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Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed.Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost.In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[β], 0.454; 95% Confidence Interval, 0.346-0.596; p 0.001) and increased hospital cost (Exp[β], 1.351; 95% Confidence Interval, 1.285-1.421; p 0.001).Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

SUMMARY: The novel coronavirus disease of 2019 pandemic presents a unique challenge to the field of plastic and reconstructive surgery. Although plastic surgeons may be postponing elective operations, there are still a number of emergent or urgent procedures that may need to be performed, and surgeons may be facing the reality of returning to a new normalcy of operating with coronavirus disease of 2019. These procedures, consisting of those such as head and neck reconstruction or maxillofacial trauma, largely require a multidisciplinary approach and may be considered of higher risk to health care workers because of the involvement of areas of the body identified as sources for viral transmission. Moreover, viral transmission may potentially extend beyond respiratory secretions, which has been the main focus of most safety precautions. The authors aim to present the scope of these procedures and the means of viral transmission, and to provide safety precaution recommendations for plastic surgery and its related disciplines.

Background The aims of this article are to examine the scope of practice differences between physician assistant and nurse practitioner providers, to identify financial cost and benefits, and to posit the impact of physician extenders on plastic surgery practices. Methods A review of the literature was performed using the PubMed database. Key words included "plastic surgery AND physician extender AND cost," "plastic surgery AND physician assistant AND cost," and "plastic surgery AND nurse practitioner AND cost." Secondarily, a search was performed for plastic surgery-related specialties of maxillofacial surgery, orthopedic surgery, and otolaryngology. Inclusion criteria consisted of any study design measuring the financial benefits associated with integrating physician extenders. Results The PubMed search yielded 91 articles. Eight articles were ultimately included, of which four (plastic, maxillofacial, and orthopedic) discussed the impact of physician assistants and four (orthopedic and otolaryngology) discussed the impact of nurse practitioners. All eight studies demonstrated that integration of physician assistants and nurse practitioners into practices was associated with a net financial gain even after taking into account their overall costs, along with other outcomes such as productivity or time involvement. Conclusions As the number of physician extenders continues to grow, especially in subspecialties, plastic surgeons should be aware of their roles and the potentially positive impact of these providers, their respective training, and their quantifiable financial impact toward a plastic surgery practice. Both physician assistants and nurse practitioners appear to have a positive effect on costs in plastic surgery and plastic surgery-related practices.

With increased attention around a value-based healthcare system, continuous emphasis has been made on the evaluation of hospital volume and its association with cost and outcomes. The aim of this study was to analyze nationwide cost variation and outcomes in relation to hospital case volume and geographical location for lower extremity flap reconstruction. A retrospective analysis of the National Inpatient Sample database was performed. Participants were patients who were admitted with the diagnosis of lower extremity trauma and underwent flap reconstruction, inclusive of pedicled and free flaps. The primary variable of interest was hospital cost. Additionally, we evaluated patient demographics, hospital characteristics, and outcomes of postoperative complications and length of stay. A total of 1200 patients were extracted. Median hospital cost for each procedure was $67,845.09. High volume hospitals had significantly lower costs than medium and low volume hospitals (p = 0.011), with median cost being $56,498.77. On regression analysis, hospital volume was not independently associated with increased hospital costs; however, notable factors identified included surgical and systemic complications, as well as longer length of stay. Of note, high volume hospitals were also associated with significantly fewer surgical complications (p = 0.002) and shorter length of stay (p

