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Keloid disorder is a morbid and disfiguring benign fibroproliferative disease with a higher incidence in groups with darker skin pigmentation. Predicting keloidogenesis in patients is difficult with treatment primarily aimed at preventing further scar expansion and improving aesthetics without addressing their unknown underlying pathophysiology. We aimed to identify potential genetic predispositions to keloid scarring in the literature. A search was conducted on 21 August 2023, by the first and second authors independently from 1985 to August 2023 using PubMed, MEDLINE, Embase, Web of Science, Scopus and CINAHL. The following MeSH terms were used: 'Keloid', 'Risk' and 'Genetic'. Two researchers independently searched for studies based on titles and abstracts and screened filtered articles by reviewing full text. If no agreement could be reached, a third senior author designated whether the article should be included. We used the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses 2020 statement as the basis of our organisation. Human studies with genetic analysis to determine an association of a protein or gene to keloidogenesis were selected for inclusion. Studies in languages other than English, reviews, conference articles, and book chapters were excluded. Fifty studies met inclusion criteria. The human leukocyte antigen (HLA) system was broadly implicated, and the DRB1*15 allele was associated with an increased risk of keloid in three separate ethnic groups. Some HLA Class I alleles were associated with keloid in one population but not in others. Additionally, polymorphisms in the E3 ubiquitin‐protein ligase (NEDD4) signal cascade and vitamin D receptor (VDR) have been implicated in diverse groups. No current genetic test can predict keloid risk. Our review identified candidate predisposing genes, including NEDD4, VDR and components of the HLA system. Further studies in heterogeneous populations are needed to identify reliable screening targets. [ABSTRACT FROM AUTHOR]

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Objectives: To perform prolonged ambulatory recordings of antruduodenal motor activity in humans. Methods: Antroduodenal manometric recordings were performed in 20 normal subjects (12 male, eight female, ages 19-41 years), using a 5-channel solid state catheter assembly (three antral, two duodenal transducers) positioned under fluoroscopy. A glass electrode simultaneously recorded pH in the antrum. Results: Continuous, simultaneous recordings of antral and duodenal motor activity were obtained for 22.5 ± 0.3 h. During fasting, 131 complete migrating motor complexes (MMCs) were recorded (6.6 ± 0.9/subject). The average interval from onset of recording to completion of the first MMC cycle was 498 ± 19.24 minutes. Significant diurnal variations were observed in MMC frequency (awake vs asleep: 0.25/subject/h vs 0.64/subject/h; p < 0.05), period (shorter during sleep), phase I duration (longer during sleep), and phase II duration (shorter during sleep). Among females, MMCs were more frequent and shorter. After meal administration, duodenal recording sites demonstrated a typical "fed" response; antral distension and/or retrograde catheter movement, on meal ingestion, however, precluded reliable antral "fed" recordings. Conclusions: Prolonged ambulatory antroduodenal manometry provides detailed and reliable information on fasting antral and duodenal motor activity, antral distension, and/or retrograde catheter migration on meal ingestion; there are limits, however, to the usefulness of this methodology for the evaluation of the fed motor response in the antrum. [ABSTRACT FROM AUTHOR]

Overlapping surgery (OS) occurs when a single surgeon is concurrently caring for patients in multiple operating rooms (OR) but is present for all critical portions of each surgery. Although this is common practice, most studies have found public disapproval of OS. This study aims to better understand attitudes toward OS of patients who gave informed consent for OS. Participant interviews covered topics including trust, OR personnel roles, and attitudes toward OS. Four representative transcripts were distributed among researchers for independent code identification. These were aggregated into a codebook, applied by two coders. Iterative and emergent thematic analyses were done. Twelve participants were interviewed to reach thematic saturation. Three themes shaped how participants felt about OS: trust in their surgeon, worries about OS, and understanding of OR personnel roles. Factors contributing to trust included personal research and the surgeon's experience. Frequently cited concerns were unpredictability of complications during operations and the surgeon's divided attention. Two participants inaccurately understood personnel roles, believing the surgeon did most or all the hands-on work while trainees were observers. Most participants felt a high or neutral level of comfort toward OS and indicated trust as the reason. In contrast to prior research, this study found that most participants had a neutral or positive view of OS. This suggests that a trusting relationship with their surgeon and informed consent are important factors in increasing comfort for OS. Participants who misunderstood OR roles felt less comfortable toward OS. This highlights an opportunity for patient education on trainee roles. [ABSTRACT FROM AUTHOR]

This restrospective cohort study of Medicare payment data found increases in the number of advanced practice providers who bill for plastic and reconstructive surgery care. The growth in advanced practice providers is expected to continue in plastic surgery, and further investigation is needed to effectively integrate these providers into academic centers., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Autologous reconstruction with DIEP flap has illustrated greater patient satisfaction with both aesthetic satisfaction and reconstructive treatment process when compared to implant-based reconstruction longitudinally. However, DIEP flap breast reconstruction is associated with longer in-patient hospitalizations to monitor flap status. This systematic review and meta-analysis aims to report outcomes regarding the use of enhanced recovery after surgery (ERAS) protocols, particularly looking at the impact on complication rates in patients who undergo DIEP flap procedures and are discharged within 5 days after surgery. A computerized search was conducted on September 29th, 2023 using the MeSH terms "Free Tissue Flaps" OR "Myocutaneous Flap" OR "Surgical Flaps" AND "Patient Discharge". Twenty-four papers reporting on 2059 patients were included in the study, and four study groups were created by length of stay as follows: LOS 1-1.99 days = Group 1, LOS 2-2.99 days = Group 2, LOS 3-3.99 = Group 3, and LOS 4-5 days = Group 4 (control). An independent samples t-test was performed to compare the mean rates of each complication between Groups 1 and 4, Groups 2 and 4, and Groups 3 and 4. This meta-analysis showed no significant differences between rates of hematoma, seroma, infection and reoperation between groups. There was a significantly lower rate of total flap loss in all 3 groups with LOS less than 4 days when compared to the group with LOS between 4 and 5 days. This meta-analysis shows that appropriate patients may be discharged safely as early as POD1 following DIEP flap., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Research is a critical component of academic medicine that may or may not be prioritized in centers with high clinical volumes. The benefits of research expansion go beyond notoriety and industry partnerships, expanding into resident training and preparation of the next