Defining the Incidence of the Impostor Phenomenon in Academic Plastic Surgery: A Multi-Institutional Survey Study

BACKGROUND

Impostor phenomenon occurs when high-achieving individuals have persistent self-doubt despite objective measures of competence and success, and has been associated with professional burnout and attenuated career advancement in medical specialties. This study aimed to define the incidence and severity of the impostor phenomenon in academic plastic surgery.

METHODS

A cross-sectional survey containing the Clance Impostor Phenomenon Scale (range, 0 to 100; higher scores indicate greater severity of impostor phenomenon) was distributed to residents and faculty from 12 academic plastic surgery institutions across the United States. Generalized linear regression was used to assess demographic and academic predictors of impostor scores.

RESULTS

From a total of 136 resident and faculty respondents (response rate, 37.5%), the mean impostor score was 64 (SD 14), indicating frequent impostor phenomenon characteristics. On univariate analysis, mean impostor scores varied by gender (67.3 for women versus 62.0 for men; P = 0.03) and academic position (66.5 for residents versus 61.6 for attendings; P = 0.03), but did not vary by race or ethnicity; postgraduate year of training among residents; or academic rank, years in practice, or fellowship training among faculty (all P > 0.05). After multivariable adjustment, female gender was the only factor associated with higher impostor scores among plastic surgery residents and faculty (estimate 2.3; 95% CI, 0.03 to 4.6; P = 0.049).

CONCLUSIONS

The prevalence of the impostor phenomenon may be high among residents and faculty in academic plastic surgery. Impostor characteristics appear to be tied more to intrinsic characteristics, including gender, rather than years in residency or practice. Further research is needed to understand the influence of impostor characteristics on career advancement in plastic surgery.

A 10-year analysis of the racial distribution of authors in plastic surgery research and the impact of minority mentorship

BACKGROUND

This study evaluates the racial distribution in Plastic and Reconstructive Surgery (PRS) publication authorship and illustrates the impact underrepresented in medicine (URiM) mentorship has on increasing diverse trainee contributions to the PRS peer-reviewed literature.

METHODS

Articles published in the seven highest-impact PRS peer-reviewed journals within the last 10 years (2012-2022) were reviewed and analyzed for first and senior authors' race and ethnicity, publication year, and citation count.

RESULTS

A total of 23,549 publications were identified of which 8250 were from the US-based institutions. A random sampling of 778 publications (∼10 ​%) were scrutinized for first and senior author race and ethnicity. Across all journals, 64.5 ​% of senior authors were White, 29.9 ​% Asian, 4.6 ​% Hispanic, and 1.0 ​% Black. First authors were 59.5 ​% White, 32.8 ​% Asian, 5.2 ​% Hispanic, and 2.6 ​% Black (p=<0.0001). The presence of a URiM senior author increased the likelihood of a URiM first author 7-fold (p=<0.0001); 95 ​% CI [3.5-14.0]). There was no statistically significant difference in the total citation count relative to author race or ethnicity. The Aesthetic Surgery Journal had the greatest proportion of White senior authors (73.6 ​%), while Microsurgery had the highest percentage of URiM senior authors (8.7 ​%).

CONCLUSIONS

URiM authorship of PRS publications is limited and mentorship is essential to improve underrepresented perspectives in the PRS peer-reviewed literature.

Association of Socioeconomic Status, Sex, Racial, and Ethnic Identity With Sustained and Cultivated Careers in Surgery

OBJECTIVE

Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school.

METHODS

This retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation.

RESULTS

Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery [adjusted relative risk (aRR): 0.92 (0.85-0.98)], while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates.

CONCLUSIONS AND RELEVANCE

This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

BACKGROUND

Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center.

METHODS

Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions.

RESULTS

A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months.

CONCLUSIONS

Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Deconstructing the Excellent Plastic Surgeon: A Survey of Key Attributes

Background

Most plastic surgeons practice in nonacademic settings, leaving a small subset of academic plastic surgeons with the responsibility of selecting the future generation of plastic surgeons without representation from a majority of our field. This raises questions as to whether the academic attributes valued during residency selection are valid predictive markers of who will become an excellent plastic surgeon. A survey was conducted of both academic and nonacademic plastic surgeons, as well as trainees, to determine what traits are considered most essential to being an excellent plastic surgeon.

