Publications

BACKGROUND: Telemedicine revolutionized healthcare post-COVID-19 by expanding virtual care across consultations, post-operative care, and inter-physician collaboration. However, its impact on adoption and effectiveness in plastic surgery remains underexplored. This study systematically compares pre- and post-pandemic telemedicine in plastic surgery, focusing on outcomes, accessibility, and patient satisfaction to inform best practices.

METHODS: A systematic review was conducted using PubMed, Medline, and Web of Science, following PRISMA guidelines, for articles published through November 2024. Extracted data included author, year, country, subspecialty, pandemic classification, sample size, demographics, utilization, barriers, travel time/distance, satisfaction, complications, and appointment duration. Meta-analyses calculated pooled estimates with 95% confidence intervals. Meta-regression and Welch's t-test assessed pre- versus post-pandemic differences. Analyses were performed in R 4.4.1.

RESULTS: Of 450 identified publications, 72 met inclusion criteria, encompassing 9435 subjects (mean age: 47.99). 89.3% (95% CI 59.3-96.2%) of patients reported willingness to reuse telemedicine, and the pooled satisfaction rate was 83.9% (95% CI 79.4-88.5; p < 0.05). Meta-analysis showed significant reductions in travel time (120 min; p < 0.05) and distance (187.1 km; p < 0.05). Five studies reported a mean appointment duration of 16.07 min. Complications were rare (7.7%; 95% CI 2.9-18.6%; p < 0.05). Post-pandemic satisfaction score was lower (81.1 vs. 91.2; p = 0.0315), likely reflecting increased utilization and technological barriers. Other outcomes, including complication rates and willingness to reuse telemedicine, showed no significant difference (p > 0.05).

CONCLUSION: Telemedicine plays an evolving role in plastic surgery, reducing travel burden and maintaining safety. However, lower post-pandemic satisfaction highlights the need to improve accessibility and technology to optimize outcomes.

LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Digital nerve repair is a procedure performed to restore sensation in fingers. While surgical microscopes are used to achieve optimal outcomes, their cost may limit accessibility. Loupes, in contrast, offer a more affordable alternative, particularly in resource-limited settings. This study compares the risk of developing skin sensation disturbances in patients who underwent digital nerve repair using microscopes versus loupes.

METHODS: The TriNetX database was queried to identify patients who underwent digital nerve repair. Patients were classified into two cohorts: microscope and loupes groups. A propensity score matching analysis was performed, adjusted for multiple covariates. The primary outcome was paresthesia, while secondary outcomes included anesthesia, hypoesthesia, and hyperesthesia. These outcomes were assessed at 3, 6, and 12 months following surgery.

RESULTS: After matching, the microscope group consisted of 1208 patients, with the same number in the loupes group. At 3, 6, and 12 months following surgery, the risk of developing skin sensation disturbances was not significantly different between the two groups. At 12 months, the risk ratios (RR) for the outcomes were as follows: paresthesia (RR 1.24, p = 0.379), anesthesia (RR 1.50, p = 0.102), hypoesthesia (RR 1.71, p = 0.102), and hyperesthesia (RR 1.71, p = 0.102).

CONCLUSION: The use of loupes for digital nerve repair appears to yield outcomes comparable to those achieved with a microscope in terms of sensation disturbances.

BACKGROUND: Postoperative pain following open mandible fracture repair is common and often necessitates opioid analgesia, which carries the risk of opioid use disorder. Methylprednisolone, a potent perioperative antiinflammatory agent, may reduce pain and subsequent opioid requirements. This study investigates whether perioperative methylprednisolone use decreases opioid consumption in the postoperative period after open mandible fracture repair.

METHODS: The TriNetX database was queried to identify patients who underwent open repair of mandibular fractures. Patients were stratified into an exposed cohort (who received methylprednisolone) and a control cohort (who received no methylprednisolone). Propensity score matching was performed to adjust for opioid use risk factors. The primary outcome was opioid use, with secondary outcomes including wound complications (external and internal dehiscence) and infectious complications (surgical site infection, pneumonia, urinary tract infection, and intravenous catheter infection). Risk estimates and Kaplan-Meier survival analyses were performed at 7 and 30 days.

RESULTS: After matching, 1967 patients were included in each cohort. At 7 days following surgery, patients who received methylprednisolone had a significantly decreased risk of opioid use (risk ratio [RR] 0.63, P<0.001) compared with the control cohort. Similarly, at 30 days following surgery, the exposed cohort had a significantly decreased risk of opioid use (RR 0.76, P<0.001) compared with the control cohort. No significant differences were observed in wound or infectious complications.

