Scientific Abstract Presentations: Posters Day 1 (Not for CME) Friday, September 27 Fri, Sep 27 9:30 a.m.-5:00 p.m. PDT

Introduction: The precision of ICD-10 codes remains pivotal in modern medical practice and research, ensuring detailed diagnosis documentation for patient care and population-level data aggregation. Despite ongoing enhancements to the ICD coding system, significant gaps persist, particularly in plastic surgery. These gaps hinder plastic surgeons' ability to document clinical encounters accurately, impacting education, research, and patient care. This study examines the advocacy efforts by plastic surgeons for ICD code modifications over the past decade, aiming to quantify their engagement and highlight areas for potential improvement. It underscores the imperative of augmenting ICD-10 code specificity in plastic surgery to mirror the field's intricacies, thereby advancing practice, research, and education efforts.

Methods: A retrospective analysis of ICD code modification proposals submitted to the ICD Coordination and Maintenance Committee from March 2013 to March 2023 was executed using publicly accessible records from the CDC National Center for Health Statistics. Duplicate proposals were identified and excluded, and the remaining proposals were categorized by source, including surgical specialty organizations, independent surgeons, and other stakeholders. Proposals were further classified by surgical specialty, with a specific focus on contributions from plastic surgery. This process aimed to gauge the level of engagement and advocacy within the plastic surgery field towards ICD code modifications.

Results: Between March 2013 and March 2023, a total of 21 ICD Coordination and Maintenance Committee Meetings were conducted, reviewing a total of 619 proposals. After the exclusion of 126 duplicate proposals, a total of 493 novel proposals were reviewed. Of these, 114 (23.1%) were submitted by surgical organizations or independent surgeons. A total of 16 surgical organizations were represented, collectively contributing to 72 (14.6%) novel proposals. The American Urological Association and the American Congress of Obstetricians and Gynecologists were responsible for the highest number of proposal submissions during the study period, promoting 25 and 24 novel proposals, respectively. Additionally, the American Academy of Ophthalmology had 7 proposals, followed by the American Association of Oral and Maxillofacial Surgeons with 4 proposals. The remaining organizations, including plastic surgery-related organizations, each submitted 1-2 proposals. A total of 8 surgical specialties were represented in surgical-related submissions by independent surgeons collectively contributing to 42 (8.5%) novel proposals. Plastic surgery was represented by 2 proposals, making up only 1.8% of all surgical-related proposals and 0.4% of all novel proposals.

Conclusion: The involvement of plastic surgeons in the ICD code modification process over the last decade has been significantly limited, highlighting an opportunity for the specialty to enhance coding precision for plastic surgery-related diagnoses. This gap underscores the imperative for codes that accurately capture the specialty's complexity. The study emphasizes the critical need for increased coding advocacy within the plastic surgery community, asserting that such engagement is pivotal for improving clinical documentation, enhancing research quality, and ultimately optimizing patient outcomes. Augmented coding specificity will empower better data collection and outcome assessment, fostering evidence-based practices and propelling advancements in the field of plastic surgery.

Citations 1. Baker MJ, Bonkowsky JL. An introduction to ICD code development for pediatric neurology. Annals of the Child Neurology Society. 2023;1(3):180-185. doi:10.1002/cns3.20028 2. Golinko MS, Berry JG, Proctor M, Bonfield CM, Meara JG. New ICD-10 diagnosis codes to improve craniosynostosis classification. Plastic and Reconstructive Surgery - Global Open. 2023;11(11). doi:10.1097/gox.0000000000005440 3. Gonzalez SR, Light JG, Golinko MS. Assessment of epidemiological trends in craniosynostosis: Limitations of the current classification system. Plastic and Reconstructive Surgery - Global Open. 2020;8(3). doi:10.1097/gox.0000000000002597 4. ICD - ICD-10-CM - coordination and Maintenance Committee. Centers for Disease Control and Prevention. September 21, 2023. Accessed February 28, 2024. https://www.cdc.gov/nchs/icd/icd10cm_maintenance.htm.

Introduction: The role of socio-environmental determinants in shaping postoperative outcomes, especially in the context of oncologic surgeries like lower extremity soft tissue sarcoma (STS) reconstructions, warrants deeper exploration given their noted impact across various surgical disciplines (1). This research aims to dissect the connection between socioeconomic factors, as gauged by the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI), and the outcomes reported by patients following their surgeries.

Methods: Our study was a single-institution, IRB-approved retrospective analysis of patients treated for lower extremity soft tissue sarcoma from 2016 to 2021. Data from 302 STS patients were analyzed for complications and patient-reported outcomes using PROMIS-29 (Patient-Reported Outcomes Measurement Information System) and TESS (Toronto Extremity Salvage Scale) surveys calibrated to 6 months postoperatively. Socioeconomic status (SES) was assessed through ADI and SVI scores, categorized into tertiles. Statistical analysis involved Chi-square, Fisher exact tests, and logistic regression using SPSS V26.0.

Results: Within the SVI categories for 302 patients, complication percentages were observed as follows: 33.3% in the high vulnerability group, 36.2% in the intermediate vulnerability group, and 42.6% in the low vulnerability group. Similarly, for ADI categories, the rates were 30.7% for the high deprivation group, 48.1% for the intermediate deprivation group, and 40.2% for the low deprivation group.

The response rate for the TESS survey was recorded at 17.96%, with 46 out of 256 patients providing feedback. Similarly, the PROMIS-29 survey yielded a participation rate of 17.19%, with 44 out of 256 patients responding. The physical function domain in the PROMIS-29 survey revealed significant differences across ADI tertiles (p=0.035), with higher ADI associated with lower physical function scores, indicating a poorer quality of life. No significant differences were observed in other domains or across SVI tertiles. TESS scores did not vary significantly by SES, indicating uniform functional recovery irrespective of socioeconomic background.

Discussion: The minimal differences in patient-reported outcomes highlights the complex interplay of factors influencing postoperative recovery. The significant finding in the physical function domain among higher ADI tertiles suggests potential underreporting of difficulties by lower SES groups, possibly due to cognitive biases shaped by lifelong socioeconomic challenges (2). This underlines the necessity of incorporating socioeconomic awareness into surgical care to identify and address potential barriers to recovery, ensuring equitable patient outcomes.

References: 1. Mehaffey, J. H., Hawkins, R. B., Charles, E. J., et al. Socioeconomic "Distressed Communities Index" improves surgical risk adjustment. Annals of Surgery, 2020;271:470-474. 2. Hao, Y., Evans, G. W., Farah, M. J. Pessimistic cognitive biases mediate socioeconomic status and children's mental health problems. Scientific Reports, 2023;13:5191.

Introduction

Conventional cleft palate surgery usually involves operating in a narrow oral cavity space with surgical loupe visualization. Today, some surgeons resort to surgical microscopes to improve visualization and obtain more precise muscle dissection. The RoboticScope is a head movement controlled system which moves the Robotic arm loaded with 3D visualization technology, allowing surgeons complete freedom to use their hands for surgery.

Aims and Objectives

This pilot case-control study compares conventional palatoplasty with RoboticScope-assisted palatoplasty, aiming to evaluate its impact on surgical outcomes. Operation duration, pain management, in-patient recovery, and finally ergonomic benefits for surgeons will be assessed. We aim to shed light on new-generation surgical technologies that may result in increased patient and surgeon's comfort and improvement in surgical performance.

Methods

This was a retrospective analysis of eight pediatric patients, split into two cohorts of four, comparing conventional palatoplasty to RoboticScope-assisted palatoplasty performed in 2023. Patient's demographics were collected: age in months, gender, and type of cleft palate. The study employed both quantitative and qualitative variables. Variables measured included operative time, post-operative analgesia, oral intake, hospital stay and complication rates. Ergonomic evaluations were performed through surgeons documenting their feedback on comfort and surgical efficiency, including dissection and repair.

Results

Results revealed that RoboticScope-assisted palatoplasty averaged 28 minutes longer than the conventional method, attributable to the time needed for equipment setup. The average duration of surgeries that were RoboticScope-assisted averaged 121 minutes (ranged 81-180 minutes), whereas duration of surgery without the RoboticScope averaged 93 minutes (ranged 84-107 minutes). Postoperative analgesic requirements differed as well. The entirety of the non-Robotic Scope group required morphine (all four patients) and half required nalbuphine. When compared to the RoboticScope group, only 2 out of four patients required morphine and none required nalbuphine. Furthermore, three out of four of the Robotic Scope group were reported to have good oral intake post-operatively on day 1 and quicker discharge in two cases, whereas poor oral intake was reported in three out of four of the non-RoboticScope group. However, there were no notable discrepancies in complication rates. Long-term outcomes such as speech development remain under review due to need for follow-up data. Finally, ergonomic assessments for surgeons operating with the RoboticScope revealed improved posture, less physical strain, and overall better ergonomics during procedures; compared to the significant neck/back strain reported during conventional palatoplasty. In terms of statistical analysis, to yield any statistical significance we will need more study participants and data.

Conclusion

This study concludes that RoboticScope assisted cleft palatoplasty is safe, feasible, associated with less analgesic needs, better oral intake and ergonomic benefits for surgeons when compared to conventional palatoplasty.

Purpose Massive weight loss patients often desire thighplasty to address their excess thigh skin, but they are at risk for increased complications due to diminished skin quality. This study sought to compare the complication rates between two common thighplasty techniques: horizontal and vertical incision.

Methods A systematic review following PRISMA guidelines was performed to assess complication rates from different thighplasty techniques. Five papers met inclusion criteria and were used to compare horizontal and vertical incision thighplasty complication rates. Complications included seroma, hematoma, wound dehiscence, skin necrosis, deep vein thrombosis, infection, scar migration, wound healing problems, lymphedema, and re-operation.

Results 285 patients (mean age 44 years, 91% female) were treated with horizontal (N = 80) or vertical (N = 205) incision medial thighplasty. Common complications in both groups included wound dehiscence, wound infection, and seroma. Wound dehiscence was the only complication that showed a statistically significant difference between the horizontal (16.3%) and vertical (28.8%) thighplasty cohorts (p=0.029). Although not statistically significant, the vertical incision group also had a greater percentage of reoperation (4.9%) compared to the horizontal incision group (1.25%). The correlation of complication rates and patient comorbidities and demographics was not possible to calculate due to inconsistent reporting of data across the studies.

Conclusion Complications are common after medial thighplasty. Wound dehiscence was found to be less likely to occur with the horizontal thighplasty technique, which may indicate its superiority in certain patient populations. Horizontal incisions may also provide an additional aesthetic benefit due to the hidden nature of the scar. The reoperation rate should also be considered, particularly among elective surgery patients. The choice to perform horizontal or vertical incision medial thighplasty may be influenced by patient demographics and history, which could also impact complication rates. The current study demonstrated that published research is lacking in the standardized reporting of factors that likely impact complication rates of thighplasty beyond the technique itself. Future research should aim to assess the impact of variables such as patient comorbidities, concomitant liposuction, average weight loss prior to surgery, resection weights, and drain use in order to determine optimal thighplasty practices.

Introduction Physicians have primarily used websites to advertise their practice to patients, but now the transition to modern social media platforms like TikTok has provided an opportunity for any physician to engage with the broader general population more frequently, advertise their practice with highly stimulating media, empower patients with more knowledge, and prevent the dissemination of misinformation (Cho, Furnas, Rohrich 2019). This case-control study provides a comparison between plastic surgeons who are widely known and popular on TikTok (Influencers) and plastic surgeons who use TikTok but have no large following (Casuals). We searched and collected analytics from TikTok's plastic surgery Influencers, defined as an account with equal to or over 100,000 followers, and Casual users, defined as accounts between 10,000 and 100,000 followers, over a three week period from December 2023 to January 2024. Our goal was to examine and categorize the different types of content both groups produce, then note any association between certain content types and either Influencer or Casual status.

Methods We queried TikTok with several search terms, such as "plastic surgeons of TikTok" and "plastic surgery", and placed accounts into either the Influencer or Casual group. Exclusion criteria were accounts pertaining to residency programs, organizations, unrelated fields, practicing outside of the U.S., with 10,000 followers or less, and accounts lacking enough posts for analysis. For each account, demographic information from a holistic view of their account and data of their most recent thirty posts were collected. Using the Casuals as a reference group, odds ratios (OR) with 95% confidence intervals were calculated via the Prism GraphPad's tool for each different type of content, then grouped into categories based on similarity.

Results Fifty-eight Casuals and forty-three Influencers were included in the study. Out of twenty-three separate content types, seven demonstrate an association, although insignificant, with Influencer status: Patient Consult, Patient Interview/Testimonial, Patient Follow-up, Medical Advice, Educational, Day in the Life, Trends. Three content types were significantly associated with Casual status: Procedure Videos, Advertising Procedures, Replying to Questions/Comments.

Conclusion The seven types of content produced by plastic surgeons on TikTok that appear to have an association, although insignificant, with Influencer status focus on the patient's perspective of the plastic surgeon and their practice, notably patient interviews, patient testimonials, and patient follow-ups. In addition to educational content, this information is very valuable to patients who are considering plastic surgery and want to learn more before proceeding. However, too much detail is unappealing. The significant association with Casual status for accounts that produce videos of the operations plastic surgeons perform, often without sensitive content warnings, and the plastic surgeon replying to questions or directly advertising procedures, suggests this type of media with great detail may not be preferred for viewers.

References Cho MJ, Furnas HJ, Rohrich RJ. A Primer on Social Media Use by Young Plastic Surgeons. Plast Reconstr Surg. 2019;143(5):1533-1539. doi:10.1097/PRS.0000000000005533

Hypothesis Neuromuscular ultrasound has emerged as a useful tool in both the diagnosis and management of cubital tunnel syndrome (1). Ultrasonographic indicators of neuropathy and edema of the ulnar nerve include hypo-echogenicity, intra-neural vascularity, and visual swelling of the nerve proximal to the compression site (2). Sonography is utilized currently for minimally invasive approaches to carpal tunnel syndrome and thus is of interest for application in minimally invasive cubital tunnel decompressions. This study explores an in-office alternative to an open surgical procedure through employing the Sonex UltraGuideCTR™ carpal tunnel release system bidirectionally at a single incision site at the level of the cubital tunnel.

Methods We postulate an alternative approach for cubital tunnel decompression via a minimally invasive surgical intervention. Utilizing the Sonex UltraGuideCTR™ as the incising instrument, dissections were performed on three cadaveric arms under live ultrasonographics. The Sonex UltraGuideCTR™ was chosen due to its inherent ability to avoid unintentional soft tissue damage and iatrogenic nerve injury via a retractable blade and inflatable balloons respectively. The cadaveric operations rigidly simulated a surgical operation in regards to time, technique, and care of dissection. Confirmation of fascial release was achieved post-operatively via an open dissection.

Results Use of real-time sonography offered the surgeon a unique vantage point to establish proper alignment of the device and to provide confidence throughout the release. In all three specimens, complete release of the deep and superficial fascia of the flexor carpi ulnaris was observed. Fascial split was associated with longitudinal split of the muscle fibers on either side of the release. There was no identified injury to any motor branches supplying the flexor carpi ulnaris muscle. Proximally, the nerve was noted to be completely decompressed in its course as well. There was no identifiable subluxation of the nerve with ranging of the elbow. The first release was completed in 14 minutes; the second release in 10 minutes; and the final release was completed in 7 minutes.

Summary Points Access to operating theaters is increasingly limited, and the ensuing exigencies of the patient population for in-office procedures has become a driver for novel interventions (3). Modeled from currently accepted minimally invasive management of carpal tunnel syndrome, the Sonex UltraGuideCTR™ device was utilized in similar fashion at the level of the cubital tunnel to successfully decompress the ulnar nerve. In response to meeting the rising need for patient access to surgical intervention outside of the operating room, such novel approaches are becoming increasingly necessary and embolden surgeons and device developers alike to expand their horizons.

References 1. Agarwal A, Chandra A, Jaipal U, Saini N. Imaging in the diagnosis of ulnar nerve pathologies-a neoteric approach. Insights Imaging. 2019 Mar 20;10(1):37. 2. Okamoto M, Abe M, Shirai H, Ueda N. Diagnostic ultrasonography of the ulnar nerve in cubital tunnel syndrome. J Hand Surg Br. 2000;25(5):499-502. 3. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-e323. doi:10.1016/S2214-109X(15)70115-4

Purpose: Palliative care involvement has been shown to improve quality of life and decrease overall costs in patients facing life-limiting conditions. However, evidence on its cost and cost-effectiveness in burn care is lacking. We therefore aimed to assess the cost-effectiveness of palliative care involvement for adult patients with severe burns.

Methods: We assessed the cost-effectiveness of standard burn treatment with or without inpatient palliative care involvement for patients admitted to a burn unit with severe burns, defined as a Baux score ≥100 and total body surface area (TBSA) >20%, from a health system perspective. We developed a Markov cohort model to assess lifetime health outcomes (Quality-adjusted Life Years, QALYs), cost (in 2023 CAN $), discounted at 1.5%, and cost-effectiveness (Incremental Cost-Effectiveness Ratio, ICER, threshold at $50,000/QALY) for palliative care. Strategies were compared across 12 scenarios with different combinations of patient age, TBSA, and inhalation injury. Our model was informed by published literature. We conservatively assumed that palliative care involvement improves quality of life with no associated cost savings (base case). Across scenarios, we determined the cost saving and quality of life improvements required for palliative care consultation to become cost-effective. We conducted deterministic sensitivity analysis to assess the robustness of our findings.

Results: Palliative care was not cost-effective across the 12 scenarios in the base case analysis with no palliative-associated cost savings. ICERs ranged from $259,788 to $573,942 per QALY gained. Expected lifetime incremental cost for inpatient palliative care involvement ranged from $280-$3,296, while incremental QALYs gained ranged from 0.0005-0.013 per person. However, scenario analysis indicated that during hospitalization, cost savings of $17 to $43 per person per day or a utility gain of 0.16-0.35 per person would render palliative care cost-effective.

Conclusions: We described the minimum cost savings and quality of life improvement required from inpatient palliative care involvement to achieve cost-effectiveness in the treatment of severe burn injuries. Previous literature on hospitalized patients reports significant cost savings with palliative care involvement, averaging $174/day for patients discharged alive and $374/day for patients who die (1) - well above the threshold for cost-effectiveness identified in our study. These findings suggest that inpatient palliative care may be cost-effective in severe burn injuries and support the implementation of palliative care policies in burn care.

1. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790. doi:10.1001/archinte.168.16.1783

Objective: Deep sternal wound infection (DSWI) remains a life-threatening complication of median sternotomy after cardiac surgery. Evidence suggests the superiority of a stepwise, staged approach to management including radial debridement, removal of sternal wires, negative pressure wound therapy (NPWT) and myocutaneous flap reconstruction. Additionally, the timing of intervention and collaboration between cardiac, infectious disease (ID) and plastic and reconstructive surgery (PRS) providers, has demonstrated importance in improving of patient outcomes. Here we evaluate the utility and timing of a multidisciplinary stepwise approach in the management of DSWI.

Methods: We performed a retrospective analysis of 65 patients with DSWI undergoing wound debridement from January 2011 to September 2022. Patients were separated into early (0-7 days) or delayed multidisciplinary consultation (>7 days), from the time of diagnosis of DSWI, to consultation of both PRS and ID teams together. Primary outcome variables included post-operative systemic complications and mortality during admission and 1-year after discharge.

Results: 67.12% of patients were male, with a mean age of 67.12, and had a BMI >30 (67.69%). Most were current or past smokers (67.69%), and had hypertension (95.38%), hyperlipidemia (70.77%), diabetes mellitus (61.54%), coronary artery disease (89.23%), and/or a history of myocardial infarction (56.92%). 47.69% of patients were entirely functionally dependent at their index procedure, with an ASA score of 4 (80%). Most patients presented with sternal wound discharge and polymicrobial infection (24.62%) within one month after coronary artery bypass graft (73.85%).

Almost all patients underwent our standard stepwise approach of early antibiotic administration (87.69%) and wound debridement within 7 days (83.08%), use of NPWT (75.38%), and myocutaneous flap reconstruction within 30 days of debridement (66.15%). IV antibiotics were administered at discharge in 98.5% of patients.

Early multidisciplinary consultation (n=40), was associated with reduced post-operative complications such as bacteremia (20% vs 45%), wound reoperation (31% vs 45%), sepsis (p=0.0073), dehiscence, (11.11% vs 30%), and reduced time to reconstructive closure (median of 8 days vs 141 days)(p=0.0049), when compared to delayed consultation (n=20). Mortality occurred in 3 patients during admission, 2 of which had delayed multidisciplinary consultation. There were no mortalities within 1-year of discharge.

Conclusion and Implications: Our data suggest that a stepwise approach is safe and effective when applied to the management of DSWI in a heavily comorbid population. Timely multidisciplinary involvement of both PRS and ID teams together, may contribute to reduced time to reconstructive closure and improved outcomes for patients.

Introduction: Syndrome of the Trephined (SoT) is a rare complication in the field of neuroplastic surgery characterized by neurological deterioration after a segment of the skull is removed. Patients with a traumatic brain injury (TBI) may be prone to developing SoT after decompressive craniectomy (1). SoT lacks well-defined diagnostic criteria, with the main feature being neurologic improvement after the skull is repaired in a cranioplasty surgery. As such, SoT remains underdiagnosed and possibly undertreated. Our aim is to elucidate the underlying pathophysiology of SoT by evaluating neurologic dysfunction in a novel mouse model of decompressive craniectomy and cranioplasty after TBI using a previously established behavioral analysis tool (2).

Methods: Four groups of 6 adult C57BL/6 mice were evaluated: 1) craniectomy with immediate replacement of the calvarial bone, 2) craniectomy without replacement of the calvarial bone, 3) craniectomy + TBI with immediate replacement of the calvarial bone, and 4) craniectomy + TBI without replacement of the calvarial bone. This study utilized a controlled cortical impact model of TBI, with an impact depth of 2mm. Behavioral analysis, via open field testing, was performed at 4 weekly timepoints after the respective surgery to evaluate anxiety, gross motor ability, and neurological function.

Results: In the first week after their respective surgeries there were significant decreases in total distance travelled, inner zone entries, inner zone distance, and inner zone time between mice who received a TBI and mice who did not (p=0.0032, p=0.0110, p=0.0358, p=>0.001 respectively). There were also significant decreases in inner zone distance between the craniectomy with skull replacement group compared to the craniectomy + TBI with and without skull replacement groups (p=0.0188 and p=0.0193, respectively). In weeks 2 through 4, no significant differences were seen between any of the 4 groups for any behavioral measurements studied. There were also no significant differences in behavior based on replacement of the skull or not.

Conclusion: Mice who received a TBI initially experienced worsened neurologic functioning. However, mice seemed to adapt to the injury by week 2. Additionally, the presence or lack of skull replacement did not have any significant impact on behavioral testing. This indicates that the neurologic differences seen were likely due to brain injury and not from removal of the skull, as would be expected with SoT. As such, further work is needed to evaluate this novel mouse model. It's our hope that this model will ultimately allow for in-depth study of the factors associated with SoT and a better understanding of its symptomatic sequelae.

Citations: 1. Sveikata L, Vasung L, El Rahal A, et al. Syndrome of the trephined: clinical spectrum, risk factors, and impact of cranioplasty on neurologic recovery in a prospective cohort. Neurosurg Rev. 2022;45(2):1431-1443. doi:10.1007/s10143-021-01655-6

2. Malkesman O, Tucker LB, Ozl J, McCabe JT. Traumatic brain injury - modeling neuropsychiatric symptoms in rodents. Front Neurol. 2013;4:157. Published 2013 Oct 7. doi:10.3389/fneur.2013.00157

Introduction: In 2018 it was estimated that 8.2 million people had wounds accounting for an estimated associated cost of $28.1 billion to $96.8 billion.1 It is believed that over 90% of chronic wounds contain biofilms, making them difficult to treat due to increasing antibiotic resistance and a constantly evolving microbiome.2 Collagen-rich hydrogel (cHG), a biocompatible hydrogel that is simple to manufacture and enhances neovascularization, is a promising way to treat these challenging wounds. This study assesses the efficacy of an antibiotic-eluting collagen-rich hydrogel (cHG+abx) for the topical treatment of a wound colonized with Methicillin-Resistant Staphylococcus aureus (MRSA) using an established murine model of biofilms.

Methods: Using a stented wound model, 120 mice were divided into four groups: control (wound only), infection only (IO), infection+cHG (IcHG), and infection+cHG augmented with antibiotic (IcHG+ABX). On post-operative day (POD) 2, infection groups were inoculated with MRSA biofilms; on POD 4, a standard occlusive dressing with or without cHG or cHG+ABX was applied. Group specific dressings were replaced every other day until sacrifice on POD 5, 8, 14, or 17. Rate and quality of wound healing was assessed via wound histology. Systemic symptoms were monitored with temperature, weight, and hematologic labs.

Results: Histological analysis demonstrated the IcHG+ABX group had significantly shorter wound lengths than the IO group at POD 5 (3263.97μm ± 79.10μm vs 3518.87μm ± 160.82μm, p<0.001), POD 8 (1408.06μm ± 104.037μm vs 3096.07μm ± 91.29μm, p<0.001) , and POD 14 (1057.19μm ± 133.70μm vs 240.19μm ± 153.08μm, p<0.001). Additionally, the IcHG+ABX group had significantly decreased inflammatory tissue thickness at POD 5 (251.05μm ± 53.73μm vs 313.32μm ± 169.71μm, p=0.0126), POD 8 (199.83μm ± 112.19μm vs 388.49μm ± 179.11μm, p<0.0001), and POD 14 (39.39μm ± 30.80μm vs 134.61μm ± 137.55μm, p<0.0001). No animals were sacrificed due to illness or signs of distress during the experiment. Diagnostic labs showed normal renal and liver function for all IcHG+ABX mice.