Methods

An electronic survey was distributed before the American Council of Academic Plastic Surgeons 10th Annual Winter Meeting. Demographics and information regarding the respondents' training and academic status were collected. Respondents were asked to select five traits that they considered most important to be an excellent plastic surgeon from a list of 20 preselected traits. Chi-square and Fisher exact tests were used to perform subgroup analyses.

Results

A total of 187 responses were received from meeting attendees, representing an 89.0% response rate. Overall, the five values endorsed as most important for a plastic surgeon were being technically sound (53%), collaborative (48%), ethical (44%), compassionate (37%), and emotionally intelligent (33%). However, the emphasis placed on these different attributes differed significantly amongst different demographic groups.

Conclusion

It is important that we use methods such as holistic review when evaluating plastic surgery applicants to ensure our selection process is congruent with the traits we value.

Visual representation of diversity in online patient education materials for reduction mammaplasty

Online patient education materials play an important role in plastic surgery, and surgeons should ensure that materials accurately reflect their patient population. This study compared the skin tone of images in online materials from the American Society of Plastic Surgeons (ASPS), academic plastic surgery programs, and private groups to the demographics of the United States (US) reduction mammaplasty population. Images within patient education materials and embedded photo galleries were assessed and skin tones were categorized using the Fitzpatrick Skin Scale (FSS). Two reviewers evaluated 616 images. Scores of 1-3 were categorized as White, while scores of 4-6 were classified as non-White. The proportion of images categorized as White and non-White were compared to the demographics of the reduction mammaplasty population in the US. Of 616 images, 82% were classified as White, while 18% were non-White. This distribution differed significantly from the racial demographic distribution of patients undergoing reduction mammaplasty in the US in 2020, where 48% identified as White and 52% as non-White (p < 0.001). There was also a statistically significant difference in the distribution of FSS scores between the materials from the ASPS, academic programs, and private surgeon groups, with private groups having a lower percentage of non-White images (p = 0.028). These findings suggest that implicit bias may impact the creation of patient education materials for reduction mammaplasty and highlights the need for improvement in distributing patient education materials that accurately represent the diverse reduction mammaplasty population.

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences

BACKGROUND

Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes.

OBJECTIVE

The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery.

DESIGN

This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery.

SETTING

Online survey for medical students in the United States.

PARTICIPANTS

All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019.

RESULTS

The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05).

CONCLUSIONS

This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Strength in Numbers: A SWOT Analysis of Plastic Surgery

Background

Plastic surgeons comprise the minority of practicing surgeons, with an even smaller minority practicing in an academic setting. As the practice of medicine and the systems in which we operate continue to evolve, it is essential that plastic surgeons have a say in the changing landscape. This study conducted a strengths, weaknesses, opportunities, and threats (SWOT) analysis of plastic surgery to identify unifying strengths and common threats.

Methods

An electronic survey was distributed to American Council of Academic Plastic Surgeons' Winter Meeting attendees on three separate occasions preceding the meeting. Respondents were asked to provide demographic information and to identify the top three strengths, weaknesses, opportunities, and threats (SWOT analysis) for the specialty. Subgroup analyses were performed based on demographic characteristics.

Results

A total of 187 responses were received from meeting attendees, representing an 89.0% response rate. Most respondents were non-Hispanic (78.6%), White (66.8%), women (59.5%), and faculty/independent physicians (65.8%). The most identified strength in plastic surgery was our problem-solving abilities (62.0%). The most identified weakness was poor public perception of plastic surgery (54.0%). The most identified opportunity was demonstration of value to health systems (67.9%), and the most identified threat was scope of practice creep by other specialties (78.1%). The SWOT analysis identified lack of surgeon diversity as a key weakness, improvement of surgeon diversity as a key opportunity, and lack of diversity among plastic surgeons as a key threat to the specialty.

Conclusion

Only through a diverse but united front can we effectively use our strengths to face our threats and employ opportunities to overcome our weaknesses.

