Plastic and Reconstructive Surgery Highlights: Plastic Surgery Focus

Abstract

The Plastic Surgery Focus section of Plastic and Reconstructive Surgery, formerly known as Special Topics before 2018, is a unique collection of articles that cover many of the critical aspects of clinical practice, education, and research in plastic surgery. These areas do not necessarily fit neatly into the traditional anatomic subspecialties of the discipline, but instead cover a broad spectrum of important topics, including business, education, global health, technology, and wellness. Now more than ever, plastic surgeons must focus not only on the technical aspects of the specialty but also on the way they are delivered within today’s health care system. As the field, and its surrounding environment, continues to evolve rapidly, the Plastic Surgery Focus section provides the ability to stay up to date with the cutting-edge advancements that continue to shape the specialty. This Plastic and Reconstructive Surgery Highlights article reviews 10 of the most notable Plastic Surgery Focus articles from 2024. While all of the articles from 2024’s section offered important contributions, several were distinguished by their topic, design, and conclusions, providing pivotal information on certain themes, including technology, business, and practice management; health care policy and outcomes; and pharmacotherapeutics in plastic surgery. TECHNOLOGY Artificial Intelligence Technology and its rapid evolution were a pervasive theme throughout 2024, and plastic surgery was no exception. Most noteworthy was the increase in utilization of different artificial intelligence (AI) platforms to improve on the delivery of health care. The Plastic Surgery Focus article from TerKonda et al. describes the important groundwork and future of AI in plastic surgery.1 The authors provide an in-depth review of critical concepts in AI, including the contributions of machine learning and, subsequently, deep learning, as well as the importance of big data in these systems. The study highlights several areas of current and potential future utilization of AI in plastic surgery, including assessment of burn depth,2 detection of vascular compromise,3 screening and classification of craniofacial anomalies,4 and analysis of beauty measures in aesthetic surgery.5 Augmented Reality Augmented reality (AR) platforms are increasingly being used in plastic surgery as an evolution of imaging-guided and virtual surgical planning. The study on spatial fidelity of AR by Cholok et al. provides an important “next step” in the integration of these platforms into the clinical setting.6 In its comparison of computed tomography-based, three-dimensionally printed models of deep inferior epigastric perforator anatomy to the same anatomy projected through a head-mounted wearable AR device, the study notably showed minor variations in translational displacement between the 2 modalities. In addition, it demonstrated the persistent limitations of holographic projections, including variability based on participant interpretation and vantage point, highlighting areas of further improvement for clinical translation of this technology. Social Media Social media continue to play a significant role in patient interactions that is pervasive throughout all plastic surgery subspecialties. A population-based survey study by Elmer et al. identified that the 3 most important factors for respondents in choosing a plastic surgeon were the surgeon’s experience with the desired procedure, board certification, and years in practice.7 The number of social media posts ranked among the 3 least important factors. Notable aspects of this study include the large survey sample size (369 respondents) and the subgroup analysis on age and income. Overall, the findings provide useful information that reinforces the importance of a surgeon’s reputation, experience, and training in surgeon selection, particularly in the age of social media marketing. BUSINESS AND PRACTICE MANAGEMENT A timely study Stoffel et al. analyzed trends in Medicare reimbursement of plastic surgery procedures in comparison with inflation.8 The results of the study are pertinent for all practicing plastic surgeons, as the authors demonstrated a mean inflation-adjusted growth in reimbursement of −13.5%, with the largest decrease in growth rate seen in microsurgery (−19.3%), followed by craniofacial surgery (−17.6%). A devaluation of effort in plastic surgery has several negative implications for government-reimbursed patient care, and reinforces the need for further advocacy and reimburse rate negotiation among all subspecialties. HEALTH CARE POLICY AND OUTCOMES One means of incentivizing high-quality care and preventing payment reductions from Medicare has been the Merit-based Incentive Payment System (MIPS). Implemented in 2017, MIPS offers performance-based payment adjustment of Medicare reimbursements, but plastic surgery performance in MIPS has not been well studied. Perez