Background This study aims to outline the 30-d complications of different velopharyngeal insufficiency (VPI) correction techniques using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric. Methods Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric, VPI cases from 2012 to 2015 were identified. Patients were subdivided into two cohorts: (1) palatal procedures and (2) pharyngeal procedures, with the latter being subdivided into (1) pharyngeal flap and (2) sphincter pharyngoplasty. Patient characteristics and postoperative outcomes were compared using Pearson's chi-squared or Fischer's exact test for categorical variables and independent t-tests, Wilcoxon-Mann-Whitney, or analysis of variance for continuous variables. Results: A total of 767 VPI cases were identified: 191 (24.9%) treated with palatal procedures and 576 (75.1%) with pharyngeal procedures, of which 444 were pharyngeal flap and 132 were sphincter pharyngoplasty. Patients who underwent palatal procedure had longer anesthesia (152.41 min) and operating time (105.72 min), whereas patients who underwent pharyngeal procedure had longer length of stay (1.66 d). There were no significant differences in outcomes between the two groups, nor were there significant differences in outcomes between pharyngeal flap and sphincter pharyngoplasty subgroups. Patients who experienced complications were younger, shorter, inpatient, and having a shorter operation time, longer anesthesia time, or longer length of stay. Plastic surgeons performed the majority of palatal procedures (62.3%), whereas pharyngeal procedures were most often performed by otolaryngologists (48.8%). Conclusions: As per national data, both palatal and pharyngeal procedures for repair can be performed with comparable 30-d complications. The chosen technique may be based on patient presentation and on the surgeon comfort level.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify the key social media platforms to use. 2. Recall the primary components of the code of conduct when using social media. 3. Recognize how to build a social media presence and brand. 4. Summarize the primary applications of social media in plastic surgery. SUMMARY Social media are a growing new tool that has emerged in recent years, with numerous applications that have allowed for an effective means to rapidly disseminate information. Plastic surgeons must gain an understanding of the technology to both grow their practices and the specialty as a whole in an ethical and responsible way. The different platforms available; code of conduct; how to build a social media presence; and the main applications of advertising, education, and research, as based on evidence-based recommendations, are presented.

BACKGROUND The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways. METHODS A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model. RESULTS The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86). CONCLUSIONS Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.

Keloids are considered as benign fibroproliferative skin tumors, and rare cases of malignancies have been reported. We present a case of low-grade myofibroblastic sarcoma arising from a recurrent painful keloid scar on the right chest wall after video-assisted thoracic surgery for pneumothorax in a 77-year-old man. Wide composite excision of the keloid, surrounding ribs, and partial diaphragm were performed. The chest wall pleural defect was reconstructed with Teflon (Chemours, Wilmington, DE), and soft tissue was reconstructed with a transverse rectus abdominis myocutaneous flap. This case highlights that refractory keloids may be considered a harbinger of malignancy.

Current understanding of steroid treatments for keloids is in regards to modulation of inflammation, proliferation, and apoptosis, with no in vivo study on the latter. Using a nude mouse model, we investigated whether triamcinolone acetonide (TA) injections induce keloids regression through enhancing apoptosis.Thirty-six keloid specimens (1 × 1 cm) were harvested from 6 patients and separated into sets of 2 from the same patient: no treatment and intralesional TA injection (0.4 mg/mL/kg) at 8 weeks of postimplantation. One set was implanted in each of 18 randomly selected nude mice, which were separated into 3 groups based on time of keloid harvesting after treatment: group A, 2 weeks; group B, 8 weeks; and group C, 14 weeks. Each group had 1 set of specimen from each patient. Histological staining was performed with hematoxylin and eosin stain. Immunohistochemistry staining was performed for human-prolyl 4-hydroxylase (hPH4) and caspase 3 protein, along with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay.All keloid specimens survived, with no noted overgrowth. Hematoxylin and eosin staining revealed dense extracellular matrix and viable fibroblasts, and hPH4 immunohistochemistry revealed strong expression, demonstrating keloid viability. Caspase 3 protein and TUNEL expressions were significantly increased in the treatment versus control groups, demonstrating that TA injections induced apoptosis.Triamcinolone acetonide intralesional injections significantly increased apoptosis in keloids, represented by increased caspase 3 protein and TUNEL expressions, supporting that steroids suppress keloids in part owing to enhancement of apoptosis.