A Practical Guide to Implementing Holistic Review during Surgery Resident Selection

Provider workforce diversity is a key component of improving healthcare quality and addressing healthcare disparities. Furthermore, the traditional approach of "score-centered" application metrics do not consistently correlate with meeting milestones in surgery, nor do they adequately predict a surgical resident's clinical strength and operative abilities. We present here an adaptable process by which surgical residency programs can identify their values and incorporate holistic review into their resident selection process to improve resident selection and physician workforce diversity.

A SWOT Analysis of Hot Topics in Plastic Surgery Resident Education: Consensus From the ACAPS 10th Annual Winter Meeting

Background

With the aim of facilitating a critical self-reflection on how to align plastic surgery education with making excellent plastic surgeons, a rotating small-group session followed by live interactive audience polling was used to perform a SWOT (strengths, weaknesses, opportunities, and threats) analysis at the 10th Annual American Council of Academic Plastic Surgeons Winter Meeting.

Methods

The final day of the conference included a 3-hour session of rotating small groups followed by live interactive audience polls discussing the following six relevant educational topics: the Plastic Surgery Common Application and resident selection, aesthetic surgery education, leadership development and business education, embedded fellowships and focused training, mentorship, and faculty retention.

Results

A total of 60 individuals participated in the activity. A SWOT analysis was successfully performed for each educational topic, and a minimum of four opportunities were identified per topic to help guide future endeavors. Examples of opportunities include releasing recommendations for the implementation of holistic review; developing formal guidelines for aesthetic surgery education in residency via collaboration between ACAPS, American Society of Plastic Surgeons, and The Aesthetic Society; creating extended focused elective rotations; integrating business education into formal curricula for all training levels; enforcing transparency regarding position expectations and offerings including salary, call schedule, and current challenges; and more.

Conclusion

The results of this study will help guide future initiatives by the ACAPS to improve resident education and academic retention.

Exploring Factors Associated with Implant Removal Satisfaction in Breast Implant Illness Patients: A PRO BREAST-Q Study

Background

Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear.

Methods

A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors.

Results

Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores (P = 0.015). Self-pay was predictive of increased breast satisfaction scores (P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms (P = 0.032). Psychiatric illness had no significant impact on the outcomes.

Conclusions

In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms.

Operation Diversify Plastic Surgery: An Innovative Strategy to Increase Diversity in Plastic and Reconstructive Surgery

Healthcare disparities remain a significant problem facing the US healthcare system with recent evidence of persistent racial and ethnic disparities especially among patients from minority backgrounds. Recent studies have documented advantages to a racially and ethnically diverse surgical workforce such as higher patient satisfaction scores, superior patient compliance with physician recommendations, and increased participation in clinical research studies by minority patients. In plastic and reconstructive surgery (PRS), there is a noted deficit among residents and faculty that come from ethnically underrepresented in medicine (URiM) backgrounds despite recent efforts to increase diversity in PRS surgeons. URiM medical students from three of the four historically Black medical universities organized to discuss pathways to PRS. Operation Diversify Plastic Surgery is a student-led organization that was developed to address the lack of diversity in PRS, challenges faced by students from institutions that lack PRS residency training programs, and unique factors that affect URiM students interested in PRS. Available studies note that mentoring relationships and research opportunities were instrumental in recruiting URiM students into PRS residency programs. Operation Diversify Plastic Surgery is an innovative solution to the insufficient URiM PRS residency candidate pool by increasing medical student exposure to PRS via educational lectures, virtual mentoring opportunities, and insights into research fellowships.

Recognition and Respect: Contextualizing the History and Contributions of Black American Plastic Surgeons

Recently, there has been heightened interest in the history of Black American plastic surgeons and their contributions to the field of plastic and reconstructive surgery (PRS). Despite the increased awareness and attention toward the lack of racial and ethnic diversity of the PRS workforce, the history of how PRS became one of the most ethnically segregated surgical specialties remains unexplored. Here, we outline the various political and cultural factors that contributed to the exclusion of Black practitioners from American PRS professional societies. This work contextualizes the rise of American PRS within the Jim Crow era and highlights the cultural significance of reconstructive procedures performed in the treatment of disfigured soldiers. Through this lens, we identify circumstances where Black surgeons were systematically denied opportunities to participate in the emerging specialty. Despite these barriers, we demonstrate how Black physicians established informal networks for professional advancement and shed light on several previously unrecognized contributions to PRS from Black surgeons. In addition, we explore how the inclusion of Black voices in PRS sparked a paradigm shift in the treatment of non-White patients that expanded the cosmetic marketplace in ways that remain significant today. Finally, we situate the ongoing disparities in Black representation in PRS within a broader historical narrative and illustrate how the stories we tell about our past continue to shape the future of our field.