generation of physician-scientists. Improving a division or department's research portfolio requires a commitment to reorganizing structure, personnel, resources, and a dedication to innovative funding models. To improve research productivity and quality, our group placed several initiatives into motion beginning in August 2017 that we have outlined and evaluated in the present study. Some of these initiatives included restructuring leadership, resourcing both bench and clinical outcomes research, providing initial funding directly from clinical profits and rewarding research fiscally., Methods: Reviews of hiring records, publications, grant allocations, and interviews with key personnel were used to generate a road map of initiatives. Average impact factor was calculated by averaging journal impact factors for all publications from the department each year, excluding any publications with greater than 5 times the raw average, and creating a corrected average that more accurately represented the work. Student t tests were used to compare mean number of publications and impact factors from 2010 to 2017 to those from 2018 to 2022., Results: Prior to restructuring (2010-2017), the department published an average of 9 articles annually, which increased to an average of 42 articles since that time (P < 0.01). Average impact increased from 0 in 2010 to 4.02 in 2022, with the number of publications in top 10 plastic surgery journals following a similar trajectory with 1 publication in 2010 and 31 in 2023. Following an initial $1 million investment to create an institutionally directed fund in 2018, the department leveraged its research to earn $3 million in endowments, $1.25 million in industry partnerships, $3.23 million in Department of Defense funding, and $1.65 million from a multi-institutional National Institutes of Health grant., Conclusion: Deliberate prioritization of research initiatives as noted above has led to remarkable growth in academic output., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: While bibliometric ranking systems have been designed to use citations, funding, and alumni productivity, there is a need for a simple metric that objectively evaluates the work of a group or organization. The present study describes a bibliometric tool, the Departmental Scholarly Index (DSI), for this purpose., Methods: Publications from academic plastic surgery programs in qualifying states of the Southeastern Society of Plastic and Reconstructive Surgeons released in 2022 were collected via PubMed affiliation search. Publications were recorded in a running list alongside the title and 2022 impact factor of their respective journals. The impact factors were averaged by summing the impact factors and dividing by the number of articles to obtain a raw average. Any publication in a journal with an impact factor greater than five multiples of the raw average was removed as an outlier. The remaining impact factors were then summed and give the final numerical value representing the DSI., Results: A total of 464 articles published in 139 individual journals were returned from PubMed between January 1, 2022, and December 31, 2022, for the 22 constituent departments. Calculated Spearman's rank coefficients comparing the DSI ranking with both the Doximity and Persad-Paisley rankings yielded values of 0.66 (P < 0.01) and 0.62 (P < 0.01), respectively. Overall, the DSI rankings largely agree with either the Persad-Paisley or Doximity rankings with notable differences seen in the rankings of Mayo Florida and the University of Alabama. A clear academic ranking of Southeastern Society of Plastic and Reconstructive Surgeons programs was generated from these data., Conclusions: The DSI represents a novel and simple approach to applying objective value to research with the advantage of using data bound to the most recent publication productivity., Competing Interests: Conflicts of interest and sources of funding: None., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Different types of abdominoplasties have been developed to address individual patient characteristics. However, an analysis of complication rates and risk factors for different types of abdominoplasties has yet to be reported., Objectives: The aim of this study was to evaluate the complication rates and risks associated with each type of abdominoplasty., Methods: Utilizing the CosmetAssure database, patients undergoing an abdominoplasty from 2015 to 2022 were identified. Demographic factors and major complications were recorded and analyzed with a chi-square test or analysis of variance. A logistic regression was performed to identify the risk for developing complications associated with each type of abdominoplasty., Results: A total of 55,596 patients underwent an abdominoplasty procedure by any method. The overall complication rate was 2.1%. There was a significant difference in the overall complication rates of all 7 types of abdominoplasties (P < .05), with fleur-de-lis abdominoplasty having the highest complication rate. The year of surgery, being underweight or morbidly obese, having diabetes, and being male placed patients at a significantly higher risk for developing a postoperative complication. Over 15,000 patients (27.2%) had concurrent procedures related to breast surgery, other body contouring, liposuction, or facial surgery. When accounting for various risk factors in a regression model, there was no significant added risk for major complications after a combination procedure with an abdominoplasty compared to abdominoplasty alone., Conclusions: Among the different types of abdominoplasties, a fleur-de-lis abdominoplasty has the highest complication rate. Concurrent cosmetic procedures with an abdominoplasty showed no added risk for major complications when compared to abdominoplasty alone., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Our understanding of facial anatomy has significantly evolved, yet the detailed contraction patterns of facial muscles and their presentation during clinical imaging remain largely unexplored. Understanding the contraction patterns and visual presentation of these muscles, particularly the zygomaticus major could enhance pre-surgical facial assessments and the development of new treatment strategies., Methods: A total of 34 healthy young individuals (17 female, 17 male) with a mean age of 23.6 (2.4) years [range: 20-30] were investigated regarding the length, thickness, width, and angle of the zygomaticus major muscle in five different facial expressions (i.e., repose, anger, joy, surprise, and sadness) utilizing MR imaging., Results: Joyful expressions caused a reduction in muscle length to 85.6% of its original length and an increase in width (103.4%), thickness (108.4%), and facial angle (2.72°) when compared to that in repose, suggesting isotonic contraction. Conversely, expressions of anger, surprise, and sadness generally led to muscle stretching, seen through changes in length (98.9%, 104.3%, and 102.7%, respectively), width (98.8%, 96.5%, and 99.4%, respectively), and thickness (91.2%, 91.0%, and 102.7%, respectively), with variable alterations in facial angle (0.55°, 1.85°, and 1.00°, respectively) depending on the specific expression., Conclusion: This MRI-based study indicates that the zygomaticus major muscle experiences isotonic contraction, characterized by decreased length and increased width and thickness. The findings underline the importance of muscle thickness as a reliable parameter in assessing facial muscle function and offer valuable guidance for practitioners in accurately evaluating muscle performance during different facial expressions., No Level Assigned: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 ., (© 2024. The Author(s).)