CONCLUSION: In this large retrospective study, perioperative methylprednisolone use during open mandible fracture repair was associated with reduced opioid requirements, without increasing wound or infectious complications.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand operative techniques for harvesting several different types of free flaps with sensory innervation. 2. Describe options for donor nerves for common recipient locations. 3. Discuss the clinical outcomes, advantages, and special considerations for free flap neurotization.

SUMMARY: As techniques have advanced in autologous free tissue transfer, increasing focus has been placed on functional reconstruction that not only achieves soft-tissue coverage but also maximizes overall function. One recent trend is the increasing use of neurotized free flaps to improve the sensibility of free flap reconstruction. Restoration of sensation to a reconstruction not only provides critically protective sensation but can also help to restore a sense of self and incorporation of the reconstructed tissues. In this article, the authors discuss recent trends and techniques in free flap neurotization.

PURPOSE: Obesity is a known risk factor for complications in autologous breast reconstruction, yet few studies evaluate outcomes after massive weight loss. As the incidence of bariatric procedures increase, more post-weight loss patients will seek reconstruction. This study compares surgical outcomes in patients with and without bariatric surgery, addressing a critical area in reconstructive planning.

METHODS: A retrospective cohort study was conducted using the TrinetX network, querying a database of 133 million US medical records over 20 years. Patients undergoing autologous breast reconstruction were identified. Nutritional laboratory values were compared at the time of bariatric surgery and reconstruction, and a secondary analysis compared outcomes in patients with prior bariatric surgery versus GLP-1 receptor agonist exposure. Outcomes up to 180 days post-surgery were compared for patients with a history of bariatric surgery and those without. Primary outcomes included fluid collection requiring drainage, hematoma, seroma, dehiscence, infection, cellulitis, fat necrosis, flap failure, embolism/thrombosis, and blood transfusion within 180 days post-reconstruction. Firth's adjusted logistic regression analyses and Kaplan-Meier survival analyses were conducted to assess complication risks and the impact of surgical timing. Subgroup analyses were performed based on flap type and BMI changes.

RESULTS: A total of 91 patients with a history of bariatric surgery and 15,847 without were identified. Patients with a history of bariatric surgery experienced significant BMI reduction (mean decrease 8.81 kg/m 2 , P < 0.001), yet presented with higher perioperative BMIs at reconstruction ( P = 0.04). Controlling for demographic factors and patient comorbidities, bariatric surgery was independently associated with higher risks of fluid collections requiring drainage (OR: 2.21, P = 0.013), seroma (OR: 2.56, P = 0.025), dehiscence (OR: 2.45, P = 0.005), and hematoma (OR: 2.28, P = 0.019). Postoperative complication rates varied significantly by reconstructive flap type. Total protein levels were significantly lower at the time of reconstruction in post-bariatric patients, while albumin and micronutrient levels were largely preserved. Compared with GLP-1 receptor agonist users, post-bariatric patients had a higher risk of blood transfusion.

CONCLUSION: Patients with a history of bariatric surgery undergoing autologous breast reconstruction face elevated risks for postoperative complications. Individualized surgical planning and rigorous perioperative monitoring are recommended to optimize outcomes.

INTRODUCTION: Declining Medicare reimbursement rates have generated financial pressures for surgeons providing services to patients with Medicare. The purpose of this study was to determine the overall prevalence and characteristics of plastic and reconstructive surgeons not participating in Medicare.

METHODS: This was a cross-sectional analysis of plastic and reconstructive surgeons in the United States. Data from the Centers for Medicare and Medicaid Services were obtained from 2000 to 2025 including the names and practice locations of physicians who opted out of Medicare. The overall prevalence of physicians opting out of Medicare was calculated for the top twenty-five specialties by number of physicians.

RESULTS: In 2025, there were 354 plastic and reconstructive surgeons in the Medicare non-participation group (8.3%) and this prevalence increased over the study period (0 to 8.3%, P<0.001). Most plastic and reconstructive surgeons opted out of Medicare at ≥30 years (48.6%) after medical school graduation. The top subspecialties represented in the Medicare non-participation group were aesthetic surgery (13.1%) and hand surgery (7.6%). The West (12.2%) had the highest rate of Medicare non-participation, and the Midwest had the lowest rate (4.3%) (P<0.001). The states with the highest rates of Medicare non-participation were Nevada (35.0%), North Dakota (28.6%), Alaska (25.0%), and Arizona (23.3%). Plastic and reconstructive surgery ranked second highest in the rate of Medicare non-participation compared to other specialties.

CONCLUSION: Plastic and reconstructive surgeons exhibited among the highest rates of Medicare non-participation. Future research is needed to understand underlying motivators of plastic and reconstructive surgeons opting out of Medicare.