Ensuring Racial and Ethnic Inclusivity in Facial Vascularized Composite Allotransplantation

Facial vascularized composite allotransplantation (fVCA) represents a valuable surgical option for reconstruction of the most devastating facial defects. There is a mounting body of evidence suggesting that healthcare disparities exist for a variety of other surgical and nonsurgical procedures. We aimed to investigate the potential existence of racial and ethnic disparities in the field of fVCA.

Methods

A comprehensive literature review was conducted by the authors of this review on PubMed/MEDLINE, and Embase databases from database inception to December 1, 2022 for studies published in the English and French languages. The search terms were (1) "face" OR "facial" AND (2) "transplant" OR "VCA" OR "vascularized composite allotransplantation" OR "vascularized composite allograft" OR "graft."

Results

Upon assessment of the racial and ethnic demographics of the 47 global cases of fVCA between 2005 and 2020, 36 were White, 10 were Asian, and one was Black. Sixteen of the 17 fVCA procedures performed in the United States involved White patients. The other patient self-identified as Black, equaling 6% of all US fVCA recipients.

Conclusion

Our analysis showed that the ethnic and racial distribution of fVCA has not proportionally reflected the racial and ethnic demographics of the general US population, underscoring the risk of such healthcare imbalances. Although large-scale studies are needed before drawing definitive conclusions, leaders in the field should take preventive steps to avoid potential disparities. Further investigations into the factors that facilitate or prohibit access to fVCA referral and surgery will be necessary moving forward.

Changing Faces: Factors Associated with the Intention to Pursue Plastic Surgery and Practice in Underserved Areas

Improving the number of plastic and reconstructive surgeons who provide care to patients in underserved communities is critical to achieving health equity. We aimed to identify factors associated with graduating medical students' intentions to pursue plastic surgery and practice in underserved areas.

Methods

De-identified data for US medical school graduates were obtained from the Association of American Medical Colleges for students who matriculated in academic years 2007-2008 and 2011-2012. Data collected included self-reported demographic and future practice intentions. Multivariate analysis was conducted to determine indicators of students' interest in plastic surgery, and their intention to practice in underserved areas.

Results

Of the 57,307 graduating US medical students in our cohort who completed the Graduation Questionnaire, 532 (0.9%) reported an intention to pursue plastic surgery. Hispanic [adjusted odds ratio (aOR): 1.45; 95% confidence interval (95% CI), 1.07-1.98] and multiracial (aOR: 1.59; 95% CI, 1.03-2.45) students were more likely to pursue plastic surgery compared with other surgical specialties. Among students interested in plastic surgery, compared with non-Hispanic White students, Black (aOR: 6.15; 95% CI, 1.96-19.26) students were more likely to report intention to practice in underserved areas. Students with community-engagement experiences were more likely to report intention to practice in underserved areas.

Conclusions

Diversity among medical trainees pursuing plastic and reconstructive surgery is critical for maintaining and expanding plastic surgery services rendered in underserved areas. These findings suggest that student demographics and experiences with community-engagement experiences are positive indicators of practicing in underserved communities.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques

BACKGROUND

A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes.

METHODS

Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed.

RESULTS

Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03).

CONCLUSIONS

The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Postoperative Antibiotics Following Reduction Mammaplasty Does Not Reduce Rates of Surgical Site Infection

BACKGROUND

The efficacy of antibiotic utilization following reduction mammaplasty has not been well studied. Furthermore, there is a lack of data describing subgroups who are historically high-risk for surgical site infection (SSI), specifically the obese population.

OBJECTIVES

This study compares SSI rates in reduction mammaplasty patients that received postoperative courses of antibiotics to those that did not. Additional analysis was performed for the subgroup of patients with body mass index (BMI) ≥30 kg/m2.