Introduction: The thyroid cartilage, an androgen-sensitive structure, enlarges during puberty in individuals assigned male at birth, often resulting in a pronounced neck protuberance. This feature can exacerbate gender dysphoria in transfeminine patients. Chondrolaryngoplasty, commonly known as tracheal shave, is a procedure incorporated into facial feminization surgery (FFS) to address this issue. This study reports on the implementation of an endoscopic-assisted chondrolaryngoplasty technique, its safety, and the outcomes observed., Methods: The authors conducted a retrospective review of chondrolaryngoplasty cases at our center, examining patient outcomes and procedural safety. The analysis included a breakdown of concurrent gender-affirming surgeries performed. An endoscopic-guided technique was utilized, and its procedural steps were documented in a video., Results: In the past five years, 32 patients received chondrolaryngoplasty at our facility. Postoperative complications were minimal, with no infections, wound separations, or surgical site complications reported. Only one patient experienced temporary hoarseness, which resolved within 6 weeks without intervention. The procedure was frequently combined with other surgical interventions, with the average patient undergoing 3 additional procedures, the most common being augmentation mammaplasty, brow lifting, and frontal bone reduction., Conclusions: Tracheal shave is an effective surgical technique for alleviating gender dysphoria in transfeminine patients. Keys to its success include the accurate identification of thyroid cartilage, especially in patients with enlarged cricoid cartilages, intraoperative coordination with anesthesia for laryngoscopic vocal cord visualization, sub-perichondrial cartilage excision to minimize the risk of bleeding and damage near the vocal cords, and carefully layered closure to optimize scar healing., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Abstract: This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction., Competing Interests: Conflicts of interest and sources of funding: G.P. is a volunteer member of the Allergan Alliance for the Future of Aesthetics and receives instrument royalties from Eriem Surgical, Inc, and book royalties from Taylor and Francis Publishing. The rest of the authors have nothing to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: With ongoing investigations of the impact of device texturing on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), studies have begun comparing complication profiles of tissue expanders. However, there is a paucity of timing and severity data of complications. The aim of this study was to provide a comparative survival analysis of postoperative complications between smooth (STEs) and textured tissue expanders (TTEs) in breast reconstruction., Methods: A single-institution experience with tissue expander breast reconstruction was reviewed for complications up to 1 year after second-stage reconstruction from 2014 to 2020. Demographics, comorbidities, operation-related variables, and complications were evaluated. Kaplan-Meier curves, Cox proportional hazard models, and a consensus-based ordinal logistic regression model were used to compare complication profiles., Results: Of 919 total patients, 600 (65.3%) received TTEs and 319 (34.7%) received STEs. There was increased risk of infection ( P < 0.0001), seroma ( P = 0.046), expander malposition ( P < 0.0001), and wound dehiscence ( P = 0.019) in STEs compared with TTEs. However, there was also a decreased risk of capsular contracture ( P = 0.005) in STEs compared with TTEs. Failure of breast reconstruction ( P < 0.001) and wound dehiscence ( P = 0.018) occurred significantly earlier in STEs compared with TTEs. Predictors for significantly higher severity complications included the following: smooth tissue expander use ( P = 0.007), shorter time to complication ( P < 0.0001), higher body mass index ( P = 0.005), smoking history ( P = 0.025), and nipple-sparing mastectomy ( P = 0.012)., Conclusions: Differences in the timing and severity of complications contribute to the safety profiles of tissue expanders. STEs are associated with increased odds of higher severity and earlier complications. Therefore, tissue expander selection may depend on underlying risk factors and severity predictors., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Abdominal contouring surgery can provide both functional and cosmetic benefits to patients with abdominal soft tissue laxity. Although these procedures have been studied in the inpatient setting, few studies describe abdominal contouring surgery in the ambulatory setting., Objective: The purpose of this analysis was to investigate patterns in patient demographics between functional panniculectomy and cosmetic abdominoplasty using national data from the last four years., Methods: Using the Nationwide Ambulatory Surgery Sample, we analyzed outpatient abdominal contouring procedures between 2016 and 2019. Encounters with a CPT 15830 were included. Procedures with ICD Z41.1 or CPT 15847 modifiers were defined as cases of cosmetic abdominoplasty., Results: A weighted estimate of 95,289 encounters were included, with 66,531 (69.8%) functional panniculectomy and 28,758 (30.2%) cosmetic abdominoplasty procedures. Among patients with a history of bariatric surgery (23.8%; 95% CI, 22.3-25.4%), there was a 28.5% (4,866 in 2016 vs 6,254 in 2019) increase in panniculectomy and abdominoplasty. Compared with individuals who underwent cosmetic abdominoplasty, individuals who underwent functional panniculectomy were more racially diverse, had more comorbidities, and were more likely to be from low-income backgrounds., Conclusions: Rates of abdominal contouring surgery in the ambulatory setting have increased in recent years especially among individuals with previous bariatric surgery. There are important demographic and clinical differences between patients who underwent functional panniculectomy and cosmetic abdominoplasty including primary payer, comorbidities, and racial identity., 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 