Conclusion: Human-derived collagen hydrogels are a promising carrier of antibiotics to topically treat biofilm-colonized wounds. We demonstrated that human-derived collagen hydrogel effectively eliminated MRSA biofilms in vivo and accelerated wound closure rate while reducing inflammation without adverse systemic effects. cHG offers a biocompatible, topical option with dual functionality; antibiotic-augmented collagen hydrogels eliminate wound biofilms while accelerating wound healing.

Citations: 1. Nussbaum SR, Carter MJ, Fife CE, DaVanzo J, Haught R, Nusgart M, Cartwright D. An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds. Value Health. 2018 Jan;21(1):27-32. doi: 10.1016/j.jval.2017.07.007. Epub 2017 Sep 19. PMID: 29304937. 2. Attinger C, Wolcott R. Clinically Addressing Biofilm in Chronic Wounds. Adv Wound Care (New Rochelle). 2012 Jun;1(3):127-132. doi: 10.1089/wound.2011.0333. PMID: 24527292; PMCID: PMC3839004.

Background: Lower extremity (LE) free tissue transfer (FTT) remains a useful reconstructive solution for the highly comorbid patient population enduring chronic, non-healing wounds. Historically, microsurgery in the end stage renal disease (ESRD) patient has been considered high-risk, likely related to poor long-term survival and lower limb ischemia [1-2], but there remains insufficient literature with a focus on these patients. Our study aims to characterize the clinical outcomes of end-stage renal disease patients who received lower extremity free tissue transfer.

Methods: A retrospective review was conducted on all patients with ESRD on hemodialysis who underwent LE FTT performed between the years of 2011 to 2023. Demographics, comorbidities, preoperative management, intraoperative details, surgical outcomes, and complications were recorded. Primary outcomes evaluated immediate flap success from postoperative day (POD) zero to 12 and rates of long-term limb salvage.

Results: A total of 14 patients with ESRD who received a LE FTT were included in this study, 10 (71.4%) of which were male and 4 (28.6%) female. Patients were on average 51.8 ± 8.0 years old, with an average body mass index (BMI) of 32.6 kg/m^2 ± 7.6 and Charlson Comorbidity Index of 5.8 ± 0.89. All 14 patients had diabetes mellitus, and 10 (71.4%) had peripheral arterial disease. On preoperative lab testing, the median hemoglobin A1c was 6.7% (IQR:3), creatinine was 5.01 ± 2.82, and glomerular filtration rate (GFR) was a median of 11 mL/min/1.73 m^3. Of note, 6 (42.9%) patients had undergone prior renal transplantation and were receiving anti-rejection immunosuppressive therapies. Preoperative limb angiogram studies of these patients found 1-vessel runoff (VRO) in 3 patients (21.4%), 2-VRO in 5 patients (35.7%), and 3-VRO in 6 patients (42.9%). Calcified vessels were found in 10 patients (71.4%) intraoperatively, and 4 patients (28.6%) required a saphenous vein interposition graft. The immediate flap success rate was 100 percent. Postoperative complications were identified in 6 patients (42.9%) throughout follow-up, including 1 hematoma (7.1%), 3 dehisced wounds (20%), 4 infections (28.6%), and 3 donor site complications (21.4%). The median patient follow-up duration was 19.0 months (IQR: 32.4). Six patients (40%) eventually required major limb amputation during long-term follow-up at an average time of 277.2 ± 305.9 days.

Conclusion: Renal disease has been associated with poor outcomes in microvascular surgery in the past, and some have even proposed amputation for chronic, nonhealing wounds in this population. However, our findings suggest that aggressive attempts at limb salvage with free flap reconstruction in these patients may be worthwhile in preserving limb length and function for a longer period of time.

Citations: 1. Chien SH, Huang CC, Hsu H, Chiu CM, Lin CM, Tsai JP. Free tissue transfers for limb salvage in patients with end-stage renal disease on dialysis. Plast Reconstr Surg. 2011;127(3):1222-1228. doi:10.1097/PRS.0b013e318205f461 2. Moellmann HL, Karnatz N, Degirmenci I, Gyurova A, Sellin L, Rana M. Influence of Renal Impairment on the Success of Reconstruction Using Microvascular Grafts-A Retrospective Study of 251 Free Flaps. J Pers Med. 2022;12(10):1744. Published 2022 Oct 20. doi:10.3390/jpm12101744

Background: Facial Feminization Surgery (FFS) is a critical gender-affirming intervention, and its significance in alleviating gender dysphoria is increasingly acknowledged (1). Public interest in FFS and other surgical subtopics can be analyzed through the lens of social media (2). This study aims to analyze the role of Instagram in shaping public perceptions and disseminating information about FFS by tracking trends and content, highlighting the significance of patient education, ethical implications, and global interest in this procedure.

Methods: Between June and October 2023, 500 Instagram posts tagged with "#facialfeminizationsurgery" were collected using a non-biased web scraping platform. Authors manually screened, categorized, and analyzed posts for tone, whether they included patient-reported or physician-reported outcomes, creator information, hospital associations, content type, and geographical distribution. Statistical analysis was performed using SPSS.

Results: Our study indicated that 85.8% of posts conveyed a positive tone. Notably, healthcare providers and organizations contributed 65.4% of the content. Demographic analysis revealed a global interest in FFS. Notably, 55% of the healthcare providers mentioned were in the United States (U.S.). Outside the U.S., South Korea (16.0%), India (25.2%), and England (19.1%) were the most frequently cited locations. Ethical considerations, including the posting of patient images, the perception of FFS (cosmetic or reconstructive), and funding challenges, were prevalent themes according to manual and keyword analysis. Intriguingly, 36.0% of posts served as direct advertisements, and 20% included educational content, emphasizing the role of social media in disseminating information about FFS.

Key Takeaways and Conclusion: Social media platforms play a significant role in shaping perceptions and disseminating information about FFS. Most posts had a positive tone and there was a notable emphasis on postoperative outcomes, highlighting Instagram as a platform for surgeons to showcase their successes and for patients to share satisfaction with their results. Due to the significant proportion of positive posts, Instagram users learning about FFS should use other resources to be fully informed about potential adverse experiences as well (3). Patient education related to FFS is an important discourse on Instagram, which is why we recommend surgeons work on spreading accurate and reliable information to empower patients (4). When doing so, surgeons are encouraged to adhere to published ethical guidelines regarding the posting of patient images by obtaining proper consent and protecting patient confidentiality (5). The global interest in FFS on Instagram reflects the increasing accessibility of FFS, and Instagram users can utilize this to facilitate outreach and foster physician-patient relationships from distant locations. Additionally, financial and insurance challenges are evident in a significant portion of Instagram posts, emphasizing the need for continued advocacy to improve access to gender-affirming care and address barriers to insurance coverage. In conclusion, we encourage surgeons to utilize hashtags like #facialfeminizationsurgery to contribute to a more robust and accurate social media landscape, promoting education, connections with patients and fellow surgeons, and dispelling misinformation.

References: 1.Chou DW, Bruss D, Tejani N, Brandstetter K, Kleinberger A, Shih C. Quality of Life Outcomes After Facial Feminization Surgery. Facial Plast Surg Aesthet Med. Nov-Dec 2022;24(S2):S44-S46. doi:10.1089/fpsam.2021.0373 2. Navarro SM, Mazingi D, Keil E, et al. Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study. World Journal of Surgery. 2020/09/01 3. ElAbd R, Alghanim K, Alnesef M, Alyouha S, Samargandi OA. Aesthetic Surgery Before-and-After Photography Bias on Instagram. Aesthetic Plastic Surgery. 2023/10/01 2023;47(5):2144-2149. doi:10.1007/s00266-023-03398-9 4. Rohrich RJ. So, Do You Want to Be Facebook Friends? How Social Media Have Changed Plastic Surgery and Medicine Forever. Plastic and Reconstructive Surgery. 2017;139(4) 5. Logghe HJ, Boeck MA, Gusani NJ, et al. Best Practices for Surgeons' Social Media Use: Statement of the Resident and Associate Society of the American College of Surgeons. J Am Coll Surg. Mar 2018;226(3):317-327. doi:10.1016/j.jamcollsurg.2017.11.022

Background: Burn injuries represent a traumatic and life-altering event with profound physical and psychological consequences. Among these, Post-Traumatic Stress Disorder (PTSD) emerges as a critical psychological aftermath affecting a considerable number of survivors. Understanding the prevalence and risk factors associated with PTSD following burn injuries is essential for developing targeted mental health interventions. This study aims to explore the incidence of PTSD among burn injury survivors and to identify demographic, clinical, and injury-related factors that may predict its development.

Methods: Utilizing a retrospective chart review design, this study analyzed medical records of 95 patients pulled from a pre-existing database with a documented mental illness pre-or post-burn injury who were treated at an ABA verified burn center over a three-year period between January 2017 and December 2020. Data extracted included demographics, burn injury characteristics (total body surface area affected, degree of burns, location of burns), and documented comorbidities. PTSD incidence was determined through diagnoses noted in medical records, based on DSM-5 criteria. Statistical analyses, including t-tests and logistic regression models, were used to identify predictors of PTSD among the study population.

Results: Preliminary analyses revealed that 20% of the burn injury survivors obtained a diagnosis of PTSD related to their burn injury. Key predictors for the development of PTSD included total body surface area burns of greater than 10% (P<0.05), burns involving the head (P<0.05), and increased length of stay in the hospital (P<0.05). Furthermore, the presence of prior psychiatric conditions pre-burn (P<0.05) had a significant relationship with PTSD incidence post-burn, with the most common pre-burn conditions being anxiety and depression. There was no significant correlation with PTSD incidence and number of OR visits (P=0.35). Interestingly, age less than 35 years at time of burn injury also correlated with increased PTSD incidence (P<0.05).

Conclusions: The high incidence of PTSD observed in this study highlights the significant psychological impact of burn injuries. The identification of predictive factors for PTSD underscores the importance of integrating psychological assessments into the standard care protocol for burn survivors, particularly for those with identified risk factors. The data suggest a strong association between the severity and location of burn injuries and the likelihood of developing PTSD, underscoring the need for early psychological assessment and support for patients with these risk factors. These findings advocate for a comprehensive approach to burn care that includes mental health support to mitigate the development of PTSD. Given the retrospective nature of the study, further prospective research is needed to validate these findings and explore the efficacy of early psychological interventions in reducing PTSD prevalence among burn injury survivors.

PURPOSE: Machine learning (ML) methods, which are uniquely powered to identify patterns in complex data, are being increasingly incorporated into plastic surgery research. In particular, the 2017 introduction of transformers in deep learning architecture represented a critical transition in the usability of advanced ML for answering clinical research questions. We conducted a scoping review to characterize and critically assess the use of ML techniques in plastic surgery research over the last five years. We detail the use of ML methods by level of supervision, model class, plastic surgery subfield, and primary research question to provide a comprehensive understanding of current trends. We then develop data-informed recommendations for improving and expanding machine learning use in plastic surgery research.

METHODS: Primary research articles at the intersection of plastic surgery and machine learning were compiled through PubMed and Embase queries. Clinical inclusion criteria were defined by the procedure list in the ACGME's minimum operative requirements for plastic surgery residency. Articles published before January 1st 2018 were excluded to restrict our review to the post-transformer era of ML. Of 624 articles reviewed to date, 157 articles have met inclusion criteria.

RESULTS: Supervised machine learning, which uses known outcome labels to train models, is the most common ML approach used in plastic surgery research. Within supervised ML, linear and logistic regression models – the simplest methods for answering regression and classification questions – were most frequently used. Conversely, unsupervised machine learning methods, which look to identify latent patterns in high-dimensional data without the bias of labels, were used in few publications. While publications with clinically–focused research questions were the most likely to incorporate ML techniques, a small subset of publications utilized ML methods for patient– and training–focused investigations. A preference for univariate and multivariate techniques over deep learning methods was also evident. A large majority of the publications did not use standard approaches to ensure model generalizability such as splitting data into training and testing sets or using internal cross-validation. Access to the code used to develop published models was also infrequently available.

CONCLUSION: Unsupervised ML approaches such as clustering and dimensionality reduction were seldom utilized in publications from the last five years. These techniques are particularly relevant for clinical research as they allow for meaningful and unbiased conclusions to be drawn from highly complex data such as electronic medical records or clinical imaging. Clustering techniques can additionally provide unbiased identification of clinically meaningful subclasses of patients. Such subtyping approaches can be used to develop more personalized care models-a prominent goal in many clinical fields. We also find that non-clinical studies in patient and education research spaces represent an area of investigation with ample opportunity for growth through the incorporation of ML modeling. Finally, while univariate and multivariate techniques are employed by many researchers, common mistakes in model design and limited utilization of deep learning algorithms suggest a need for more training and/or collaboration to facilitate the use of more advanced ML methods in plastic surgery research.

Introduction: The reverse sural flap (RSF), otherwise referred to as distally-based sural flap, reverse-flow island flap, and the sural fasciocutaneous flap, is a random-type, pedicled flap based on sural artery perforators indicated for traumatic wounds of the lower extremity. The RSF has demonstrated comparable results to free flap placement in the adult population for reconstruction of distal third defect. While many publications on RSF use in adult populations exist, few reports describe its application and outcomes in the pediatric population. To best investigate the RSF's use in the pediatric population, we examined the post-surgical sequelae of RSF use exclusively in pediatric patients.

Methods: We investigated RSF application in pediatric patients (<18 years of age) by way of systematic review and meta-analysis. Pubmed, Scopus, CINAHL, and ProQuest databases were utilized. Literature search was conducted on articles pertaining to "reverse sural flap", and results were limited to original research published after 2000 and in English-language. Two reviewers independently screened titles and abstracts from 244 articles, while a third reviewer settled any discrepancies. Inclusion criteria included case series and chart studies reporting on pediatric patients. The selected primary outcomes included overall flap survival rate, venous congestion, and necrosis. After duplicates and unrelated studies were removed, 16 studies were selected for further review and statistical analysis. Effect size was calculated for each of the primary outcomes.

Results: Through our methods this resulted in the inclusion of 207 patients treated with a mean age of 9.51 +/- 2.27 years, (range 3-17). 71.1 percent of patients were male and 28.9 percent were female. The majority of studies focus on the distal third as the primary site for RSF reconstruction, with fasciocutaneous being the most commonly-used flap type, followed by neurocutaneous and adipofascial, respectively. Trauma was the primary etiology responsible for soft tissue defect (91.0%) and average flap dimensions measured 53 cm2. Mean postoperative follow-up period was 20.07 months. Analysis of selected outcome measures shows a survival rate of 91.0% for reverse sural flaps. Approximately 13% of patients experienced venous congestion. Flap necrosis occurred in 15% of cases, although the vast majority of these cases were sub-total necrosis (93.1%) and successfully managed through excision and additional skin grafting. Six patients (2.9%) reported moderately impaired ambulatory function.

Conclusions: Thus, through our analysis, the RSF and its multiple variates demonstrate reproducible promising results in the pediatric population for distal third defects. With a comparable efficacy to free flaps for small and mid-sized defects in the pediatric population as well as similar success rates to adult RSF patients, the RSF should be considered first line therapy for soft tissue reconstruction for lower extremity wounds.

Purpose: The introduction and refinement of nerve transfers is said to have contributed to a "quantum leap" and paradigm shift in peripheral nerve surgery over the last two decades (1,2). While studies analyzing case logs of plastic and orthopedic surgeons suggest an increasing familiarity with nerve transfer techniques, the impact of trends in the utilization of nerve graft vs. nerve transfer procedures on Medicare beneficiaries remains unclear (3,4). By examining data from one of the largest single payers in the United States, this analysis aims to clarify how a predicted paradigm shift in the use of nerve grafts versus nerve transfers progressed.

Methods: Data on services billed to Medicare from 2000-2022 were analyzed using Medicare Part B National Summary Data files. Each service is identified by a Current Procedural Terminology (CPT) code, with the total number of services performed annually associated with each code published. Twelve CPT codes associated with nerve graft procedures (64890, 64891, 64892, 64893, 64895, 64896, 64897, 64898, 64901 and 64902) and one CPT code representing nerve transfer procedures (64905) were queried. Trends were longitudinally analyzed from 2000 to 2022 by tracking the total allowed services performed by physicians each year. Utilization rates for each procedure were used to assess changes in the proportion of nerve graft and nerve transfer procedures over twenty-two years.

Results: In 2000, nerve transfer procedures represented less than 1% of the sum of nerve graft and nerve transfer CPT code services billed to Medicare. By 2011, this proportion increased to less than 7%. Remarkably, by 2022, nerve transfers represented nearly 78% of all graft and transfer services performed by physicians paid by Medicare. Graft codes encompassed services performed for nerve grafts in the hand, foot, arm, and leg as well as the head and neck. Between 2000 and 2011, utilization of nerve graft procedures decreased by 6.56%. However, between 2011 and 2022, nerve graft procedures increased by 13.38%, representing an overall increase of 5.94% between 2000 and 2022. Nerve transfer procedures exhibited a dramatic increase in percentage, with a 1000% increase from 2000-2011, and a 5322% increase from 2011-2022. This cumulative increase amounted to nearly 60,000% increase across 2000-2022, skyrocketing from only 2 procedures billed in 2000 to 1,292 in 2022. When analyzing trends in the ratio of nerve graft to nerve transfer procedures, the proportion of transfer procedures steadily increased from 2000-2016, albeit remaining a minority (38.98%) compared to graft procedures. By 2017, nerve transfer procedures surpassed the utilization rate of graft procedures, comprising 57.19% of total graft and transfer procedures performed.

Conclusion: Our analysis reveals a substantial increase in nerve transfer procedures across 2000-2022, indicating a notable shift in practice models of peripheral nerve surgical intervention. These findings highlight the impact of a paradigm shift in peripheral nerve surgical techniques and underscore the evolving landscape of overall reconstructive techniques. Further research is warranted to elucidate differences between specialties and geographical trends in adoption of nerve transfers.

1.Domeshek, Leahthan F., et al. "Nerve transfers-a paradigm shift in the reconstructive ladder." Plastic and Reconstructive Surgery Global Open 7.6 (2019). 2. Shin, Alexander Y. "Paradigm shift." Techniques in Hand & Upper Extremity Surgery 24.2 (2020): 53-54. 3. Morris, Marie, et al. "Trends in nerve transfer procedures among board-eligible orthopedic hand surgeons." Journal of hand surgery global online 3.1 (2021): 24-29. 4. Varagur, Kaamya, et al. "Following a Surgical Paradigm Shift Through the Adoption of Nerve Transfers Among Board-Eligible and Practicing Plastic Surgeons." Hand (2023): 15589447231167582.

Abstract Background: The prognosis of necrotizing fasciitis (NF) depends on early recognition and management. Idiopathic NF may be more challenging, due to the lack of a known causative factor. 1, 2 Necrotizing fasciitis caused by streptococcal infection can occur on the healthy young patients and often spreads rapidly, leading to widespread necrosis of the subcutaneous tissues and even fatal sepsis. 3-5Early diagnosis and treatment of idiopathic streptococcal NF remained as a clinician difficulty. Aim and Objectives: The patients with necrotizing fasciitis caused by streptococcal infection were classified in to two groups, based on their routes of infection. Our purpose in this study was to identify the specific features of idiopathic streptococcal NF that are important in early recognition and to assess the factors associated with prognosis.
Materials and Methods: This is a single-center retrospective study between J January 1st 2013 and December 31st 2019. The patients were enrolled based on the tissue or wound culture reports of Streptococci. The records of 49 patients with pathologically confirmed necrotizing fasciitis were retrospectively reviewed. We collected the data of route of infection, patients' demographics, predisposing factors, microbiology, hematology, frequency of surgery, the duration between the onset of symptoms and surgery, and outcomes, and then compared these data in to the two groups by performing a statistical analysis. Univariate analysis and multivariate analysis, and receiver operating characteristic curve analyses were performed. Results: Idiopathic NF occurred in 25 of 47 patients (53%). Of the 49 patients, there were 2 cases excluded due to short of strong evidence of NF. The incidence of the idiopathic groups was slightly higher. Patients in idiopathic NF group were more like than those with secondary NF to have younger population and higher qSOFA score (0.84±0.9 vs. 0.32±0.6, p=0.031). Even white blood counts(WBC) were not significantly defferent between idiopathic and secondary NF, the significant higher C-reactive protein levels and blood lactate levels were found in patients of idiopathic group (25.99mg/dL vs. 19.59mg/dL, p=0.046; 3.47mg/dL vs. 1.71mg/dL, p=0.007, respectively). There was no significant difference in predisposing factors and mortality rate between the two groups. More patients needed ICU admission and longer hospital stay in the idiopathic streptococcal NF group than the secondary group (52% vs 13.6%, p value= 0.012; 35.4 days vs. 23.59 days, p value=0.045). Multivariate analysis revealed that the serum lactate levels and qSOFA score independently predicted the idiopathic streptococcal NF group (Odds ratio: 3.058, p value= 0.031; Odds ratio: 2.306, p value=0.044). Conclusion: Patients with idiopathic NF present among relatively young and healthy populations, without skin lesions or traumatic history. We should stay vigilant in such patients with extremely high CRP level and serum lactate level. By elucidating the differences in clinical presentation, we can enhance the clinical approach to idiopathic NF and provide effective management promptly.

Reference 1. Hakkarainen TW, Kopari NM, Pham TN, et al. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014;51:344-362 2. Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis 1995;1:69-78 3. Chelsom J, Halstensen A, Haga T, et al. Necrotising fasciitis due to group A streptococci in western Norway: incidence and clinical features. Lancet 1994;344:1111-1115 4. File TM, Jr., Tan JS, DiPersio JR. Group A streptococcal necrotizing fasciitis. Diagnosing and treating the "flesh-eating bacteria syndrome". Cleve Clin J Med 1998;65:241-249 5. Misiakos EP, Bagias G, Patapis P, et al. Current concepts in the management of necrotizing fasciitis. Front Surg 2014;1:36

Introduction: Large Language Models like ChatGPT have become increasingly used to generate fluent content in a variety of different styles. Developers have trained the algorithm on internet-based sources of written human speech and encyclopedic knowledge. Studies have investigated the software's knowledge base including performance on exams like the Plastic Surgery In-Training Exam¹ and European Hand Certification Exam², generation of readable and accurate patient content³, and advanced educational content for students. The purpose of this study is to assess ChatGPT-3.5's performance on the Annual Hand Surgery Self-Assessment Examination, examine trends in accuracy over time, and determine any particular gaps in knowledge or patterns of interest.  Methods: Annual Hand Surgery Self-Assessment Examinations from years 2015 to 2021 were obtained as a question bank source. Each examination contained 200 multiple choice questions categorized under one of the following sections: basic science, bone and joint, neuromuscular, skin, vascular, ancillary, miscellaneous. Questions were formatted similarly on all years of examinations; an initial question stem followed by a single blank line and five response options labeled A through E. Each response option was entered on a separate line. In total, 1,400 questions spanning a seven-year period were collected. All 1,400 questions were entered as queries to ChatGPT using the Google Sheets ChatGPT-3.5 extension. Questions were formatted identical to how they appeared on the self-assessment examinations, minus any associated tables or media. Due to ChatGPT's adaptive learning ability within a conversation box, questions were queried in individual chat sessions. This was accomplished through use of the Google Sheets ChatGPT-3.5 extension. Analysis was performed in Microsoft Excel with an ANOVA and Student's t-test. Questions containing media necessary for answer selection were excluded. Results: ChatGPT-3.5 only passed two of the seven examinations, which were the more recent examinations with newer information available. Overall percentage was 47.9%, less than passing score. Results possibly due to reference lag of five to seven years, as ChatGPT-3.5 was trained on data from 2013 to 2020. No statistically significant difference in word count between correct and incorrect responses. No significant difference in ChatGPT's selection of letter answers, however, a slight nominal bias toward "C" was present. ChatGPT scored higher on "ancillary" and "miscellaneous" sections (p=0.25⁻⁴), which include hand therapy, splints, ethics, infections, tumors, and congenital hand. Conclusions: ChatGPT-3.5 does not reliably perform to passing standards on the self-assessment exam, making falsification for CME credit non-viable. Chat-GPT "hallucinates" answers consistently even in the deliberate setting of incomplete information and does not cite sources. It is not recommended as a study resource for hand surgery. Overall, ChatGPT-3.5 performed better on categories with broader range and less depth.

1. Gupta, R., et al., Performance of ChatGPT on the Plastic Surgery Inservice Training Examination. Aesthet Surg J, 2023. 43(12): p. Np1078-np1082.
2. Thibaut, G., A. Dabbagh, and P. Liverneaux, Does Google's Bard Chatbot perform better than ChatGPT on the European hand surgery exam? Int Orthop, 2023.
3. Crook, B.S., et al., Evaluation of Online Artificial Intelligence-Generated Information Common Hand Procedures. J Hand Surg Am, 2023. 48(11): p. 1122-1127.

INTRODUCTION: As abdominal-based microsurgical breast reconstruction continues to gain momentum, new avenues exist to expand its reach to a broader population. Hybrid breast reconstruction can alleviate the discordance between donor flap and desired breast volume in patients previously excluded from flap-based modalities. The authors review their consecutive experiences with two novel hybrid microsurgical breast reconstruction techniques.