METHODS

The 2010 to 2021 PearlDiver Mariner dataset (PearlDiver Inc, Colorado Springs, CO) was reviewed to identify reduction mammaplasty patients. Patients were confirmed to have received perioperative antibiotics. Postoperative antibiotic use was determined based on the presence of postoperative prescriptions, and 1:1 matching was performed for those with and without postoperative antibiotics based on age and Elixhauser Comorbidity Index. Ninety-day rates of SSI, emergency department (ED) visits, and readmissions were recorded and compared. A subgroup analysis was performed on patients with BMI ≥30 kg/m2.

RESULTS

Among patients that were confirmed to receive perioperative antibiotics, 2230 patients that also received postoperative antibiotics were identified and matched to 2230 patients that did not. Rates of SSI, ED visits, and readmission were not statistically different. 218 obese patients were identified from this group and matched. Rates of SSI, ED visits, and readmission were not statistically different.

CONCLUSIONS

The current study found no difference in SSI rates between patients that received postoperative antibiotics and those that did not. These observations are corroborated in the obese population. These data may assist surgeons when considering postoperative antibiotics in reduction mammaplasty.

Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia

BACKGROUND

Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG).

OBJECTIVES

The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG.

METHODS

A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes.

RESULTS

Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience.

CONCLUSIONS

This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.

LEVEL OF EVIDENCE: 4

Society of Black Academic Surgeons (SBAS) diversity, equity, and inclusion series: Microaggressions - Lessons Learned from Black Academic Surgeons

Background:

Microaggressions can target individuals based on a variety of differences and these can include sexual orientation, nationality, gender, or personal traits and are often disruptors in the healthcare setting.

Methods:

To address this issue, The Society of Black Academic Surgeons (SBAS) convened a series of presentations and a panel discussion by leaders from SBAS regarding the issue of microaggressions in the surgical workplace. This program was part of a monthly diversity, equity, and inclusion series produced by the Advances in Surgery Channel in alliance with the American College of Surgeons. Dr. Yewande Alimi addresses microaggressions in surgical training, Dr. Fabian Johnston talks about microaggressions in the black male physician, Dr. Lola Fayanju speaks to microaggressions and the black female surgeon, Dr. Carla Pugh discusses microaggressions in the surgical workplace, and Dr. Paris Butler presents on allyship, policies, and real solutions.

Results:

Specifically, through the lens of the Black surgeon experience, SBAS leaders candidly articulate and elaborate on microaggressions’ pervasiveness and the deleterious impact on the profession. Authentic opinions are rendered and constructive techniques to mitigate this challenge are provided. The concept of majority allyship is also introduced, and recommendations on how this can be operationalized is also examined.

Conclusions:

There are a lot of experiences that contribute to our understanding of microaggressions. We look forward to finding new ways to partner with our allies and continuing the conversation.

Representation Matters: One Urology Residency Program's Approach to Increasing Workforce Diversity

OBJECTIVE

To address the challenge in urology in recruiting physicians from backgrounds racially and ethnically underrepresented in medicine (URiM), we sought to design, implement, and evaluate methods for recruiting URiM candidates to our urology residency program.

METHODS

We developed a 3-pronged approach aimed at increasing the number of interviewed applicants, and subsequently number of URiM residents recruited to our program. The 3 facets included: (1) funded visiting student rotation, (2) holistic evaluation of applications, (3) implemented targeted outreach. Statistical analysis of the applicants interviewed and matched into our residency program, as well as traditional metrics used for residency recruitment, were performed from 2015 to 2022.

RESULTS

The number of URiM interviewees significantly increased from 6.1% in 2015 to its peak, 40%, in 2020. In 2015, there were no URiM residents in our urology residency program. By 2022, the total URiM complement increased to 35%. In evaluating traditional metrics of residency recruitment, there was no significant difference in mean USMLE Step 1 score before compared with after the implementation of our recruitment approach. The maximum rank number reached to fill the urology residency positions also remained relatively stable throughout the study period, with a range from 5 to 38.

CONCLUSION

We demonstrate that the implementation of our innovative and intentional 3-pronged recruitment approach effectively increased the number of URiM interviewees and residents in our residency program. The diversification of our urology workforce depends on the implementation of such efforts, and we encourage urologists to lead the way on such initiatives.