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: Pain control after autologous breast reconstruction is important for patient satisfaction and early recovery. Transversus abdominis plane (TAP) blocks are commonly used as part of an enhanced recovery after surgery (ERAS) pathway for breast reconstruction. It is uncertain whether liposomal bupivacaine used in TAP blocks offers additional advantages. This study aimed to compare the efficacy of liposomal bupivacaine versus plain bupivacaine for patients undergoing deep inferior epigastric perforator flap reconstruction., Methods: This double-blinded randomized controlled trial studied patients undergoing abdominally based autologous breast reconstruction between June of 2019 and August of 2020. Subjects were randomly assigned liposomal or plain bupivacaine, performed using ultrasound-guided TAP block technique. All patients were managed according to an ERAS protocol. Primary outcomes were postoperative narcotic analgesia required, measured in oral morphine equivalents from postoperative days 1 to 7. Secondary outcomes included numeric pain scale score on postoperative days 1 to 7, nonnarcotic pain medication use, time to first narcotic use, return of bowel function, and length of stay., Results: Sixty patients were enrolled: 30 received liposomal bupivacaine and 30 received plain bupivacaine. There were no significant differences in demographics, daily oral morphine equivalent narcotic use, nonnarcotic pain medication use, time to narcotic use, numeric pain scale score, time to bowel function, or length of stay., Conclusion: Liposomal bupivacaine does not confer advantages over plain bupivacaine when used in TAP blocks for abdominally based microvascular breast reconstruction in patients under ERAS protocols and multimodal approaches for pain control., Clinical Question/level of Evidence: Therapeutic, I., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood., Methods: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics., Results: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population., Conclusions: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Breast reconstruction procedures are among the most commonly performed plastic surgery operations. Although there are well-validated patient-reported outcomes measures (PROMs) for breast reconstruction, there are several patient-, provider-, and service-level barriers to their implementation in routine clinical settings. Therefore, we developed a short-form PROM to evaluate breast reconstruction outcomes., Methods: Using a mixed-methods approach, the Vanderbilt Mini-PROM-Breast (VMP-B) was constructed and validated to assess patient-reported outcomes from breast reconstruction. Classic test theory methods were used to evaluate acceptability, reliability, and validity. External validation was subsequently performed using the BREAST-Q as a reference standard., Results: The VMP-B is a 16-item instrument composed of three domains: quality of life, body image, and breast satisfaction. Psychometric properties including acceptability, reliability, and validity exceeded reference criteria. When tested with 104 patients, the authors found significant benefits of breast reconstruction on quality of life, body image, and breast satisfaction. These results were associated with sizeable effect sizes (g) (g = 0.421, g = 0.520, and g = 1.25) demonstrative of clinically meaningful results. When tested concurrently in 70 patients, the VMP-B and the BREAST-Q showed similar results, exhibiting excellent convergent validity., Conclusions: The VMP-B is a validated short-form PROM that reliably assesses breast reconstruction outcomes. As a short form, the VMP-B decreases both patient and provider burden, which allows for routine, point-of-care collection of breast reconstruction outcomes., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019., Methods: Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS)., Results: This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019., Conclusion: Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Institutional protocols often mandate the use of x-rays when a microneedle is lost intraoperatively. Although x-rays can reliably show a macroneedle, the benefit of x-rays in detecting microneedles in human tissues has not been established as available data on this topic are investigated in anthropometric models. The current study aims to evaluate whether x-rays can reliably detect retained microneedles in a human cadaveric model. We hypothesize that microneedles would be detected at a significantly lower rate than macroneedles by x-ray in human tissues., Materials and Methods: Needles ranging from 4-0 to 10-0 were placed randomly throughout a cadaveric hand and foot. Each tissue sample was x-rayed using a Fexitron X-Ray machine, taking both anteroposterior and lateral views. A total of six x-ray images were then evaluated by 11 radiologists, independently. The radiologists circled over the area where they visualized a needle. The accuracy of detecting macroneedles (size 4-0 to 7-0) was compared with that of microneedles (size 8-0 to 10-0) using a chi-square test., Results: The overall detection rate for the microneedles was significantly lower than the detection rate for macroneedles (13.5% vs 88.8%, p < .01). When subcategorized between the hand and the foot, the detection rate for microneedles was also significantly lower than the rate for macroneedles (hand: 7.6% for microneedles, 93.2% for macroneedles, p < .01; foot: 19.5% for microneedles, 84.4% for macroneedles, p < .01). The detection rate, in general, significantly decreased as the sizes of needles became smaller (7-0:70.5%, 8-0:18.2%, 9-0:16.7%, 10-0:2.3%, p < .01)., Conclusion: X-rays, while useful in detecting macroneedles, had a significantly lower rate of detecting microneedles in a cadaveric model. The routine use of x-rays for a lost microneedle may not be beneficial. Further investigation with fresh tissue and similar intraoperative x-ray systems is warranted to corroborate and support these findings., (© 2024 Wiley Periodicals LLC.)

