Utilization of the gastrocnemius flap for post-traumatic knee reconstruction: a systematic review.

PURPOSE: High-energy injuries to the knee may lead to extensive soft tissue loss, fractures, and potential loss of extensor function. The gastrocnemius flap is a prominent reconstructive option for patients with injuries involving the knee and proximal third of the lower extremity. To the best of our knowledge, there has not been an informative review that has evaluated outcomes of patients who have undergone post-traumatic knee reconstruction with a pedicled medial or lateral gastrocnemius flap. The goal of this study is to assess outcomes in patients who have undergone gastrocnemius flap reconstruction after traumatic injuries to the knee. METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gastrocnemius, flap, knee, and traum*. RESULTS: A total of 204 studies were imported for screening, from which five papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were case series followed by retrospective chart reviews. In total, 43 patients with traumatic soft tissue knee defects were included with an average patient age of 27.28 years. All patients had successful and clinical viable flaps post-operatively, and there were a total of five patients who had complications. CONCLUSION: The gastrocnemius flap has demonstrated to be an effective option for individuals undergoing post-traumatic knee reconstruction. Infection rates, loss of mobility, and scarring represent a minority of complications that may be seen when this reconstructive technique is utilized. Still, additional randomized controlled trials and retrospective studies are required in order to further evaluate for other potential complications that may occur in this patient population.

Machine learning analysis of online patient questions regarding breast reconstruction.

BACKGROUND: Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction. METHODS: Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers. RESULTS: 522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?" CONCLUSIONS: Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

A multimetric health literacy analysis of online gender affirmation surgery materials: From facial to genital surgery.

BACKGROUND: The transgender patient population is expanding, and gender affirming surgery (GAS) volume is increasing. Accurate, comprehensive, and easily navigable resources on GAS are lacking. We aim to evaluate the readability of online materials for specific gender affirming surgical procedures to identify mechanisms of improving information access for transgender patients. MATERIALS AND METHODS: "Facial feminization", "facial masculinization", "MTF breast augmentation", "FTM chest masculinization", "MTF vaginoplasty", "metoidioplasty", and "FTM phalloplasty" were searched on Google. Per keyword, the first 75 text-containing results were included. Text was analyzed for reading difficulty using the Flesch-Kincaid Reading-Ease (FKRE) test and grade level using the Flesch-Kincaid Grade Level (FKGL) formula, Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman-Liau Index (CLI). Scores were compared using independent t-and ANOVA tests (α = 0.05). RESULTS: Mean readability scores (FKRE 37.44) and grade-levels (FKGL 12.87, GFI 15.61, SMOG 11.91, CLI 15.00) correlated with college-level difficulty. Masculinizing surgical materials were more difficult to read than feminizing ones (p ≤ 0.023). Top surgery materials were easier to read than facial and genital surgery materials (p ≤ 0.013). Specifically, chest masculinization resources were more difficult to read than those for breast augmentation (p ≤ 0.006). No differences were found between facial feminization and masculinization surgery resources, nor between resources for different gender affirming genital surgeries. CONCLUSION: Online GAS materials are written above the recommended 6th grade reading-level, with resources for transgender men being significantly more challenging to understand. Improving readability of online resources can help overcome barriers to care for the transgender patient population.

Reconstruction of Acquired Defects of the External Genitalia: A 24-Patient, Single-Institution Experience.

PURPOSE: Patients undergoing resection of the external genitalia are often faced with significant deformity and decreased quality of life. Plastic surgeons are tasked with the challenge of reconstructing these defects to minimize morbidity and increase patients' quality of life. The authors have set out to investigate the efficacy of local fasciocutaneous and pedicled perforator flaps in external genital reconstruction. METHODS: A retrospective review was conducted of all patients undergoing reconstruction of acquired defects of the external genitalia from 2017 to 2021. In total, 24 patients met inclusion criteria for the study. Patients were allocated into 2 cohorts: patients with defects reconstructed using local fasciocutaneous flaps (FF) versus patients with defects reconstructed using pedicled islandized perforator flaps (PF). Comorbid conditions, ablative procedures, operative times, flap size, and complications were compared across all groups. Fisher exact test was used to analyze differences in comorbidities, while independent t tests were used to analyze age, body mass index, operative time, and flap size. Significance was set at P < 0.05. RESULTS: Of the 24 patients included in the study, 6 underwent reconstruction with islandized PFs (either profunda artery perforator or anterolateral thigh), and 18 underwent reconstruction with FFs. The most common indication for reconstruction was vulvectomy for vulvar cancer, followed by radical debridement for infection, and lastly penectomy for penile cancer. The PF cohort had a significantly higher percentage of previously irradiated patients (50% vs 11.1%, P = 0.019). Although mean flap size was larger in the PF cohort, this difference did not reach statistical significance (176 vs 143.4 cm2, P = 0.5). Perforator flaps had significantly longer operative times when compared with FFs (237.33 vs 128.99 minutes, P = 0.003). Average length of stay was 6.88 days in FF and 5.33 days in PF (P = 0.624). Complication profile including flap necrosis, wound healing delays, and infection were similar between groups despite a significantly higher rate of prior radiation in the PF cohort. CONCLUSIONS: Our data suggest that PFs such as profunda artery perforator and anterolateral thigh flaps are associated with longer operative times but may offer a suitable option for reconstruction of acquired defects of the external genital compared with local FFs, especially in the setting of prior radiation.

Performance of ChatGPT on the Plastic Surgery Inservice Training Examination.

BACKGROUND: Developed originally as a tool for resident self-evaluation, the Plastic Surgery Inservice Training Examination (PSITE) has become a standardized tool adopted by Plastic Surgery residency programs. The introduction of large language models (LLMs), such as ChatGPT (OpenAI, San Francisco, CA), has demonstrated the potential to help propel the field of Plastic Surgery. OBJECTIVES: The authors of this study wanted to assess whether or not ChatGPT could be utilized as a tool in resident education by assessing its accuracy on the PSITE. METHODS: Questions were obtained from the 2022 PSITE, which was present on the American Council of Academic Plastic Surgeons (ACAPS) website. Questions containing images or tables were carefully inspected and flagged before being inputted into ChatGPT. All responses by ChatGPT were qualified utilizing the properties of natural coherence. Responses that were found to be incorrect were divided into the following categories: logical, informational, or explicit fallacy. RESULTS: ChatGPT answered a total of 242 questions with an accuracy of 54.96%. The software incorporated logical reasoning in 88.8% of questions, internal information in 95.5% of questions, and external information in 92.1% of questions. When stratified by correct and incorrect responses, we determined that there was a statistically significant difference in ChatGPT's use of external information (P < .05). CONCLUSIONS: ChatGPT is a versatile tool that has the potential to impact resident education by providing general knowledge, clarifying information, providing case-based learning, and promoting evidence-based medicine. With advancements in LLM and artificial intelligence (AI), it is possible that ChatGPT may be an impactful tool for resident education within Plastic Surgery.

Utilization of ChatGPT for Plastic Surgery Research: Friend or Foe?

On November 20, 2022, ChatGPT was made available to the general public free of charge. As a large language model (LLM), the software was able to process inquiries by users and generate text based on compiled datasets in a humanist manner. Due to the importance of research in the Plastic Surgery community, we set out to determine if ChatGPT could be utilized to produce novel systematic review ideas relevant to Plastic Surgery. Out of 80 systematic review ideas generated by ChatGPT, we found that the software was highly accurate in creating novel systematic review ideas. Beyond aiding in Plastic Surgery research, ChatGPT has the potential to be used for virtual consultations, pre-operative planning, patient education, and post-operative care for patients. ChatGPT may be a simple solution for the complex problems encountered in Plastic Surgery.

Expanding Cosmetic Plastic Surgery Research With ChatGPT.

BACKGROUND: In the past 3 months, OpenAI, a San Francisco-based artificial intelligence (AI) research laboratory, has released ChatGPT, a conversation large language model. ChatGPT has the ability to answer user questions, admit to mistakes, and learn from users that are accessing the program. OBJECTIVES: Due to the importance of producing evidence-based research in plastic surgery, the authors of this study wanted to determine how accurate ChatGPT could be in creating novel systematic review ideas that encompass the diverse practice of cosmetic surgery. METHODS: ChatGPT was given commands to produce 20 novel systematic review ideas for 12 different topics within cosmetic surgery. For each topic, the system was told to give 10 general and 10 specific ideas that were related to the concept. To determine the accuracy of ChatGPT, a literature review was conducted with PubMed, CINAHL, EMBASE, and Cochrane. RESULTS: A total of 240 "novel" systematic review ideas were constructed by ChatGPT. We determined that the system had an overall accuracy of 55%. When topics were stratified by general and specific ideas, we found that ChatGPT was 35% accurate for general ideas and 75% accurate for specific ideas. CONCLUSIONS: ChatGPT is an excellent tool that should be utilized by plastic surgeons. ChatGPT is versatile and has uses beyond research, including patient consultation, patient support, and marketing. As advancements in AI continue to be made, it is important for plastic surgeons to consider the utilization of AI in their clinical practice.

Targeted Muscle Reinnervation in the Setting of Traumatic Bilateral Above-Knee Amputations: A Case Report.

CASE: We present the case of a 20-year-old man who was pedestrian struck and sustained bilateral traumatic above-knee amputations. Targeted muscle reinnervation (TMR) was performed with nerve transfers, including tibial nerve to semitendinosus (bilateral), superficial peroneal nerve to biceps femoris (left), deep peroneal nerve to biceps femoris (left), and common peroneal nerve to biceps femoris (right). CONCLUSIONS: Less than 1 year postoperatively, the patient was ambulating on his myoelectric prosthesis and experienced no Tinel or neuroma-type pain. This case is a testament to the impact TMR, an innovative surgical technique, can have on the quality of life of patients sustaining devastating limb injuries.

Assessing the Impact of COVID-19 on Facial Aesthetic Surgery Search Interest.

ABSTRACT: The global COVID-19 pandemic reshaped many components of modern health care practice. Before the pandemic, research was beginning to demonstrate the impact of self-facing cameras, selfie images, and webcams on patient interest in head and neck (H&N) aesthetic surgery. We sought to determine temporal changes in patient interest in aesthetic surgery of the H&N as compared with the rest of the body because of COVID-19, and the subsequent surge in Web-conferencing and telecommunication. The 2020 Plastic Surgery Trends Report produced by the American Society of Plastic Surgeons was used to identify the 5 most common aesthetic surgical procedures performed on the H&N and the rest of the body for 2019: blepharoplasty, face lift, rhinoplasty, neck lift, cheek implant, and breast lift, liposuction, tummy tuck, breast augmentation, and breast reduction, respectively. Google Trends filters, which provide relative search interest for greater than 85% of Internet searches, were applied to gauge interest from January 2019 to April 2022. Relative search interest and mean interest were plotted as a function of time for each term. Our findings demonstrate a sharp decline in online aesthetic surgery interest in March 2020, coinciding with the beginning of the COVID-19 pandemic for both the H&N and the rest of the body. Search interest increased shortly after March 2020 and reached values greater than those of the prepandemic year (2019) in 2021 for rest of the body procedures. After March 2020, there was a brief, sharp increase in search interest for rhinoplasty, neck lift, and facelift, whereas patient interest in blepharoplasty increased more gradually. There was no increase in search interest for H&N procedures as a result of COVID-19 when using the mean values of the included procedures, although current interest has returned to prepandemic levels. The COVID-19 pandemic caused a disruption of normal trends in aesthetic surgery interest, with a sharp decline in search interest in March 2020. Afterward, there was a sharp increase in rhinoplasty, face lift, neck lift, and blepharoplasty interest. Patient interest in blepharoplasty and neck lift has remained elevated compared with 2019. Interest in rest of the body procedures has returned to and even surpassed prepandemic levels.

A machine learning analysis of patient concerns regarding mastopexy.

BACKGROUND: Social media plays an important role in connecting patients and plastic surgeons. We utilized patient inquiries regarding mastopexy from an online social media site to determine the most prevalent patient concerns, while employing a machine-learning algorithm to generate the questions representative of the dataset. OBJECTIVE: This data allow plastic surgeons to better tailor their preoperative consultations to address common concerns, set realistic expectations, and improve overall satisfaction. METHODS: A total of 2,011 inquiries from the mastopexy section of Realself.com were obtained using an open-source web crawler. Each inquiry was manually categorized as preoperative or postoperative and classified into subcategories based upon the free text entry. Lastly, questions were analyzed using machine learning to determine ten questions most representative of the inquiry pool. RESULTS: Of the 2,011 inquiries analyzed, 52.91% were preoperative and 47.09% were postoperative. Most preoperative questions asked about procedure eligibility (309, 29.04%), surgical techniques and logistics (260, 24.44%), and the best type of breast lift for the user (259, 24.34%). Among postoperative questions, questions regarding appearance were the most common (491, 51.85%), followed by symptoms after surgery (197, 19.75%) and behavior allowed/disallowed (145, 15.31%). Appearance was further subcategorized with the most common categories being appearance of the nipple (98, 19.86%), skin discoloration (88, 17.92%), and scarring (74, 15.07%). CONCLUSION: By utilizing the data that social media websites, like Realself.com, provide, plastic surgeons can better understand common patient concerns. This data aid in optimizing the preoperative consultation process to address the common concerns, recalibrate unrealistic expectations, and improve overall satisfaction.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

The Relative Citation Ratio: A Modern Approach to Assessing Academic Productivity within Plastic Surgery.

The accurate assessment of physician academic productivity is paramount and is frequently included in decisions for promotion and tenure. Current metrics such as h-index have been criticized for being biased toward older researchers and misleading. The relative citation ratio (RCR) is a newer metric that has been demonstrated within other surgical subspecialties to be a superior means of measuring academic productivity. We sought to demonstrate that RCR is a valid means of assessing academic productivity among plastic surgeons, and to determine demographic factors that are associated with higher RCR values. Methods: All Accreditation Council for Graduate Medical Education-accredited plastic and reconstructive surgery residency programs and faculty throughout the United States were compiled from the American Council of Academic Plastic Surgeons website. Demographic information was obtained for each surgeon via the program's website, and RCR data were obtained utilizing iCite, a bibliometrics tool provided by the National Institutes of Health. Surgeons were excluded if any demographic or RCR data were unavailable. Results: A total of 785 academic plastic surgeons were included in this analysis. Surgeons who belonged to departments with more than six members had a higher median RCR (1.23). Increasing academic rank (assistant: 12.27, associate: 24.16, professor: 47.58), chief/chairperson status (47.58), male gender (25.59) and integrated model of residency training program (24.04) were all associated with higher median weighted RCR. Conclusions: RCR is a valid metric for assessing plastic surgeon academic productivity. Further research is warranted in assessing disparities among different demographics within academic plastic surgery.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery.

BACKGROUND: Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery. METHODS: The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified. RESULTS: In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover. CONCLUSION: This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery.

BACKGROUND: Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified. RESULTS: A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R2=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times. CONCLUSION: Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.

Increasing Incidence of Hand and Distal Upper Extremity Injuries Associated With Electric Scooter Use.

PURPOSE: Electric scooters (e-scooters) have seen an increase in popularity in cities across the United States as a form of recreation and transportation. The advent of ride-sharing applications allows anyone with a smartphone to easily access these devices, without any investment or experience required. In this study, the authors analyze scooter-related injuries of the hand and upper extremity. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of e-scooters between 2010 and 2019. Data collected included demographic information, the location of the injury, the injury diagnosis, and disposition. National estimates (emergency room visits in the United States) were calculated using the weight variable included in the NEISS database. Miscoded reports were excluded. As a corollary, Google Trends data were utilized to establish a correlation between e-scooter-related injuries and the relative number of e-scooter hits on the Google search engine. RESULTS: From 2010 to 2019, there were 730 e-scooter-related injuries reported to the NEISS database. This corresponds to an estimated 26,412 injuries nationally during this time period. The incidence of scooter-related injuries increased by over 230% (2,130 national injuries in 2010; 7,213 national injuries in 2019; relative difference 5,083). Injuries most commonly occurred in patients aged 10 to 18 years (30.3%). The most frequent site of injury was the wrist (41.9%). The most common injury diagnosis was fracture (55.3%). Additionally, there was a correlation between the number of Google Trends e-scooter hits and the number of injuries during this time period. CONCLUSIONS: The incidence of e-scooter-related upper extremity injuries increased dramatically in the United States between 2010 and 2019. CLINICAL RELEVANCE: As novel e-scooter-sharing apps become increasingly popular, it is imperative that users are educated about the risk of injury and that use of proper protective equipment is encouraged.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction.

BACKGROUND: Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures. METHODS: The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis. RESULTS: Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279). CONCLUSION: Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.