A Blueprint for Increasing Ethnic and Racial Diversity in U.S. Residency Training Programs

PROBLEM

People who identify as African Americans, Latinos, or from indigenous backgrounds, are dramatically underrepresented in the U.S. physician workforce. It is critical for academic health centers to recognize racial and ethnic diversity at the residency level and implement changes to enhance diversity among trainees.

APPROACH

The Office of Graduate Medical Education (GME) at the University of Pennsylvania Health System (UPHS) developed a multipronged approach to enhance diversity and inclusion (D&I) among residency trainees. The approach included the development of an underrepresented in medicine (UIM) professional network; UIM-focused visiting clerkship programs; holistic review implementation by selection committees; and targeted outreach to UIM candidates, overseen by an associate designated institutional official for UIM Affairs. The authors reported demographic data on residency applicants invited for interviews and matching for all programs at UPHS from 2014-2015 (baseline) to 2020-2021. They also reported data on maximum ranking number programs reached to fill their positions and the average United States Medical License Examination (USMLE) Step 1 scores of matched candidates. Finally, they discussed the implications for leaders who wish to enhance D&I at academic health centers.

OUTCOMES

During the baseline year (2014-2015), UIMs represented 12.1% of interviewees and 8.7% of all matched candidates into UPHS residency programs. Over the successive 6 years after incremental implementation of the approach, UIM representation steadily increased. In 2020-2021, UIMs represented 23.2% of interviewees and 26.4% of matched candidates. Programs' maximum rank number to fill and USMLE Step 1 scores of matched candidates remained relatively unchanged.

NEXT STEPS

The UPHS Office of GME incorporated a purposeful approach to enhance the D&I of its residents. Across 6 years of implementation, UIM representation among resident matches tripled while quantitative program and candidate metrics remained unchanged. Similar efforts should be given further consideration for implementation and evaluation nationwide.

Opportunity Costs of Internal Promotions in Plastic Surgery: Are Women Given a Fair Shot?

Background:

Methods:

Results:

Conclusions:

Racial and Ethnic Disparities in Surgical Outcomes after Postmastectomy Breast Reconstruction

BACKGROUND

Women of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction.

STUDY DESIGN

Data were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively.

RESULTS

Compared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications.

CONCLUSION

Disparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.

Prevalence of Workforce Diversity Research Among Surgical Specialties in the United States: How Does Plastic Surgery Compare?

BACKGROUND

Plastic surgeons are not as diverse as expected in relation to the increasingly diverse patient and medical student population. The authors assess the state of diversity in 8 primary surgical specialties in the United States and evaluate trends in research interest in diversity over the past 30 years.

METHODS

Articles regarding diversity in surgery from 1990 to 2020 were systematically reviewed. The Association of American Medical Colleges Physician Specialty Data Reports and the Accreditation Council for Graduate Medical Education Data Resource Books provided resident/fellow and faculty data from 2011 to 2016. Trends were analyzed over time per specialty.

RESULTS

From 1990 to 2020, a total of 199 publications related to diversity were identified among the various surgical specialties. Orthopedic surgery had significantly more publications per year compared with other specialties (P < 0.05). Every specialty demonstrated a significant increase in publications about diversity over time (P < 0.05). A majority of publications were related to sex rather than underrepresented in medicine topics. The proportion of female surgeons was significantly higher for plastic surgery than for orthopedic surgery and neurosurgery (P < 0.001). Plastic surgery exhibited the highest growth rate in female residents (+1.6% per year, P < 0.001). The proportion of underrepresented minorities composing surgical trainees has not significantly increased in any surgical specialty between 2011 and 2016 (P > 0.05).

CONCLUSIONS

Although diversity representation in surgery has somewhat improved, the rate is too slow to match the growing diversity of the US population. Outcomes have been disparate between specialties and demonstrate greater increases in sex equality relative to ethnic/racial equality. Evidence-based interventions need to be developed and implemented.

"Diversity in Surgery-How Do We Change the Narrative: Pipeline to Professor?"

The goal of our paper is to provide our perspectives on why there is a need to change the narrative in academic surgery to improve health equity by increasing the pipeline of pre-med students to professors. It is well documented that Health disparities hurt many different people, but they especially hurt Black, Indigenous, and People of color. Black men and women have a decreased life expectancy. Differences in care are associated with greater mortality among minority patients and that care provided to black patients by black physicians can lead to improved compliance with medications and care plans. The lack of black diversity in the medical profession proportional to the societal ethnic distribution is alarming. We have opportunities for improvement for recruitment, retention and promotion within the field of surgery.

Quantifying the Pipeline of Ethnically Underrepresented in Medicine Physicians in Academic Plastic Surgery Leadership

BACKGROUND

The lack of underrepresented in medicine (UIM) physicians in academic plastic surgery is emerging as a critical issue. Lack of diversity has a negative effect on patient care and on the culture of our health care system. This study reports the current status of ethnically UIM physicians in the plastic surgery pipeline, starting from the medical student level and progressing to national leadership positions.

METHODS

The Electronic Residency Applications Service, National Resident Matching Program, Association of American Medical Colleges, and professional Web sites for journals and national societies were accessed for racial demographic information from 2008 to 2019.

RESULTS

Over the past decade, there has been no change or a slight decrease in representation of Blacks among plastic surgery residency applicants, trainees, and academic faculty, at half or less than expected, compared with US Census data. The first point of drop-off occurs at the resident (3.8% of integrated and 5.6% of independent residents) to faculty level (<2.8%). Two percent of program directors and department heads/division chiefs are Black. The next point of drop-off occurs at the national level: there has never been a Black president of American Society of Plastic Surgeons or Plastic Surgery Foundation, and there are no Black editors-in-chiefs of major plastic surgery journals.Following LatinX American surgeons down the pipeline over the past decade, there has been no change or a decrease in representation among plastic surgery residency applicants, resident physicians, and academic faculty, at one-third or less than expected, compared with US Census data. The first point of drop-off occurs at the faculty (4.8%) to local leadership level (0% of program directors and department heads/division chiefs) where there is no representation of LatinX. Once this drop-off occurs, there is no recovery at the national leadership level.

CONCLUSIONS

In order for our profession to reflect our nation's demographics, academic plastic surgery is in need of a paradigm shift now. Attrition of UIM physicians in plastic surgery begins at medical school graduation and persists through surgical training, faculty appointments, and attainment of leadership positions. Creative and innovative commitment to diversity and inclusion is necessary.

Persistent Disparities in Postmastectomy Breast Reconstruction and Strategies for Mitigation

For many women, breast reconstruction is an essential component of the breast cancer care continuum after mastectomy. Despite postmastectomy breast reconstruction now being a standard of care, numerous studies over the past decade have documented persistent racial disparities in breast reconstruction rates, physician referral patterns, and patient knowledge of their reconstructive options. These disparities have disproportionately impacted women of color-most specifically, African American women. Recent data have revealed racial differences in patient comorbidities, informed decision-making satisfaction, and clinical outcomes after breast reconstruction. Explicitly, African American women have significantly more risk factors for complications and less baseline knowledge regarding reconstructive options than white women. With a recent heightened attention focused on social determinants of health, studies designed to improve these racial differences have demonstrated promising results through educational outreach to underserved communities, implementation of tailored legislation promoting inclusion, diversity, and equity, and encouragement of additional recruitment of ethnically underrepresented-in-medicine surgeons. This study uses a targeted review of the literature to provide a summary of racial disparities in breast reconstruction for African American women, with our perspective on opportunities for improvement.

Assessing Disparities in Reduction Mammaplasty: There Is Room for Improvement

BACKGROUND

Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery.

OBJECTIVES

The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores.

METHODS

Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups.

RESULTS

A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all P < 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (P < 0.001), BMI vs preoperative physical well-being (P < 0.001), and ethnicity vs preoperative physical well-being (P = 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (P < 0.001), median income by zip code (P < 0.001), improvement in satisfaction with breasts (P = 0.039), satisfaction with information (P = 0.007), and satisfaction with office staff (P = 0.044).

CONCLUSIONS

Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling.