Background: Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees., Methods: A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review., Results: Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment., Conclusions: The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Growth of the aesthetic surgery marketplace has increased patient choice in provider selection. This study aimed to characterize how patients choose an aesthetic surgeon, identify knowledge gaps in this decision-making process, and understand why patients select academic aesthetic surgeons., Methods: A qualitative interview study of aesthetic surgery patients from an academic center was conducted. Purposive sampling maximized representation regarding surgeon, surgery type, and patient demographics. An interview guide was developed in collaboration with content and methodology experts, then refined through pilot testing. Emergent themes were identified using a codebook constructed by grounded theory., Results: Thematic saturation was achieved with 24 patients. When selecting a surgeon, participants valued bedside manner (24 of 24) and past patients' satisfaction (18 of 24). Most participants (16 of 24) ascribed low importance to board certification. Reasons given for choosing an academic practice included the institution's reputation (13 of 24) and the availability of medical records and other specialties if complications arise (8 of 24). Participants demonstrated knowledge gaps regarding medical training and licensure. No participant (0 of 24) was aware that any licensed physician can offer aesthetic surgery, and nearly all participants (23 of 24) expressed discomfort with this., Conclusions: Patients prioritize subjective elements when selecting an aesthetic surgeon, relying less on objective and meaningful qualifications like board certification and training background. Academic aesthetic practice is valued because of reputation and ability to function as a medical home. Given the lack of public understanding regarding physician training, initiatives promoting transparency are needed to ensure that patients can make safe, informed decisions., Competing Interests: Conflicts of interest and sources of funding: This study was supported by CTSA award no. UL1 TR002243 from the National Center for Advancing Translational Sciences. The authors have no financial interests to declare in relation to the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Limited literatures used validated instruments to evaluate patient-reported outcomes (PROs) for transgender and gender-diverse population undergoing gender-affirming surgeries (GASs). This study aimed to evaluate PROs using a newly validated psychometric instrument, Vanderbilt Mini Patient-Reported Outcome Measures-Gender (VMP-G)., Methods: Vanderbilt Mini Patient-Reported Outcome Measures-Gender assesses 4 scales: quality of life, self-concept, satisfaction, and gender dysphoria. Scores range from 20 to 100, with higher scores representing superior PROs. Descriptive analysis was performed, and outcomes were compared in different races/ethnicities, gender identities, age, types of GAS, and time. Patients seeking GAS at Vanderbilt University Medical Center from October 11, 2021, to October 11, 2022, were included. Data were collected anonymously via the Research Electronic Data Capture survey tool at preoperative or postoperative clinic visits., Results: A total of 207 patients completed VMP-G. Average age was 31.8 years (SD, ±11.5 years). Fifty-three percent of patients were postoperative GAS. In bivariate and linear regression analyses, postoperative patients scored higher on all scales compared with preoperative patients ( P < 0.001). After adjustment, postoperative patients scored 12.5 higher on VMP-G compared with preoperative patients ( P < 0.01). In subset analyses, GAS was associated with improved PROs in White, non-White, binary, and nonbinary and patients younger than 21 years ( P < 0.05). After GAS, patients younger than 21 years reported similar outcomes, compared with patients older than 21 years ( P > 0.05). No PROs differences were reported between patients who underwent top versus bottom surgery ( P = 0.2). Postoperative patients reported low rates of regret (2.8%). Scores on the VMP-G were sustained even 1 year after GAS. Each month after GAS was associated with a score improvement of 0.02 in the gender dysphoria domain after adjusting for patient demographics ( P = 0.02)., Conclusions: Using a validated GAS-specific measure, we found that surgery sustainably improves patients' self-reported outcomes including gender dysphoria., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The location of tissue expanders in implant-based breast reconstruction remains controversial due to variation in surgical techniques and devices., Objectives: The aim of this study was to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders., Methods: A retrospective cohort study was conducted of all adult female patients who had undergone 2-stage implant-based breast reconstruction between 2013 and 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders., Results: In total, 854 patients were included; 76% of patients underwent a subpectoral tissue expander placement. After the first-stage procedure, the early complication rate was 34% and the late complication rate was 36.4%. After the second-stage procedure, the early complication rate was 16.3% and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR, 2.1 and 2.4, respectively) as well as late infection after the second stage of reconstruction (HR, 5.3; all P < .05)., Conclusions: Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Breast reconstruction remains an important part of a patient's journey after the diagnosis of breast carcinoma and treatment with mastectomy. Although inpatient immediate breast reconstruction has been described, there is a paucity information about whether similar procedures are performed in the ambulatory setting., Objective: The authors sought to investigate rates and patterns for delayed and immediate breast reconstruction in the ambulatory surgery setting using nationally representative data from 2016 to 2019., Methods: Using the Nationwide Ambulatory Surgery Sample database, we identified patients with an International Statistical Classification of Disease and Related Health Problems, Tenth Revision, procedure code for breast reconstruction. Demographic and clinical characteristics were recorded for each encounter of breast reconstruction, and linear regression and logistic regression were used to assess for trends and disparities., Results: National weighted estimates for ambulatory breast reconstruction increased by 15.6% from 89 237 in 2016 to 103 134 in 2019, resulting in 377 109 procedures during the study period. Inflation-adjusted total charges for ambulatory breast reconstruction were $14 billion between 2016 and 2019, or 1.7% of overall charges for ambulatory surgery. Immediate reconstruction was performed in 34.7% (95% CI, 33.4%-36.1%) of cases and increased by 46.9% from 26 930 in 2016 to 39 559 in 2019. Racial disparities were observed in access, comorbidities, and spending., Conclusions: Our findings indicate a moderate increase in ambulatory breast reconstruction with a substantial growth in the performance of immediate breast reconstruction in the ambulatory setting., Competing Interests: Conflict of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare in relation to this work.

Background: Letters of recommendation play an important role in resident selection. While plastic surgery's Standardized Letter of Recommendation (SLOR) form most commonly serves as an adjunct to narrative letters, the SLOR provides objective data in the review process and could eventually replace narrative letters. The utility of the SLOR in predicting Match outcomes has not been studied., Methods: Applicant data from 225 first-time residency applicants in 2020-21 were collected. Logistic regression modeling was used to predict Match outcomes. This model was validated using 100 randomly selected applicants from 2019-20., Results: Rank placement (SLOR Question 6) was the most important factor when predicting Match outcomes (p<0.0001). All other SLOR questions were not predictive and subject to notable score inflation. No SLOR score differences were noted based on race; female applicants were rated higher in two of ten domains (p<0.05)., Conclusions: One question on the plastic surgery SLOR was highly predictive of an applicant matching. However, the remaining SLOR questions had little utility and were subject to gross score inflation. Further work should be done to optimize the utility of the SLOR in differentiating applicants. This has important implications in ensuring the selection of professional, competent residents according to the aims of the Accreditation Council of Graduate Medical Education., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare in relation to this work.

