Publications by Type: Journal Article

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.

Background: The US Medical Licensing Examination (USMLE) Step 1 change to pass/fail has been met with mixed reviews, and the impact on medical student education and residency match is unknown. We surveyed medical school student affairs deans regarding their thoughts on the upcoming transition of Step 1 to pass/fail. Methods: A questionnaire was emailed to medical school deans. Deans were asked to rank the importance of the following after the Step 1 reporting change: Step 2 Clinical Knowledge (Step 2 CK), clerkship grades, letters of recommendation, personal statement, medical school reputation, class rank, Medical Student Performance Evaluation, and research. They were asked how the score change will affect curriculum, learning, diversity, and student mental health. Deans were asked to select 5 specialties they thought would be most affected. Results: Regarding perceived importance of residency applications following the scoring change, the most frequent number 1 choice was Step 2 CK. The majority of deans (93.5%, n = 43) felt that the change to pass/fail would benefit medical student education/learning environment; however, most (68.2%, n = 30) did not believe their school curriculum would change. Students applying to dermatology, neurosurgery, orthopedic surgery, ENT, and plastic surgery were felt to be most affected by the scoring change; 58.7% (n = 27) felt it would not adequately address future diversity. Conclusion: The majority of deans feel the USMLE Step 1 change to pass/fail would benefit medical student education. Deans feel that students applying to traditionally more competitive specialties (ie, programs with fewer overall residency positions available) will be most affected.

BACKGROUND: Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS: NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS: A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS: There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

BACKGROUND: The effectiveness of utilizing social media platforms to promote clinical practices and attract patients has been well established. This study aimed to assess what plastic surgery social media content and educational material the public is most responsive to.

METHODS: An anonymous 25-question survey was distributed using REDCap and Amazon's Mechanical Turk to ascertain demographic information, patterns of social media use, levels of interest in plastic surgery, and preferences for plastic surgery content.

RESULTS: Of 401 participants, the typical respondent was between 25 and 34 years old and on social media daily. Almost half of the respondents (46.1%) have intentionally viewed plastic surgery content on social media, of which most used Instagram (71.1%) and Facebook (55.4%). Participants grouped as either younger or older than 35 years old were equally likely to have viewed plastic surgery content (p = 0.33). Content categories with the highest interest were before and after results (mean Likert weight 4.00 ± 1.10), patient testimonials (3.73 ± 1.15), and recovery process (3.67 ± 1.14). Content on celebrities (2.89 ± 1.17), comedic videos (2.79 ± 1.19), and surgeons' private lives (2.51 ± 1.08) received negative interest. Photo posts (51.4%) were preferred more than video posts (27.2%). Before and after results on social media were the most influential factor in the selection of a plastic surgeon (45.9%).

CONCLUSIONS: The importance of social media for plastic surgeons to be able to interact with patients is at unprecedented heights. Understanding patterns of the public's social media content preferences will help plastic surgeons optimize their social media reach and influence their target audience.