Otero et al. conducted the first analysis of MIPS performance among plastic surgeons and found that total performance, promoting interoperability, and improvement activities increased between 2019 and 2021, whereas quality scores decreased.9 Additional important findings included the correlation between larger practices as a significant predictor of receiving bonus payments and the concern of potential bias against socially disadvantaged patient populations. One clinical focus of plastic surgery that has fallen behind the current landscape of reimbursement and coding is lymphatic surgery. In a health policy special topic article from 2024, Rochlin et al. investigated variation in commercial payor rates for the many Current Procedural Terminology codes used in physiologic and reductive lymphedema surgery procedures, including lymphovenous bypass, vascularized lymph node transplants, suction lipectomy, and direct excision.10 They identified significant variability both within and across hospital systems in negotiated rates, as well as relative undervaluation of physiologic procedures compared with excisional ones. This study reinforces the need for the development of standardized coding for lymphedema surgery. National health care outcomes were the focus of an important study on gender-affirming surgery by Kilmer et al.11 The authors propensity score–matched 3134 gender-dysphoric patients who underwent surgery with a control group based on data from a national insurance claims–based database. They found that those who underwent surgery had decreased postoperative rates of antidepressant use, as well as improved mental health indices. The study provides important evidence on the mental health benefits of gender-affirming surgery for the gender-dysphoric population in appropriately selected patients. EDUCATION Plastic surgery training has evolved to encompass not only traditional core components of plastic surgery but also more comprehensive aspects of modern health care practice. Along these lines, how well are plastic surgery trainees readied for the “real world”? The article by Krasniak et al. analyzed a critical component of this, financial literacy, through a survey study of 112 plastic surgery trainees in U.S. residency programs.12 The authors identified that 1 in 5 trainees did not feel prepared to manage finances after graduation, and the majority had received no finance education during training. The study highlights the important need to bolster financial literacy curricula in residency programs as a means improving wellness and decreasing burnout in future practicing plastic surgeons. PHARMACOTHERAPEUTICS A wealth of research has been dedicated to assessing venous thromboembolism risk and minimizing the occurrence of venous thromboembolism after plastic surgery procedures. The 2024 Plastic Surgery Focus review article by Othman et al. comprehensively and succinctly describes the pharmacology, dosing, indications, advantages, and disadvantages of different chemoprophylaxis agents, including unfractionated heparin, low-molecular-weight heparin, and indirect factor Xa inhibitors.13 Important recommendations based on randomized controlled trials and meta-analyses of randomized controlled trials are provided, particularly regarding the use of enoxaparin prophylaxis for high-risk inpatients with a Caprini score of 7 or greater,14 as well as the need for additional high-level-of-evidence data on oral Xa inhibitor prophylaxis for plastic surgery patients. Tranexamic acid (TXA) is another important pharmacologic agent that has been increasingly utilized in plastic surgery as a means of reducing surgical blood loss. Brown et al. performed a systematic review and meta-analysis of 45 studies on the use of TXA in plastic surgery procedures.15 The authors identified high-certainty evidence for the use of TXA in cosmetic surgery, particularly rhinoplasty, to reduce blood loss and moderate-certainty evidence for blood loss reduction in craniofacial and burn surgery. On the other hand, evidence was lacking for improved outcomes in breast surgery, face lift procedures, and microsurgery. The study provides important clinical recommendations for TXA use and highlights areas in need of further research. CONCLUSIONS This collection of Plastic Surgery Focus articles from 2024 covers many important areas in the modern practice of plastic surgery. Notable topics include the increased utilization of AI and AR in plastic surgery, the role of social media in patient interactions, procedural reimbursement trends and incentive programs, gender-affirming surgery outcomes, financial preparation of trainees, and important pharmacologic agents within plastic surgery. Overall, these articles describe important advances in knowledge, review essential topics for the practicing plastic surgeon today, and define many of the future directions of the field. DISCLOSURE Dr. Salibian is a research consultant for AbbVie, Inc.

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