Background Sternal rigid plate fixation (RPF) has been adopted in recent years in high-risk cases to reduce complications associated with steel wire cerclage, the traditional approach to sternal closure. While sternal RPF has been associated with lower complication rates than wire cerclage, it has its own complication profile that requires evaluation, necessitating a critical examination from a national perspective. This study will report the outcomes and associated risk factors of sternal RPF using a national database. Methods Patients undergoing sternal RPF from 2005 to 2016 in the American College of Surgeons-National Surgical Quality Improvement Program were identified. Demographics, perioperative information, and complication rates were reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications. Results There were 381 patient cases of RPF identified. The most common complications included bleeding (28.9%), mechanical ventilation >48 hours (16.5%), and reoperation/readmission (15.2%). Top risk factors for complications included dyspnea (odds ratio [OR], 2.672; P Conclusions Sternal RPF is associated with increased rates of three primary complications: blood loss requiring transfusion, ventilation >48 hours, and reoperation/readmission, each of which affected over 15% of the study population. Smokers remain at an increased risk for surgical site infection and sternal dehiscence despite RPF’s purported benefit to minimize these outcomes. Complications of primary versus delayed sternal RPF are roughly equivalent, but individual patients may perform better with one versus the other based on identified risk factors.

Background Given the rising popularity in body-contouring procedures (BCPs) in the United States, it is important to assess the currently unknown association between resident involvement and postoperative complications. As such, the aim of this study was to evaluate the impact of resident involvement on outcomes in BCPs using a large national database. Methods A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed (2006-2012) to identify patients undergoing BCPs, using relevant Current Procedural Terminology codes. Outcome measures included postoperative complications, hospital length of stay, and operation time. Multivariate regression models were used to assess the impact of resident involvement and resident experience on outcomes. Results A total of 9638 cases were identified, of which 3311 involved resident participation. Resident involvement was associated with significantly higher rates of complications (7.8% vs 4.4%; P = 0.003) and longer operation times (180.7 vs 171.9 minutes; P = 0.005). For each year increase of resident postgraduate year, there was a significant decrease in odds of complications (odds ratio, 0.906; P = 0.013) and operative time (-2.7 minutes; P = 0.001). Conclusions Resident involvement in BCPs was associated with an increased rate of overall complications in a large, national database. However, the clinical significance of these outcomes may be debated. Increased postgraduate year experience as a surgical resident was inversely associated with overall complications. Guided resident autonomy and earlier exposure to BCPs could lead to an optimization of clinical outcomes and resident education.

BACKGROUND Integrative medicine (IM) centers are becoming more established nationwide and provide an expansive range of therapeutic services. Given the high prevalence of IM usage among plastic surgery patients, we sought to define referrals rates to IM centers by plastic surgeons to investigate (1) the role of IM in the continuous care process of plastic surgery patients and (2) whether IM centers are being effectively utilized. METHODS Institutions with plastic surgery residency programs were identified using the American Medical Association's Fellowship and Residency Electronic Interactive Database Access System in January 2017. Data on the presence of a named IM center, director/administrator contact information, and types of therapeutic services offered were extracted. The total number of IM services at these centers was summed and tabulated for preliminary analyses. A survey questionnaire was sent to the center to ascertain referral patterns in February 2017. RESULTS Of 96 institutions with plastic and reconstructive surgery residency programs in North America, 49 (51%) provide IM services, and 24 (25%) have affiliated named IM centers of which we attained a survey response from 13 (54.5%). Of these centers, 10 (76.9%) evaluate more than 50 patients per week. Patient referrals to these centers were primarily from the department of medicine (73.8%) as opposed to surgery (13.1%) (P < 0.0001). An average of 0.77% of surgical referrals, or 0.077% of all referrals, arose from plastic and reconstructive surgery. CONCLUSIONS Plastic surgeons appear to infrequently refer patients to IM centers. Given the high prevalence of IM usage among our patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field.