INTRODUCTION: Previous studies have highlighted emerging deficiencies in the surgical workforce. This study analyzed plastic and reconstructive surgery workforce adequacy in the United States (US).

METHODS: This was a cross-sectional analysis of US-based plastic and reconstructive surgeons leveraging data from the Health Workforce Simulation Model. Demand and supply were defined as the projected number of full-time equivalent physicians needed and working in plastic and reconstructive surgery, respectively. Demand was modeled under status quo and improved access scenarios. Adequacy was defined as the ratio of supply and demand. Linear regression was used to analyze trends from 2024 to 2037.

RESULTS: The supply of plastic and reconstructive surgeons was projected to decrease from 10,310 to 8,540 over the study period (17.2% decrease, P<0.001). Demand was projected to increase under status quo (11,280 to 11,600, 2.8% increase, P<0.001) and improved access (15,290 to 16,270, 6.4% increase, P<0.001) scenarios. As a result, workforce adequacy in plastic and reconstructive surgery was projected to decrease under status quo (91.4% to 73.6%, P<0.001) and improved access (67.4% to 52.5%, P<0.001) scenarios. Non-metropolitan areas were projected to have significantly less workforce adequacy than metropolitan areas. In 2037, states with the lowest projected plastic and reconstructive surgery workforce adequacy were Maine (33.3%), New Mexico (33.3%), Indiana (32.0%), and Arkansas (27.3%).

CONCLUSION: Sizeable projected shortages exist for plastic and reconstructive surgeons, which are greatest in certain states and non-metropolitan areas. Future work is needed to improve the adequacy of the plastic and reconstructive surgery workforce.

BACKGROUND: Peripheral nerve block (PNB) usage in breast reconstruction (BR) improves post-operative pain with minimal risks. This study examined outcomes of patients receiving PNB for post-operative analgesia in BR.

METHODS: A retrospective analysis using the ACS-NSQIP database identified women that underwent BR from 2012-2021. Patients who received regional anesthesia in addition to general anesthesia were included. Patients that received other forms of anesthesia were excluded. Post-operative complications were compared between PNB and non-PNB groups, as well as among BR timing, modality, operative time and ASA class. Group differences assessed via t-tests and Fisher's Exact tests. Multivariate logistic regression assessed whether complications were independently associated with receiving PNBs.

RESULTS: Out of 25,188 patients, 9,429 patients (37.4%) received PNB for perioperative BR analgesia. Patients that received PNBs had longer operative times, more wound complications, reoperations and readmissions. PNB usage was associated with increased likelihood of SSI even when BR modality, timing, operative time and ASA classification were isolated (p<0.05). Further, sub-group analysis revealed PNB use was associated with SSI for all BR modalities and timing.

CONCLUSIONS: The decision to use PNBs in BR should be made with awareness of the associated risk of increased wound complications. Despite that, benefits of PNBs may still very well outweigh these risks for all our patients. However, based on our findings we still suggest increased surveillance and more comprehensive consultation. Further research into the association of PNB usage and wound complications should be performed such that our patients can obtain maximal benefit and minimize unwanted side-effects.

BACKGROUND: Health literacy is an understudied topic among published Spanish resources. Research focused on resources written in English demonstrates that content exceeds the recommended reading level for patients. Given the prevalence of breast reduction procedures and the increase in diverse patients undergoing the procedure in the last few years, this study explores the readability of Spanish information discussing breast reduction surgery by private and academic organizational websites.

METHODS: Using a de-identified Google search engine, we identified the first 20 Spanish websites that provided breast reduction information. Two independent reviewers used the Patient Education and Materials Assessment Tool (PEMAT) and Cultural Sensitivity Assessment Tool (CSAT) to assess understandability, actionability, and cultural sensitivity of each website. The Spanish SMOG readability formula (SOL), Gilliam-Peña-Mountain, the Fry Readability Adaptation for Spanish Evaluation (FRASE), and Crawford assessments were used to assess readability.

RESULTS: Both private- and academic-based websites scored above 70% for understandability but had lower scores for actionability. CSAT scores were just marginally above the threshold. Both private and academic readability assessments revealed consistently high reading grade levels 2 ranging from ninth to eleventh grade, except Crawford scores, which assessed a mean reading level of 6th grade.

CONCLUSION: Websites displaying Spanish content exceed the recommended level for patient educational materials. While the average understandability scores may be satisfactory on some websites, many have room for improvement, specifically regarding actionability. A limited sample size also emphasized the need to advocate for institutions to cater to patients who speak languages other than English. Important Points: Online Spanish resources on breast reduction are often too complex and exceed the recommended reading level for patients. Spanish resources need to be more than simple English translation to promote more cultural sensitivity. There is a significant gap in published online Spanish resources on breast reduction, particularly from academic and private organizations.

LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .