Publications

UNLABELLED: The Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions limiting residents to 80 hours per week in 2003 and further extended restrictions in 2011 to improve resident and patient well-being. Numerous studies have examined the effects of these restrictions on patient outcomes with inconclusive results. Few efforts have been made to examine the impact of this reform on the safety of common plastic surgery procedures. This study seeks to assess the influence of ACGME duty-hour restrictions on patient outcomes, using bilateral breast reduction mammoplasty as a marker for resident involvement and operative autonomy.

METHODS: Bilateral breast reductions performed in the 3 years before and after each reform were collected from the National Inpatient Sample database: pre-duty hours (2000-2002), duty hours (2006-2008), and extended duty hours (2012-2014). Multivariable logistic regression models were constructed to investigate the association between ACGME duty hour restrictions on medical and surgical complications.

RESULTS: Overall, 19,423 bilateral breast reductions were identified. Medical and surgical complication rates in these patients increased with each successive iteration of duty hour restrictions (P < 0.001). The 2003 duty-hour restriction independently associated with increased surgical (OR = 1.51, P < 0.001) and medical complications (OR = 1.85, P < 0.001). The 2011 extended duty-hour restriction was independently associated with increased surgical complications (OR = 1.39, P < 0.001).

CONCLUSIONS: ACGME duty-hour restrictions do not seem associated with better patient outcomes for bilateral breast reduction although there are multiple factors involved. These considerations and consequences should be considered in decisions that affect resident quality of life, education, and patient safety.

Diplopia after rhinoplasty is a rare complication that requires immediate medical attention. Workup should include a complete history and physical examination, appropriate imaging, and consultation with ophthalmology. Diagnosis may be challenging due to the wide differential ranging from dry eyes to orbital emphysema to an acute stroke. Patient evaluation should be expedient, though thorough to facilitate time-sensitive therapeutic interventions. Here, we present a case of transient binocular diplopia presenting 2 days after closed septorhinoplasty. The visual symptoms were attributed to either intra-orbital emphysema or a decompensated exophoria. This is the second documented case of orbital emphysema after rhinoplasty presenting with diplopia. It is the only case with a delayed presentation as well as the only case that resolved after positional maneuvers.

BACKGROUND: With the rapidly changing health care marketplace, there is constant pressure on the health care industry to progress and to ensure high-quality and cost-effective service delivery. The aim of this article is to review the economic value and to evaluate the effectiveness and safety of the independent services provided by physician extenders in plastic surgery.

METHODS: The PubMed database was used to review the literature. The search was performed using key words "plastic surgery AND ("nurse practitioner" OR "physician assistant" OR "physician extenders"). Inclusion criteria were any study that evaluated economic value associated with the integration of the physician extenders as well as safety and effectiveness of the independently provided services by midlevels in plastic surgery.

RESULTS: The PubMed search yielded 182 articles. Following evaluation of the titles and abstracts, 27 articles were included in a qualitative review of content. Of these articles, 10 were ultimately included: four that analyzed economic value and six that evaluated effectiveness and safety of the independently provided services by physician extenders in plastic surgery. All four articles were associated with financial gain and six articles demonstrated safe and effective provision of the independently provided services by physician extenders.

CONCLUSIONS: The integration of physician extenders has the potential to achieve more efficient workflow with well-coordinated and high-quality care for patients. The authors' review suggests the integration of physician extenders in plastic surgery adds economic value to the practice and improves effectiveness and efficiency of the workflow safely.

BACKGROUND:  Microsurgery is a foundational plastic surgery principle. However, public unawareness of microsurgery and its associated rigorous training in the United States may contribute to current misconceptions and undervaluing of plastic and reconstructive surgeons. This study aims to characterize public knowledge of microsurgery.

METHODS:  A cross-sectional survey was conducted from August to September 2021 using Amazon Mechanical Turk to assess baseline public knowledge of microsurgery. A multivariable logistic regression model was constructed to evaluate the association between baseline knowledge and demographic characteristics. Significance was set to a p < 0.05.

RESULTS:  A total of 516 responses were analyzed. The mean age was 36.7 years (standard deviation, 16.04 years; white, 84%; non-Hispanic, 70%). Of those surveyed, 52% agreed that general surgeons perform microsurgery, while only 28% agreed that plastic and reconstructive surgeons perform microsurgery. When asked if head and neck reconstruction, breast reconstruction, and finger replantation required microsurgery, only 28, 41, and 41% of respondents agreed, respectively. When controlled for sociodemographic factors, Hispanics had significantly more odds to mistake that head and neck reconstruction did not require microsurgery (odds ratio [OR] 95% CI 0.49; 0.30-0.80; p = 0.004) and less odds to consider plastic and reconstructive surgeons for reconstruction (OR 0.51; 95% CI 0.32-0.84; p = 0.008). Females had 1.63 more odds of considering plastic and reconstructive surgeons for reconstruction (95% CI 1.09-2.43; p = 0.017). Low-educated participants had significantly more odds to consider general surgeons as those who performed reconstructive microsurgery (OR 8.70; 95% CI 1.09-69.40; p = 0.041).

CONCLUSION:  Misconceptions of microsurgery as a foundational principle of plastic surgery persist and correlate with undervaluing the specialty. Knowledge differs by ethnicity, level of education, and gender. Therefore, patient counseling should use culturally appropriate elements to demystify microsurgery, build value, and better inform risks and benefits.

BACKGROUND: Madelung deformity is a rare congenital hand difference with little known regarding the patient perspective. In this cross-sectional survey study, we harnessed the global reach of social media to understand the clinical spectrum of Madelung deformity and its impact on physical, mental, and social health.

METHODS: A survey was developed based on a previously published protocol and multiple Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. The survey was distributed on several Madelung deformity communities on Facebook and Instagram. T-scores were calculated, interpreted, and compared between patients who underwent surgery and those who did not. Correlations between scores were calculated using the Spearman rank correlation coefficient.

RESULTS: Mean PROMIS scores for adults were as follows: pain intensity, 4.9 ± 2.8; pain interference, 57.6 ± 10.0; upper extremity, 35.2 ± 8.1; depression, 53.8 ± 11.1; anxiety, 55.4 ± 11.4; and ability to participate in social roles and activities, 42.5 ± 7.7. Mean scores for children were as follows: pain intensity, 5.0 ± 2.8; pain interference, 55.7 ± 11.3; upper extremity function, 24.6 ± 10.4; depressive symptoms, 57.7 ± 11.3; anxiety, 57.3 ± 11.9; and peer relationships, 42.2 ± 10.3.

CONCLUSIONS: Madelung deformity has significant effects on patients' physical, mental, and social well-being, even after surgical treatment. Using social media, we were able to compensate for Madelung deformity's rarity by engaging an international audience, demonstrating the feasibility to conduct research through it, and providing a global perspective of the disease entity.

BACKGROUND: Although both botulinum toxin and facial filler injections are safe procedures with high efficacy and patient satisfaction, it is unclear how knowledgeable the general public is about the risks of these common cosmetic, nonsurgical procedures. The goal of this study is to assess public knowledge of the risks of botulinum toxin and facial filler injection, as well as perceived comfort with various providers delivering these injections.

METHODS: A cross-sectional survey was performed through Amazon Mechanical Turk regarding knowledge of the risks of botulinum toxin and facial filler injection, as well as provider and location preferences among adults 18 years and older and currently residing in the United States.

RESULTS: When asked to identify potential risks of botulinum toxin injections from a list, asymmetry, bruising, and drooping of parts of the face were correctly identified by 38%, 40%, and 49% of respondents, respectively. Asymmetry, bruising, blindness, and blood vessel clotting (vascular occlusion) were identified as risks of filler injection by 40%, 51%, 18%, and 19% of respondents, respectively. In addition, plastic surgeons were the most preferred provider for botulinum toxin and facial filler injections, preferred by 43% and 48% of participants, respectively.

CONCLUSIONS: Although most people would consider botulinum toxin or facial filler injections, the potential risks of these procedures, especially the serious risks of facial fillers, may be poorly appreciated by the general public.

BACKGROUND: TikTok is a short-form video social media platform created in 2016 that has rapidly grown in popularity. The aim of this study was to examine trending plastic surgery videos on TikTok and to understand the dynamics of the #PlasticSurgery conversation on this relatively new social media platform.

METHODS: A prospective analysis of TikTok videos identified by directly querying the platform using #PlasticSurgery was performed during November of 2020. Top trending videos at time of data collection, defined as having more than 100,000 likes, were included. Videos were analyzed for user credentials, video engagement (number of views, likes, shares, and comments), associated hashtags, and video purpose and content.

RESULTS: The top 376 trending videos were viewed a total of 1,680,910,700 times at time of analysis. Videos made by board-certified plastic surgeons were, on average, more popular than videos made by non-plastic surgeons [490.4 versus 378.6 million likes ( P = 0.006); 5.1 versus 3.8 billion views ( P = 0.046)]. The most popular procedures featured were augmentation mammaplasty (531,143,800 views; 42,825,400 likes), followed by body contouring procedures such as liposuction and abdominoplasty (276,810,500 views; 22,362,000 likes) and rhinoplasty (243,724,100 views; 27,588,200 likes). Educational videos on average had significantly higher levels of engagement than entertainment-focused videos [549,336 versus 340,163 likes ( P = 0.002); 6.3 versus 2.9 million views ( P < 0.001)].

CONCLUSIONS: Videos about plastic surgery, particularly educational videos by board-certified plastic surgeons, perform exceptionally well on the TikTok platform. TikTok presents an opportunity for plastic surgeons to educate patients about plastic surgery procedures and to present themselves as board-certified plastic surgeons.

BACKGROUND: Following the reopening of elective surgery, the authors' division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential coronavirus disease of 2019 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction.

METHODS: A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient operations. Odds ratios were calculated to determine whether any preoperative factors increased odds of 30-day complications.

RESULTS: A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR, 0.275; 95% CI, 0.047 to 1.618; P = 0.153). Patients with complications had significantly longer median operating times [5.0 hours (interquartile range, 4.0 to 6.0 hours) versus 4.0 hours (interquartile range, 3.0 to 5.0 hours; P = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR, 1.596; 95% CI, 1.039 to 2.451; P = 0.033). Age was independently associated with increased risk of 30-day complication (OR, 1.062; 95% CI, 1.010 to 1.117; P = 0.020).

CONCLUSION: The authors' findings support a continuation of same-day discharge strategy, which could decrease costs for patients and hospitals without increasing complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.