Background Defects following Mohs micrographic surgery (MMS) can range in size from small defects requiring linear closure to large defects needing flap coverage. Reconstruction is dependent on defect size and facial aesthetic unit involvement. The aim of this study was to review the types of facial reconstruction per aesthetic unit involvement and describe their outcomes. Methods All data were retrieved for patients ≥18 years who underwent multidisciplinary treatment including dermatological MMS and plastic surgical reconstruction at a single tertiary hospital center (2001-2017). Patient characteristics, tumor pathology, surgical specifics, reconstructive modalities, and surgical outcomes were analyzed. Results A total of 418 patients were included. Patients were predominantly White, non-Hispanic (97%) and female (58%) with a mean age of 60 ± 13.9 years. Tumor pathology was predominantly basal cell carcinoma in 73% of all cases followed by squamous cell carcinoma in 14%. The nasal aesthetic unit was mostly affected (50%). Local advancement flaps and different types of grafts were used in 51% and 25% of reconstructions, respectively. Complications were observed in 3% and local cancer recurrence in 4% of the patients. Scar revision was needed in 6% of the patients. Conclusion Reconstruction of facial defects after Mohs micrographic surgery can be challenging due to its technical complexity and aesthetic implications. There were differences in complications in reconstructions performed within the same day versus 1 week, with a majority of complications occurring within same-day Mohs reconstructions. A multidisciplinary structured approach, which incorporates patient-reported outcomes, may be needed to optimize surgical results.

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 Non-board-certified plastic surgeons performing cosmetic procedures and advertising as plastic surgeons may have an adverse effect on a patient's understanding of their practitioner's medical training and patient safety. The authors aim to assess (1) the impact of city size and locations and (2) the impact of health care transparency acts on the ratio of board-certified and non-American Board of Plastic Surgeons physicians. METHODS The authors performed a systematic Google search for the term "plastic surgeon [city name]" to simulate a patient search of online providers. Comparisons of board certification status between the top hits for each city were made. Data gathered included city population, regional location, practice setting, and states with the passage of truth-in-advertising laws. RESULTS One thousand six hundred seventy-seven unique practitioners were extracted. Of these, 1289 practitioners (76.9 percent) were American Board of Plastic Surgery-certified plastic surgeons. When comparing states with truth-in-advertising laws and states without such laws, the authors found no significant differences in board-certification rates among "plastic surgery" practitioners (88.9 percent versus 92.0 percent; p = 0.170). There was a significant difference between board-certified "plastic surgeons" versus out-of-scope practitioners on Google search between large, medium, and small cities (100 percent versus 92.9 percent versus 86.5; p < 0.001). CONCLUSIONS Non-board-certified providers tend to localize to smaller cities. Truth-in-advertising laws have not yet had an impact on the way a number of non-American Board of Plastic Surgery-certified practitioners market themselves. There may be room to expand the scope of truth-in-advertising laws to the online world and to smaller cities.

Background The novel coronavirus disease 2019 (COVID-19) has swept the world in the last several months, causing massive disruption to existing social, economic, and health care systems. As with all medical fields, plastic and reconstructive surgery has been profoundly impacted across the entire spectrum of practice from academic medical centers to solo private practice. The decision to preserve vital life-saving equipment and cancel elective procedures to protect patients and medical staff has been extremely challenging on multiple levels. Frequent and inconsistent messaging disseminated by many voices on the national stage often conflicts and serves only to exacerbate an already difficult decision-making process. Methods A survey of relevant COVID-19 literature is presented, and bioethical principles are utilized to generate guidelines for plastic surgeons in patient care through this pandemic. Results A cohesive framework based upon core bioethical values is presented here to assist plastic surgeons in navigating this rapidly evolving global pandemic. Conclusion Plastic surgeons around the world have been affected by COVID-19 and will adapt to continue serving their patients. The lessons learned in this present pandemic will undoubtedly prove useful in future challenges to come.