METHODS: A retrospective review of all consecutive patients who received microsurgical flap reconstruction was performed over a five-year period, both with and without hybrid techniques. The HyPAD® technique combines flap reconstruction with stacked pre-pectoral acellular dermal matrix (ADM), while the HyFIL® technique combines a flap, pre-pectoral implant, and fat transfer (lipofilling). Demographic, health-related, surgical, and outcome indicators were measured for comprehensive qualitative and quantitative analysis.

RESULTS: During the study period (September 2018 to November 2023), 101 patients with hybrid breast reconstruction (HyPAD® n=40, HyFIL® n=61) were compared to 208 patients who received DIEP flap reconstruction alone. Hybrid patients were significantly younger (47.3 versus 52.9 years, p < 0.01) had lower BMIs (24.9 versus 30.3 kg/cm^2, p < 0.01), and had reduced flap weights (348.7 versus 683.5 grams, p < 0.01). Hybrid patients had fewer clinically significant breast infections (1 versus 14, p = 0.03). No significant differences were found for length of stay (p = 0.56) or readmission (p = 0.84). No implant or ADM extrusions occurred in the hybrid cohort.

CONCLUSIONS: Hybrid breast reconstruction is a safe and reliable method to enhance core projection in microsurgical breast reconstruction and is valuable in correcting volume imbalance.

Background: Addressing gender dysphoria requires consideration of diverse individual factors, surpassing a simplistic approach. Our study delves into insurance denial claims for gender-affirming procedures in California, specifically those subjected to Independent Medical Review (IMR). We analyzed both upheld and overturned cases, categorizing decisions based on the reviewer's rationale, specialty, and the utilization of national guidelines and peer-reviewed literature.

Methodology: We conducted a qualitative review of 230 publicly available records provided by California's Department of Managed Health Care Independent Medical Review on insurance denials for gender-affirming procedures between 2016 and 2023. Variables collected included claim year, treatment subcategory, patient demographics, reviewer specialty, and citation of national guidelines and peer-reviewed evidence. Overturned decisions were categorized as medically necessary, reconstructive, case-by-case, or other. Upheld decisions were broken down into insufficient medical necessity documentation, gender-neutral appearance, aesthetic vs. reconstructive, prerequisites not met, misalignment with medical literature, and other.

Results: Preliminary findings expose inconsistencies in applying national guidelines and peer-reviewed literature when reviewing claims, with claims only citing at rates of 64% and 45%, respectively. Overturned claims predominantly hinge on being medically necessary (60%), while upheld claims are often attributed to insufficient documentation (26%), gender-neutral appearance (22%), and ambiguity in aesthetic versus reconstructive intent (22%).

Discussion and Conclusion: Our research underscores the distinctive nature of gender-affirming care, advocating for a withdrawal from generic denial approaches and a shift to case-specific care. To create a more inclusive healthcare system, the study emphasizes the crucial need for transparency and consistency in decision-making for gender-affirming care claims.

OBJECTIVE
To conduct a systematic review examining how different medications for diabetes and weight loss management affect wound healing and the incidence of wound development.

METHODS Using systematic review methodology, we searched multiple databases, including PubMed/Medline, Cochrane Central, and Embase. The search was conducted in February 2024 with no limit on publication date. Inclusion criteria focused on studies regarding wound healing. Specifically, our primary search teams included wound, wound healing, diabetes, diabetes medications, GLP, DPP, and topiramate. We excluded studies that noted chemotherapy, neoadjuvant, and radiation. Abstracts were independently reviewed for inclusion or exclusion. The 2020 PRISMA guidelines were followed.

RESULTS A preliminary systematic review yielded 146 records that addressed the first aim of our study, of which 19.8% (29/146) met the inclusion criteria. Outcome measures of glucagon-like peptide-1 (GLP-1) in 44.8% (13/29), dipeptidyl peptidase-4 (DPP-1) in 48.3% (14/29) and topiramate 10.3% (3/29) of studies. Of those studies with an outcome of DPP-4, 35.7 % (5/14) noted an improvement in angiogenesis and wound healing. Similarly, GLP-1 enhanced angiogenesis and attenuated the inflammatory response in 23.0% (3/13) of studies. Topiramate was found to improve the quality of wound healing through signaling pathways involved with inflammation and growth factors in 66.6% (2/3) of studies.

CONCLUSION
This systematic review highlights the possible wound-healing benefits of GLP-1, DPP-4, and topiramate. Although promising, most study data has been generated using animal models, with few studies assessing systemic medications in humans. Given the increased use of GLP-1 medications in both the general and diabetic populations, further studies are necessary to investigate their clinical significance as they relate to wound healing. Furthermore, there remains a need for systematic evidence from randomized trials on these classes of medications in the chronic wound care setting.

Introduction: ChatGPT's Code Interpreter is a new feature accessible to premium users that integrates code generation and execution into the unified GPT-4 environment. The advent of this tool has the potential to democratize access to statistical analysis for all physicians, including plastic surgeons. Statistical knowledge and data analysis are critical tools in the armamentarium of the modern-day plastic surgeon, as evidence-based medicine underpins patient care and the advancement of surgical techniques. Despite the acknowledged importance of statistics in medicine, many physicians are constrained by an inadequate understanding of statistical principles or limited access to data analysis tools. Even the new, more tech-savvy generation of plastic surgeons has encountered a similar dilemma, as studies have shown that plastic surgery residents recognize the value of biostatistics yet lack the knowledge to apply it. Hence, our goal is to investigate Code Interpreter's suitability as a statistical aid for plastic surgeons. Our hope is for plastic surgeon-scientists to gain a comprehensive grasp of statistics through this tool, ultimately enhancing the practice of evidence-based plastic surgery.

Methods: A subset of the National Inpatient Sample was selected for the assessments. Data analysis tasks were divided into descriptive statistics and inferential statistics. Descriptive statistics included mean, standard deviation, median, and interquartile range calculations. These were evaluated based on the accuracy of the outputted values. Inferential statistics included Chi square, Pearson correlation, Independent two-sample t-test, One-way ANOVA, Fisher's exact, Spearman correlation, Mann-Whitney U test, and Kruskal-Wallis H test. Inferential statistics tasks were evaluated based on method selection, statistical assumptions, and outputted values. For both descriptive and inferential statistics, a series of prompts were developed to instruct ChatGPT on how to perform the task. Each prompt was inputted into ChatGPT ten times to ensure reliability. Verification analyses were then conducted using SAS.

Results: Code Interpreter demonstrated proficiency throughout the descriptive statistics assessments, correctly outputting the requested values across all attempts. Inferential statistics testing also exceeded expectations. ChatGPT selected the correct method in 75 of 80 attempts at inferential statistics. In those 75 correct attempts, ChatGPT also provided the correct assumptions, test statistics, and p-values.

Conclusion: For plastic surgeons with statistical knowledge but limited programming skills, Code Interpreter represents a valuable research tool, capable of assisting with exploratory data analysis. While its high accuracy and efficiency underscore its potential as an analytical tool, the occasional incorrect outputs highlight the need for confirmatory analysis through traditional statistical methods. Hence, we do not recommend this be used in published research without the input of a biostatistician. This tool also offers an invaluable learning opportunity for surgeons with minimal statistical background, encouraging hands-on experimentation to foster a deeper understanding of biostatistics. Through interactive engagement, plastic surgeons can enhance their comprehension of when and how to apply statistical tests, and grasp the implications of these tests in their research and clinical practice. Ultimately, we believe ChatGPT has the potential to increase statistical literacy among plastic surgeons, enabling them to better understand and practice evidence-based medicine.

Breast reconstruction is the third most common reconstructive surgery done by plastic surgeons; most of these reconstructions use implants [1]. One factor limiting access to health care is insurance reimbursement for surgery. Autologous reconstruction is labor intensive with poor reimbursement rates [2]. There is limited data regarding hospital charges versus collections or physician charges versus collections [3]. The purpose of this study is to determine the costs and reimbursements for the operating room and physician at a county hospital.

A retrospective review of charges and collection was completed using the CPT codes 19357(expander) and 19042(delayed implant) from 10/2018 to 10/2023. The charges and collection were obtained for both the operating room and physician. The data was collected for all procedures completed on the day of the surgery and specifically for their corresponding code.

Most of the patients had either Managed Medicaid (31%) or Medicare (24%) insurance. The delayed implant reconstruction with combined procedures had a mean operating room charge of $15,925.48 and physician charge of $8,730.31. The average reimbursement from insurance for the operating room and physician were 17% and 12% of the charges, respectively. The mean length of stay was 0 days. The expander placement with combined procedures had an operating room charge of $46,282.68 and physician charge of $9,587.51. The mean reimbursement from insurance for the operating room and physician were 20% and 16% of the charges, respectively. The mean length of stay was 0.6 days. The mean collection for CPT code 19357 and 19042 were $722.63 (16%) and $462.10 (16%), respectively. The Unmanaged Medicaid physician reimbursements were denied.

Overall, insurance companies have control over the reimbursement of procedures. Our results show poor physician reimbursement rates, especially for unmanaged Medicaid patients. Without reimbursement a surgeon's ability to provide the most common form of breast reconstruction may be limited in these patients leading to even greater disparities between privately insured and government-sponsored patients [3].

Citations: [1] Malekpour M, Malekpour F, Wang HT. Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome. World J Clin Cases. 2023 Apr 6;11(10):2201-2212. doi: 10.12998/wjcc.v11.i10.2201. PMID: 37122510; PMCID: PMC10131028. [2] Alderman AK, Storey AF, Nair NS, Chung KC. Financial impact of breast reconstruction on an academic surgical practice. Plast Reconstr Surg. 2009 May;123(5):1408-1413. doi: 10.1097/PRS.0b013e3181a0722d. PMID: 19407610; PMCID: PMC2702767. [3] Odom EB, Schmidt AC, Myckatyn TM, Buck DW 2nd. A Cross-Sectional Study of Variations in Reimbursement for Breast Reconstruction: Is A Healthcare Disparity On the Horizon? Ann Plast Surg. 2018 Mar;80(3):282-286. doi: 10.1097/SAP.0000000000001228. PMID: 28984659; PMCID: PMC5800946.

Introduction: Bone grafting is essential for management of residual alveolar cleft in patients with a cleft lip and palate. Previous studies have reported that alveolar bone grafting can reduce nasal asymmetry, raise and support a collapsed alar base and nostril, and produce better esthetic and functional outcomes with respect to lip and nose (1). Secondary alveolar bone grafting affects the central nasolabial aesthetic subunit in unilateral complete cleft lip (2). Soft tissue changes after bone grafting in the overlying central face remains under characterized. The purpose of this study is to retrospectively utilize a three-dimensional stereophotogrammetry system (Vectra 3D) software to evaluate soft tissue volumetric changes after alveolar bone grafting. We hypothesized that soft tissue changes after bone grafting would induce favorable volumetric and linear outcomes in the study area.

Materials and methods: After obtaining the IRB approval, this pilot study was conducted. Patients with unilateral cleft lip and palate, age range between 7-20 years, underwent secondary bone graft and had 3D stereophotogrammetry (Vectra 3D) images taken before and at least 3 months after alveolar bone grafting. Pre-existing pre-surgical (T1) and post-surgical (T2) 3D-stereophotogrammetry images from patients with a unilateral cleft lip and palate were analyzed on the Vectra3D software. Pre and post-surgical images were superimposed and the same software and volumetric analysis of the soft tissue changes before and after alveolar bone grafting was performed. The differences in various regions of the face (alar base, upper lip, lower lip) and the amount of symmetry were assessed. The primary predictor variables were Enemark's marginal bone status and time between images. The primary outcome variables were upper lip volume (ULV), columellar length (CL), alar width (AW), and nasolabial angle (NLA). Standard statistical analysis was performed using (SPSS 27).

Results: Six patients met the inclusion criteria; mean age at SABG (n=10.4 years), mean imaging time (N=111 days). All SABGs procedures were Enemark's grade 3 or greater. Upper lip volume (ULV) in cubic centimeter (cc) increased from 112 vs.122, nasolabial angle (NLA) 114o vs. 129o whereas columellar length (CL) decreased from 9.3 mm vs 8.7 mm and alar width (AW) from 9.6 mm vs 9.3 mm (p=.008, .018, .004, .007 respectively). When comparing the affected to non-affected side to control for growth ULV increase 0.89 cc vs. 0.53 cc, NL angle 10.7o vs. 8.1o and CL decreased from -0.62 mm vs -0.06 mm, AW -0.35 mm vs. +0.87 mm (p=.018, .008, .004, .008 respectively)

Conclusion: Our findings demonstrate reliable volumetric expansion of the lip at the cost of worsening alar shape. The central nasolabial aesthetic subunit is favorably affected by expansion of the upper lip volume and nasolabial angle whereas alar length and alar width are significantly decreased after SABG. This study represents an ongoing effort to comprehensively evaluate soft tissue changes after secondary alveolar bone grafting in CLP patients. By utilizing 3D-stereophotogrammetry (Vectra 3D) software analysis, we aim to enhance the current understanding in the facial morphology of CLP patients and offer valuable insights that may influence future treatment decisions.

1. Cho-Lee, G.Y., et al., Review of secondary alveolar cleft repair. Ann Maxillofac Surg, 2013. 3(1): p. 46-50.

2. Stasiak, M., A. Wojtaszek-Slominska, and B. Racka-Pilszak, Current methods for secondary alveolar bone grafting assessment in cleft lip and palate patients - A systematic review. J Craniomaxillofac Surg, 2019. 47(4): p. 578-585.

Purpose: Robotic-assisted harvest of the latissimus dorsi (LD) flap is a minimally invasive alternative to traditional techniques. The smaller incision required for muscle harvest has been shown to reduce postoperative pain and improve cosmetic outcomes (1). The present study demonstrates the utility of robotic LD flaps for revision surgeries following breast reconstruction compromised by radiation damage. Methods: Patients who received robotic-assisted pedicled LD flap breast reconstruction procedures from 2016-2022 were identified. Patients who received robotic-assisted LD flap for other indications were excluded. All cases were performed by the senior author (A.Y). The LD flap was harvested using the da Vinci operating system as previously described in the literature (2). Demographics, operative details, and postoperative outcomes were collected. Results: Six patients met inclusion criteria, with an average age of 47 ± 11.2 years and body mass index (BMI) of 24 ± 2.8 kg/m2. All patients presented requiring revision surgery after their initial breast reconstruction with associated tissue damage and complications from adjuvant radiation therapy. Four (67%) patients had received implant-based reconstruction. Of these patients, one additionally had implant failure and another was not suitable for abdominal-based reconstruction due to prior abdominoplasty. Two (33%) patients had received abdominal-based autologous free flaps with subsequent complications including flap loss and tissue expander placement with capsular contracture, and flap atrophy after excessive liposuction at another institution, respectively. All procedures were successfully completed without converting to an open approach. The mean axillary incision measured 6.2 ± 1.1 cm and the mean procedure time was 489 ± 62 minutes. Five patients underwent simultaneous implant placement, while one patient opted for simultaneous fat grafting. The average follow-up time was 964 days (range 79-2907 days), or 2.6 years, following their robotic procedure. None of the patients experienced flap loss. Most postoperative complications were resolved on an outpatient basis, consisting of two seromas and one instance of breast erythema treated empirically with oral antibiotics. One patient received intravenous antibiotics for diffuse cellulitis after failing to pick up postoperative antibiotics. Overall, patients were satisfied with post-operative arm mobility and cosmesis. Conclusions: Robotic LD muscle flaps provide vascularized healthy tissue to areas with radiation damage using markedly smaller axillary incisions than the open technique (6 cm vs 20-45 cm). The mean procedure time was longer than previously reported due to the challenging dissection of radiation-damaged tissue in this population. Nonetheless, patients had promising clinical, cosmetic, and functional outcomes. These findings demonstrate the utility of robotic LD muscle harvest flaps for patients who have suffered significant radiation damage, are not suitable abdominal-based flap candidates, or have failed other types of breast reconstruction.

References: 1. Winocour S, Tarassoli S, Chu CK, Liu J, Clemens MW, Selber JC. Comparing Outcomes of Robotically Assisted Latissimus Dorsi Harvest to the Traditional Open Approach in Breast Reconstruction. Plast Reconstr Surg. 2020;146(6):1221-1225. doi:10.1097/PRS.0000000000007368 2. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg. 2012;129(6):1305-1312. doi:10.1097/PRS.0b013e31824ecc0b

Background/Purpose: Prior studies characterizing surgically managed frontal sinus fractures are small, institutional studies from major trauma centers (1-5). The current study characterizes the concomitant injuries and complications following open treatment of frontal sinus fractures across the United States.

Methods: Patients who underwent open treatment for a frontal sinus fracture between 2010 and 2022 were identified in a national administrative database. Patients <18 years old and with <90 days of follow-up were excluded. Type of fracture (simple or complex), frontal sinus obliteration and concomitant fractures (facial, vertebral, extremity) were identified. 90-day surgical site infection, sinusitis, meningitis, brain abscess and cerebrospinal fluid leak were identified, as well as mucocele any time after surgery.

Results: There were 1,492 adult patients with open treatment of frontal sinus fractures: 654 (44%) with simple fractures and 838 (56%) with complex fractures. There were 157 (11%) patients with frontal sinus obliteration. Concomitant fractures included facial (715 patients, 48%), vertebral (55, 4%), upper extremity (40, 3%) and lower extremity (53, 4%). Within 90 days of surgery, 155 (10%) patients had a complication: surgical site infection (42, 2.8%), sinusitis (29, 1.9%), meningitis (25, 1.7%), brain abscess (23, 1.5%), and cerebrospinal fluid leak (63, 4.2%). There were 11 (0.7%) patients who developed a mucocele, and <11 (<0.7%) underwent reduction of contour deformity. On multivariate analysis, complex frontal sinus fracture and concomitant vertebral/extremity fracture were associated with increased likelihood of a complication.

Conclusion: Over the last thirteen years, complication rates are low following surgically managed frontal sinus fractures. Comminuted fractures and those involving the posterior table increase the likelihood of a complication, likely due to increased injury severity. The results of the current study generally align with the published single-institution studies on complications of frontal sinus fractures treated with surgery. These findings from a large, nationwide cohort strengthen prior conclusions and increase the generalizability of reported complication rates.

References 1. Lopez CD, Rodriguez Colon R, Lopez J, Manson PN, Rodriguez ED. Frontal Sinus Fractures: Evidence and Clinical Reflections. Plast Reconstr Surg Glob Open. 2022;10(4):e4266. 2. Schultz JJ, Chen J, Sabharwal S, et al. Management of Frontal Bone Fractures. J Craniofac Surg. 2019;30(7):2026-2029. 3. Weitman E, Shilo D, Emodi O, Rachmiel A. Solitary Frontal Sinus Fractures Compared to Multiple Facial Fractures, Energy Impact Dependency. J Craniofac Surg. 2017;28(7):1812-1815. 4. Chen KT, Chen CT, Mardini S, Tsay PK, Chen YR. Frontal sinus fractures: a treatment algorithm and assessment of outcomes based on 78 clinical cases. Plast Reconstr Surg. 2006;118(2):457-468. 5. Gossman DG, Archer SM, Arosarena O. Management of frontal sinus fractures: a review of 96 cases. Laryngoscope. 2006;116(8):1357-1362.

Background

The competitiveness of Integrated Plastic Surgery Residency (IPSR) makes the application process unpredictable and costly. With the return of away rotations post-COVID-19 and USMLE Step 1 now pass/fail, future applicants can benefit from recent match data. The Texas Seeking Transparency in Application to Residency (STAR) survey promotes transparency in residency matching by sharing application data, and the National Residency Matching Program (NRMP) provides insights from program directors (PDs) on important factors for applicant ranking. Though similar analyses have been conducted for other competitive surgical subspecialties, these trends in the application to IPSR have yet to be clarified. This study seeks to examine the characteristics of recently matched versus unmatched IPSR applicants through analysis of the Texas STAR database and compare these findings to attitudes expressed in the 2020 NRMP PD survey.

Methods

We retrospectively reviewed the Texas STAR database for IPSR cycles 2020-2023. Information collected included academic, standardized test performance, extracurricular, and match cycle outcome data. Descriptive statistics were calculated, and univariate analyses were used to compare matched and unmatched applicants. Percent of PDs citing factors and the average score of the factor were multiplied to give a standardized score.

Results

A total of 209 IPSR applicants participated in the Texas STAR survey from 2020-2023, with a match rate of 70.3% (147). There were no significant differences between matched versus unmatched applicants in Step 1 scores ≥240 (p = 0.708) and Step 2 scores ≥ 250 (p = 0.465), class quartile (p = 0.198), number of honored clerkships (0.351), honors/A in surgery (p = 0.286), Alpha Omega Alpha (AOA) membership (p = 0.307), Gold Humanism Honor Society membership (p = 0.108), number of volunteer experiences (p = 0.779), number of leadership positions (p = 0.709), or number of programs applied to (p = 0.923). However, matched applicants reported a significantly greater median number of peer- reviewed publications (8 [4,11] vs 5 [3, 9], p = 0.023) and a greater median aggregate research output (18 [12, 22] vs 14.5 [9,19], p = 0.013) than unmatched applicants. Matched applicants attended significantly more interviews (13 [9, 18] vs 9.5 [4, 14], p < 0.001).

PDs rated letters of recommendation, USMLE Step 1 score, and AOA membership as the three most important factors for interview selection. 100% of PDs who responded ranked interpersonal skills, as well as interactions with faculty and staff during the interview as factors included in ranking to match.

Conclusions

Application to IPSR is competitive. Although exam scores, grades, and honor society memberships in both matched and unmatched applicants were high, there were no significant differences among these factors between the two groups. This stresses that most applicants will be academically excellent, but they must stand out with research and interpersonal skills to successfully match as well. This is perhaps why research output was found to be greater in matched applications and was the fourth most important factor for interview selection. This is further supported by the findings from the PD survey, which lists interpersonal traits as imperative to match.

Background: The use of a split-thickness skin graft (STSG) is a mainstay for managing chronic, non-traumatic lower extremity (LE) wounds. However, the biomechanics of LE anatomy introduces shearing forces and natural pressure points that can lead to STSG failure (1, 2). Such challenges may deter surgeons from considering STSG in regions such as the heel and ankle when such efforts could lead to successful limb salvage. This study aims to determine if wound location and surface impacts STSG outcomes.

Methods: A retrospective review of patients who underwent STSG from December 2014 to December 2022 was conducted. Wounds pre-treated with synthetic dermal matrix (SDS) prior to STSG placement were excluded. Patient demographics, wound characteristics, and post-operative outcomes were collected. Wound location was classified into seven categories: forefoot, midfoot, hindfoot, transmetatarsal amputation (TMA) site, ankle, leg, and knee. Foot wounds were further classified as plantar or dorsal. Graft failure, defined as complete necrosis or removal of the STSG, was compared among groups. An additional sub-analysis of plantar wounds treated with and without SDS was performed.

Results: A total of 168 patients with 245 wounds underwent STSG during the study period. Overall, the cohort was 61.3% male with a median age of 61.9 (IQR: 15.1) years and BMI of 28.5 (IQR: 8.9) kg/m2. The median Charlson Comorbidity Index (CCI) score was 4 (IQR: 3), reflecting prevalent rates of diabetes mellitus (DM) (57.1%), chronic kidney disease (CKD) (22.6%) and peripheral artery disease (PAD) (36.9%). Median wound size was 29 (IQR: 71) cm2. Wounds were located on the forefoot (n=48/245, 19.6%), midfoot (n=20/245, 8.2%), hindfoot (n=36/245, 14.8%), ankle (n=45/245, 18.4%), lower leg (n=78/245, 31.8%), knee (n=15/245, 6.1%), and TMA (n=5/245. 2.0%). Overall, rate of graft failure was 18.0% (n=44/245), with no differences between location groups (p=0.601). In the foot, wounds on plantar surfaces exhibited significantly higher rates of graft failure compared to dorsal defects (n=11/37, 29.7% vs. n=8/70, 11.4%, p=0.018). Furthermore, in a univariate regression, plantar foot wounds were associated with a 3.3-fold increase in the odds of graft failure (OR: 3.3, CI: [1.1, 9.1], p=0.022). Subanalysis of plantar defects treated with and without SDS prior to STSG demonstrated that pre-treatment with SDS decreases graft failure rates significantly by 23.6% (7.1% vs. 30.8%, p=0.019).

Conclusions: Our results suggest that STSG is a viable method for LE wound coverage across multiple locations. However, wounds on plantar surfaces are more susceptible to graft failure. In these cases, the use of SDS prior to STSG may increase chances of graft success. Our institution's rigorous approach to postoperative immobilization and ambulation restrictions may have contributed to the overall success of STSG in our highly comorbid cohort. Emphasizing off-loading protocols is critical to improve graft outcomes in high-risk areas in a comorbid patient population.

References: 1. Braza ME, Fahrenkopf MP. Split-Thickness Skin Grafts. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551561/ 2. Knowles, A. (1998). The role of pressure relief in diabetic foot problems. Diabetic Foot, 1, 55-63.

