Lifei Guo

Background: Integrated plastic surgery applicants complete among the highest number of visiting audition rotations of any specialty. In the 2021 match, we observed that the elimination of audition rotations and in-person interviews drastically increased the number of applicants who matched at their home program. We sought to evaluate the effect of applicants participating in one selective visiting subinternship rotation on home program match rates. Methods: Top 50 plastic surgery residency programs were identified by 2021 Doximity rankings. Publicly available, online plastic surgery match spreadsheets were used to collect available information including matched applicants' medical school, the institution at which they matched, whether they matched at their home institution, and whether they had previous communication with their matched program including research year or visiting subinternship completed. Results: Fourteen percent of applicants matched at their home institution in 2022, comparable with recent prepandemic rates of 14.1% and 16.7%, versus 24.1% in 2021. The largest effect was observed among the top 25 programs. Separately, approximately 70% of applicants provided self-reported information on whether they completed a subinternship. Among the top 50 programs, 39.0% of applicants completed an audition rotation at the institution at which they eventually matched. Conclusions: The allowance of medical students to perform only one visiting subinternship in the 2022 match cycle normalized home match rates to the prepandemic baseline, possibly driven by a large proportion of students matching at their visiting rotation institution. Perhaps from both a program and applicant standpoint, 1 away rotation may provide sufficient exposure for eventual match success.

Background Medicare reimbursement for plastic surgery procedures increased by 2% while inflation increased by 19% in the past decade. Given increasing national breast reduction case volume and the negative impact decreased reimbursements have on surgeon well-being, we sought to evaluate actual surgeon reimbursements for bilateral breast reduction over a decade. Methods A retrospective review was performed including all identifiable breast reduction procedures (Current Procedure Terminology 19318) performed at a tertiary academic hospital between October 2011 and September 2021 (fiscal year 2012–2021). The annual number of patients undergoing breast reduction, the payor, and average yearly amounts reimbursed were evaluated and trended over time. Percent change from Medicare average yearly reimbursements was evaluated and trended over time. All values were adjusted to 2021 US dollars. Results During our study period, there were 486 bilateral breast reduction procedures with 36 outlier payments; therefore, 450 reimbursements were included in the study. There were 5 payors, and the average adjusted reimbursement amount was $2418.74 ± $1123.83. All private payors had significantly higher average reimbursement than Medicare (P < 0.0001), and Medicare was the only payor with significant decrease in reimbursement over time (−$58.58 per year, 95% confidence interval, −$110.80 to −$6.33, P = 0.033). Conclusions Our data demonstrate that a difference exists between public and private payors for bilateral breast reduction procedures. Private payor reimbursements outpaced inflation. Medicare is an unreliable benchmark that may indirectly lead to declining reimbursements over time.

Purpose: Healthcare spending will account for 20% of US gross domestic product by 2028. One strategy to address rising costs is evaluating the utilization fraction (UF) of surgical trays. Utilization fraction averages between 13% and 27% among surgical specialties, yet data from plastic surgery are lacking. Methods: This prospective observational study assessed UF of surgical instruments in all reduction mammoplasty performed at 2 sites in the same healthcare system over a 6-month period. Site 1 is a tertiary hospital and site 2, an outpatient surgical center. Utilization fraction was calculated as percent fraction of used, or if operating surgeons touched them, to opened instruments. A new surgical tray was created by removing instruments not used in 20% of cases. Reprocessing costs and savings were calculated using published reprocessing figures of $0.10 to $0.51 per instrument. Descriptive statistics and parametric variables reported as mean ± standard deviation. Unpaired Student t test was performed to determine statistical significance of findings (P < 0.05). Results: Four plastic surgeons performed 37 procedures, 11 at site 1 and 26 at site 2. At site 1, 112 instruments are opened in one tray with 53 unique and 59 duplicates. At site 2, 155 instruments are opened in 2 trays with 58 unique, 20 shared, and 77 duplicates. Instrument user did not vary by site (P = 0.446), with 19 ± 3 instruments and 17 ± 3 instruments used per case; however, UF varied significantly (P < 0.0001) with average UF of 16.6% ± 2.8% and 11.5% ± 1.7% at sites 1 and 2, respectively. Estimated reprocessing costs per case are currently $11.20 to $57.12 at site 1 and $15.50 to $79.05 at site 2, with unused instruments accounting for $9.34 to 47.64 and $13.72 to $69.96, respectively. The new surgical tray includes 32 instruments, 18 unique and 14 duplicates, with estimated reprocessing cost of $3.20 to $16.32 per case. Adoption would reduce reprocessing costs by approximately $8.00 to $40.80 and $12.30 to $62.73 per case at sites 1 and 2, respectively. Conclusions: Despite studying a single, but common, plastic surgery procedure, our findings reveal consistency in excessive appropriation of instruments between sites with values similar to those in the literature. These findings exemplify a cost-saving opportunity at our institution and chance to optimize UF for other high-volume plastic surgery procedures.

Background: Although gender-affirming surgery is increasingly performed, few studies have examined any temporal correlation between legislations mandating transgender care and the actuation of such surgical care. Methods: We assembled a retrospective cohort utilizing the National Inpatient Sample database from 2000 to 2018. We stratified utility trends of gender-affirming surgery based on insurance payer types and regions in a crisscrossing effort to detect any temporal or cause-effect relationship between legislations and outcomes. All regions according to the latest National Inpatient Sample categorization were examined based on the nature of their member state’s legislations relating to gender-affirming care coverage. Diametrically, opposite regions were selected for further comparisons. Interrupted time series analyses were used to demonstrate any significant uptrend since implementation of relevant legislations. Results: In states with explicit inclusion of gender-affirming care, our interrupted time series analyses showed a significant increase in the number of patients on state-dependent insurance (Medicaid and private insurance) receiving gender-affirming surgery around the time during which state legislations began mandating care (P < 0.01) and thereafter (P < 0.01). This significance was not seen in the same regions among patients under nonstate-dependent payers (Medicare and self-pay), nor was it seen in either payer group in states without explicit inclusion of gender-affirming care. At the federal level, statistical significance was noted among Medicare recipients across all states around the time federal legislations took effect and thereafter. Conclusion: Legislations mandating coverage seem highly effective in actuating surgical care of transgender patients in corresponding jurisdictions, which may provide a roadmap for further care expansion.

Background: Many breast-conserving surgical options exist for patients with breast cancer. Surgical choices can have lasting effects on a patient’s life, so patient satisfaction is important to assess. Patient-reported outcome measures provide important tools when evaluating surgical modalities. This systematic review aimed to evaluate how patients describe breast-conserving surgical choices in standard partial mastectomy and oncoplastic surgery options. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was performed in PubMed for studies discussing standard partial mastectomy or oncoplastic surgery and measurement of preoperative and postoperative patient-reported outcomes using the BREAST-Q or other validated patient-reported outcome measures. Oncoplastic surgery was categorized as volume displacement or volume replacement. Articles in languages other than English, not involving partial mastectomy or oncoplastic surgery, or not measuring patient-reported outcomes were excluded. Weighted proportions were generated and analyzed with a Welch t test. Results: Of 390 articles, 43 met inclusion criteria, and 8784 patients were included in a pooled database. Although standard partial mastectomy scored well, oncoplastic surgery performed significantly better than partial mastectomy in all postoperative BREAST-Q categories: satisfaction with breasts (74.3 versus 65.7), psychosocial well-being (81.3 versus 78.0), sexual well-being (61.6 versus 54.9), and satisfaction with outcome (85.4 versus 62.2). Level 2 volume displacement surgery had the most favorable scores. Conclusions: Breast-conserving surgical choices that include a variety of oncoplastic surgery and partial mastectomy methods all score well in patient-reported outcome measures, with oncoplastic surgery significantly preferred over partial mastectomy. Oncoplastic surgery should be considered in all cases, and the appropriate breast-conserving surgical choice should depend on the patient’s tumor presentation and anatomy.

The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.