Background: There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method., Methods: PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes., Results: A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1)., Conclusions: While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications., Competing Interests: Conflicts of interest and sources of funding: G.P. is a volunteer member of the Allergan Alliance for the Future of Aesthetics and receives instrument royalties from Eriem Surgical, Inc, and book royalties from Taylor and Francis Publishing. The other authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Venous congestion after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction is a complication that may be partially attributable to variations in venous abdominal wall anatomy. In previous work, we have shown that ferumoxytol may be used as a bloodpool contrast agent to perform high-resolution venous imaging. Our current aim was to use this technology to perform a detailed analysis of the venous anatomy among patients undergoing DIEP flap breast reconstruction., Methods: All patients undergoing DIEP flap reconstruction with preoperative ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) were retrospectively reviewed. A detailed anatomic analysis of each abdominal wall on FE-MRAwas performed before review of operative findings. Statistical analysis was used to determine venous characteristics associated with superficial inferior epigastric vein (SIEV) augmentation., Results: From 2012 to 2016, 59 patients underwent preoperative FE-MRA. This resulted in imaging for 118 hemiabdomen and 99 flaps. Superficial-deep communication was identified in 117 of 118 hemiabdomen. Fifty (93%) of 59 patients had greater than 1-mm venous communication of the superficial system across midline. Reconstructed breasts were based on dominant medial row perforators in 82 (83%) of 99 flaps. The mean diameters of the SIEVand dominant venous perforator were 3.8 and 2.8mm, respectively. Anatomic characteristics associated with SIEVaugmentation included SIEVdiameter ( P = 0.01), dominant perforator diameter ( P = 0.04), and the ratio between these 2 variables ( P = 0.001)., Conclusions: Ferumoxytol-enhanced magnetic resonance angiography provides excellent imaging of the venous system. Anatomic characteristics such as the diameter of the SIEVand the diameter of the dominant perforator may be useful in determining which flaps require venous augmentation using the SIEV., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Improved techniques for lymphedema detection and monitoring of disease progression are needed. This study aims to use the noninvasive MyotonPRO Device to detect differences in biomechanical skin characteristics in patients with breast cancer-related lymphedema (BCRL)., Methods: The handheld Myoton device was used to measure skin parameters including dynamic skin stiffness, oscillation frequency (tone), mechanical stress relaxation time, and creep in 11 women diagnosed with BCRL. Seven anatomical sites were measured bilaterally for each participant. The average values in the affected arms were compared with those in the contralateral unaffected arms., Results: Among the 11 female participants with unilateral BCRL Stages 0 to II, the combined averages for dynamic skin stiffness and frequency measurements were decreased in the affected arms when compared with those for the contralateral control arms (ratio < 1). The median ratio of stiffness (affected to unaffected control arm) was 0.91 (interquartile range [IQR] 0.78-1.03) while frequency was 0.94 (IQR 0.89-1.0). Skin relaxation time and creep averages were increased in the affected arms. The relaxation time median ratio (affected to unaffected control arm) was 1.07 (IQR 1.02-1.14) and the median ratio of creep was 1.06 (IQR 1.03-1.16)., Conclusions: This study suggests the Myoton can detect differences in skin biomechanical parameters of the affected and unaffected arms in patients with BCRL. Larger studies are needed to draw strong conclusions., (© 2022, HMP Global. All rights reserved. Reproduction in whole or in part prohibited. Content may not be reproduced in any form without written permission. Rights, Permission, Reprint, and Translation information is available at www.hmpglobal.com.)

Background: Microvascular free tissue transfer is an increasingly popular modality for autologous tissue breast reconstruction. However, flap failure remains an ominous risk that continues to plague surgeons and patients even in the setting of meticulous surgical technique and monitoring. Venous and arterial thromboses are the leading causes of free flap failure. The purpose of this study was to determine whether thrombocytosis is associated with breast free flap failure., Methods: A retrospective study was conducted of breast reconstruction with free flaps in North America between 2015 and 2020 using the National Surgical Quality Improvement Program database. Patient comorbidities and preoperative laboratory tests were used to determine risk factors for free flap failure., Results: During the study interval, 7522 female patients underwent breast reconstruction with free flaps, and flap failure occurred in 2.7% patients (n = 203). In multivariate regression analysis, breast free flap failure was significantly higher in patients smoking cigarettes within the past year (P = 0.030; AOR, 1.7) and dyspnea on moderate exertion or at rest (P = 0.025; AOR, 2.6). Furthermore, each 50 K/mcL elevation in platelet count was independently associated with an increased odds of flap failure (P < 0.001; AOR, 1.2). Patients experienced significantly higher rates of flap failure with platelet counts greater than 250 K/mcL (P = 0.004), which remained significant through progressively increasing thresholds up to 450 K/mcL., Conclusions: Platelet count greater than 250 K/mcL is associated with progressively increasing risk of free flap failure in breast reconstruction. Future studies of personalized patient anticoagulation protocols based on hemostatic metrics may improve free flap survival after autologous tissue breast reconstruction., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Amidst the rising trend of bariatric surgical procedures being performed across the country and around the world, patients seeking functional panniculectomy after massive weight loss represent a different population than those seeking cosmetic abdominoplasty. The purpose of this study was to determine whether certain complications are more likely to occur in patients undergoing functional panniculectomy, as well as identify risk factors that are implicated in the occurrence of adverse events., Methods: Retrospective cohort study was conducted of patients undergoing cosmetic abdominoplasty and functional panniculectomy in North America between 2015 and 2019 using the National Surgical Quality Improvement Program database sponsored by the American College of Surgeons. Comorbidities and postoperative complications between these two cohorts were analyzed with appropriate statistics., Results: During the study interval, 11,137 patients underwent excision of excessive infraumbilical abdominal skin, including 57.4% (n = 6397) patients undergoing functional panniculectomy and 42.6% (n = 4740) patients undergoing cosmetic abdominoplasty. Patients undergoing functional panniculectomy were significantly more likely to have comorbidities than those undergoing cosmetic abdominoplasty (p < .001). Overall adverse events (p < .001), medical complications (p = .047), surgical complications (p < .001), related readmission (p < .001), and related reoperation (p < .001) were significantly higher in patients undergoing functional panniculectomy. Surgical complications significantly higher in functional panniculectomy included superficial incisional infection (p < .001), deep incisional infection (p < .001), organ/space infection (p < .001), dehiscence (p = .003), and bleeding requiring transfusion (p = .003)., Conclusions: Patients undergoing functional panniculectomy are significantly more likely to have comorbidities and experience postoperative wound infection, dehiscence, sepsis, bleeding, related readmission, and related reoperation., Competing Interests: Declaration of Competing Interest Authors do not have financial or nonfinancial conflicts of interest., (Copyright © 2022. Published by Elsevier Ltd.)

Introduction: Although neurotization has the potential to improve sensory outcomes after autologous breast reconstruction, this technique remains controversial. There is debate regarding the clinical outcomes and the recipient nerve of choice. This histoanatomical study aims to quantitatively compare the sensory components of the recipient nerves involved in neurotization of the deep inferior epigastric perforator flap., Methods: Subjects undergoing bilateral autologous breast reconstruction were enrolled. Transected nerve specimens underwent immunohistochemical staining with antibodies against neurofilament 1 and choline acetyltransferase for total and motor neurons within the axons, respectively. Photomicrographs were captured, and axons were analyzed using ImageJ. Sensory axons were calculated as equal to the difference between the total and cholinergic axonal counts., Results: Thirty-eight nerves from 19 subjects were included. The overall mean sensory axon count was 1246.3 (±1171.9) in the lateral cutaneous branch (LCB) of the fourth intercostal nerve and 1123.8 (±1213.0) in the anterior cutaneous branch (ACB) of the third intercostal nerve.The fourth LCB presented with an additional 10.9% sensory axonal count (P > 0.05). On average, sensory fibers constituted 36.7% and 31.7% of all fibers in the third ACBs and fourth LCBs, respectively., Conclusions: This study provides anatomic and histological evidence that the fourth LCB and third ACB contain comparable mean numbers of sensory axons. Both constitute adequate recipient nerves for coaptation in deep inferior epigastric perforator reinnervation to achieve optimal sensory return after breast reconstruction. The fourth LCB should be preferable when the third ACB remains intact to preserve any native breast flap sensation., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of postamputation neuroma varies widely. The objective of this study was to determine the incidence of patients who developed symptomatic neuromata after lower-limb amputation through a systematic review and meta-analysis., Methods: A systematic review of the literature was performed on 4 major databases. Studies that reported the incidence of symptomatic neuroma in lower-limb amputees were included. A meta-analysis was performed to calculate the pooled incidence of neuromata., Results: Thirteen studies consisting of 1329 patients were included in this meta-analysis. The reported incidence of patients who developed symptomatic neuromata ranged between 4% and 49%. The median duration of follow-up was 8.6 years (interquartile range, 2.0-17.4 years). The pooled percentage (95% confidence interval [CI]) of lower-limb amputees who developed symptomatic neuromata was 19% (12%-29%). In studies with a duration of follow-up at least 3 years, the pooled percentage (95% CI) of lower-limb amputees who developed symptomatic neuromata was 30% (22%-40%). In studies with a follow-up period of fewer than 3 years, the pooled percentage (95% CI) of neuroma incidence was 3% (2%-6%)., Conclusions: In summary, the overall incidence of patients who developed symptomatic neuromata was 19% or approximately 1 in 5 lower-limb amputees. Symptomatic neuromata are more commonly diagnosed when the follow-up period is longer than 3 years. These findings suggest that neuroma after amputation might be underestimated in studies with a short duration of follow-up., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Venous thromboembolism (VTE) is a life-threatening postoperative complication that carries high morbidity and mortality for plastic surgery patients. In 2011, the American Society of Plastic Surgeons recommended the adoption of a VTE risk stratification and mitigation; however, successful implementation of VTE prophylaxis protocols has not been well described. To address and reduce the VTE burden at our academic center, a risk assessment protocol was implemented for patients undergoing outpatient plastic surgery procedures., Method: All patients who received outpatient plastic surgery between August 2018 and July 2019 were eligible for the VTE modified Caprini risk assessment screening. Sampling of practice patterns was done by chart review from the first week of each month. The study was divided into 3 phases to assess the relationship of screening compliance rates with each protocol change. Compliance was defined as completion of VTE Caprini screening with documentation in patients' charts., Results: Over the 12-month study period, 277 patients met the inclusion criteria. From August to November 2018 (phase 1), patients were screened at the initial clinic visit with an average compliance rate of 11.1%. In December 2018 (phase 2), patients were screened on the day of surgery, with an average compliance rate of 47.1%. From January to July 2019 (phase 3), surgeons recorded the numerical Caprini score into the patient's electronic medical record with a subsequent compliance rate of 61.3%. The overall compliance during the 12 months was 44.8%. The median calculated Caprini score for this population was 4 (range, 1-7)., Conclusions: Standardization of VTE risk assessment is vital for patient safety and outcomes. Successful implementation and long-term protocol sustainability are not a simple goal. In this study, protocol compliance greatly improved after tailoring the guidelines to the specific institutional needs and workflow. These results reinforce the importance of continuous protocol review and modification to ensure optimal departmental buy-in and sustainability., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Resident Aesthetic Clinics (RACs) are an important element for training in plastic surgery residency programs. RACs provide increased exposure to aesthetic surgery as well as greater autonomy in clinical decision making. In an effort to increase RAC volume and thereby enhance resident education, we made two important changes to our operations. First, we reduced the resident surgeons' fees by 75%, and second, we began utilizing social media to promote our residency program and their involvement in aesthetic surgery., Methods: Total RAC cases were queried using a RAC specific billing code and individual chief resident case logs for quality control. To generate an accurate timeframe, cases and procedures were compared from 18 months before and after the implemented changes., Results: We found that the number of cases and procedures increased by 135% and 255%, respectively. The five most commonly performed procedures were liposuction, augmentation mammoplasty, abdominoplasty, mastopexy, and rhytidectomy., Conclusion: By both reducing the resident surgeons' fee and promoting the RAC on social media, we have demonstrated a pronounced increase in both cases and procedures performed by residents. As other institutions seek to increase resident exposure to aesthetic surgery, they may consider similar changes to these., 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 ."

Background: The purpose of the present study was to evaluate the website pages of integrated plastic and reconstructive surgery resident aesthetic clinics in the United States., Methods: Website pages dedicated to resident aesthetic clinics in all integrated plastic and reconstructive surgery residency programs ( n  = 79) were accessed between October and November 2019 and evaluated across several criteria, including: number of pages, procedures offered, faculty participation, respective prices, patient photographs, patient testimonials, contact information, and specific recruitment incentives., Results: Seventy-nine integrated and 54 independent residency programs were identified, 31 of which had both an integrated and an independent residency program for a total of 102 distinct programs. Out of these, only 11 programs (10.8%) had a webpage dedicated to their resident aesthetic clinic (Figure 1). Twelve other programs (13.7%) that did not have a dedicated webpage mentioned a resident aesthetic clinic elsewhere on their residency program website. For each of the eleven programs with space for the resident aesthetic clinic, there was exactly one dedicated webpage. None of the programs with dedicated webpages included photographs of before and after cases, nor procedures performed, nor a listing of resident aesthetic clinic prices. Three of the dedicated webpages included information about faculty participation. Out of the 24 ASAPS endorsed aesthetic fellowship programs, 6 (25%) had a webpage dedicated to the fellow aesthetic clinic. Four of these webpages were comprised of a single webpage, while one program had 6 webpages and one program had 8 webpages. Only one program's webpage included before and after pictures. Four programs (16.7%) included information about faculty participation on the webpage. Five out of the 6 programs had a procedure list on the webpage., Discussion: Resident aesthetic clinic websites are an important tool in recruiting patients as well as medical students. Addressing the lack and quality of such websites may improve recruitment of patients and students to plastic and reconstructive surgery residency programs. As a primary source of information for potential future residents and patients, plastic and reconstructive surgery programs need to maximize the content and utility of their websites., Competing Interests: The authors have no financial relationships or conflicts of interest to disclose., (© 2020 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.)

Background: In the contemporary healthcare environment, there is a need for physicians to understand business fundamentals. Nonsurgical residencies have implemented formal business education, but surgical training programs have been slower to adapt. Further research is needed to evaluate the status of business education in plastic surgery residency., Methods: A 12-question survey was created. Ninety program director (PD) e-mails were obtained and the survey was distributed using SurveyMonkey. The survey evaluated program demographics and current resources, commitments, and attitudes toward business training. The survey also identified the most important topics to include in a business curriculum., Results: Thirty-six surveys were completed (response rate = 40%). Whereas most PDs agreed that business education in plastic surgery residency was important (78%) and that their programs should have more business training (73%), only 39% currently offered business training. Only 42% of PDs believed that their chief residents were competent to handle the business aspects of plastic surgery upon graduation. No programs offered a formal gap year to pursue a professional business degree. The most important topics identified for a business curriculum were economics and finance (83.3%), management (64%), and marketing (53%)., Conclusions: There is disconnect between perceived importance and resources available for plastic surgery residents to receive business education. Increased attention is needed to resolve this discrepancy to ensure that future plastic surgeons are equipped to excel in their personal careers and stimulate the advancement of the field. Future research should aim to outline a business curriculum for plastic surgery trainees.

Background: The American Board of Cosmetic Surgery (ABCS) offers a certification process for physicians desiring third-party credentials in aesthetic surgery. This study aims to examine the training backgrounds and scope of practice of ABCS-certified physicians., Methods: The ABCS online directory was used to identify diplomates. Additional board certifications were identified using the American Board of Medical Specialties physician database. Scope of training was defined using American Council for Graduate Medical Education or Commission on Dental Accreditation requirements for residency training programs. Scope of practice was determined using ABCS physician profiles and professional websites., Results: Three hundred forty-two ABCS-certified physicians were included in the study. Two-hundred twelve (60.2 percent) also held American Board of Medical Specialties board certifications. Over half (62.6 percent) of ABCS diplomates advertised surgical operations beyond the scope of their American Council for Graduate Medical Education or Commission on Dental Accreditation training. Specialties with the highest prevalence of practicing beyond scope of training were internal medicine [n = 2 (100 percent)], general surgery [n = 69 (95.8 percent)], obstetrics and gynecology [n = 17 (85 percent)], otolaryngology [n = 65 (59.1 percent)], dermatology [n = 16 (51.6 percent)], and oral and maxillofacial surgery [n = 30 (50 percent)]. The most commonly offered out-of-scope procedures were liposuction (59.6 percent), abdominoplasty (50.0 percent), breast augmentation (49.7 percent), and buttock augmentation (36.5 percent)., Conclusions: ABCS-certified physicians include internists and dermatologists, who market themselves as board-certified cosmetic surgeons, and the majority of ABCS members perform complex aesthetic procedures outside the scope of their primary residency training. Patients who rely on ABCS certification when selecting a cosmetic surgeon may not understand the scope of that physician's training experience and qualifications.