Introduction: The number of patients undergoing gender-affirming surgery (GAS) has continued to rise in recent years (Chaya 2022). There has been an increase in literature regarding the medical and surgical outcomes associated with GAS, but findings on sexual health outcomes have been slow to follow. In particular, gender-affirming chest masculinization has not been extensively studied in its role in sexual health. This study aims to conduct a literature review into the outcomes of gender-affirming chest masculinization associated with sexual satisfaction and wellbeing. Methods: Studies were identified through PubMed, Google Scholar, and Cochrane Libraries. We considered all studies published through December of 2023. Results: Forty-five studies were identified and evaluated. Many studies suggested that there was a significant increase in several sexual health-related outcomes including but not limited to sexual confidence, feeling sexually attractive when unclothed, and increase in sex drive. Post-surgical improvements in the number of patients were reported of up to 77%, 94%, and 54%, respectively (Poudrier 2019, Davis 2014). Several studies found there to be a lack of sufficient existing evaluation tools explicitly tailored to the transgender and gender-diverse population (Barone 2017). Discussion: To the best of our knowledge, this is one of few literature reviews to consolidate findings regarding sexual health and wellbeing of individuals who underwent gender-affirming chest masculinization procedures. There are few studies that focus exclusively on these types of procedures and even fewer that further separate out the various approaches to chest masculinization and their respective outcomes. A lack of existing validated evaluation tools that are catered to transmasculine and non-binary individuals assigned female at birth is a possible reason for this dearth in knowledge. We recommend that future evaluation tools be created to be inclusive of the breadth of chest masculinization surgery and its various approaches, unique gender identities, and sexual outcomes as related to the transgender and gender-diverse community.

1. Chaya BF, Berman ZP, Boczar D, et al. Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes. LGBT Health. 2022;9(8):582-588. doi:10.1089/lgbt.2021.0224
2. Poudrier G, Nolan IT, Cook TE, et al. Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study. Plast Reconstr Surg. 2019;143(1):272-279. doi:10.1097/PRS.0000000000005113
3. Davis SA, Colton Meier S. Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People. International Journal of Sexual Health. 2014;26(2):113-128. doi:https://doi.org/10.1080/19317611.2013.833152
4. Barone M, Cogliandro A, Di Stefano N, Tambone V, Persichetti P. A Systematic Review of Patient-Reported Outcome Measures Following Transsexual Surgery. Aesthetic Plast Surg. 2017;41(3):700-713. doi:10.1007/s00266-017-0812-4

Introduction Low-middle-income countries (LMICs) suffered the highest age-standardized rates (ASRs) of incidence of deaths and DALYs from orofacial clefts (Wang, et al). Short-term missions have been a strategy for surgeons from high-income countries to support surgical needs in LMICs. However, these missions have come under criticism due to issues with sustainability and continuity of care. A more sustainable model of care is essential to address these inequities in the distribution of pediatric surgical care, particularly in populations where the prevalence of surgical needs is low, yet unmet. Starting in 2019, we expanded specialty pediatric surgical services, including craniofacial services. We describe our experience from 20 years of implementing a Regional Model for diagnostic clinics with centralized surgical care as a potential model for global craniofacial programs. We describe why this model is appropriate in the Eastern Caribbean Region and the composition of our referral network of craniofacial and plastic surgery services.

Methods
We used retrospective data of patients receiving craniofacial care from our organization in the Eastern Caribbean Region from 2002-2023 to provide a cross-sectional descriptive analysis of services provided. We then conducted online surveys to construct network mapping of the craniofacial services available in the Eastern Caribbean Region.

Findings From 2005-2023, we provided 295 craniofacial and plastic surgery services to the Eastern Caribbean Region, representing an average of 21 craniofacial surgeries annually from 2019, 2022-2023. We developed a referral network map of our organization's craniofacial and plastic surgery services, providing evidence for the establishment of a Regional Model for craniofacial surgery in the Eastern Caribbean.

Discussion In partnership with regional health agencies and governments, our Regional Model aims to provide comprehensive pediatric craniofacial care to children in the Eastern Caribbean with critical healthcare services often unavailable in these small island nations. The model decentralized diagnostic clinics while maintaining centralized surgical care, increasing access to craniofacial services more cost-effectively. While this regional model has been described, our study provides a network referral of craniofacial services available in the Eastern Caribbean Region. Understanding best practices and models to implement global craniofacial programs that increase surgical access in LMICs will continue to be important to the growth and development of the global surgery field. This regional model provides a framework for other global surgery programs, especially in other regions where resources and incidence of surgical needs are low and unmet. The technology of network mapping can be used to establish a needs assessment of plastic surgery and neurosurgery services available in the region. Understanding best practices and models to implement global surgery programs that increase surgical access in LMICs will continue to be important to the growth and development of the global surgery field.

Introduction: The increasing popularity of facial procedures, both surgical and non-surgical, is attributed to their aesthetic advantages. To ensure patient safety and optimal outcomes, a thorough understanding of facial vascularization and risk assessment is essential [1,2]. This study investigates the effectiveness of thermal scanning and Doppler ultrasonography in evaluating vascular risks associated with facial procedures.

Material and Methods: A prospective study included 80 patients, undergoing preoperative thermal scanning and Doppler ultrasonography to visualize facial vasculature and identify potential risk areas. We observed and documented vascular injuries in all patients, while also noting the presence of any prior aesthetic procedures.

Results: Among the subgroup where we utilized Doppler scanning imaging and thermal scanning before and during the procedure, 5% (2 patients) experienced complications (ecchymoses). In contrast, among the 40 subjects who did not undergo ultrasound and thermoscanning 15% (6 patients) experienced vascular injuries, including 3 ecchymoses, 2 hematomas, and 1 vascular occlusion (of the inferior labial artery). The preprocedural evaluation revealed a significant difference in postinterventional complication rates. The combined use of thermal scanning and Doppler ultrasonography proved to be valuable in assessing vascular risk for facial procedures, emphasizing the importance of preoperative assessments in identifying patients prone to vascular complications.

Conclusions: Thermal scanning and Doppler ultrasonography provide a comprehensive approach to evaluating vascular risk in facial procedures. By identifying abnormal vascular patterns and altered blood flow dynamics, these techniques enhance patient safety and contribute to effective procedure planning. [1] Cotofana S, Alfertshofer M, Schenck TL, Bertucci V, Beleznay K, Ascher B, Lachmann N, Green JB, Swift A, Frank K – Anatomy of the Superior and Inferior Labial Arteries Revised: An Ultrasound Investigation and Implication for Lip Volumization. Aesthetic Surg J 2020. [2] Hallock GG – Dynamic infrared thermography and smartphone thermal imaging as an adjunct for preoperative, intraoperative, and postoperative perforator free flap monitoring. Plast Aesthetic Res 2019.

Introduction Currently there are no standard guidelines for surgical skills lab curricula in plastic surgery, leaving educators with the significant challenge of determining how to optimize learning in the lab. Though skills labs are becoming increasingly common in plastic surgery programs, we do not fully understand how to maximize resource utilization and how to align skills lab curricula with the specific needs of resident learners. As part of the process of refining our curriculum, we aimed to perform a targeted needs assessment to investigate attitudes toward our current plastic surgery skills lab at UCSF.

Methods Plastic Surgery residents at UCSF participate in a recurring 2-year longitudinal skills lab curriculum, held once a month with a combination of cadaver labs and other hands-on workshops. We conducted semi-structured interviews with plastic surgery resident learners and faculty facilitators to explore the perceived value of skills lab in resident education, the utility of its content, and the strengths and limitations of the current skills lab curriculum. Two residents involved with this project were excluded. All interviews were de-identified, transcribed verbatim, and then analyzed using a constructivist grounded theory approach. A sub-analysis was performed comparing junior resident (PGY1-3) to senior resident (PGY4-7) responses.

Results 15 of 19 eligible integrated plastic surgery residents and 4 frequent skills lab facilitators among the surgical faculty were interviewed. Regardless of PGY level, all residents cited the skills lab as one of the most valuable educational settings in residency, providing opportunity for 1) low stress, low stakes deliberate practice, 2) detailed anatomical dissection, and 3) practice with "unique procedures," including: procedures for rare pathologies, procedures for urgent indications, and procedures less frequently seen at UCSF specifically (i.e. cosmetic and brachial plexus). All residents experienced a change in the educational environment when learning in mixed-level groups compared to near-peer groups; While both juniors and seniors acknowledged the benefit of practicing teaching skills when in mixed groups, juniors appreciated more hands-on practice and focus on fundamental skills (i.e. preoperative marking, dissection) when in junior resident groups, while senior residents appreciated "struggling together" to troubleshoot more complex dissections in senior resident groups. Both residents and attendings cited instrument, implant and hardware selection as particularly valuable skills to practice in the lab, and an area that could be more represented in future curricular iterations. Attendings strongly believed learners in the lab should focus on practicing fundamental technical skills and improving their understanding of anatomy rather than focusing on specific procedures.

Conclusions Despite the wide variability in training and exposure to different aspects of plastic surgery across residency programs, our analysis revealed important insights into broad skill categories such as instrument selection and anatomical dissection that are valued by residents and educators alike in the skills lab setting. Additionally, factors that influence the educational climate such as near-peer interactions are critical to consider when designing skills lab curricula.

References 1. Blau, J. A., Atia, A. N., & Powers, D. B. (2021). Clinical Competency Committees in Plastic Surgery Residency. Plast Reconstr Surg Glob Open, 9, e3833. https://doi.org/10.1097/GOX.0000000000003833 2. Braza, M. E., Adams, N. S., & Ford, R. D. (2020). Perceptions of Preparedness in Plastic Surgery Residency Training. Plastic and Reconstructive Surgery - Global Open. https://doi.org/10.1097/GOX.0000000000003163 3. Courteau, B. C., Knox, A. D. C., Vassiliou, M. C., Warren, R. J., & Gilardino, M. S. (2015). The development of assessment tools for plastic surgery competencies. Aesthetic Surgery Journal, 35(5), 611–617. https://doi.org/10.1093/asj/sju068 4. Daloğlu, M., & Alimoğlu, M. K. (2020). What do otolaryngologists want to learn? An educational targeted needs assessment study. Brazilian Journal of Otorhinolaryngology, 86(3), 287–293. https://doi.org/10.1016/j.bjorl.2018.12.001 5. Dickinson, K. J., Zajac, S., McNeil, S. G., Benavides, B., & Bass, B. L. (2020). Institution-specific utilization of the American College of Surgeons/Association of Program Directors operative skills curriculum: From needs assessment to implementation. Surgery (United States), 168(5), 888–897. https://doi.org/10.1016/j.surg.2020.07.009

Background: Vascular anastomosis in living donor renal transplantation is usually performed by a urologist only. The diameter of the renal artery is large enough to be anastomosed under a surgical loupe. One of its anatomic variants is multiple renal arteries (MRAs), including the main trunk of the renal artery and the accessory renal arteries (ARAs), and the reported incidence of grafts with MRAs is relatively high (18%–30%). Anastomosis of small ARAs under a surgical loupe is challenging; therefore, ARAs with a diameter of 2 mm or less are sometimes ligated. However, all ARAs need to be anastomosed, if possible. In urology, a common technique of arterial reconstruction of MRA grafts is to conjoint the renal arteries ex vivo during bench surgery. In our institution, anastomosis is performed in all patients with ARAs using microsurgery and a microscope to expand the perfusion area. Furthermore, supercharging for ARAs is performed in vivo to reduce ischemia time.

Methods: This was a retrospective review of 11 consecutive patients undergoing renal transplant from a living donor with microsurgical supercharging and MRA grafts from September 2018 to April 2022 at Osaka Metropolitan University Hospital. We assessed patient characteristics and surgical outcomes.

Surgical procedure: A urologist anastomosed the main trunk of the renal artery to the internal iliac artery or the external iliac artery and the renal vein to the external iliac vein. After the blood flow was restored in the graft, microsurgical supercharging was performed in vivo. The recipient arteries to be anastomosed to ARAs were selected depending on the arterial condition of recipient site. The first choice of the recipient artery was a branch of the internal iliac artery; the second was the deep inferior epigastric artery, including the superior pedicle; and the third was the external iliac artery in an end-to-side fashion.

Results: Upper polar arteries were identified in all patients, and lower polar arteries were identified in three patients. Fourteen ARAs were anastomosed to recipient arteries: five to a branch of the internal iliac artery, five to the deep inferior epigastric artery, and four to the external iliac artery. The mean diameter of ARAs was 2.2 mm. The mean cold ischemia time was 78 minutes, which was not longer than that in usual living donor renal transplantation. The mean time of ARA anastomosis under microscope was 67 minutes. No vascular complications were found. The patency of ARAs was identified using a renogram and ultrasound. The median serum creatinine level was 1.36 mg/dl. No graft failure occurred.

Conclusions: Supercharging in vivo under a microscope is safe and does not challenge the microsurgeon. We believe that a microsurgery could deliver a successful anastomosis in small-caliber ARA and contribute to a favorable outcome of supercharged living donor renal transplantation.

(PURPOSE) Recently, 4K 3D exoscope has been developed, enabling high-precision images to be obtained. Because there is no need to look through the lens, the surgeon can perform surgery in any posture he or she likes, which reduces the burden on the body. The small size of the exoscope body allows the camera arm angle to be adjusted freely, making it possible to perform surgeries at angles that were previously difficult, such as looking up position. On the other hand, it is necessary to become accustomed to the operation of the exoscope, and previous studies reported that the time required for vascular anastomosis is longer than that for surgery using a microscope. Our institution adopted the Olympus ORBEYE exoscope system in April 2022 and has been using it for head and neck reconstruction. We evaluated head and neck reconstruction using the ORBEYE. (Material) Sixty consecutive patients who underwent free flap reconstruction using the ORBEYE at our institution were included in the study. Surgical time, blood loss, perioperative complication rate, time required for arterial and venous anastomosis, and time spent using an exoscope were investigated. Head and neck reconstructions performed using a microscope were used for comparison. Comparisons were also made between the first 30 and second 30 patients who underwent surgery using an exoscope. (Results) There were no significant differences in any of the parameters between the microscopic and the exoscopic surgery groups. Significant reduction of anastomosis time was observed in the latter 30 cases compared to the first 30 cases. The comparison of the anastomosis time, blood loss, and perioperative complication rate were not significantly different between the exoscope and microscope groups. (Discussion) The advantages of using an exoscope are as follows: (1) Surgery can be performed in a comfortable posture with the head up. (2) The camera is easy to handle due to its small size, and the angle of the arm can be adjusted freely. (3) The screen on the monitor can be shared. Although there are some reports that the transition from microscope to exoscope is smooth, the first 30 cases gave the impression that it took some time to get used to it. In fact, the time to use the microscope and the time for anastomosis of arteries and veins decreased significantly, suggesting that it takes time to become accustomed to the use of the microscope. (Conclusion) It took time to become accustomed to the use of the exoscope. Once accustomed, the time required for vascular anastomosis was comparable to that of surgery under a microscope, and therefore the advantages of the exoscope were maximally enjoyed.

Introduction: The opioid crisis and concerns over the risks associated with opioid medications have led to an increased exploration of non-opioid analgesics for managing postoperative pain. This approach is especially important for patients receiving gender-affirming surgeries like gender-affirming mastectomy (GAM), who may face an increased risk of substance use disorders from the stress and mental health challenges associated with gender incongruence and societal stigma. As postoperative opioid prescriptions are a significant contributor to the opioid crisis, it is crucial for healthcare providers to explore and adopt alternative strategies for pain management. Although evidence supporting non-opioid analgesia exists across various surgical domains, its application specially in GAM remains underexamined. As the prevalence of GAM rises, identifying strategies to enhance postoperative care is vital. This study aims to evaluate efficacy of multimodal non-opioid analgesic regimen in patients undergoing GAM.

Methods: This was a prospective study of patients undergoing GAM at the University of California, San Francisco (UCSF) compared to historical control patients in randomized surgeon blinded regional block study. Similarly, those who were under 18 years old, had a history of opioid use disorder, chronic pain syndromes, and/or neuropathy were excluded from this study. Patients were discharged with 100 mg gabapentin and 500 mg acetaminophen tablets to take as needed. Additionally, pain levels were recorded in a pain diary utilizing a visual analog scale, and medication intake was logged for the first postoperative week. One month postoperatively, patients completed an online quality of recovery survey through a Qualtrics form. Comparisons were made with a historical cohort of patients treated with 0.5 mg hydrocodone. Data analysis was performed using Stata version 17.0 (College Station, TX, USA) and utilized descriptive statistics along with t-tests.

Results: To date seven patients were enrolled in the non-opioid postoperative regime and were compared to 21 patients who received the opioid-based regimen after GAM. There was no significant differences in age (27.5 versus 32.1 years, p=0.27) and case duration (156.0 versus 142.1 minutes, p=0.26) between the cohorts. Postoperative pain scores were comparable across both cohorts, ranging from 2.0 to 3.5 in the opioid group and 2.3 to 4.4 in the non-opioid group, with no significant differences at any time point. Data collected on medication intake revealed peak consumption patterns: the opioid cohort showed maximum intake on postoperative days 0 and 1, whereas the non-opioid cohort peaked on days 3 and 4. On average, 2.4 tablets of hydrocodone were consumed on post-operative day 0 and 2.2 tablets on day 1. Conversely, an average of 6.5 tablets of acetaminophen and 3.0 tablets of gabapentin were consumed on day 3, and 5.7 tablets of acetaminophen and 2.7 tablets of gabapentin on day 4. Regarding the postoperative survey, an average score of 8.6/10 was recorded across the domains of physical health, psychological well-being, and social well-being, highlighting excellent outcomes following surgery.

Conclusion: Preliminary findings suggest that multimodal non-opioid analgesic regimen may effectively manage postoperative pain in GAM patients. As the study progresses, integrating an opioid-sparing approach to postoperative care following GAM is recommended for consideration.

Purpose: Wound complications are a source of increased hospital costs and adverse patient outcomes, particularly in open spine procedures (1, 2). A growing body of literature suggests the use of prophylactic muscle flaps during primary closure can reduce the risk of wound complications (3). Risk stratification is critical in identifying patients at higher risk of developing postoperative complications. Current risk assessment tools that assess the overall likelihood of complication development have limited utility in risk-specific assessment of complications such as delayed wound healing or dehiscence. Artificial intelligence may help to increase the accuracy of current risk models. The aim of this study was to (1) use machine learning (ML) to create a novel algorithm to stratify risk of wound complications after open spine procedures and (2) to compare this ML model to commonly used general surgical risk scores in a national quality-improvement database.

Methods & Materials: Patients who underwent any open spine procedures with a posterior approach between 2012 and 2022 were identified using the Current Procedural Terminology (CPT) and included. A novel risk scoring algorithm for development of wound complications was created and validated using L1 Logistic regression, Naive Bayes, Random Forest, and XGBoost, using 10-fold cross validation on 85% of the patient cohort to predict the risk of wound complications. Potential predictors of wound complication included patient demographics, eighteen distinct comorbidities, procedural type, surgical specialty, and operative time. We also evaluated our models on the remaining 15% of the patient cohort to assess model calibration, and performed the same validation of the mFI-5.

Results: A total of 25,159 patients were included. The cohort was stratified by patients with any incidence of wound complications (n= 6,289) and patients without(n=18,870). The final logistic regression model included 11 predictors, with procedural type encoded into 3 distinct procedural risk categories. The L1 Logistic Regression, Naive Bayes, Random Forest, and XGBoost models scored mean area under the receiver operator characteristic curve (AUROC) of 0.69, 0.69, 0.70, and 0.70, respectively and mean average precision (AP) of 0.45, 0.43, 0.47, and 0.47, respectively. In comparison, the mFI-5 scored AUROC and AP of 0.56 and 0.32, respectively.

Conclusions: A machine learning based risk stratification model demonstrates promising results for estimating the risk of spine wound complications. This novel assessment tool can potentially help plastic and reconstructive surgeons determine which patients may benefit from prophylactic intervention when undergoing open spine surgery.

References:

1. Calderone RR, Garland DE, Capen DA, Oster H. Cost of Medical Care for Postoperative Spinal Infections. Orthopedic Clinics of North America. 1996;27(1):171-182. doi:https://doi.org/10.1016/s0030-5898(20)32060-5
2. Whitmore RG, Stephen J, Stein SC, et al. Patient Comorbidities and Complications After Spinal Surgery. Spine. 2012;37(12):1065-1071. doi:https://doi.org/10.1097/brs.0b013e31823da22d
3. Cohen LE, Fullerton N, Mundy LR, et al. Optimizing Successful Outcomes in Complex Spine Reconstruction Using Local Muscle Flaps. Plastic and Reconstructive Surgery. 2016;137(1):295-301. doi:https://doi.org/10.1097/prs.0000000000001875

Background: Cleft palate is a common congenital anomaly characterized by the failure of palatal shelf fusion during embryonic development. Palatoplasty techniques aim to reconstruct the levator veli palatini (LVP) muscle to establish proper velopharyngeal closure. Although morphology and function of the LVP have been studied in both normal and cleft palate patients,(1)(2) there is no consensus on the quantitative characterization of successful cleft palate repair procedures and further, to date, no studies have directly evaluated or measured the cleft morphology and defect immediately pre- and post-palatoplasty via intraoperative magnetic resonance imaging (MRI).

Methods: In this study, we compare the immediate pre- and post-palatoplasty anatomy of the LVP in six patients between the ages of 11 and 51 months via intraoperative MRI. Measurements of LVP length and thickness were obtained using the oblique coronal plane and measurements of velar length, velar thickness, and velopharyngeal gap were obtained using the sagittal plane. Paired sample T-test was used to assess for statistical significance between immediate pre- and post-palatoplasty.

Results: The mean LVP length increased from 47.8mm to 61.2mm (p=0.010) while the mean LVP thickness at the central palate was reconstructed to 7.8mm (p<0.001). The mean velar length increased from 8.9mm to 26.3mm (p=0.002), and the mean velar width increased from 5.8mm to 11.9mm (p<0.001). The mean velopharyngeal gap decreased from 6.9mm to 1.7mm (p=0.013).

Discussion: Results indicate that MRI quantification provides a valuable evaluation of the pre-operative LVP anatomy. This study reports the first use of intraoperative MRI measurements in a cohort of patients to objectively assess cleft palate pre-operative anatomy and surgical repair results. Early post-surgical results indicate no evidence of fistula formation or velopharyngeal insufficiency.

References: 1. Perry JL, Kuehn DP, Sutton BP, Goldwasser MS, Jerez AD. Craniometric and Velopharyngeal Assessment of Infants With and Without Cleft Palate. Journal of Craniofacial Surgery. 2011;22(2):499-503. doi:10.1097/SCS.0b013e3182087378 2. Kuehn DP, Ettema SL, Goldwasser MS, Barkmeier JC. Magnetic resonance imaging of the levator veli palatini muscle before and after primary palatoplasty. Cleft Palate Craniofac J. Nov 2004;41(6):584-92. doi:10.1597/03-060.1

Background

Health literacy allows patients to make more informed decisions about their healthcare. Surgical cost transparency is one important aspect of literacy; without an adequate understanding of pricing, a patient cannot make a fully autonomous choice, especially in elective procedures. To address obfuscated prices and resulting unexpected medical bills, the U.S. Centers for Medicare and Medicaid Services mandated in 2021 that government-funded hospitals clearly publish their pricing on their home web pages. One year after the rule went into effect, a study found that only 13% of hospitals were compliant in posting their standard charges for plastic surgery procedures (1). In this study we sought to expand upon this assessment, focusing on breast reconstruction with regard to the current state of hospital price transparency.

Methods

We evaluated Level 1 hospitals, which are mandated to publish pricing under the CMS ruling. Using the Texas Department of Health Database, the authors identified 19 adult CMS Level 1 hospitals in Texas. Two separate medically fluent investigators searched the website of each hospital system to find the price list or chargemaster. Charges related to general breast reconstruction (CPT codes 19357 and 19366), implant-based reconstruction (19340 and 19342), and free flap reconstruction (19364) were noted. Costs were analyzed to factor in if the patient had Cigna PPO, Humana PPO, or was uninsured. These companies were selected for their substantial market presence and diverse policy offerings, providing insights into varied coverage levels and patient financial impacts.

Results

Although all 19 Level 1 hospitals investigated had their pricing linked conspicuously as per the CMS ruling, only eleven (58%) had pricing available for breast reconstruction operations. For general breast reconstruction, eight hospitals had viewable uninsured charges, with an average cost of $20,204 ± $14,069. When insured by Humana, the average charge decreased significantly to $7,485 ± $6,065 at 3 hospitals, while the average Cigna charge was $7,283 ± $6,353 at 2 hospitals. For implant-based breast reconstruction, seven hospitals had viewable uninsured charges (average of $15,202 ± $11,813). One hospital provided viewable charges for Humana-insured patients ($8,806). Charges for Cigna-insured patients were available at 3 hospitals, with an average of $9,607 ± $8,949. For free flap reconstruction, only 2 hospitals had viewable uninsured charges with an average of $12,824 ± $11,940. No hospitals had viewable charges for Humana-insured patients, and 2 hospitals had viewable charges for Cigna-insured patients, averaging $9,861 ± $7,783.

Conclusion

The study highlights the lack of transparency in breast reconstruction charges in Level 1 Texas hospitals. Despite being mandated, access to cost information is limited, with wide cost variances across procedures and insurers. This greatly limits patient autonomy and the ability to make informed healthcare decisions.

Sources

1. Askinas C, Shih S, Puyana S, Chaffin AE, Jansen DA. Investigation of hospital pricing information for plastic surgery procedures reveals widespread violation of the CMS Price Transparency Act. Plastic & Reconstructive Surgery. 2023;152(2):455-462. doi:10.1097/prs.0000000000010299

Purpose: Autologous tissue transfer has become the gold standard of breast reconstruction. Patients with disorders of hypercoagulability represent a unique population at increased risk of thromboembolic events. Many surgeons use additional anticoagulation medications, beyond standard venous thrombosis prophylaxis, to reduce this risk. Most current literature on this topic centers on lower extremity reconstruction, and data on breast reconstructions is sparse. The purpose of this study is to review thrombotic-related surgical outcomes in hypercoagulable patients undergoing free flap breast reconstruction.

Methods: A retrospective case series was conducted at a single institution examining data from June 2018 to December 2023. Patients were included if they underwent autologous free flap breast reconstruction during a hypercoagulable state due to heterozygous factor V Leiden, antiphospholipid syndrome, sickle cell trait, sickle cell anemia, protein S deficiency, methylenetetrahydrofolate (MTHFR) mutation, or perioperative hormone therapy with tamoxifen. Patient data collected included the cause of hypercoagulability, age, sex, BMI, past medical history, medications, and perioperative anticoagulation regimen. Thrombosis-related complications examined included total flap failure, fat necrosis observed clinically and requiring surgical debridement, and deep venous thrombosis/pulmonary embolism (DVT/PE). Patients were divided into two categories: those who received standard DVT prophylaxis with weight-adjusted low molecular weight heparin (Lovenox) during hospital stay and those who received additional anticoagulation such as postoperative oral aspirin and intraoperative intravenous (IV) heparin. Confidence intervals were calculated for proportions and Fisher's exact tests were performed.

Results: Out of 575 patients, 14 patients with a total of 24 free flaps were reviewed. This included 19 (79%) deep inferior epigastric perforator (DIEP) flaps, four (17%) transverse upper gracilis (TUG) flaps, and one (4%) transverse rectus abdominis muscle (TRAM) flap. Five flaps were performed with routine perioperative Lovenox, and nineteen flaps were performed with additional anticoagulation medication. The patient group that received additional anticoagulation experienced a higher percentage of uneventful postoperative courses compared to the standard anticoagulation group (79% versus 60%, p = 0.568) and a lower rate of fat necrosis requiring surgical debridement (5% versus 40%, p = 0.099). In the cohort with additional anticoagulation, one patient (5%) experienced total flap loss on postoperative day two, and one patient experienced DVT/PE on postoperative day eight. Additional anticoagulation regimens used included 5000 units IV heparin intraoperatively (16 flaps, 84%), daily 81 mg aspirin postoperatively until discharge (8 flaps, 42%), and continuation of Lovenox after discharge (2 flaps, 11%).

Conclusions: Autologous breast reconstruction in hypercoagulable patients appears safe with the addition of anticoagulation beyond DVT prophylaxis. A larger sample size is needed to further examine complication rates and determine optimal anti-thrombotic regimens. Risks with autologous tissue transfer for patients with hypercoagulability can be mitigated with appropriate chemoprophylaxis.

Background: Patients undergoing below-knee amputation (BKA) for diabetic complications often experience heightened anxiety and poor psychosocial outcomes perioperatively. Patient-initiated-communication (PIC) has been utilized to address unclear information, but may also lead to burnout among surgeons and office staff. Our study aims to characterize patient factors associated with increased PIC in this patient population.

Methods: We retrospectively reviewed patients receiving BKA from December 2021 to August 2023. PIC in the form of phone calls and portal messages documented in the perioperative period (defined as ±90 days of surgery) were reviewed. PIC patients were compared to patients that did not initiate PIC (non-PIC). We further conducted a subgroup analysis of patients who initiated preoperative PIC (pre-PIC) and postoperative PIC (post-PIC). Primary outcomes were 1) incidence of PIC within the perioperative period, 2) rationale for PIC, and 3) characteristics associated with PIC patients.

Results: A total of 88 patients underwent BKA, 65 (73.9%) of whom initiated communication during the perioperative period, for a total of 206 communication encounters in the perioperative period. The cohort was primarily male (n=59, 67.1%) and the mean age was 57.9 ± 13.3 years with a mean Charlson Comorbidity Index (CCI) of 5.0 ± 2.8. Pre-PIC (n=111, 53.9%) was more common than post-PIC (n=95, 46.1%). Collectively, the majority of PICs were administrative (n=73, 35.4%). Pre-PIC was related to medication, (n=20, 18.0%), wound care (n=18, 16.2%), wound symptoms (n=13, 11.7%) and procedural details (n=7, 6.3%), and post-PIC concerned medication (n=25, 26.3%) and wound care (n=14, 14.7%). There were no differences in age (p=0.464), gender (p=0.345), or CCI (p=0.382) between patients that engaged in PIC and those that did not. Overall, PIC patients demonstrated a higher rate of psychiatric history other than major depressive and generalized anxiety disorders (38.7% vs. 0.0%, p=0.011) compared to non-PIC patients. Subgroup analysis revealed that pre-PIC patients were more likely to be married (61.3% vs. 38.6%, p=0.033) than non-pre-PIC patients. Post-PIC patients were more commonly discharged to home rather than a rehabilitation facility (28.6% vs. 10.3%, p=0.047) and experienced less complications requiring a return to the OR 30 days postoperatively (6.1% vs. 24.3%, 0.026).

Conclusions: Perioperative PIC is prevalent among BKA patients at our institution. Identifying reasons for PIC and high-incident patient groups can guide quality improvement efforts to proactively address patient concerns and reinforce resources already established by our institution, such as amputee support groups and prosthetist consultations.

Purpose

Breast cancer is a common diagnosis with mastectomy a common treatment modality. Mastectomy skin flap necrosis (MSFN) occurs when the blood supply to the skin flaps is insufficient to meet metabolic demands. We sought to determine whether mammography would aid in preoperative risk stratification of patients hypothesizing that a thicker subcutaneous adipose tissue layer would be associated with a lower rate of postoperative MSFN. Methods

A prospectively maintained database was retrospectively analyzed to identify 50 consecutive patients who underwent nipple sparing mastectomy (NSM) and subsequent implant based or autologous breast reconstruction. Using each patient's preoperative mammography, measurements were made to determine the thickness of the subcutaneous tissue. This was performed by taking an average of six measurement points. Three points were obtained on the craniocaudal view and three on the medial lateral oblique view.

Results

Forty-four patients and 73 breasts were included in final data analysis. Forty-three (58.9%) patients experienced mastectomy flap necrosis. On multivariable regression, subcutaneous thickness (p = 0.04) was found to be predictive of mastectomy skin flap necrosis along with BMI (p = 0.02) and smoking status (p=0.02).

Conclusions

A significant association between subcutaneous tissue thickness and MSFN was identified. Two hypotheses are proposed; 1) the subdermal plexus in patients with thinner subcutaneous tissues is less robust, and 2) the subdermal plexus is more easily disrupted mechanically intraoperatively in patients with thinner subcutaneous tissues. Further studies may be aimed at determining if there is a specific value beyond which mastectomy skin flap necrosis can be expected.

Background Craniosynostosis occurs in approximately 1:2000 to 1:2500 births, of which 5-15% involve multiple sutures(1). Encephalocele is observed in 1:10,000 live births(2). Herein we report a rare variant of bicoronal craniosynostosis with bilateral temporal encephaloceles, cleft palate, and almost complete agnathia with only symphysis present. Only few reports in the literature note concomitant craniosynostosis and encephalocele formation. These highlight diminished fetal activity due to neural tube defects and no article to date has described the development of an encephalocele in-line with the synostotic suture(3). This case and literature review describe a rare variant of craniosynostosis and a novel in-line encephalocele with subtotal agnathia.

Methods A literature review was undertaken using Pubmed, Web of Science, Scopus, and Google Scholar databases. Keywords used included "neural tube defect craniosynostosis" and "encephalocele craniosynostosis". A single clinical case is described.

Surgical Management of Clinical Case Craniofacial abnormalities were first detected in utero. Genetic evaluation was unrevealing for known syndromic craniosynostosis causes. A custom approach to the surgical management of the rare variant was undertaken. The patient underwent cranial vault suturectomy with bicoronal craniosynostosis suture release at 3 weeks of life for progressive expansion of encephalocele. At five months old, the skull had re-fused, and the patient underwent posterior vault distraction. With growth, the child had an improved cranial shape and made major developmental strides. He subsequently underwent fronto-orbital advancement at age 2 for the management of residual fronto-facial and calvarial deformity.

Results A literature review demonstrated limited reports of associated cephaloceles and craniosynostosis with no reports of 'in-line' encephaloceles. In total, five cases were identified, including occipital and frontonasal encephaloceles and coronal, sagittal, and pansutural craniosynostosis. Apert syndrome was reported in one case while the remaining four had no associated syndrome(4). Surgical intervention began as early as 15 days of age (range 15 days-13 years) for encephalocele repair with or without ventriculoperitoneal shunting. Two patients underwent encephalocele repair without later craniosynostosis repair owed to sudden death or pneumonia months following first surgical intervention. Craniosynostosis repair was performed as a second stage procedure in one patient while encephalocele repair and craniectomy were performed in the same stage in two patients(5). Three surviving patients were reportedly doing well at last postoperative follow up (range 3-6 months).

Despite wide, early suturectomies and standard approaches in this patient, there was a persistence of the encephalocele and re-fusion of affected cranial sutures in this case. The child's neurodevelopment and functional status improved significantly with progressive interventions, most recently at 3 months post-fronto-orbital advancement. Ongoing challenges for this patient include continued home ventilation and gastrostomy tube feedings. Additionally, the patient has persistent right-sided congenital ptosis.

Conclusions This case demonstrates the advantages of early and staged surgical interventions in a uniquely complex presentation of craniosynostosis with concomitant bilateral temporal encephaloceles and severe mandibular deficiency. To our knowledge, this is the first such reported clinical entity combination.

References 1. Shlobin NA, Baticulon RE, Ortega CA, et al. Global Epidemiology of Craniosynostosis: A Systematic Review and Meta-Analysis. World Neurosurgery. 2022;164:413-423.e3. doi:https://doi.org/10.1016/j.wneu.2022.05.093 2. ‌Oumer M, Kassahun AD. Birth prevalence of encephalocele in Africa: a systematic review and meta-analysis. BMJ Paediatrics Open. 2021;5(1):e001117. doi:https://doi.org/10.1136/bmjpo-2021-001117 3. Martínez-Lage JF, Poza M, Lluch T. Craniosynostosis in neural tube defects: A theory on its pathogenesis. Surgical Neurology. 1996;46(5):465-470. doi:https://doi.org/10.1016/S0090-3019(96)00213-3 4. Waterson JR, DiPietro MA, Barr M, Opitz JM, Reynolds JF. Apert syndrome with frontonasal encephalocele. American Journal of Medical Genetics. 1985;21(4):777-783. doi:https://doi.org/10.1002/ajmg.1320210422 5. Borkar SA, Sarkari A, Mahapatra AK. Craniosynostosis Associated with Neural Tube Defects: Is There a Causal Association? Pediatric Neurosurgery. 2011;47(5):337-341. doi:https://doi.org/10.1159/000336879

Introduction Understanding barriers to research is crucial to optimize the productivity and impact of busy physician-scientists. Research achievement is an increasingly important metric for medical students seeking to match into competitive specialties and elite residency programs.(1,2) Surgical residency programs often require research to graduate, and research is a key component for career advancement in academia.(3) The purpose of this study was to identify common barriers to research productivity that are specific to medical students, residents, and attending surgeons in plastic surgery.

Methods A survey was distributed to members of the American Counsel of Educators in Plastic Surgery to investigate factors influencing research productivity. The users were de-identified and maintained anonymity. Users who elected to participate in the survey answered a total of 43 questions. Questions focused on demographics, level of career, details of research productivity, and factors that may have affected completion. Univariate analysis was performed with student's t test, and multivariate analysis was performed with logistic regression. Statistical significance was determined to be p<0.05.

Results A total of 109 people responded to the survey; 42 were medical students, 19 were plastic surgery residents or fellows, 7 were junior attendings, and 41 were senior attendings. Of the 19 residents and fellows, 14 had research as a requirement for their program. Among the 48 attendings, 42 worked at academic institutions. The most common stage at which a project failed was during writing of the manuscript (n = 43), followed by awaiting IRB approval (n = 33). 30 people spent 16-40 hours and 22 people spent 8-16 hours on projects that did not reach completion in the last five years. Overall, 39 people had >10 completed projects and 31 had >5 incomplete projects, with the senior attendings being responsible for most successes and failures. In the group of people who had >10 completed projects, 53.8% also had >5 incomplete projects.

When comparing high productivity individuals to the remainder of the cohort, there was a statistically significant difference in the percentage of people whose programs had dedicated research staff (59 vs 31%, p=0.0061), institutional support for research (77 vs 57%, p=0.0389), and offered travel reimbursement (59 vs 33%, p=0.0081). Predictive factors for having >10 research projects included being a PGY1-3 (OR 13.3, p = 0.006), junior (OR 10.5, p = 0.026) and senior (OR 7.8, p=0.001) attending status, having dedicated research staff (OR = 6.1, p=0.0019), and getting travel reimbursement (OR 3.1, p = 0.032).

Conclusion Research remains an integral part of scientific discovery and career advancement in plastic surgery. This study identifies several factors that may help future physician scientists increase research productivity while reducing inefficiency. Furthermore, we found that individuals with high academic productivity are more likely to also have the highest number of unsuccessful projects. Programs that support research productivity with dedicated research staff and adequate travel reimbursement are likely to have more research success.

1. Amgad M, Tsui MMK, Liptrott SJ, Shash E. Medical student research: An integrated mixed-methods systematic review and meta-analysis. PLoS One. 2015;10(6). doi:10.1371/journal.pone.0127470
2. Lemme NJ, Li NY, Twomey-Kozak J, et al. Characterization and Fate of Unpublished Research Articles Reported by Orthopedic Surgery Residency Applicants. J Surg Educ. 2020;77(3). doi:10.1016/j.jsurg.2019.11.005
3. Schumm MA, Huang IA, Blair KJ, et al. Association of research timing with surgery resident perceptions of operative autonomy and satisfaction: A multi-institutional study. Surgery (United States). 2022;172(1). doi:10.1016/j.surg.2022.01.045

Background The use of local advancement myocutaneous flaps and free flaps has become a mainstay of pelvic reconstructive surgery requiring complex closure.(1) The link between tobacco smoking and vascular disease is well established, which has been shown by some studies to negatively affect wound healing in the postoperative period. Further, the success of complex flap-based reconstruction largely depends on oxygen delivery to reconstructed tissue, which can be compromised in smokers.(2) Beyond the surgical success of reconstructive flaps, patient fitness and preoperative optimization are crucial components of postoperative recovery and desirable surgical outcomes.(3) There is a scarcity of literature exploring the comorbidities associated with smoking in the preoperative period, particularly for patients undergoing complex reconstructive procedures. The purpose of this study is to analyze trends in preoperative comorbidities in smoking vs. nonsmoking patients undergoing flap-based pelvic floor reconstruction.

Methods In this single-center retrospective study, participants were identified using electronic medical records and CPT code data. Included patients were males and females over 18 who underwent flap-based pelvic floor reconstruction at Loyola University Medical Center between 2012 and 2022. Patients were excluded from analysis if they lacked postoperative follow-up. Patient information collected included age, sex, race, BMI, smoking status, insurance type, comorbidities, and hospital readmission data. Statistical analysis was performed using the Fisher's Exact Test and the Wilcoxon Rank Sum Test for categorical and continuous variables, respectively, comparing relevant demographic and preoperative clinical factors among non-smokers vs. former and current smokers. Univariate and multivariate logistic regression models were used to analyze the relationship between key patient data and smoker status, with the p-value set to <0.05 for significance.

Results Retrospective data collection yielded 608 patients that met study criteria. History of smoking was more prevalent among Whites/Caucasians (OR 1.15, 95% CI: 1.00, 1.31, p=0.044) and less common in females (OR 0.80, 95% CI: 0.74, 0.87, p <0.001). Mean BMI was lower in smokers than in nonsmokers (μ = 27 vs. 29; p=0.011). Smokers were more likely than nonsmokers to have chronic pulmonary disease (OR 1.14, 95% CI: 1.02, 1.27, p =0.026) and connective tissue disease (OR 1.29, 95% CI: 1.01, 1.65, p=0.044) in both univariable and multivariable logistic models. Smokers were more likely than nonsmokers to have peripheral vascular disease in univariable logistic models (OR 1.17, 95% CI: 1.06, 1.29, p <0.001) but not in multivariable models. Smoking was positively correlated with a designation of ASA class III (OR 1.54, 95% CI: 1.11, 2.12, p=0.009). Length of hospital stay following surgery was lower in nonsmokers than in smokers and former smokers (7 vs. 8 days, p=0.007). There was no significant difference in ER visits or hospital readmission at any amount of time following discharge between the groups. Finally, our study found no significant difference between smokers and nonsmokers with regard to rates of postoperative complications, including hematoma, seroma, wound dehiscence, and infection.

Conclusions This study reveals key preoperative morbidity associations among smokers undergoing pelvic floor reconstruction. White/Caucasians and men were more likely to be smokers in this patient population, found to be a predictor of a preoperative diagnosis of chronic pulmonary disease and connective tissue disease in our cohort. Smokers undergoing pelvic floor reconstruction were also more likely to be designated as ASA class III and experienced longer hospital stays when compared to nonsmokers. Our analysis found no significant difference in postoperative complications between smokers and nonsmokers. Understanding the relationships between patient behaviors and preoperative fitness can help to optimize patient counseling and can be applied more broadly to guide the clinical decision-making of plastic and reconstructive surgeons employing local advancement flaps for pelvic reconstruction.

References 1 Eseme, E. A., Scampa, M., Viscardi, J. A., Ebai, M., Kalbermatten, D. F., & Oranges, C. M. (2022). Surgical outcomes of Vram vs. Gracilis Flaps in vulvo-perineal reconstruction following oncologic resection: A proportional meta-analysis. Cancers, 14(17), 4300. https://doi.org/10.3390/cancers14174300
2 Lefevre, J. H., Parc, Y., Kernéis, S., Shields, C., Touboul, E., Chaouat, M., & Tiret, E. (2009). Abdomino-perineal resection for anal cancer. Annals of Surgery, 250(5), 707–711. https://doi.org/10.1097/sla.0b013e3181bce334 3 Schusterman, M. A., Miller, M. J., Reece, G. P., Kroll, S. S., Marchi, M., & Goepfert, H. (1994). A single centerʼs experience with 308 free flaps for repair of head and neck cancer defects. PRS,93(3), 479–480

Scalp lacerations present challenges for both emergency room physicians and plastic surgeons due to the scalp's unique anatomy and rich blood supply. The complexity of these wounds, combined with the potential for hair loss and cosmetic concerns, emphasizes the critical role of effective closure techniques.

Purpose: The study aims to assess the efficacy of different closure techniques for scalp lacerations in preserving hair and achieving optimal patient outcomes.

Methods: A comprehensive systematic literature review was conducted using three major databases: PubMed, Embase, and Google Scholar, covering publications from 1850 to 2023. The inclusion criteria comprised studies reporting clinical outcomes of scalp laceration repairs using sutures, staples, or flap techniques, with a specific focus on hair loss as a postoperative complication. Data extraction was performed independently by the research team, and any discrepancies were resolved through discussion and consensus.

Experience: The final analysis included eleven studies involving a total of 439 patients. Closure techniques encompassed traditional methods such as sutures and staples, as well as innovative approaches like the hair apposition technique (HAT) and various flap procedures. Follow-up assessments were conducted at intervals ranging from 7 to 14 days post-repair, focusing on parameters such as pain, cosmetic satisfaction, hair loss, and complications.

Results: The findings revealed distinct differences in outcomes among the different closure techniques. Sutures and staples were associated with higher rates of cosmetic dissatisfaction, pain, and hair loss compared to HAT. Notably, the HAT demonstrated shorter emergency department stays, lower complication rates, and minimal hair loss, while maintaining comparable or higher levels of patient satisfaction. Additionally, flap techniques, including advancement, transposition, and rotation, exhibited promising results in managing larger scalp defects, with satisfactory hair growth observed in the majority of cases.

Conclusions: The management of scalp lacerations poses a multifaceted challenge for emergency room physicians and plastic surgeons alike, predominantly stemming from the scalp's distinct anatomical features and rich vascularity. This systematic literature review critically examines the existing gap in research regarding the impact of different closure techniques with a specific focus on sutures, staples, and HAT, and their implications for aesthetic complications - notably hair loss following scalp laceration repairs. Our findings suggest that a nuanced approach to scalp laceration management can contribute to elevated patient satisfaction, avoid complications, and enhance aesthetic results. This research informs healthcare providers on the gamut of scalp repair techniques and their differential outcomes especially with regard to hair loss ultimately improving quality of care for scalp trauma patients.

Trends in Nipple Reconstruction in Gender-Affirming Mastectomies

Sumin Yang BS, Armin Edalatpour MD, Jacqueline Israel MD, Katherine Gast MD, MS

Introduction: Gender-affirming surgeries have been shown to improve the psychosocial functioning, mental and physical health of transgender and non-binary people. Many transmasculine and non-binary patients who experience chest dysphoria that impacts their daily functioning choose to pursue masculinizing top surgery, also known as gender-affirming mastectomy. One aesthetic option available to patients is to forgo nipple preservation with nipple grafting during surgery to create a smooth flat chest with no nipples. We hypothesize that in the last few years, more non-binary compared to transmasculine patients have chosen to forgo nipple-areola complex (NAC) preservation with nipple grafts in gender-affirming mastectomy surgery and testosterone use is associated with preservation of a NAC for a more traditionally masculine chest.

Methods: A chart review of 443 transgender patients who underwent gender-affirming mastectomies at UW Health between the years 2017-2023 was completed. A Pearson Chi-Square test was run on categorical data while an independent sample t-test was run on continuous data.

Results: In recent years, patients who chose to have nipple grafts declined steadily from 100% in 2017 to 77.8% in 2022. Patients who identified with genders outside the binary (e.g. nonbinary, agender, gender expansive) comprised the majority of those that opted out of receiving nipple grafts. In contrast, most of the patients who chose to receive nipple grafts identified as transmasculine. We found that the statistically significant factors in deciding to forego nipple grafts were a patient's gender identity, pronouns, and absence of prior testosterone therapy. Factors that were not associated with nipple preservation were race, age, BMI, time from social transition to surgery, time from medical transition to surgery, chest binding history, marital status, and employment history.

Conclusions: As predicted, the recent yearly trend shows a steadily increasing proportion of patients opting out of nipple grafts when undergoing gender-affirming mastectomies. Patients who identified outside the gender binary and did not pursue testosterone therapy were more likely to choose a flat chest with no nipples. These findings establish an evolving need for different surgical outcomes compared to the past that directly correlates to gender. We can safely assume this no-nipple trend will only increase in the coming future and hope to use our findings to advocate for physicians to readily present and accept this aesthetic option for their transgender patients.

Background: Children with visible medical conditions, such as craniofacial anomalies (CFAs), may be vulnerable to peer relationship problems. The current literature exploring peer relationships in children with CFAs is limited and mixed, making it difficult to guide informed psychosocial interventions. This study aims to characterize peer problems in children with CFAs and examine potential risk factors for peer problems. We examined physician-rated severity of CFAs as one risk factor as well as two cognitive risk factors: perceived stigmatization (e.g., the extent to which children perceive others are stigmatizing them due to their CFA) and hostile attributions (e.g., the extent to which children ascribe negative intent to others' ambiguous actions). We hypothesized that children with CFAs would have increased experiences of withdrawal/depression and social problems compared to norms. Second, we hypothesized that previously identified risk factors, including greater CFA severity rating, perceived stigmatization, and hostile attributions of peers would be associated with increased peer difficulties.

Methods: Participants included N = 43 children (39.53% girls; M age = 9.27 years, SD age = 1.88, 32.56% Black/African American, 44.19% White, 4.65% Hispanic/Latino/a, 2.33% Asian/Asian American, 2.33% bi/multiracial, and 13.95% not reported/missing) and their caregiver(s) (76.74% female) who were patients seen in a multidisciplinary craniofacial clinic at an academic medical center located in the southern United States. Caregivers and their children completed questionnaires about children's psychosocial functioning and behaviors. Medical providers reported on CFA severity for participating children. All questionnaires utilized in the current study have been previously used with school-aged populations and demonstrate good psychometric properties.

Results: Data analyses included descriptive statistics of various peer problems (i.e., withdrawal/depression, aggression, and victimization) in children with CFAs. Mean scores for withdrawal/depression (t(37) = 4.92, p < .0001), social problems (t(37) = 5.34, p < .0001), and aggressive behavior (t(37) = 2.81, p = 0.008) were significantly higher for children with a CFA compared to norms. Spearman Correlations revealed that children who perceived their peers to be staring at them were shyer (r = 0.51, p < .001) and had more symptoms of withdrawal/depression (r = 0.49, p < .01). Children who perceived their peers to be hostile engaged in more physical and relational aggression (r = 0.33, p < .05). Lower physician rated CFA severity was associated with increased relational aggression (r = -0.32, p < .05). Hostile attributions were not significantly associated with increased peer problems.

Conclusion: In the current study, children with CFAs experienced increased peer problems including withdrawal/depression, social problems, and aggressive behaviors compared to their peers. As hypothesized, perceived stigmatization was associated with increased peer problems, including increased shyness, withdrawal/depression, and physical and relational aggression. Additionally, children's perceived experiences of peer hostility and staring were associated with increased peer problems. Lower physician-rated CFA severity was associated with increased relational aggression, which is often associated with increased social dominance among peers. Increased knowledge of peer difficulties in this population can guide clinical intervention efforts, including interventions focusing on improving the self-image of children with CFAs.

Purpose:

The purpose of this study was to investigate the impact of posterior vault distraction surgery on lateral ventricular volume in a patient presenting with nonsyndromic sagittal craniosynostosis and concurrent Slit Ventricle Syndrome (SVS). Posterior vault distraction may benefit patients with SVS by reducing postoperative shunt revisions and other complications related to elevated ICP. However, comprehensive volumetric analyses of the lateral ventricles and their implications in predicting long-term outcomes for SVS within the broader context of craniosynostosis have yet to be described.

