Current Applications of Artificial Intelligence in Billing Practices and Clinical Plastic Surgery.

Integration of artificial intelligence (AI), specifically with natural language processing and machine learning, holds tremendous potential to enhance both clinical practices and administrative workflows within plastic surgery. AI has been applied to various aspects of patient care in plastic surgery, including postoperative free flap monitoring, evaluating preoperative risk assessments, and analyzing clinical documentation. Previous studies have demonstrated the ability to interpret current procedural terminology codes from clinical documentation using natural language processing. Various automated medical billing companies have used AI to improve the revenue management cycle at hospitals nationwide. Additionally, AI has been piloted by insurance companies to streamline the prior authorization process. AI implementation holds potential to enhance billing practices and maximize healthcare revenue for practicing physicians.

A Day in the Life of a Surgical Instrument: The Cycle of Sterilization.

Surgeons must be confident that the instruments they use do not pose risk of infection to patients due to bioburden or contamination. Despite this importance, surgeons are not necessarily aware of the steps required to ensure that an instrument has been properly sterilized, processed, and prepared for the next operation. At the end of an operation, instruments must be transported to the sterile processing unit. There, instruments are decontaminated before being sterilized by heat, chemical, or radiation-based methods. Following this, they are stored before being brought back into use. This review highlights the intricacies of the processing of surgical instruments at the conclusion of an operation so that they are ready for the next one.

A 16-Year Analysis of Aesthetic Surgery Volume and Its Association With US Economic Performance.

Historically, demand for plastic surgery has been associated with the performance of the US economy. This study evaluates the relationship between economic performance indicators and the popularity and profitability of aesthetic surgery from 2006 to 2022, considering several recessions and the rise of social media. The data were collected from the Aesthetic Society's (AS) Aesthetic Plastic Surgery National Databank and the American Society of Plastic Surgeons' (ASPS) Plastic Surgery Statistics Report from 2006 to 2022. Procedures analyzed included the most performed cosmetic surgeries, as well as neuromodulator injections and dermal fillers. Pearson correlation tests were used to analyze the strength of association between 8 financial indicators and case volumes and expenditures for each procedure. From 2006 to 2020, ASPS data demonstrated gross domestic product (GDP) per capita year-over-year (YOY) change that was positively correlated with case volume and expenditures across 13 out of the 24 different procedure metrics (54.2%). From 2006 to 2016, AS data were positively correlated with the YOY change of theNational Association of Securities Dealers Automated Quotations (NASDAQ), Standard and Poor's 500, and Dow Jones in 12 of the 24 variables (50%). This was followed by GDP YOY change, with positive correlations to 11 variables (45.8%). YOY changes of consumer-level finances and inflation indicators were less frequently associated among both datasets.In conclusion, our study shows that aesthetic plastic surgery procedures and expenditures correlate with GDP. Although aesthetic surgery demand may be difficult to anticipate, this study elucidates several factors plastic surgeons may use as a bellwether for their practices.

Picture Perfect: Standardizing and Safekeeping Clinical Photography in Plastic Surgery.

Plastic surgery relies heavily on clinical photography to document preoperative and postoperative changes, visualize surgical approaches, and evaluate outcomes. However, the contemporary landscape of plastic surgery photography faces challenges, including a lapse in standards due to the prevalence of smartphones, social media platforms, and security concerns related to data storage and cyberattacks. In this comprehensive review, the authors aim to provide plastic surgeons with practical guidelines for achieving standardized, high-quality clinical photography while navigating the evolving landscape of technology, security, and ethical considerations. We explore the security challenges associated with storing clinical photographs, emphasizing the legal obligations under the Health Insurance Portability and Accountability Act (HIPAA). We also discuss various storage options, including HIPAA-compliant cloud services, electronic medical records, and emerging technologies like blockchain and artificial intelligence.

Current Weight Loss Medications: What Plastic Surgeons Should Know.

The World Health Organization (WHO) estimates that over 650 million adults are obese worldwide. Recently, antidiabetic medications have rapidly become popular as weight loss medications. With the rising prevalence of obesity and the increasing demand for aesthetic procedures, it is anticipated that a growing number of patients presenting for consultation will be prescribed these medications. Therefore, it is critical for practicing plastic surgeons to understand their potential synergistic effects and safety considerations. This manuscript explores the potential benefits and considerations of antidiabetic medications in plastic surgery patients for weight loss therapy. The authors discuss the mechanisms of action, clinical efficacy, potential side effects, and relevant considerations for incorporating these medications into plastic surgery practices and medical spas.

The Looming Future of Private Equity in Plastic Surgery.

Private equity acquisition of independent private practices has grown dramatically in the last decade, with private equity firms increasingly investing in surgical specialties that practice in outpatient ambulatory centers. This trend has slowly started to creep into plastic surgery; therefore, understanding the concepts of private equity ownership in healthcare and its benefits and risks is critical. This article provides a fundamental economic background on private equity, describes its current state in healthcare, including trends in plastic surgery, and provides recommendations for plastic surgeons considering private equity acquisition.

Forty-Year Follow-Up After Great Toe-to-Thumb Transfer: A Literature Review.

The thumb is a crucial part of the hand, and traumatic thumb amputation is a devastating injury that significantly diminishes hand function. In situations in which replantation is not possible, great toe-to-thumb transfer is a well-established option for reconstruction. Although most studies describe excellent functional outcomes and patient satisfaction, there is a paucity of literature presenting long-term follow-up to determine whether these outcomes are maintained. In this case report, we present a case of great toe-to-thumb transfer performed 40 years ago and evaluate outcomes using validated questionnaires and standardized examination maneuvers. Our results highlight sustained patient satisfaction and excellent functional outcomes decades after the initial reconstruction.

Impact of a tobacco sales ban on the frequency of tobacco consumption in India during the COVID-19 pandemic.

INTRODUCTION: Measures to address the COVID-19 pandemic in India included a ban on the sale and use of tobacco products during 2020 when stay at home guidance (lockdown) was in place. In this study we examined the extent of reduction in frequency of tobacco consumption across all products. METHODS: Telephone survey was conducted between July and August 2020 across an existing cohort of tobacco users (n=801) residing in Delhi (55.4%) and Chennai (44.6%), India. The participants were recruited irrespective of their gender and use of any kind of tobacco product(s). The survey questionnaire was based on the STOP (Studying Tobacco users Of Pakistan) survey and adapted to the context of smoking and smokeless tobacco use in India. RESULTS: Cigarette consumption declined from a median value of 5.0 (IQR: 2-10) sticks in the pre-lockdown period to 2.0 (IQR: 0.4-5) sticks during the lockdown period. Reductions were reported in the daily use of bidis, from 8 (IQR: 4-12) sticks to 5 (IQR: 2-10) sticks and for smokeless tobacco users from 3.5 (IQR: 2-5) packs to 2 (IQR: 1-4) packs during the lockdown. Furthermore, the number of daily cigarette smokers in our cohort decreased from 32.6% (n=261) in the pre-lockdown period to 27.5% (n=220) during lockdown and smokeless tobacco users decreased from 35.8% (n=287) in pre-lockdown period to 30.3% (n=243) during the lockdown period. CONCLUSIONS: The decrease in tobacco use can be attributed to various societal and environmental factors. However, the pandemic-linked lockdown provided an opportune condition to reduce the use of tobacco products, which could be due to restricted access and increase in health awareness during the COVID-19 lockdown.

Objective Residency Applicant Assessment Using a Linear Rank Model.

OBJECTIVES: Residency applicant assessment is imperfect, with little objectivity built into the process, which, unfortunately, impacts recruitment diversity. Linear rank modeling (LRM) is an algorithm that standardizes applicant assessment to model expert judgment. Over the last 5 years, we have used LRM to assist with screening and ranking integrated plastic surgery (PRS) residency applicants. This study's primary objective was to determine if LRM scores are predictive of match success and, secondarily, to compare LRM scores between gender and self-identified race categories. DESIGN: Data was collected on applicant demographics, traditional application metrics, global intuition rank, and match success. LRM scores were calculated for screened and interviewed applicants, and scores were compared by demographic groups. Univariate logistic regression was used to evaluate the association of LRM scores and traditional application metrics with match success. SETTING: University of Wisconsin, Division of Plastic and Reconstructive Surgery. Academic institution. PARTICIPANTS: Six hundred seventeen candidates who applied to a single institution over 4 application cycles (2019-2022). RESULTS: Using area under the curve modeling, LRM score was the most predictive indicator for match success. With every one-point increase in LRM score, there was an 11% and 8.3% increase in the likelihood of screened and interviewed applicant match success (p < 0.001). An algorithm was developed to estimate the probability of match success based on LRM score. No significant differences in LRM scores were appreciated for interviewed applicant gender or self-identified race groups. CONCLUSIONS: LRM score is the most predictive indicator of match success for PRS applicants and can be used to estimate an applicant's probability of successfully matching into an integrated PRS residency. Furthermore, it provides a holistic evaluation of the applicant that can streamline the application process and improve recruitment diversity. In the future, this model could be applied to assist in the match process for other specialties.

Offering No-Cost Cosmetic Revisions: The Experience of an Academic Cosmetic Surgery Program.

Background: The financial principles of a no-cost revision policy and their implications for revision rates are not well understood. Objectives: Therefore, the primary objective of this retrospective study is to report our no-cost revision rates and, secondarily, to survey the cosmetic revision policies of other cosmetic surgery practices and detail the financial principles underpinning no-cost revisions. Methods: All aesthetic surgeries and no-cost revisions performed by the plastic surgeons, oculoplastic surgeons, and facial plastic and reconstructive surgeons at our academic outpatient cosmetic surgery center from January 1, 2016 to June 30, 2022 were identified using procedural codes. Data on the number of surgeries, number of revisions, operative minutes, and time intervals between initial and revision surgeries were collected. A survey was administered to assess the revision policies of similar cosmetic surgery practices. Results: A total of 1491 aesthetic surgeries and minimally invasive procedures were included, and 125 revision procedures were performed (8.4%). Thigh lifts (3, 13.6%), rhinoplasties or septoplasties (25, 15.8%), and otoplasties (3, 27.3%) had the highest revision rates. Three practices (15%) offered cosmetic revisions at no cost, 9 (45%) did not apply a surgeon's fee, 5 (25%) evaluated fees on a case-by-case basis, 1 (5%) offered revisions with an insurance policy, and 2 (10%) cosmetic surgery practices did not offer revisions at a reduced rate. Conclusions: Despite offering revisions at no cost, our revision rates are reasonable for an academic cosmetic surgery practice. The revision policies offered to patients on the private market are varied, but most surveyed practices offer revisions at either a reduced rate or no cost.

Out-of-scope Cosmetic Surgery: A Review of Malpractice Lawsuits against Nonplastic Surgeons.

The increasing patient demand for cosmetic surgeries and minimally invasive procedures has encouraged physicians without aesthetic surgery training accredited by the American Board of Medical Specialties to provide these services. This systematic review aims to determine the rate of out-of-scope practice in medical malpractice lawsuits involving cosmetic surgery or minimally invasive procedures performed by nonplastic surgeons. Methods: Our systematic review of the Westlaw legal database from 1979 to 2022 included 64 malpractice cases. Inclusion criteria were cosmetic surgeries or minimally invasive procedures in medical malpractice lawsuits not involving board-certified plastic surgeons. Out-of-scope was defined using the procedural competencies established by the American Council for Graduate Medical Education, the Commission on Dental Accreditation, and the Council of Podiatric Medical Education. Data on legal proceedings, provider credentials and board certification, surgical interventions, and legal outcomes were collected. Results: The majority of malpractice cases involving cosmetic surgeries or minimally invasive procedures occurred when providers were practicing out of scope (N = 34; 55.7%). The verdict was ruled in favor of the plaintiff (patient) in 34.4% of cases. Out-of-scope practice occurred most in family/internal medicine, no board certification, and obstetrics/gynecology (N = 4, N = 4, and N = 3, respectively). The most common allegation was permanent injury or disfigurement (N = 21; 21.4%). Plastic surgeons provided expert testimony 44.0% of the time. Conclusion: Our review of the Westlaw legal database suggests that the majority of nonplastic surgeon cosmetic malpractice cases may occur in the setting of out-of-scope practice.

The Price Is Right? An Economic Analysis of Factors Influencing Cosmetic Surgery Prices.

BACKGROUND: Cosmetic surgery is a large portion of practice revenue for many plastic surgeons, and therefore understanding the economic principles of pricing is critical. Although national averages provide a starting point for price determination, they may not reflect specific economic factors. Over the last decade, publicly reported pricing for cosmetic surgery has increased in prevalence, improving price transparency for patients and surgeons alike. OBJECTIVES: This study aims to compare publicly reported prices to national cosmetic surgery averages and identify variables that have the greatest impact on price determination. METHODS: An Internet search was performed with the term "cosmetic surgery, price" for practices that publicly reported cosmetic surgery prices. Publicly reported prices were compared to national averages generated from The Aesthetic Society's Aesthetic Society Plastic Surgery National Databank Statistics. The impact of regional prices, practice type, and surgeon accreditation were analyzed for the most popular cosmetic surgery procedures. RESULTS: Sixty-six practices were identified that reported cosmetic surgery pricing information. Publicly reported prices were significantly higher for all surgical procedures except nipple procedures, excision of (excess) skin, fat grafting, fat harvest, and lip enhancement. Facility/operating room fees (n = 38) and anesthesia fees (n = 34) were the most common components included in a price, after surgeons' fees (n = 66). A significant price difference was appreciated when separating practices by region for all procedures except breast augmentation (P = .074) and liposuction (P = .088). CONCLUSIONS: Publicly reported prices provide greater insight than national averages into specific pricing factors and strategies that can be employed when setting surgical prices.

The Anatomy of a Malpractice Lawsuit.

Medical malpractice lawsuits can be a source of emotional, physical, and financial distress for both providers and patients. A thorough understanding of the medical malpractice process's history and current landscape will help providers navigate malpractice challenges. Given the impact and prevalence of medical malpractice, in this paper, the authors sought to dissect the intricate anatomy of a medical malpractice lawsuit. This includes a comprehensive and detailed report of tort reform, the criteria of a medical malpractice suit, and a description of the court proceedings. In addition, the authors also performed an extensive review of the medicolegal literature and have provided recommendations for healthcare providers to avoid these lawsuits in their practice.

The Implications of the Emergency Medical Treatment and Labor Act and the No Surprises Act for Plastic and Reconstructive Surgeons.

SUMMARY: The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986 to protect uninsured patients against economic discrimination. Although this law has been established for several decades, recent passage of the No Surprises Act may invoke new implications for the health care system under EMTALA. Therefore, it is worthwhile to review EMTALA's applications to the practice of plastic surgery and review EMTALA in the context of the recently passed No Surprises Act. First, providers are mandated by EMTALA to administer a medical screening examination to any patient presenting for emergent care. Second, providers must administer medical stabilization if the medical screening examination reveals an emergent condition. If the hospital lacks specialized capabilities to provide stabilizing care, they are required to transfer the patient to a facility that can provide care. Although EMTALA's provisions protect patients and provide them with leverage to obtain emergency care, the act has been associated with out-of-network, or "surprise," medical bills for the insured population and, ultimately, may be detrimental to plastic surgeons in emergency settings. The concerns related to EMTALA within plastic surgery involve the overburdening of surgeons at tertiary care centers because of uncompensated care and high rates of interfacility transfers. In addition, the recent passage of the No Surprises Act to end out-of-network emergency bills may further impact care provided by plastic surgeons in emergency settings under EMTALA's mandate. Potential methods to address these concerns include increasing on-call reimbursement rates and implementation of emergency department telemedicine services.

Endothelial Responses to Curvature-Induced Flow Patterns in Engineered Cerebral Aneurysms.

Hemodynamic factors have long been associated with clinical outcomes in the treatment of cerebral aneurysms. Computational studies of cerebral aneurysm hemodynamics have provided valuable estimates of the mechanical environment experienced by the endothelium in both the parent vessel and aneurysmal dome walls and have correlated them with disease state. These computational-clinical studies have recently been correlated with the response of endothelial cells (EC) using either idealized or patient-specific models. Here, we present a robust workflow for generating anatomic-scale aneurysm models, establishing luminal cultures of ECs at physiological relevant flow profiles, and comparing EC responses to curvature mediated flow. We show that flow patterns induced by parent vessel curvature produce changes in wall shear stress (WSS) and wall shear stress gradients (WSSG) that are correlated with differences in cell morphology and cellular protein localization. Cells in higher WSS regions align better with the flow and display strong Notch1-extracellular domain (ECD) polarization, while, under low WSS, differences in WSSG due to curvature change were associated with less alignment and attenuation of Notch1-ECD polarization in ECs of the corresponding regions. These proof-of-concept results highlight the use of engineered cellularized aneurysm models for connecting computational fluid dynamics to the underlying endothelial biology that mediates disease.

Stiff Shape Memory Polymers for High-Resolution Reconfigurable Nanophotonics.

Reconfigurable metamaterials require constituent nanostructures to demonstrate switching of shapes with external stimuli. Yet, a longstanding challenge is in overcoming stiction caused by van der Waals forces in the deformed configuration, which impedes shape recovery. Here, we introduce stiff shape memory polymers. This designer material has a storage modulus of ∼5.2 GPa at room temperature and ∼90 MPa in the rubbery state at 150 °C, 1 order of magnitude higher than those in previous reports. Nanopillars with diameters of ∼400 nm and an aspect ratio as high as ∼10 were printed by two-photon lithography. Experimentally, we observe shape recovery as collapsed and touching structures overcome stiction to stand back up. We develop a theoretical model to explain the recoverability of these sub-micrometer structures. Reconfigurable structural color prints with a resolution of 21150 dots per inch and holograms are demonstrated, indicating potential applications of the stiff shape memory polymers in high-resolution reconfigurable nanophotonics.

The No Surprises Act: What Do Plastic Surgeons Need to Know?

Background: Out-of-network, or "surprise" bills, have grown common in recent years and have raised substantial concern for patients. Congress recently enacted the No Surprises Act, effective on January 1, 2022, ending the majority of out-of-network bills for privately insured patients. The aim of this review is to briefly summarize the history of surprise billing, describe the regulations of the No Surprises Act, and examine the impact this legislation will have on the field of plastic surgery. Methods: A PubMed and Google Scholar literature search was conducted on out-of-network billing, or surprise bills, and the No Surprises Act. Media outlets, governmental agencies, and local and national medical organizations were additionally queried for surprise billing and the No Surprises Act. Results: Under the No Surprises Act, privately insured patients are protected from surprise medical bills in emergency and nonemergency settings, and uninsured or self-pay patients must be provided a good faith estimate of service fees before receiving nonemergent care. Plastic surgeons may consent patients to receive out-of-network bills if consent is obtained at least 72 hours before rendering a nonemergency service. Despite these patient protections, this act may influence plastic surgeons' reimbursement rates and incentivize surgeons to alter their network status. Conclusions: The No Surprises Act provides significant protections for patients. However, it may have adverse effects for plastic surgeons. Plastic surgeons will only get paid in-network fees while providing care to patients unless consent is properly obtained in a nonemergent setting.

The Management of Postsurgical Pyoderma Gangrenosum following Breast Surgery.

Background: Postsurgical pyoderma gangrenosum is a rare condition characterized by ulcerative lesion development at surgical sites. It is frequently misdiagnosed as infection and mismanaged with surgical debridement, which only worsens the condition. Achieving the correct diagnosis is crucial to delivering the appropriate medical therapy. This article presents four clinical cases of postsurgical pyoderma gangrenosum in breast surgery patients, and proposes a work-up schematic to aid in its diagnosis based on literature review and author experience. Methods: Four patients who developed postsurgical pyoderma gangrenosum following breast surgery were identified by chart review at our institution. Results: The cases include two breast reduction patients, an abdominally based breast reconstruction patient, and a breast augmentation patient. The time to diagnosis and treatment varied greatly between the patients, with diagnosis achieved as early as 13 days postoperatively to as late as one year postoperatively. Two of the four patients were initially mismanaged with surgical debridement, and all patients were treated with at least one course of antibiotics for a misdiagnosis of surgical site infection before they were correctly diagnosed. Conclusions: Postsurgical pyoderma gangrenosum is a rare, ulcerative condition that is difficult to diagnose and often mismanaged with surgical debridement. Diagnosis requires a high clinical suspicion and should be considered in patients with ulcerative lesions resistant to antibiotic therapy, in patients who have bilateral lesions with NAC sparring, and in those with systemic inflammatory conditions. Diagnosis is usually delayed, so it is imperative that surgeons keep this diagnosis in mind when treating breast patients with postsurgical wounds.

Azithromycin for Poorly Controlled Asthma in Children: A Randomized Controlled Trial.

BACKGROUND: Azithromycin has immunomodulatory actions, and its beneficial effects have been demonstrated in asthmatic adults. Data on children are limited. RESEARCH QUESTION: Does the addition of oral azithromycin to standard therapy in children with poorly controlled asthma improve asthma control compared with standard treatment alone? STUDY DESIGN AND METHODS: This open-label randomized controlled trial included children (5-15 years of age) with poorly controlled asthma defined by Asthma Control Test (ACT) and Childhood Asthma Control Test (CACT) score of ≤ 19. They were randomized to receive azithromycin (10 mg/kg) three times weekly for 3 months along with standard treatment or standard treatment alone. The primary outcome was the ACT and CACT scores at 3 months. Secondary outcomes were asthma control according to Global Initiative for Asthma (GINA) guidelines, the number of exacerbations, change in spirometry parameters, change in fractional exhaled nitric oxide (Feno) level, positive throat swab results, and side effects. RESULTS: The trial included 120 children (89 boys; 60 in each group). The mean ± SD age was 9.9 ± 3 years. The baseline parameters were similar between the groups. Mean ± SD ACT and CACT scores (available for 115 children) at 3 months of intervention were 21.71 ± 2.17 vs 18.33 ± 2.19 (P < .001) in the azithromycin and control groups, respectively. The numbers of children with well-controlled asthma according to GINA guidelines were 41 of 56 vs 10 of 56 in the azithromycin and control groups, respectively (P < .001). The median number of exacerbations requiring emergency visit and steroid use were fewer in the azithromycin group: 0 (interquartile range [IQR], 3) vs 1 [IQR, 6]; P < .001). No difference was found in Feno level, spirometry parameters, positive throat swab results, and adverse effects between the groups. INTERPRETATION: The use of azithromycin in children with poorly controlled asthma resulted in improved asthma control and reduced exacerbations. TRIAL REGISTRY: Clinical Trials Registry - India; No.: CTRI/2019/06/019727; URL: www.ctri.nic.in.