reported use of prescribed postoperative narcotics and 24% experienced minor complications. Minor complications were defined as any event that did not require returning to the operating room. Such adverse outcomes included erythema, ecchymosis, paresthesia and decreased sensation, small hematomas, and minor bleeding around the incision site. As it pertains to marijuana users, 41% of patients disclosed use of postoperative narcotics while 17% sustained minor complications.

Conclusion: Despite current progression, marijuana is classified as a schedule I substance with the potential to incite opioid abuse. Such classification raises concern for clinicians regarding how cannabis use may negatively impact healthcare. Contrary to said reservations, the findings in this study suggests that marijuana use does not negatively influence perioperative surgical management, specifically pertaining to postoperative narcotic use and complication rates, when compared to non-users.

References 1. Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. International Journal of Transgender Health. 2022;23(3):255-273. doi:10.1080/26895269.2022.2038334 2. Ong CB, Puri S, Lebowitz J, et al. Preoperative cannabis use does not increase opioid utilization following primary total hip arthroplasty in a propensity matched analysis. Archives of Orthopaedic and Trauma Surgery. 2022;143(6):3629-3635. doi:10.1007/s00402-022-04619-7 3. Edalatpour A, Attaluri P, Larson JD. Medicinal and recreational marijuana: Review of the literature and recommendations for the plastic surgeon. Plastic and Reconstructive Surgery - Global Open. 2020;8(5):1-6. doi:10.1097/gox.0000000000002838 4. Narouze S, Strand N, Roychoudhury P. Cannabinoids-based medicine pharmacology, drug interactions, and perioperative management of Surgical Patients. Advances in Anesthesia. 2020;38:167-188. doi:10.1016/j.aan.2020.08.004

The AI-Driven Physician Leader: Optimizing for Business Development and Strategy in Academic Plastic Surgery

Background: Academic plastic surgery programs face unique financial and growth circumstances in the modern healthcare environment. Previous studies have shown business management and leadership expertise are key to improving top lines and optimizing the delivery of medical care in plastic surgery1. Many programs lack the metrics to navigate business challenges effectively, however. The purpose of this study was to evaluate and identify business development and strategy indicators in the management of plastic surgery units, provide insights to improve plastic surgery programs' financial performance, and promote program alignment with broader business of medicine initiatives.

Methods: All current academic plastic surgery chiefs and chairs (program-dependent) were contacted and included in the study population. Program leaders were surveyed anonymously on twenty-four metrics. Data points collected from programs included the highest RVU procedures, the number of regional competitors, and the average procedure insurance reimbursement value. Data analysis and matrix generation for this study were accomplished using generative large language models (LLMs), including Chat-GPT and Google Gemini.

Results: Of the twenty-seven plastic surgery program leaders surveyed, 48% headed plastic surgery programs with average RVUs per surgeon per year between 6,000 and 9,000 RVUs, with all programs having at least seven plastic surgeons as faculty. 92% of these programs faced competition for procedures within their hospital with other divisions, departments, or sections. 67% of all programs elected breast surgery as their highest RVU driver, and 41% of programs felt they were excelling, despite operating in difficult markets and facing adverse financial factors.

Conclusions: This is the first study to both characterize plastic surgery programs by specific business archetypes and to leverage LLMs to drive practice management recommendations in academic plastic surgery. The findings show few programs are capitalizing on high opportunities within their operable markets, with a majority of these programs lacking crucial information regarding patient population, reimbursement models, and historical clinical caseloads to drive value and differentiation. Plastic surgery leaders should be aware of the advantages and disadvantages of their competitive landscape, surgical offerings, program development stage, and internal characterization, on their ability to innovate, meet demand, and compete for revenue with other surgical subspecialties. This study further validates both the use of artificial intelligence tools in augmenting academic plastic surgery research and its applications in plastic surgery practice management decision-making.

References: 1. Al-Shaqsi S, Hong B, Austin RE, Wanzel K. Practice Management Knowledge Amongst Plastic Surgery Residents in Canada: A National Survey. Aesthet Surg J Open Forum. 2020 June 7;2(3):ojaa024. doi: 10.1093/asjof/ojaa024. PMID: 33791648; PMCID: PMC7671285.