Methods:

We conducted a case report involving a patient with nonsyndromic sagittal craniosynostosis and SVS. Syngo.via imaging software was used to conduct volumetric analysis of the lateral ventricles on preoperative and postoperative CT imaging. Two age and sex-matched patients who underwent PVDO for nonsyndromic sagittal craniosynostosis without SVS were chosen as controls. Postoperative volumetric analyses were performed using follow-up CT imaging following completion of activation phase of distraction.

Results:

Preliminary data reveal significant differences in preoperative lateral ventricular volume for the patient with SVS compared to the controls. Preoperative lateral ventricular volume was 1.98 cm3 in the patient with SVS compared to 8.17 cm3 in the age and sex-matched controls. Following posterior vault distraction, the patient's lateral ventricle volume increased to 6.24 cm3 versus the age-sex matched controls, increasing by much smaller amount to 8.81 cm3.

Conclusion:

This case study highlights the notable change in volume of the lateral ventricles in a patient with SVS and sagittal craniosynostosis after undergoing posterior vault distraction. Further investigation and more extensive studies are warranted to confirm these findings and explore the potential for therapeutic management of patients with craniosynostosis and slit ventricle syndrome.

PURPOSE Although the relationship between diabetes mellitus (DM) and carpal tunnel syndrome (CTS) is well-documented due to neuropathic complications (1), a relationship specific to CTS and obesity has not yet been identified on a population level. Given the direct relationship between obesity and DM (2), the current study seeks to compare CTS prevalence among obese and non-obese patients, examine various associations between obesity, DM, and CTS, and evaluate the role of BMI in CTS risk.

METHODS & MATERIALS Data used in this study came from Epic Cosmos, a community collaboration of health systems representing over 227,000,000 patient records from over 1,301 hospitals and 28,600 clinics. All patients at least 18 years of age with an encounter between December 2013 and December 2023 were included and assorted based on presence or absence of ICD-10 codes for CTS, obesity, DM, and BMI values. Other than <19.9 and >70.0, BMI values were grouped in intervals of 10.0 for comparison. 99% confidence intervals were recorded, and odds ratios were calculated for group comparison. Significance was determined by p<0.01.

RESULTS All adult patients with a documented obesity diagnosis (n=26,702,609) showed a significant, near 6-fold increase in CTS prevalence (5.9% ± 0.012%) compared with non-obese adult patients (n=161,410,353; 1.1% ± 0.002%; OR=5.41, p<0.0001).

When only including adults with a documented DM diagnosis, obesity was also associated with a significantly increased CTS prevalence (n=7,981,900; 7.9% ± 0.025%) compared with both non-obese, diabetic patients (OR=2.67, p<0.0001) and non-diabetic obese patients (n=18,720,709; 5.0% ± 0.013%; OR=1.62, p<0.0001). When excluding those with a documented DM diagnosis, this relationship was largely maintained with a significant, 5-fold increased prevalence in obese adults without DM (n=18,720,709; 5.0% ± 0.013%) compared with non-obese adults without DM (n=150,929,553; 1.0% ± 0.002%; OR=5.21, p<0.0001). Additionally, obese adults without DM had a higher rate of CTS compared to non-obese, diabetic adults (n=10,480,800; 3.1 ± 0.014%; OR=1.65, p<0.0001).

Stratifying by BMI, the 30.0-39.9 group (n=13,452,382) had significantly higher CTS comorbidity (6.0% ± 0.017%) than the <19.9 group (n=1,937,281; 2.7% ± 0.030%; OR=2.26, p<0.0001) and the 20.0-29.9 group (n=165,403,966; 1.2% ± 0.002%; OR=5.06, p<0.0001). However, the 40.0-49.9 group (n=3,316,957; 5.5% ± 0.032%; OR=0.91, p<0.0001), 50.0-59.9 group (n=563,017; 4.6% ± 0.072%; OR=0.77, p<0.0001), 60.0-69.9 group (n=99,203; 3.6% ± 0.152%; OR=0.59, p<0.0001), and >70.0 group (n=38,837; 3.4% ± 0.236%; OR=0.55, p<0.0001) each had significantly lower rates of CTS than the 30.0-39.9 group.

CONCLUSIONS While DM patients are classically associated with CTS presentation, obesity, even without DM, possesses a similar and more powerful relationship. Additionally, comorbidity of obesity and DM suggests an additive effect between the two diagnoses on increased CTS prevalence. Although CTS prevalence initially increases with increased BMI, this relationship is far from linear. Further research must be undergone to evaluate the anatomic and pathologic mechanism of this relationship.

REFERENCES 1. Papanas N, Stamatiou I, Papachristou S. Carpal Tunnel Syndrome in Diabetes Mellitus. Curr Diabetes Rev. 2022;18(4):e010921196025. doi:10.2174/1573399817666210901114610 2. Malone JI, Hansen BC. Does obesity cause type 2 diabetes mellitus (T2DM)? Or is it the opposite?. Pediatr Diabetes. 2019;20(1):5-9. doi:10.1111/pedi.12787

Background:

Ethnic and female disparities still exist in plastic surgery despite the closing gap in the medical field. Women are continually underrepresented in primary and senior authorship positions in academic literature. There is limited information about the authorship trends for women in plastic surgery. This study examines the gender and country of origin trends of authorship in the Plastic and Reconstructive Surgery Journal.

Methods:

The Web of Science database was used to collect bibliographic records of all peer-reviewed publications published in the Plastic and Reconstructive Surgery (PRS) journal between 2004 and 2023. All publication types were considered, and the search strategy had no exclusion criteria. A Python script was developed to determine the genders of all authors using Genderize.io, an Application Programming Interface (API). Articles that either had authors with initials as their first names or with mononyms were removed, leaving 11,312 articles. Logistic regression analysis was conducted to examine the relationship between the prevalence of female authorship in first and last positions across the 10 countries with the most articles. The USA was used as the reference for comparison. Odds ratios were computed to assess the likelihood of female authorship.

Results:

P-values indicated statistical significance in the variation of female authorship across different countries compared to the United States. Canada, Japan, China, Germany, France, the Netherlands, and Turkey all had p-values less than 0.05 for the gender of their first author, suggesting meaningful deviations from trends observed in the United States. Notably, the Netherlands had the highest first author odds ratio (2.38), indicating that the odds of a female being the first author of an article in the Netherlands is 2.38 times higher than in the United States. Japan, which had the smallest first author odds ratio, has the likelihood of a female being the first author of an article at 50% that of the United States. Last author gender p-values contained less statistically significant data: Canada, England, China, Germany, and the Netherlands. The odds ratio for the last author position in the Netherlands, at 2.19, is the highest among the countries analyzed, indicating a significantly greater likelihood of female senior authorship compared to the United States. However, Germany, with the smallest odds ratio of 0.59, suggests a notably lower probability of female representation in senior academic roles within the field of plastic and reconstructive surgery.

Conclusion:

This study highlights disparities in gender representation within the PRS journal authorship, with a focus on variations across countries. While nations like the Netherlands show a progressive stance towards female authorship, in both primary and senior positions, others, such as Japan or Germany, reveal a more conservative pattern. This study calls for a broader cultural shift within the academic community, encouraging a more inclusive representation of genders across all levels of authorship.

Purpose: Full-thickness burns to the eyelids are associated with high rates of contracture, corneal injury, and infection, posing a significant threat to vision. Early excision and grafting are recommended to reduce the risk of these complications. Our center utilizes split-thickness skin grafts for early coverage to avoid sacrificing full-thickness donor sites prior to stabilization of all burn wounds. Here we report the incidence, management, and outcomes of full-thickness eyelid burns at a single institution.

Methods: A retrospective review of all patients admitted to a large, urban burn center from January 2015 to December 2023 was performed. Admission documentation was screened to identify patients with eyelid involvement. Data was collected on patient demographics, hospital course, and outcomes, and reported with descriptive statistics.

Results: Of the 3,247 patients admitted for burns during the study period, 137 (4.2%) had involvement of the eyelids. Depths of eyelid burns were inconsistently documented; however, at least 11 (0.34%) patients had confirmed full-thickness injuries. The median age of these patients was 36 (IQR: 29-51.5), and all were male. Notably, four (36%) patients were homeless, and the eight that received admission urine toxicology screens all tested positive for at least one substance, including stimulants (n=5, 62.5%), benzodiazepines (n=4, 50%), cannabis (n=3, 37.5%), opioids (n=2, 25%), and dissociative agents (n=1, 12.5%). Burns were caused by flame (n= 9, 82%) and chemicals (n=2, 18%), with a median total body surface area burned of 70.3% (IQR: 43.6-86.5%). Only five of 11 (45.5%) patients had full-thickness eyelid burns in the context of survivable burn injuries, meaning they were not placed on comfort care and did not die within 72 hours of admission. All five received artificial tears and ophthalmic antibiotics, while two (40%) received amniotic membrane insertion and one (20%) underwent temporary tarsorrhaphy. Exposure keratopathy developed in three patients (60%) prior to skin grafting. The median time to skin grafting was 14 days (IQR 9-21 days). Initial skin grafts were split-thickness (12-14/1000") and harvested from the thigh (n = 3), medial arm (n = 2), and abdomen (n = 1). Cicatricial ectropion developed in three patients (60%), necessitating contracture release and regrafting following discharge. One patient (20%) experienced partial graft loss that was successfully left to heal by secondary intention. Another patient (20%) developed infection, a perforated globe, and blindness, ultimately requiring enucleation. Preservation of pre-burn visual acuity was achieved in all other patients (80%).

Conclusions: Full-thickness eyelid burns are relatively uncommon, especially in patients with survivable injuries. Adult male patients under the influence of substances seem to be at higher risk. Despite early protective measures, exposure keratopathy was common. Split-thickness skin grafting performed at 1-3 weeks had high rates of cicatricial ectropion necessitating later revision. However, this approach was successful in preserving vision and full-thickness donor sites for delayed reconstruction. Additional research is needed to elucidate optimal management strategies for these patients.

BACKGROUND: Serial debridement to achieve a negative culture has become a standard protocol before closure of chronic, lower extremity (LE) wounds. However, in this population, achieving sterility is often not feasible. The current study aims to evaluate the impact of the qualitative debridement cultures obtained immediately before STSG placement on STSG outcomes.

METHODS: We performed a retrospective review of all patients receiving an STSG for chronic LE wounds from December 2014 to December 2022. Patient demographics, wound characteristics, and post-operative outcomes were collected. Microbiological data included pathogen type and bacterial load. Wounds that had a preoperative positive culture (PC) on the day of STSG were compared to those that had a negative culture (NC). Primary outcomes were STSG failure, defined as complete necrosis or removal of the STSG, infection, and reintervention, defined further surgery performed at the original wound site. A subanalysis of graft failure was conducted on PC wounds only.

RESULTS: A total of 114 patients underwent STSG for 164 chronic LE wounds. The majority of wounds had PC (n=128, 78.1%) while only 36 wounds (22.0%) had NC. Overall, the cohort had a median age of 63 (IQR: 19.5) and BMI of 29.4 (IQR: 9.3), with no differences between groups (p=0.617 and p=0.430, respectively). Charlson Comorbidity Index (CCI) for the PC group was 5 (IQR: 3) and 4 (IQR: 3.5) for the NC group (p=0.212). On the date of STSG, median wound sizes for the PC wounds were larger than NC groups (23.3, IQR: 48.3 cm2 vs. 38, IQR: 109.5 cm2, p=0.204). Of the PC wounds, 63.3% (n=81/128) were polymicrobial, 74.2% (n=95/128) contained gram positive organisms, and the majority (51.2%) were quantified as "light" volume of growth. There were no differences in graft failure (18.8% vs. 19.4%, p=0.925) or reintervention (38.4% vs. 22.2%, p=0.073) between the PC and NC groups. However, PC wounds demonstrated a significantly higher rate of infection (17.2% vs. 2.8%, p=0.028) compared to NC wounds. Subanalysis of PDC wounds demonstrated that wounds that had heavy bacterial loads (p=0.035) and were polymicrobial (p=0.024) had significantly higher rates of graft failure.

CONCLUSIONS: Our findings suggest that the presence of a PC prior to STSG placement for chronic LE wounds does not adversely affect postoperative outcomes when compared to NC. Rather, it is the quality of the PC, specifically polymicrobial presence and heavy growth, that significantly influences the outcome of the graft. This challenges the conventional emphasis on achieving negative cultures before proceeding with STSG. We show that a positive culture result alone does not necessarily impact outcomes.

Purpose: Pressure ulcers represent a significant clinical challenge, particularly at advanced stages, due to their impact on patient morbidity, healthcare costs, and quality of life. Stage IV pressure ulcers require innovative treatment strategies to promote healing. Recent advancements have introduced acellular fish skin grafts as a promising option for wound management, leveraging their bioactive properties to facilitate tissue repair. This case report details the successful application of acellular fish skin grafts in treating a Stage IV pressure ulcer in a 38-year-old male, showcasing the potential of this novel treatment modality.

Case Presentation and Methods: A 38-year-old male with a past medical history of paraplegia presented with a Stage IV pressure ulcer on the left hip. The ulcer measured 0.5x0.4x2.6 cm3, with exposed bone and significant tissue loss. Despite conventional treatments, including debridement and standard dressings, the ulcer showed minimal improvement and slow healing. The treatment strategy was revised to include acellular fish skin grafts. The patient underwent two applications of the fish skin matrix, with each application following wound debridement with ulcer most recently measured at ulcer measured 0.3x0.4x1.3 cm3.

Discussion:

Acellular fish skin grafts, derived from the North Atlantic cod (Gadus morhua), offer a novel approach to wound care, particularly for challenging cases such as Stage IV pressure ulcers. These grafts are not only rich in omega-3 fatty acids, which possess anti-inflammatory properties and promote wound healing, but also provide a conducive scaffold for cell migration and tissue regeneration (1). Their structural similarity to human skin makes them an excellent option for facilitating the healing process in complex wounds.

In this case, significant healing was observed with the first fish skin matrix application. This outcome is consistent with the literature, which suggests that acellular fish skin grafts can accelerate wound healing, reduce the risk of amputation, and improve patients' quality of life compared to standard care (2). Furthermore the grafts' effectiveness in managing hard-to-heal lower extremity chronic ulcers, supports their use in similar complex wound scenarios.

The rapid and complete healing of the Stage IV pressure ulcer in this patient underscores the potential of acellular fish skin grafts as a viable treatment alternative for advanced pressure ulcers. This case contributes to the growing body of evidence supporting the integration of biotechnological advancements into wound care protocols, potentially offering substantial benefits for patients with difficult-to-heal ulcers. Further research and clinical trials are warranted to explore the full scope of applications for acellular fish skin grafts in wound management and to establish standardized treatment guidelines.

References: 1. Baldursson BT, Kjartansson H, Konrádsdóttir F, Gudnason P, Sigurjonsson GF, Lund SH. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. 2015;14(1):37-43. doi:10.1177/1534734615573661 2. Hadikhosuma, Jessica & Lake, Maria & Lewa, Anwar. (2023). The Use of Acellular Fish Skin Grafts in Diabetic Foot Ulcers Management – a Systematic Review. INTERNATIONAL JOURNAL OF MEDICAL SCIENCE AND CLINICAL RESEARCH STUDIES. 03. 10.47191/ijmscrs/v3-i10-01.

INTRODUCTION

Hidradenitis suppurativa (HS) is a disease characterized by chronic inflammation of apocrine glands in the axillae, inframammary folds, groin, perineal, and perianal regions that greatly impacts the patient's quality of life, commonly measured by the Dermatologic Life Quality Index (DLQI) [1, 2]. The DLQI scale ranges from 0 to 30, with a higher score indicating a greater degree of impact on quality of life [3]. HS is usually characterized by the Hurley staging system, which includes 3 stages of increasing severity [1, 4]. Antibiotic and immunotherapy are typically the starting treatment for early stages of HS, while surgery is generally reserved for Hurley Stage 2 or 3 diagnoses [1, 5]. This study focuses on the surgical interventions for HS and their impact on DLQI scores.

METHODS

A systematic review and meta-analysis were performed in accordance with the PRISMA guidelines to assess the treatment efficacies of surgical interventions with regards to patient quality of life, using DLQI as our primary outcome. Search terms included 'hidradenitis suppurativa" and "DLQI". Baseline and post-intervention mean and standard deviation DLQI were analyzed for significance. 22 studies were included, and subgroup analysis was conducted on eight surgical studies.

RESULTS

All studies showed a decrease in DLQI after the operation for HS treatment. Nine of the twelve studies reported a post-operative mean DLQI score of 5 or less, which correlates to a minimal effect on daily life. Subgroup analyses, based on region of operation, Hurley Stage classification, and type of operation did not provide significant clarification on the factors contributing to the improvement in quality of life for HS surgical patients. The subgroup analysis of procedure type showed that the wide local excision (WLE) with photodynamic therapy (PDT) group experienced the greatest mean difference of 21.59 (95% CI: 19.5, 24.03).

DISCUSSION

This meta-analysis supports surgery as an effective treatment for HS. Many HS patients have comorbidities such as obesity and an extensive smoking history, both of which factors greatly impact surgical outcomes [1, 4]. However, because of the variety of antibiotic and immunologic treatments prior to surgery, along with the subjective nature of the DLQI metric, it is difficult to discern the best surgical plan for patients. Nonetheless, WLE with either a flap or photodynamic therapy displays promising results for HS patients. More research regarding surgical options for HS, including analysis of post-operative complications and recurrence of symptoms, should be conducted to establish an effective treatment plan.

REFERENCES: 1. Scuderi N, Monfrecola A, Dessy LA, Fabbrocini G, Megna M, Monfrecola G. Medical and Surgical Treatment of Hidradenitis Suppurativa: A Review. Skin Appendage Disord. 2017;3(2):95-110. doi:10.1159/000462979

2. Yazdanyar S, Jemec GB. Hidradenitis suppurativa: a review of cause and treatment. Current Opinion in Infectious Diseases. 2011;24(2):118. doi:10.1097/QCO.0b013e3283428d07

3. Krajewski PK, Matusiak Ł, von Stebut E, et al. Quality-of-Life Impairment among Patients with Hidradenitis Suppurativa: A Cross-Sectional Study of 1795 Patients. Life (Basel). 2021;11(1):34. doi:10.3390/life11010034

4. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: A comprehensive review. Journal of the American Academy of Dermatology. 2009;60(4):539-561. doi:10.1016/j.jaad.2008.11.911

5. Menderes A, Sunay O, Vayvada H, Yilmaz M. Surgical Management of Hidradenitis Suppurativa. Int J Med Sci. 2010;7(4):240-247. Accessed December 27, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920468/

Introduction: The thumb carpometacarpal joint (CMC) is the second most common joint of the hand to develop arthritis (1). Current interventions are either simply temperative or surgically invasive, requiring long recovery and destruction of the joint (2). Autologous fat transfer is emerging as a minimally invasive solution to reduce pain and improve function in patients with CMC arthritis.

Purpose: The purpose of this study is to analyze the effect of autologous fat transfer on outcomes in patients with basilar thumb arthritis.

Methods: Twenty-five patients with CMC arthritis underwent autologous fat transfer under fluoroscopic guidance. Autologous fat was harvested from the abdomen and separated with non-adherent gauze (Telfa). After processing, 2 ml of fat was injected into the CMC joint. All patients were placed in a prefabricated orthoplast splint for 2 weeks immediately after undergoing fat transfer.

Patients completed Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire both preoperatively and postoperatively at 1 month, 6 months, 12 months, and 24 months. Paired t-tests were used to compare pre-treatment to post-treatment DASH scores. Significance was set at a p-value <0.05 (95% CI).

Results: Of the 25 patients, 18 patients were women, and 7 patients were male. Radiographically, patients were staged between Eaton-Littler stages II and IV: 8 patients stage II, 8 patients stage III, 6 patients stage IV, and 1 patient was not classified. The average preoperative pain score on a visual analog scale was 8.28 out of 10. The average preoperative DASH score was 52.99 (N=25) (SD=14.51), 95% CI [46.99, 58.98]. The average postoperative DASH score at 1-month follow up was 27.82 (N=24) (SD=15.04), followed by an average DASH score at 6-month follow-up of 22.16 (N=16) (SD=14.12), an average DASH score at 12-month follow-up of 26.45 (N=16) (SD=18.81), and an average DASH score at 24-month follow-up of 15.41 (N=6) (SD=9.26). Significant improvements in DASH scores were reported at the 1 month, 6-month, 12-month and 24-month follow up (p<0.01). No adverse events were observed.

Conclusion: Autologous fat transfer for the treatment of CMC osteoarthritis significantly improved DASH scores in our cohort. Our patients' 50% improvement in DASH scores at 12-months highlights the clinical significance of autologous fat transfer as a longer lasting alternative to steroid injection and less invasive alternative than trapeziectomy. Additional study of fat transfer is warranted to better understand the physiologic mechanisms and longer term benefits.

1. Swigart CR. Arthritis of the base of the thumb. Curr Rev Musculoskelet Med. Jun 2008;1(2):142-6. doi:10.1007/s12178-008-9022-7
2. Herold C, Rennekampff HO, Groddeck R, Allert S. Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study. Plast Reconstr Surg. Aug 2017;140(2):327-335. doi:10.1097/prs.0000000000003510

Introduction: Breast cancer therapy requires complex coordination of multidisciplinary care, and the addition of immediate breast reconstruction (IBR) further complicates this. This study evaluates the impact of IBR on wait times to adjunctive therapies in breast cancer treatment.

Methods: A retrospective chart review identified 337 patients who underwent IBR following total mastectomy for therapeutic breast cancer treatment. Patients were divided into groups: Surgery First (SF) and Neoadjuvant Chemotherapy (NC). Wait times were compared against Canadian and global benchmarks. Further subgroup analysis evaluated the impact of reconstructive modality (alloplastic vs. autologous) on wait-times.

Results: Surgery First experienced longer wait times compared to Neoadjuvant Chemotherapy with delays of 24 days in biopsy to treatment initiation (62 ± 51 vs 38 ± 28, p<.001), 25 days in first consultation to treatment initiation (47 ± 51.5 vs 22 ± 22, p<.001), and 23 days in transitioning from first to second treatment modality (62 ± 35 vs 39 ± 17, p<.001). Furthermore, 74% of Surgery First did not meet the benchmark of receiving surgery within 6 weeks of diagnosis (p<.001), compared to 43% of Neoadjuvant Chemotherapy. Additionally, 61% of Surgery First and 44% of Neoadjuvant Chemotherapy waited longer than 8 weeks for radiotherapy (p=.048). Within subgroups, Surgery First alloplastic had shorter wait times compared to Surgery First autologous for biopsy to treatment by 14 days (60 ± 49.5 vs 74 ± 49, p=.007) and first consultation to treatment by 10 days (43 ± 51.5 vs 53 ± 59, p=.030). For Surgery First alloplastic only 69% did not initiate treatment within 6 weeks of diagnosis compared to 84% of Surgery First autologous patients (p=.014).

Conclusion: IBR patients receiving surgery first, particularly those undergoing autologous reconstruction, experienced the most prolonged wait times. By identifying this vulnerable patient group, care providers can make informed decisions around prioritization of care and attempt to reduce discrepancies in wait times between treatment orders and reconstructive modalities. However, an important consideration is that our data was limited to was restricted to IBR patients only. Future work should aim to include both IBR and delayed reconstruction patients to capture a broader population of breast cancer patients.

Purpose: There is a paucity of literature that thoroughly examines the utility of 3D printing in plastic surgery. To address this gap, we conducted a comprehensive review of the evolution, applications, and emerging trends of 3D printing in plastic surgery.

Methods: We utilized Lingo3G, a cluster analysis software, to analyze 5,924 publications sourced from PubMed from 2015 to 2022. Included papers were selected utilizing 65 MeSH terms related to technological innovations, materials, techniques, challenges, and clinical applications of 3D printing within plastic surgery. Utilizing ChatGPT-4 Advanced Data Analytics, we conducted thematic and temporal analyses of common and topic-focused keywords to identify prevalent trends and evolution in the field. Findings were corroborated with manual review.

Results: An increase in the volume of publications in plastic surgery related to 3D printing was observed over the years 2015 (58 articles) to 2022 (2,114 articles). Keyword analysis revealed frequent association of 3D printing with tissue engineering, additive manufacturing, scaffold creation, and bioprinting purposes. Notably, the fields of tissue engineering and bioprinting exhibited significant growth in research focus. The application of 3D printing technology was found to be extensive across various anatomical areas, including hand, breast, and craniofacial regions, with predominant uses in maxillary, orbital, and mandibular regions. In terms of the materials used for 3D printing, there was a marked preference for polymer and ceramic filaments compared to metal and resin materials. Clinically, the data revealed a significant increase in the use of 3D printing, particularly for the development of patient-tailored implants and intraoperative planning.

Conclusions: Our review highlights the evolving role of 3D printing in plastic surgery. The integration of 3D printing in plastic surgery has contributed to the push for precision medicine through innovation allowing for advances in implant and reconstruction customization.1 Over the span from 2015 to 2022, the integration of 3D printing technology into plastic surgery has led to transformative innovations characterized by enhanced precision, customization, and patient outcomes.1 The advancements in the field, particularly in the development of patient-tailored implants, surgical guides, and tissue scaffolds, demonstrate potential to streamline surgical procedures, introduce longer-term cost efficiencies, and possibly enhance outcomes.1,2,3 Our temporal analysis showed notable shifts in focus on themes such as implant technology, anatomical applications, and clinical utilization. As technology continues to evolve and mature, it appears increasingly likely that areas currently viewed as experimental, such as bioprinting and tissue engineering, may soon become integral and standard components of clinical practice in plastic surgery.