LEVEL OF EVIDENCE: 2

How to Be An Antiracist Hand Surgery Educator

Racism that unjustly marginalizes black people in the United States is not a new concept. It underlies nearly every aspect of American history, leading to the systemic racism that is ingrained in our society today. With the recurrent theme of people of color having worse health outcomes than the majority community, it is important for hand surgeons to employ cultural competence and antiracist education to provide better care and support for patients, staff, students, and colleagues. In this article, we will provide a definitional framework, clinical examples, and practical pearls to promote change. To reduce racial and ethnic health care inequities and diversify the field of hand surgery, we must advocate on behalf of black and brown colleagues, staff, students, and/or friends to address racist policies and procedures.

Looking Beyond the Numbers: Increasing Diversity and Inclusion Through Holistic Review in General Surgery Recruitment

OBJECTIVE

The purpose of this study is the examine the effect of a holistic review process on the recruitment of women and students underrepresented in medicine (UIM) in a general surgery residency program.

DESIGN

A retrospective study comparing the proportion of women and UIM students ranked and matched into categorical positions from 2013 to 2020 before and after the implementation of the holistic application review process. United States Medical Licensing Exam (USMLE) scores and American Board of Surgery In-training Exam (ABSITE) scores were also compared between groups.

SETTING

General Surgery residency program at a tertiary, academic center.

PARTICIPANTS

Medical students applying for and matriculated to categorical positions.

RESULTS

After the implementation of holistic review in 2017, there was a statistically significant increase in the proportion of women (42% vs. 61%, p < 0.01) and UIM students (14% vs. 20%, p = 0.046) ranked in our program compared with the prior "traditional" approach. The proportion of matched female (33% vs. 54%, p = 0.11) and UIM applicants (14% vs. 21%, p = 0.48) also increased after holistic review, although the changes were not statistically significant. The median USMLE Step 1 scores were equivalent for both ranked (250 vs. 250, p = 0.81) and matched (250 vs. 249, p = 0.32) applicants before and after the intervention. The median ABSITE scores for the matched intern classes was lower after initiation of holistic review (519 vs. 483, p = 0.01). However, these scores were consistently above the national medians and subgroup analysis showed no difference between the median aggregate ABSITE scores for UIM and female categorical interns and non-UIM males (475 vs. 520, p = 0.09).

CONCLUSIONS

Increasing emphasis is being placed on the diversification of residency training to reflect an expanding, diverse patient population. The incorporation of a holistic review process, providing broader assessment of applicants, can play a pivotal role in increasing the proportion of women and UIM students represented in the general surgery recruitment process.

Reassessing career pathways of surgical leaders: An examination of surgical leaders' early accomplishments

BACKGROUND

The American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and Society of Black Academic Surgeons (SBAS) partnered to gain insight into whether inequities found in surgical society presidents may be present earlier.

METHODS

ACS, ASA, AWS, and SBAS presidents' CVs were assessed for demographics and scholastic achievements at the time of first faculty appointment. Regression analyses controlling for age were performed to determine relative differences across societies.

RESULTS

66 of the 68 presidents' CVs were received and assessed (97% response rate). 50% of AWS future presidents were hired as Instructors rather than Assistant professors, compared to 29.4% of SBAS, 25% of ASA and 29.4% of ACS. The future ACS, ASA, and SBAS presidents had more total publications than the AWS presidents, but similar numbers of 1st and Sr. author publications.

CONCLUSION

Gender inequities in academic surgeon hiring practices and perceived scholastic success may be present at first hire.

Mentoring Residents Underrepresented in Medicine: Strategies to Ensure Success

OBJECTIVE

To provide a framework for effective mentorship of residents underrepresented in medicine (UIM) situated in the context of their experiences in healthcare teams.

DESIGN

A perspective summarizing the important elements for the effective mentorship of UIM residents.

CONCLUSION

Mentorship of trainees is of profound importance in medical education as it provides tangible benefits for professional and personal development. However, given their unique experiences and position in our teams as well as the larger healthcare construct, the mentorship of UIM residents requires special consideration and focus. Implementing programs that foster diversity, cross-cultural mentorship, and sponsorship are imperative.

Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy

INTRODUCTION

We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT).

STUDY DESIGN

Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications.

RESULTS

284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group.

CONCLUSIONS

MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.