References: 1. Singh TS, Bhola N, Amit Reche. The Utility of 3D Printing for Surgical Planning and Patient-Specific Implant Design in Maxillofacial Surgery: A Narrative Review. Cureus. 2023;15(11). doi:https://doi.org/10.7759/cureus.48242

2. Han Ick Park, Lee JH, Sang Jin Lee. The comprehensive on-demand 3D bio-printing for composite reconstruction of mandibular defects. Maxillofacial Plastic and Reconstructive Surgery. 2022;44(1). doi:https://doi.org/10.1186/s40902-022-00361-7

3. Darwich K, Ismail MB, Al-Mozaiek MYAS, Alhelwani A. Reconstruction of mandible using a computer-designed 3D-printed patient-specific titanium implant: a case report. Oral and Maxillofacial Surgery. 2020;25(1):103-111. doi:https://doi.org/10.1007/s10006-020-00889-w

Purpose: The free osteocutaneous fibula is the flap of choice for complex composite mandibular and maxillary reconstruction.  However, recipient defect size, flap volume, and donor site morbidity pose individual challenges.  We present an anatomic study and clinical application of a perforator-preserving free fibula flap with multiple individual skin islands and a lateral hemisoleus.  The chimeric multiple perforator free fibula (CMPF) design increases the versatility of the flap, obviates the need for secondary free tissue transfer, and improves donor site morbidity.                                                                                                                         Methods: A perforator preserving technique was used in 38 cadaveric flap dissections.  A total of 138 cutaneous perforators were isolated, averaging 3.64 perforators per leg, 78% of which were musculocutaneous. Twenty-six percent were located in the proximal third, with an average length of 6.8 cm.  The tibioperonal trunk gave rise to the proximal peroneal perforator in 15.2% of cases and was not included in the single-pedicle free fibula flap dissection.  From April 2011 to May 2017, the CMPF flap was utilized in 117 composite mandibular and maxillary reconstructions.  Age ranged from 7 to 74 years.  Flap design was based on defect size and isolated cutaneous and muscular perforators.

Results: All patients were reconstructed using the CMPF flap technique.  The flap contained multiple skin islands in 87 cases (74.4%) and a single proximal skin island in 25 cases (21.3 %).  In 86.3% of patients, the proximal perforator was a direct branch of the peroneal artery.  It followed a musculocutaneous course in 88% of cases, with an average length of 7.4 cm.  In 13,7% of patients, the proximal perforator was a direct branch of the tibioperonealtrunk, leading to a distal flap design. The lateral hemisoleus was harvested in 61,5% of cases. The proximal leg defect was primarily closed in 76.8% patients and skin grafted in 23.2%; distal leg donor site was grafted in 87%.  There were no proximal donor site dehiscences and all skin grafts healed well.  The distal donor site dehiscence rate was 72.8% and required local wound care or regrafting. Nine flaps (7.7%) were lost due to salivary fistula or infection, all of which occurred in complex tertiary cases.

Conclusion: The CMPF flap is based on a single peroneal vascular pedicle and provides independent skin and muscle components for large volume complex head and neck reconstructions.  Utilizing the proximal perforator and associated skin island improves donor site morbidity.

Background: Diabetic foot ulcer (DFU) care and surgical management represent a significant challenge in plastic and reconstructive surgery. The rise of artificial intelligence (AI), notably ChatGPT, represents a resource for DFU patients to seek information regarding their care. In attempts to qualify its utility as a patient resource, we evaluated the accuracy, comprehensiveness, and safety of ChatGPT responses to frequently asked questions (FAQs) related to DFU care.

Methods: 11 DFU care FAQs were posed to ChatGPT Model 3.5 in December 2023. Questions were divided into topic categories of Wound Care, Concerning Symptoms, and Surgical Management. 4 plastic surgeons in our wound care department evaluated responses for quality on a 10-point Likert scale for accuracy, comprehensiveness, and danger, defined by the extent to which closely following ChatGPT-3.5's advice could harm patients. Department attendings provided qualitative feedback. Response readability was assessed using 10 different readability indexes.

Results: Overall, ChatGPT answered patient questions with an mean accuracy of 8.7±0.3, comprehensiveness of 8±0.7, and danger of 2.2±0.6. Averaged across all readability metrics, ChatGPT answered at mean grade level of 11.9±1.8. Qualitatively, physician reviewers complimented the "comprehensiveness and simplicity" of the responses (n=11/11) and the AI's ability to provide "generally good" information (n= 4/11). While only 3 responses were noted to present explicitly incorrect information, the majority of responses (n=10/11) left out key information, such as DVT symptoms and comorbid conditions impacting salvage.

Conclusion: We observed that ChatGPT may provide misinformation, omit crucial details, and respond at nearly 4 grade levels higher than the American average, warranting caution for DFU patients and providers alike. However, ChatGPT was sufficient in its ability to provide general information, which may allow DFU patients to make more informed decisions, be more comfortable with their care, and learn how to prepare for their recovery. The utility of ChatGPT is likely to be further integrated into clinical practice and consultations. It is becoming increasingly synonymous with the future of healthcare and to keep pace with emerging trends, physicians should be prepared to talk about AI with their patients. Physicians must bridge the gap between potential benefits of ChatGPT and the current limitations, as seen in our study.

Background: The washing of lipoaspirate (LA) is imperative to any reconstructive or aesthetic procedure requiring autologous fat grafting. Many approaches exist, ranging from manual (i.e., Cotton gauze rolling, decantation) to commercialized processing devices (i.e., REVOLVE, Puregraft). However, given the lack of standardization between methodologies, there is a prevalent degree of variability resulting in graft take ranging from 20-80%. We hypothesize that a new closed-loop, peristaltic pump-driven fluidic device could enhance the washing process, resulting in minimal adipose tissue manipulation and comparable tissue purity.

Methods: We designed and fabricated the Preparation Device (PD) to improve the washing of LA within a closed-loop system. Using human LA samples, the PD was optimized for use in a batch and dynamic wash protocol and was compared to a traditional washing approach. Resultant adipose tissue samples underwent a visual colorimetric comparison and were enzymatically digested for ex vivo measurement of cell counts, cell viability, and Mesenchymal Stem Cells (MSCs) and Endothelial Progenitor Cells (EPCs). LA samples were mechanically processed using our lab's Emulsification and Micronization Device (EMD) for downstream stem/progenitor cell analysis.

Results: The PD produced similar results to traditional manual washing using both batch and dynamic washing protocols. Internal baffles within the PD helped increase agitation and facilitate mixing within the PD's internal cavity. No significant changes in cell counts or viability were noted and both MSC and EPC populations arose from using the PD and peristaltic pumps. Combining the EMD within the PD platform enabled closed-loop mechanical processing and significantly improved EPC numbers (5-fold) compared to manual washed/syringe pump-driven EMD processing.

Conclusions: Our new PD platform demonstrates effective washing of LA within a closed-loop system and demonstrates minimal manipulation and purity of final adipose tissue. Additionally, this platform enables the simple integration of LA mechanical processing in a minimal footprint while enriching for EPCs. Future directions will explore fat graft retention within an in vivo murine model and full automation for improved reproducibility within clinical settings.

Purpose: There are several published guidelines from different plastic surgery societies (ASAPS, ASPS, ISAPS, ISPRES, and IFATS) that emphasize that the fat graft in Brazilian Butt Lift (BBL) surgery must only be injected above the muscle in the subcutaneous layer. However, there is no consensus on the most effective and safe method to precisely inject fat into the subcutaneous space. We aimed to perform a proportions meta-analysis to assess whether using real-time intraoperative ultrasound for gluteal fat grafting can help achieve this goal.

Methods: We conducted a systematic literature search in PubMed, Cochrane Library, and Embase databases up to February 2024 looking for articles that performed BBL surgery with ultrasound guidance and reported the following outcomes: mortality, fat embolism, fat necrosis, infection, and seroma. A random-effects model was used. The proportions meta-analyses used the Freeman-Tukey Double arcsine transformation. Statistical analyses were performed using R version 4.1.2.

Results: Two retrospective studies comprising 6,015 patients were included. The patients' average age and BMI were 34 years and 30.4 kg/m². In the pooled analysis, the mortality rate was 0.00 per 100 (95% CI: 0.00–0.03%), the prevalence of fat embolism was 0.00 per 100 (95% CI: 0.00–0.03%), the prevalence of fat necrosis was 0.40 per 100 (95% CI: 0.25–0.57%; I² = 0%), the prevalence of infection was 0.37 per 100 (95% CI: 0.00–1.28%) and the prevalence of seroma was 2.50 per 100 (95% CI: 0.36–6.45%)

Conclusion: Our meta-analysis suggests that utilizing ultrasound guidance during the BBL procedure could eliminate adverse serious events such as death and fat embolism. It might also decrease the incidence of other complications like infection, fat necrosis, and seroma.

Introduction Though recent advances in the treatment of burns have considerably improved overall survival rates, they have also highlighted several long-term sequelae related to the injury. Hypertrophic scars, for example, can impair function, reduce quality of life, and require multiple procedures as well as physical therapy. The purpose of this study was to investigate the effects of topical application of anti-inflammatory drugs on burn wound progression, overall wound healing, and quality of healing.

Materials and Methods 15 deep-partial thickness burns were created on the dorsum of four anesthetized swine using a custom burn device at 100°C. Analgesia was provided prior to all surgical procedures with buprenorphine and the animals were monitored for pain twice every 24 hours for the first 72 hours. The burn wounds were randomized to receive amiloride, celecoxib, dexamethasone or minocycline formulated in a hydrogel. Silver sulfadiazine cream and blank hydrogel acted as controls. The animals were followed for 90 days and the wounds were assessed on days 3, 14, 28 and 90 post-burn. Assessments were performed using digital photographs (macroscopic healing, contraction), laser-Speckle imagery (blood perfusion), 3D camera (scarring, pigmentation), and histology (burn wound depth, epidermal thickness, rete ridges).

Results 15 deep-partial thickness burns were evaluated. It was shown that on day 3, burn depth varied from 155 µm (celecoxib) to 222 µm (blank hydrogel) but no statistically significant differences were observed. In terms of wound healing, the results showed that by day 14 post-burn, percent wound closure ranged from 45% (dexamethasone) to 84% (celecoxib) but no significant differences were observed. By day 28 post-burn all the wounds were fully healed. Quality of healing was studied on day 90 post-burn. Wound contraction varied from 28% (celecoxib) to 43% (minocycline) but no significant differences were seen. No differences were observed in the thickness of epidermis or number of rete ridges.

Conclusions This study concluded that topical application of amiloride, celecoxib, dexamethasone or minocycline formulated in a hydrogel did not mitigate burn wound progression, promote wound healing or increase quality of healing when compared to controls.

Purpose Patients face several barriers in scheduling medical appointments, including work constraints, financial burdens, and limited appointment availability (Chapman et. Al, 2022). With the digitalization of healthcare, patients are increasingly turning to the Internet to self-diagnose. Online symptom checkers, however, have demonstrated low diagnostic accuracy (Wallace et al., 2022). Given the rapid advancement of artificial intelligence, natural language processors like ChatGPT 4.0 have emerged as alternatives to traditional search engines. Although some studies have explored the efficacy of ChatGPT 4.0 in making clinical diagnoses, there is limited literature investigating ChatGPT's diagnostic accuracy for upper-extremity musculoskeletal conditions (Kuroiwa et al., 2023). This study explores ChatGPT 4.0's utility as an interim diagnostician for common non-traumatic hand conditions. Secondarily, this study evaluates the terminology ChatGPT associates with each condition by assessing its ability to generate condition-specific questions from a patient's perspective.

Materials and Methods Five common hand conditions were identified: trigger finger (TF), Dupuytren's Contracture (DC), carpal tunnel syndrome (CTS), de Quervain's tenosynovitis (DQT), and thumb carpometacarpal osteoarthritis (CMC). Author-generated questions were created by synthesizing symptoms from patient-facing medical websites. The validity of author-generated questions was verified by a board-certified hand surgeon. ChatGPT was then queried using the list of author-generated questions. For each query, authors recorded the frequency of correct diagnoses, differential diagnoses, recommendations to seek a healthcare provider, common symptoms, disease causes, diagnostic tests, treatments, and risk factors. Chi-squared tests were run in R Statistical Package and used to compare response quality between conditions for author-generated questions. ChatGPT was further prompted to produce its own questions using the following query: "You are a patient. Ask a doctor about symptoms that you are having of [diagnosis] without knowing that is the diagnosis." A Python script was used to count the most common terms in ChatGPT-generated questions.

Results For the author-generated questions, ChatGPT's diagnostic accuracy significantly differed between conditions (p<0.005). While ChatGPT was able to diagnose CTS, TF, and DQT with 100% accuracy and DC with 96% accuracy, it correctly diagnosed CMC only 60% (n=15) of the time. Additionally, there were significant differences between the number of times ChatGPT provided differential diagnoses (p<0.005), diagnostic tests (p<0.005), and risk factors for each condition (p<0.05). ChatGPT recommended visiting a healthcare provider for 97% (n=121) of the author-generated questions. Analysis of ChatGPT-generated questions showed four of the top ten most used terms were shared between DQT and CMC.

Conclusions The study results suggest that ChatGPT 4.0 has excellent potential to be used as a preliminary diagnostic tool. Although analyses showed significant variation in some categories of qualitative output between conditions, ChatGPT was able to reach a correct diagnosis over 95% of the time for four out of the five conditions. Along with asking ChatGPT to provide preliminary diagnoses, our study further identified potential language patterns that ChatGPT uses to describe common hand conditions. Future studies should build on these findings by investigating factors that improve or worsen AI's diagnostic power, and by studying the implications of patient utilization of ChatGPT.

References 1. Chapman KA, Machado SS, van der Merwe K, Bryson A, Smith D. Exploring Primary Care Non-Attendance: A Study of Low-Income Patients. J Prim Care Community Health. Jan-Dec 2022;13:21501319221082352. doi:10.1177/21501319221082352 2. Wallace W, Chan C, Chidambaram S, et al. The diagnostic and triage accuracy of digital and online symptom checker tools: a systematic review. NPJ Digit Med. Aug 17 2022;5(1):118. doi:10.1038/s41746-022-00667-w 3. Kuroiwa T, Sarcon A, Ibara T, et al. The Potential of ChatGPT as a Self-Diagnostic Tool in Common Orthopedic Diseases: Exploratory Study. J Med Internet Res. Sep 15 2023;25:e47621. doi:10.2196/47621

In 2021, Susan G. Komen (SGK) published landscape analyses of breast cancer disparities across ten metropolitan areas (MTAs) with the most significant health inequities in breast cancer outcomes for Black women.(1) While SGK reported racial disparities along many aspects of the care continuum, it did not investigate disparities in breast reconstruction (BR) in women who undergo mastectomy. BR has become standard of care in the continuum of comprehensive breast cancer treatment and can dramatically improve quality of life.(2) The purpose of this study was to expand upon the results from SGK and investigate racial disparities in implant-based BR utilization across the United States (US).

This descriptive study was performed using data from the Centers for Medicare & Medicaid Services. Black and White women with Medicare Part A insurance and a breast cancer diagnosis who underwent at least one mastectomy between January 2016 and December 2022 were included. Racial disparities were investigated through three primary outcomes: overall BR utilization (%), immediate BR utilization (%), and mean days to delayed BR. Summary statistics were generated for all outcomes at the national level, and across all core-based statistical areas (CBSAs). A disparity index (DI) was calculated for each outcome per CBSA; DIs were sorted into DI deciles (DIDs) indicating low (1-3), moderate (4-7), and high (8-10) disparity. Qualitative analyses were conducted for ten key CBSAs, anchored in the MTAs explored by SGK, to contrast with disparity patterns previously reported.

A total of 487,577 women (44,337 Black [9.1%], 443,240 White [90.9%]) across the US met eligibility criteria. At the national level, Black women underwent BR at a slightly lower rate than White women (5.6% vs. 6.4%); the greatest DI was in Washington-Arlington-Alexandria (Black: 5.4%, White: 11.3%, DID=9). Black women also had a slightly lower rate of immediate BR across the US compared to White women (75.5% vs. 76.7%). The greatest DI for immediate BR was in Houston-The-Woodlands-Sugar-Land (Black: 47.7%, White: 63.6%, DID=8). Further, there was a disparity in days to delayed BR at the national level, with Black women having a longer wait time compared to White women (306 vs. 287 days). The greatest DIs were in St. Louis and Dallas-Fort-Worth-Arlington (385 vs. 259 days; DID=9, and 413 vs. 291 days; DID=8, respectively).

Disparities for Black women were observed across the US in overall BR utilization, immediate BR utilization, and mean days to delayed BR. Such disparities may result from several factors, including access to and quality of care, socioeconomic status, and health literacy-which were not controlled for in our descriptive investigation. Our analysis is cursory; hence, further research is needed to investigate underlying mechanisms that foster disparities, especially in those MTAs identified in our study as having a high DI.

1. Susan G. Komen. Closing the Breast Cancer Gap: A Roadmap to Save the Lives of Black Women in America: Executive Summary 2021. https://www.komen.org/wp-content/uploads/Landscape-Analysis-Exec-Summary.pdf.
2. L. Sala, Bonomi S., Ciniselli C. M., et al. Patient-reported outcome measurements in post-mastectomy implant-based breast reconstruction and radiotherapy: Analysis of BREAST-Q data. Tumori. 2023;109(3):295-300.

Background: Hypertrophic scarring is a fibro-proliferative disorder caused by abnormal cutaneous wound healing. Circulating metabolites and the gut microbiome may be involved in the formation of these scars, but high-quality evidence of causality is lacking.

Objective: To assess whether circulating metabolites and the gut microbiome contain genetically predicted modifiable risk factors for hypertrophic scar formation.

Methods: Two-sample Mendelian randomization (MR) was performed using MR-Egger, inverse-variance weighting (IVW), Mendelian Randomization Pleiotropy RESidual Sum and Outlier, maximum likelihood, and weighted median methods.

Results: Based on the genome-wide significance level, genetically predicted uridine (P=0.015, odds ratio [OR]=1903.514, 95% confidence interval [CI] 4.280–846,616.433) and isovalerylcarnitine (P=0.039, OR=7.765, 95% CI 1.106–54.512) were positively correlated with hypertrophic scar risk, while N-acetylalanine (P=0.013, OR=7.98E-10, 95% CI 5.19E-17–0.012) and glycochenodeoxycholate (P=0.021, OR=0.021 95% CI 0.003–0.628) were negatively correlated. Gastranaerophilales and two unknown gut microbe species (P=0.031, OR=0.378, 95% CI 0.156–0.914) were associated with an increased risk of hypertrophic scarring.

Conclusion: Circulating metabolites and gut microbiome components may have either positive or negative causal effects on hypertrophic scar formation. The study provides new insights into strategies for diagnosing and limiting hypertrophic scarring.

Introduction: Gender-affirming bilateral mastectomy, also known as transmasculine top surgery (TMTS), is a vital step in the transition process for transgender male or nonbinary individuals due to its proven role in alleviating gender dysphoria. Despite increasing access and performance of TMTS, the impact of patient factors on postoperative outcomes remains underexplored. With this large retrospective study, we aimed to evaluate the impact of age, BMI, and comorbidities on complication and re-intervention rates in TMTS patients in hopes of strengthening current surgical recommendations for optimized patient outcomes.

Methods: An IRB-exempt retrospective chart review was conducted for 228 patients who underwent TMTS at a single academic institution from March 2018 to September 2023. All patients had confirmed diagnoses of persistent gender dysphoria and were >16 years old at the time of surgery. Age, BMI, smoking history, comorbidity history (e.g. diabetes, hypertension, hyperlipidemia, coagulopathy, cancer, venous thrombosis), operative details, and post-operative outcomes were evaluated. Logistic regression analysis was performed to assess the relationship between various patient factors and rates of short-term complications and re-intervention up to 6 months following surgery.

Results: Of the 228 patients, 11.0% had a history of ≥1 systemic comorbidity, 15.4% were former smokers, and 11.8% were current smokers. Average age at surgery was 28.4 years and average BMI was 29.1. Postoperatively, 31.6% of patients were noted to have any degree of contour irregularity or asymmetry, 16.2% widened or hypertrophic scarring, 11.0% seroma formation, and 5.7% hematoma formation. In all, 16.7% of patients required re-intervention. The reasons for re-intervention were seroma aspiration (36.8%), scar revision (28.9%), hematoma evacuation (18.4%), contour revision (7.9%), nipple-areolar complex revision (5.3%), or other (2.6%). Patients with a history of ≥1 systemic comorbidity had a significantly increased likelihood of re-intervention (p<0.012). Both current and former smokers had a significantly increased risk of hematoma formation (p<0.010; p<0.024 respectively). With every one-year increase in age, patients had a 7% increased likelihood of seroma formation (p<0.015) and 8% increased likelihood of any contour irregularity or asymmetry (p<0.001). Increasing BMI did not significantly impact the likelihood of hematoma formation (p<0.106) or re-intervention (p<0.095).

Conclusion: History of systemic comorbidity, older age, and history of smoking were all found to be associated with a significantly increased risk of developing a major complication or needing re-intervention following TMTS. These findings support the importance of conducting more robust preoperative evaluations and risk assessments in order to provide more individualized recommendations for TMTS patients regarding their personal risk factors for specific adverse surgical outcomes. Furthermore, an improved understanding of how patient comorbidities influence surgical outcomes can better guide surgeons in their preoperative and postoperative planning, including taking extra precautions to reduce rates of complications and reoperation in higher-risk patients. Altogether, these practices have the potential to improve TMTS patient trust, satisfaction, and quality of life. Future studies should assess the utility of refining preoperative risk criteria to allow for the reduction of modifiable risk factors.

Purpose: This poster aims to assist surgeons and their patients with decisions regarding the optimal surgical lip lift technique suited to each individual patient and situation by providing a resource that succinctly describes and compares contemporary surgical lift lip approaches. The poster includes descriptions of the Bullhorn, Corner, Gullwing, Italian, Upper Lip Advancement, Cupid, and Scarless techniques. It covers the focus, surgical equipment, contraindications, and acknowledged difficulty of each approach. Visual representations of each technique and its intended results are incorporated, providing a comprehensive review of the most relevant techniques that any facial plastic surgeon should be able to offer to their patients.

Methods/Materials: A review of articles describing the various surgical approaches to lip lifts was conducted via PubMed, Google Scholar, and Embase. Evidence-based approaches that have been utilized in the past five years (from January 2018 to December 2023) with at least 50% patient satisfaction or statistically significant improvement in procedure-specific outcomes (such as percentage improvement of lip measurements and percentage retention of the lift over time) were included. The information gathered from this review was then synthesized into a poster describing the technique, efficacy, utility, and described advantages and risks of each relevant technique.

Experience: For thoroughness, this poster is a review of surgical techniques and their outcomes as described in previous publications on online databases; final data comes from this review rather than cases conducted by the authors themselves.

Results: Plastic surgeons currently utilize numerous surgical approaches to lip lifts, each with unique result focuses, potential adversities, and reliability factors (Nagy et al. (2022), van der Sluis et al. (2022), Zhao et al. (2023)). This poster will outline the relevant approaches in a detailed yet succinct and accessible poster, broadening many surgeons' and patients' knowledge of the options available to them and streamlining the process of ensuring that the optimal technique for each individual is used.

Conclusions: The field of plastic surgery continues to advance at a rapid pace. It is difficult, but imperative, to stay up-to-date on the current techniques available for various operations. As a frequently performed aesthetic surgery, the multitude of approaches to lip lifts constitute a significant portion of the most relevant aspects of facial plastics. This poster provides easy access to thorough descriptions of each of the contemporary approaches, with which surgeons may guide future operational decisions and patient education concerning lip lifts.

References: 1. Nagy C, Bamba R, Perkins SW (2022) Rejuvenating the aging upper lip: The longevity of the subnasal lip lift procedure. Facial Plastic Surgery & Aesthetic Medicine 24:95–101. doi: 10.1089/fpsam.2021.0077 2. van der Sluis N, Gülbitti HA, van Dongen JA, van der Lei B (2022) Lifting the mouth corner: A systematic review of techniques, clinical outcomes, and patient satisfaction. Aesthetic Surgery Journal 42:833–841. doi: 10.1093/asj/sjac077 3. Zhao H, Wang X, Qiao Z, Yang K (2023) Different techniques and quantitative measurements in Upper Lip Lift: A systematic review. Aesthetic Plastic Surgery 47:1364–1376. doi: 10.1007/s00266-023-03302-5

Purpose The advent of artificial intelligence (AI) software has spurred a number of applications to consolidate data but also perform tasks, both of which have potential to augment patient care. The aim of this study is to assess the usefulness of the AI search engine ChatGPT in the aesthetic field for patients via evaluation of the accuracy and literacy of the information it can provide.

Materials and Methods Ten of the most common aesthetic procedures were selected as the search topics. Patient information on these topics from The Aesthetic Society website were extracted, along with outputs from the ChatGPT search. ChatGPT was then asked to improve on the readability of its outputs. Readability scores were compared between The Aesthetic Society and ChatGPT, as well as between ChatGPT (pre-readability adjustment) and ChatGPT (post-readability adjustment), via t-tests. Readability was analyzed using established tests: Coleman-Liau, Flesch-Kincaid, Flesch Reading Ease Index, FORCAST Readability Formula, Fry Graph, Gunning Fog Index, New Dale-Chall Formula, New Fog Count, Raygor Readability Estimate, and Simple Measure of Gobbledygook (SMOG) Readability Formula.

Results The mean reading grade level for patient information extracted from The Aesthetic Society website was 9.55 at the high school grade level whereas mean reading ease scores was 61.23 at the standard level. Mean reading grade level for aesthetic information extracted from ChatGPT was 12.12, whereas mean reading ease score was 47.87, falling in the difficult level. Mean reading grade level for ChatGPT (post-readability adjustment) was 6.65 and mean reading ease score was 71.23 at the fairly easy level. There was a significant difference in reading grade level and reading ease (p<0.001) between both The Aesthetic Society and ChatGPT aesthetic information, as well as between ChatGPT (pre-readability adjustment) and ChatGPT (post-readability adjustment). ChatGPT text was accurate in comparison to that of The Aesthetic Society, although shorter in length and scope.

Conclusion Although ChatGPT extracted patient information at baseline is significantly more difficult than that from The Aesthetic Society, with both above that of the average American adult middle school level, ChatGPT does have potential to efficiently create accurate, more readable texts to improve health literacy for aesthetic patients.

Purpose: Temporal patterns of burn admissions have been demonstrated throughout the day, week, and year, while additional research shows trauma admission peaks in the summer, October, and December. The purpose of this study is to analyze adult and pediatric burn admissions surrounding major United States (US) holidays to identify periods of time that require increased resource allocation and targeted patient education.

Methods: A retrospective review of all patients admitted to a large urban burn center from January 2015 to December 2023 was conducted. Patients admitted within 48 hours of major holidays were included, and patients in the control cohort were identified as patients admitted at other time points. Demographics, burn injury data, and treatment course data were extracted. Independent sample t-tests were used to compare admissions across holidays and descriptive statistics were used to present Independence Day data.

Results: Of the major US holidays assessed (New Years, Memorial Day, Labor Day, Independence Day, Halloween, Thanksgiving, Christmas), only Independence Day showed a significantly higher burn admission rate (n = 1.55 burns/day) when compared to the control group (n = 0.91 burns/day) (p = 0.0001). A total of 62 patients were admitted within 48 hours of Independence Day, of which 62.9% (n = 39) were male. The mean patient age was 28.1 (SD = 20.8), which was younger than the mean age of the control population (p = 0.0001). Most patients were hispanic or latino (58.1%, n = 36), single (56.5%, n = 35), housed (96.8%, n = 60), and insured through the government (74.2%, n = 46). On average, patients presented for care 2.43 days post injury (SD = 4.2). Burn etiology included firework (41.9%, n = 26), flame (21.0%, n = 13), scald (14.5%, n = 9), contact (9.7%, n = 6), chemical (4.8%, n = 3), and other (8.1%, n = 5). Of note, firework burns comprised 0.7% (n = 18) of control group injury (p = 0.000). Inhalational injury was rare (1.6%, n = 1). The mean total body surface area burned was 9.5% (SD = 15.5). A total of 9.7% (n = 6) and 27.4% (n = 17) of patients screened positive for alcohol and illicit drugs on admission, respectively. Surgical intervention was necessary for 29.0% (n = 18) of patients with 11.3% (n = 7) requiring multiple operations. Intensive care was required by 25.8% (n = 16) patients, of which 9.7% (n = 6) required mechanical ventilation. Mean hospital length of stay was 8.3 days (SD = 11.2) and the in-hospital mortality rate was 3.2% (n = 2).

Conclusion: Burn admissions at this large urban burn center significantly increased on Independence Day, with no significant variation across other US holidays. The characterization of patients and injuries should be used by burn units nationwide to allocate staff and material resources at this time of year. Additionally, risk of burn is associated with holiday specific activity and younger patient age. This calls for community level intervention, specifically burn education and prevention with special focus on Independence Day precautions.

Introduction: Complex facial trauma presents a challenge to the reconstructive surgeon as the loss of facial buttresses makes accurate reduction of fractures more and more difficult. Accurate 3D printed models and virtual surgical planning have become a mainstay in many other aspects of craniomaxillofacial surgery. However, turnaround times from industry produced models frequently preclude their use in the unplanned acute surgical setting. Purpose: We seek to evaluate the use of in-house printed 3D models for facial trauma and the efficacy and safety of the procedures performed with the aid of these models. Methods: All patients from January 2017 to August 2023 that received an in-house 3D printed model to help treat facial fractures were analyzed. Chart review was performed to extract demographic data, fracture type, mechanism, complications, comorbidities, and operative time. Analysis was performed in Microsoft Excel. Results: A total of 24 patients had 3D models created for facial fractures. The average age was 24.5 years. Motorized vehicles were involved in 15 cases (62.5%). The most commonly injured region was the midface (19 patients; 79.2%) and 8 patients had true panfacial fractures (33.3%). 17 patients (71%) had complex fractures involving multiple buttresses. For acute treatments, average time from presentation to operative treatment was 9 days. Average operative time was 282 minutes. 3 patients (12.5%) had minor complications, including localized infection treated with antibiotics and a small wound dehiscence. 2 patients (6.25%) had major complications: a draining sinus tract that required excision and a cicatricial lagophthalmos due to a laceration near the eyelid margin. 96% of patients had satisfactory facial contour. Conclusion: 3D printing anatomical models can be helpful in assisting surgical decision making for patients with facial fractures as well as the process of surgery itself by allowing for pre-bending of plates. In the acute setting, when turnaround times are short, in-house 3D printing can produce models in a timely fashion to help surgeons operate safely and efficaciously.

Introduction: Plastic surgeons may be involved in lawsuits claiming fraudulent practices. Research on the prevalence and nature of these incidents in plastic surgery is limited. In this study, we utilized an academic legal database to analyze the characteristics of these lawsuits in plastic surgery. To our knowledge, this is the only study in the literature to investigate fraud lawsuits involving plastic surgeons.

Methods: A retrospective review of all jury verdicts and settlements from appellate state and federal cases that involved a fraud claim from 1990 through 2020 was queried using the LexisNexis legal database. A total non-representative sample of 148 cases was collected. Of these, 44 met criteria for lawsuits involving fraud filed by or against a plastic surgeon(s). Cases were analyzed for demographics of plaintiffs and defendants, type of fraud claim, location, verdict or settlement results, and compensation.

Results: Of the 44 cases analyzed, 40 involved male surgeons. Majority of cases involved aesthetic surgery, with only 6 (15%) of the lawsuits involving cases of reconstruction. All cases involved plastic surgeons operating in a private practice setting, with Texas being the most commonly involved state (15). The most common fraud type was malpractice fraud (26), followed by deceptive trade practice (7) and business fraud (5). There were 4 cases of contract fraud and 3 cases of billing/insurance fraud. Amongst all cases, 15 were ruled in favor of the plastic surgeon and 12 were settled; of the cases ruled in favor of the opposite party, almost all involved fraud claims related to malpractice.

Conclusion: Lawsuits related to plastic surgery that involve allegations of fraud have arisen in multiple contexts such as malpractice, deceptive trade practices, contracts, and billing disputes. All cases identified occurred in private practice, with claims involving malpractice in the setting of aesthetic surgery being the most common.

Purpose: Facial reanimation procedures mitigate functional and psychosocial impairments associated with facial paralysis. While sling-type procedures offer static solutions for achieving resting facial symmetry in adult facial paralysis, nerve repair or transfer procedures aim to restore dynamic movement and natural facial expression by reestablishing nerve function and connectivity to facial musculature. Though the choice between these approaches depends on several patient factors, literature suggests many surgeons have a preferred reanimation technique (1). Our analysis examines trends in nerve-type versus sling-type reanimation procedures in the Medicare population from 2000 through 2022.

Methods: We conducted an analysis of Medicare Part B National Summary Data files from 2000 to 2022, identifying the annual frequency of each service by its associated Current Procedural Terminology (CPT) code. Procedure categories included CPT codes for facial reanimation (64716, 64864, 64865, 64868, 64886, 15840, 15841, 15842, and 15845), with separate analysis for codes associated with definitive facial nerve transection (42425 and 64742). Other commonly used codes (64885, 64910, 65727, 67917, 67912, 61590, 67900) were excluded from primary analysis due to redundancy with other nerve repair or ophthalmic procedures. Repair codes were classified into nerve-type repairs and non-nerve or sling-type repairs, consistent with previously published literature (2,3). Trends in total services performed by physicians were longitudinally analyzed from 2000 to 2022. Utilization rates for each procedure type category were compared and used to estimate trends in dynamic reanimation procedures versus static, sling-type procedures.

Results: Sling-type procedures saw a 37% increase in utilization from 2000 to 2011, followed by a 34% decrease from 2011 to 2022, resulting in a net 10% decrease over 22 years. Conversely, nerve repair procedures experienced a 118% increase from 2000 to 2011 and a 72% increase from 2011 to 2022, totaling a near 280% rise from 2000 to 2022, with 1,779 procedures billed in 2022 compared to 472 in 2000. Notably, CPT code 15842, representing free muscle flap with microsurgical technique for facial nerve paralysis, saw a 90% increase in allowed service from 2000 to 2022. In 2000, sling type repairs and nerve type repairs were evenly distributed, with each constituting approximately 50% of facial reanimation procedures. However, by 2011, the proportion of sling repair procedures relative to nerve repairs decreased to 37%. This trend continued, with sling repairs comprising only 19% of procedures by 2022, indicating a significant decline in comparison to nerve type facial reanimation procedure trends.

Conclusion: Our analysis underscores a notable shift towards nerve-based procedures in facial reanimation, highlighting evolving trends in the surgical management of facial nerve injuries over the last twenty-two years. Further research is warranted to clarify differences between specialties in management preferences, as well as geographical trends in the adoption of these techniques.

References: 1. Oyer, Samuel L., et al. "Comparison of objective outcomes in dynamic lower facial reanimation with temporalis tendon and gracilis free muscle transfer." JAMA otolaryngology–head & neck surgery 144.12 (2018): 1162-1168. 2. Crawford, Kayva L., et al. "Race and sex demographics in the surgical management of facial nerve palsy." Laryngoscope Investigative Otolaryngology (2023). 3. Lu, G. Nina, et al. "Analysis of facial reanimation procedures performed concurrently with total parotidectomy and facial nerve sacrifice." JAMA Facial Plastic Surgery 21.1 (2019): 50-55.

Introduction: Breast implant illness (BII), also known as autoimmune/inflammatory syndrome induced by adjuvants (ASIA), describes a cluster of patient-reported autoimmune-like symptoms following silicone breast implant surgery. The most agreed upon hypothesis is that BII is a result of an autoimmune or inflammatory reaction, though the exact etiology of this condition remains unknown and its existence remains controversial. Despite this, the patient experience with BII cannot be ignored, as devastating, life altering effects have been described. Here, we analyze the online support groups for BII patients to understand the needs of this unique population.

Methods: A systematic search for BII support groups on FaceBook was conducted and all English-language groups active in the last six years were included. Posts were read by two independent reviewers to understand the needs, goals, and forms of support provided by the users in the group. Data analysis included group metrics and post contents.

Results: A total of 24 support groups were identified, of which 29% (n = 7) were public and 71% (n = 17) were private. Most groups were established between 2015 to 2019 (88%, n = 21), with only an additional 12% (n = 3) formed more recently. The median group size is 1,950 members (interquartile range = 5,078.8). Common post-themes across groups was as follows: reporting symptoms (n = 23), helping others navigate care (n = 22), sharing feelings (n = 21), seeking recommendation for symptom relief (n = 20), seeking recommendation for providers (n = 18), and reporting on interactions with providers (n = 12). Education in the form of sharing articles and videos was common, with one group dedicated to posting peer-reviewed articles. Furthermore, patient frustration was frequently expressed, with regards to lack of diagnosis, conflicting information, and difficulty finding physicians. No individual shared that they were diagnosed with BII, though other diagnoses related to their BII symptoms included a spectrum of autoimmune disorders, chronic pain/fatigue, anaplastic large cell lymphoma, anxiety, depression, fibromyalgia, postural orthostatic tachycardia syndrome, and monoclonal gammopathy of unknown significance. Many patients reported symptom relief after explant in 63% (n = 15) of groups.

Conclusion: Patients reporting BII symptoms are actively using online support groups to share experiences, recommend providers, offer emotional support, and educate others. Frustration with lack of diagnosis is clear among users, which helps to understand the high level of activity on these platforms. Patients are seeking empathy and understanding from both peers and providers, as well as advocating for increased attention to BII symptomatology. Providers can use this information to best address patient concerns within limited time during encounters.

Background
Carpal tunnel syndrome (CTS) is a common median nerve neuropathy, constituting 90% of all neuropathies.[1]Treatment options for CTS range from conservative measures to surgical intervention, with options including open or endoscopic carpal tunnel release (CTR). Although both surgical approaches aim to decompress the median nerve through transverse carpal ligament division, they vary in incision size and instrumentation.[2] It is unknown how these differences affect early post-operative outcomes, as a consensus has not been reached in the literature.[3] Presently, several randomized controlled trials have investigated post-operative outcomes between open and endoscopic CTR using validated patient measures.[4, 5] However, to date, no prospective-matched cohort analysis has assessed the early post-operative outcomes using well-defined hand and upper extremity patient-reported outcome (PRO) measures such as the Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) surveys. Hence, this study seeks to fill this gap, focusing on early PROs.

Methods
We conducted a single-institution prospective cohort study of patients undergoing either endoscopic or open carpal tunnel release as index operations from August 2023 to January 2024. Patients planning to undergo CTR were enrolled before their surgery. At enrollment, the following patient demographic data were recorded: age, sex, race/ethnicity, BMI, comorbidities, and insurance status. Exclusion criteria included age < 18, previous need for revision, EMG-documented peripheral neuropathy, and uncontrolled diabetes. Outcome variables measured included QuickDash Outcome and PROMIS scores. These were evaluated preoperatively and postoperatively at 1 week and 6 weeks.

Results
Seventy-six patients were included. The endoscopic (n = 27) and open (n = 49) CTR cohorts were comparable when assessing age, sex, race/ethnicity, BMI, insurance status, and comorbid conditions. Preoperatively, there were no significant differences in QuickDash and PROMIS scores between the two cohorts. Postoperatively, patients undergoing endoscopic CTR exhibited significantly improved QuickDash and PROMIS Upper Extremity scores at 1 week compared to the open CTR cohort (p = 0.0419 and p = 0.0145, respectively). However, at 6 weeks postoperatively, no significant differences in PROs were observed between the two cohorts.

Conclusions
In this prospective matched cohort analysis, patients undergoing endoscopic CTR demonstrated significantly improved upper extremity function and decreased disability at 1 week postoperatively as evidenced by a greater improvement in QuickDASH and PROMIS scores. While endoscopic CTR facilitated an earlier return to function and relief of symptoms compared to open CTR, these differences normalized by the sixth week after surgery.

References

1. Aboonq, M.S., Pathophysiology of carpal tunnel syndrome. Neurosciences (Riyadh), 2015. 20(1): p. 4-9.
2. Kim, P.T., et al., Current approaches for carpal tunnel syndrome. Clin Orthop Surg, 2014. 6(3): p. 253-7.
3. Miles, M.R., et al., Early Outcomes of Endoscopic Versus Open Carpal Tunnel Release. J Hand Surg Am, 2021. 46(10): p. 868-876.
4. Atroshi, I., et al., Extended Follow-up of a Randomized Clinical Trial of Open vs Endoscopic Release Surgery for Carpal Tunnel Syndrome. Jama, 2015. 314(13): p. 1399-401.
5. Kang, H.J., et al., Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial. Clin Orthop Relat Res, 2013. 471(5): p. 1548-54.

Background: Perforating vessels from the deep inferior epigastric pedicle can in some instances travel around the medial edge of the rectus abdominis muscle without passing through any portion of the muscle itself. Such "paramuscular" perforators do not require any muscular dissection and allow for a longer pedicle length, and thus are highly favorable for use in deep inferior epigastric perforator (DIEP) flap breast reconstruction procedures. Recently developed advanced imaging modalities now allow for enhanced identification and greater quantitative description than previously possible. Therefore, the purpose of this study was to utilize high-resolution magnetic resonance angiography (MRA) to quantify the presence and anatomic characteristics of paramuscular perforators.

Methods: A retrospective institutional review was conducted of patients who underwent DIEP flap breast reconstruction between 2016 and 2023. Patients who had a preoperative MRA of their abdominal vascularization were included. Patient demographics and anatomic variables of any paramuscular perforators were collected. Descriptive statistics was performed to analyze the incidence of the perforator and the average infraumbilical distance among the cohort. The p-value was set to 0.05 for relative variables.

Results: MRA series from 517 patients met the criteria and were analyzed. A total of 72 paramuscular perforators were identified in 64 patients. Paramuscular perforators were unilaterally present in 10.8% (n=56) of patients and bilaterally present in 1.5% (n=8) of patients. When unilaterally present, paramuscular perforators were found on the right side in 38 patients and on the left side in 18 patients (p<0.001). The mean infraumbilical distance of the right-sided paramuscular perforators was 4.6 ± 2.5 cm, and left-sided paramuscular perforators was 4.1 ± 1.8 cm.

Conclusions: By utilizing high-resolution MRA imaging the present study found that paramuscular perforators were unilaterally present in 10.8% of patients and bilaterally present in 1.5% of patients. Furthermore, when unilaterally present, paramuscular perforators were more than twice as likely to be present on the right side as on the left side.

Purpose: Greater pain and opioid consumption in the acute postoperative period have been associated with chronic pain following breast cancer surgery (1,2). However, factors affecting acute postoperative pain following breast reconstruction are not well studied (3,4). The present study investigated the characteristics and predictive factors of acute postoperative pain and opioid requirements following deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods: A retrospective chart review was conducted of patients receiving DIEP flap breast reconstruction between 2019 and 2023. Patient-reported pain (0-10 Numerical Rating Scale [NRS]) scores and postoperative inpatient opioid requirements (morphine milli-equivalents [MMEs]) were collected and stratified based on patient variables. Predictive factors for postoperative pain and opioid requirements were investigated using linear regression analyses.

Results: A total of 209 patients (306 breasts) were included in the study. Overall, patients reported average and maximal pain scores of 1.6 and 5.6 within 24 hours of admission, and 2.0 and 8.0 over the entire hospital stay (mean 88.2 hours), respectively. Mean postoperative opioid requirements totaled 101 MMEs. White patients experienced greater average pain than their Black and Asian counterparts (P = 0.046), though they were only given significantly more opioids than Asian patients (P = 0.040). Patients identifying as Hispanic received more opioids than non-Hispanic patients (P < 0.01) though pain scores were similar (P = 0.21). Patients receiving abdominal nerve blocks had less pain (P < 0.01) and opioid requirements (P = 0.014); the addition of a chest nerve block did not affect either outcome. Patients with history of smoking (P < 0.01) or psychiatric diagnoses (P < 0.01) also experienced more pain, though only the latter had greater opioid requirements (P = 0.015). A multivariable linear regression model revealed that higher average pain scores throughout the hospital stay was predicted by younger age, greater pain within the first 24 hours, and greater maximal pain overall (adjusted R2 = 0.657, P < 0.01). Higher opioid consumption was predicted by higher average pain scores, longer hospital stays, current marijuana use, and identifying as Hispanic (adjusted R2 = 0.555, P < 0.01). Prior opioid prescriptions, insurance type, BMI, laterality, timing of reconstruction (delayed vs immediate), procedure time, intraoperative opioid requirements, and intraoperative temperatures were not independent predictors of pain or opioid requirements.

Conclusion: These results offer valuable insights into the complex interplay of demographic and historical variables as predictors of acute postoperative pain and opioid use. Interestingly, factors like race, ethnicity, smoking, and marijuana use exhibited varying impact on pain scores and opioid requirements, highlighting the need for further investigation in future studies. These findings will inform patient discussions and targeted interventions to mitigate chronic pain and opioid misuse following breast reconstruction.

References 1. J Ghadimi D, Looha MA, Akbari ME, Akbari A. Predictors of postoperative pain six months after breast surgery. Sci Rep. 2023;13(1):8302. Published 2023 May 23. doi:10.1038/s41598-023-35426-8 2. Wang L, Guyatt GH, Kennedy SA, et al. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ. 2016;188(14):E352-E361. doi:10.1503/cmaj.151276 3. Chu JJ, Janis JE, Skoracki R, Barker JC. Opioid Overprescribing and Procedure-Specific Opioid Consumption Patterns for Plastic and Reconstructive Surgery Patients. Plastic and Reconstructive Surgery. 2021;147(4):669e. doi:10.1097/PRS.0000000000007782 4. Egan KG, De Souza M, Muenks E, Nazir N, Korentager R. Predictors of Opioid Consumption in Immediate, Implant-Based Breast Reconstruction. Plast Reconstr Surg. 2020;146(4):734-741. doi:10.1097/PRS.0000000000007150

-- RISK OF BLEEDING AFTER THE USE OF LOW MOLECULAR WEIGHT HEPARIN IN ABDOMINOPLASTY -- Nicolle Victoria Costa de Andrade, MD -- FACIAL SUSPENSION AND RECONSTRUCTION OF THE NASOLABIAL FOLD WITH THE USE OF LOCAL DERMAL-FAT FLAP -- Nicolle Victoria Costa de Andrade, MD -- STROMAL VASCULAR FRACTION ASSOCIATED WITH ACELLULAR DERMAL MATRIX ON THE HEALING OF SKIN WOUNDS IN RABBITS - COLLAGENIC, ANGIOGENIC AND HEALING POTENTIAL -- Nicolle Victoria Costa de Andrade, MD -- CLINICAL APPLICATIONS OF STROMAL VASCULAR FRACTION: A SYSTEMATIC REVIEW -- Ana Belen Gutierrez Rodriguez, MD -- EXPERIMENTAL ANIMAL MODELS IN FACIAL TRANSPLANTATION RESEARCH- A SYSTEMATIC REVIEW -- Ana Belen Gutierrez Rodriguez, MD -- Assessment of Critical Tissue Perfusion - Thermal vs Hyperspectral Imaging -- Zlatko Vlajcic, MD -- The use of OASIS Extracellular matrix in complex reconstruction of the lower leg after massive avulsion --Davor Jurisic, MD -- Efficacy of proximal medial branch in DIEP flap for breast reconstruction using Hartrampf zone IV -- Hitomi Matsutani -- Artificial Intelligence-Based Aesthetic Outcome Evaluation for Mandibular Reconstruction - Comparison among Vascularized Bone Grafts, Mandibular Reconstruction Plates, and Soft Tissue Flaps -- Takeaki Hidaka, MD -- Surgical Management and Early Recurrence of Extracranial Arteriovenous Malformations: A 15-Year Retrospective Cohort Study in Japan -- Makoto Shiraishi, MD -- AI-driven 3D video analysis in facial palsy: validity on face angles toward an assessment of spontaneous smile -- Keigo Narita, MD -- Potential anti-cancer effect of vascularized lymph node transfer Erika Kusajima -- Vascular Variation of Temporoparietal fascia in Microtia Associated with Hemifacial Microsomia Hojin Park -- Long-term Volumetric Stability of Diced ADM in Oncoplastic Breast Surgery Jeong Jin Park -- Surgical management of the hand in 
Apert Syndrome: a 27-year experience. Rini Vyas -- Papaverine Loaded Injectable and Thermosensitive Hydrogel System for Prevention of Vascular Spasm to Improve Flap Survival in Rat Dorsal Skin Flaps --
Hwan Jun Choi, MD -- Minimum skin incision extended endoscopic LD flap for breast reconstruction using a two-step port penetration technique and a tip movable endoscope -- Shinsuke Akita, MD -- Generating Evidence in Plastic Surgery using Wearable Technology: a Series of Cohort studies -- Richard Kwasnicki, MD -- Impact of SARS-CoV-2 pandemic on diagnosis and management of non-melanoma skin cancers: the popcorn effect -- Giulia Tringale, MD

Objective: The frequency of performing male to female gender affirming surgery has increased over the past decade, indicating the importance of characterizing the complication profile. Therefore, we performed a multi-institutional analysis to present the postoperative outcomes and risk factors for adverse events after male to female gender affirming surgery.

Methods: Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2021). Patients were identified by those that underwent procedure CPT 55970; intersex-male to female surgery. The postoperative outcomes included 30-day reoperation, readmission, and surgical and medical complications. Demographic factors, medical comorbidities, and preoperative laboratory values were analyzed using univariate and multiple logistic regression to determine risk factors for complication occurrence.

Results: We identified 376 patients who underwent surgery from 2011-2021. The average patient age was 35.9±12 years, with most patients being white (n=266; 71%) and documented as female (n=273, 73%). The average number of concurrent procedures was 3.5±3.6 and operation time was 250 ±93 minutes. Complication rate was 15% (n=56), with wound disruption (n=30, 8%), readmission (n=13, 3.5%) and return to OR (n=10; 2.7%) accounting for the most common adverse events. For every minute increase in operation time, the odds of a surgical complication were 1.004 (p<0.0001) higher and the odds of any complication were 1.006 (p<0.0001) higher. The odds of a surgical complication were 2.5 (p=0.015) times higher in smoking patients.

Conclusion: Wound disruption made up the majority of complications for male to female gender affirming surgery, indicating an important outcome to assess for postoperatively. There are no preoperative factors that can be optimized to improve outcomes except for smoking cessation, which is well-established and supported by this analysis. In addition, when operative planning physicians should expect that any additional time in the OR increases chances of complications.