Background: Prior studies have shown a lack of diversity among plastic surgery trainees. The authors evaluate trends in minority representation among applicants to plastic surgery and the correlation with practicing residents, compared to other specialties. Methods: The Association of American Medical Colleges Electronic Residency Application Service provided applicant data for integrated, independent plastic surgery, and other select specialties from 2010 to 2016. Journal of the American Medical Association Graduate Medical Education annual reports and Association of American Medical Colleges graduate student questionnaires provided resident and medical student data. Binomial distribution analysis was used to assess differences in Black, Hispanic, and female proportions of applicants and residents. Best-fit trend lines were compared among groups and specialties. Results: Women have seen an increase in integrated and independent resident representation (+2.23 percent and +0.7 percent per year, respectively) over the past 7 years, despite a relative decrease in applicants. The proportion of female applicants and residents correlated yearly for all specialties (p > 0.05). Conversely, for all years and all specialties, the Black proportion of applicants was significantly higher than the resident representation of the same year (p < 0.05). Hispanic applicant and resident representation have seen a minimal change. Conclusions: Female representation among trainees has increased greatly, but there has been a decline in Black representation of integrated plastic surgery residents despite increases in medical school graduates and applicants. The data highlight a discrepancy between the population of applicants and residents suggesting that barriers starting from medical school may contribute to the lack of diversity in plastic surgery.

Background Prior studies have shown that roadblocks exist for women to achieve higher career levels in plastic surgery. The authors evaluate female representation as lecturers, panelists, and moderators at national and regional plastic surgery meetings. Methods The annual meetings between January 2014 and January 2019 for 12 national and regional plastic surgery societies were included in this study. Data regarding sex of speakers were extracted from meeting programs. Binomial distribution analysis was used to compare female representation at meetings as compared with female representation among plastic surgeons. Analysis of variance with Tukey post hoc analysis was used to evaluate for differences in female representation among regions and subspecialties. Results Females comprised 14.8% of speakers, including instructors, moderators, and panelists, at all included plastic surgery meetings. There has not been a significant increase in the representation of females at plastic surgery meetings in the past 5 years (P = 0.08). Five of 12 societies had significantly lower female representation as speakers than expected by the proportion of female plastic surgeons (P < 0.05). American Society for Craniofacial Surgeons had significantly lower representation as compared with other subspecialty meetings (P < 0.01), and Texas Society of Plastic Surgeons had significantly lower representation among regional meetings (P < 0.05). Conclusions Female representation among plastic surgery residents and faculty has increased, yet women remain disproportionately underrepresented on the podium at educational meetings. Providing women the opportunity to serve as speakers, moderators, and panelists at meetings will ultimately enhance the diversity of our plastic surgical leadership.

With increasing numbers of gender-affirming chest surgery, new questions regarding breast cancer management and surgical practice arise. Guided by our case report, we present a comprehensive review of breast cancer surgery in a transman to educate both plastic and breast surgeons on various factors to consider when caring for these patients. Our case involves a 31-year-old transmale patient who presented for plastic surgery consultation for gender-affirming mastectomy but was subsequently found to have a right breast mass. This is the first case in the literature of a transmale on hormone therapy with breast cancer interested in gender-affirming surgery, thus requiring a dual-surgeon approach for oncologic and gender-affirming mastectomy. With a multidisciplinary patient-centered approach involving breast surgery, plastic surgery, medical oncology, and radiology, we devised a surgical plan to safely remove his breast tissue with consideration for his gender-affirming goals. He underwent a right skin-sparing mastectomy with sentinel node biopsy and left prophylactic skin-sparing mastectomy through skin markings by the plastic surgeon, with bilateral free nipple grafts. Final pathology confirmed estrogen and progesterone receptor–positive and androgen receptor–positive invasive ductal carcinoma with clear margins and negative sentinel node. The patient did not require adjuvant chemotherapy or radiation but was started on adjuvant hormone therapy targeting his hormone receptor positive cancer. He elected to stay on low-dose masculinizing hormone therapy with continued surveillance examinations. We follow our case with a review of the current literature involving breast cancer in transmales to explore current screening practices, surgical recommendations, adjuvant therapies, continuation of masculinizing hormone therapy, and postoperative surveillance guidelines in the hopes of informing plastic surgeons in having these discussions with their transmale patients and thus improving informed cancer care for this population.

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BackgroundToday, patients can access a myriad of information sources regarding plastic surgery procedures prior to meeting with a surgeon. Despite their widespread use, the role of these sources in a patient’s decision-making remains undefined. We hypothesized that the physician remains the key information source for patients making surgical decisions in plastic surgery, but that other sources may deliver important insights and prove helpful to varying degrees. We also explored motivations for this outside information search and any differences in perceived value among patients.MethodsWe administered a survey regarding various information sources to our breast reconstruction, reduction, and abdominoplasty patients. Responses were compared between surgery groups and demographic groups. Ordinal logistic regression analysis was used to determine the impact of patient characteristics on helpfulness rank of different sources.ResultsSurvey results were obtained from 58 patients, of whom 10 (17.2%) had abdominoplasty, 35 (60.3%) breast reconstruction, and 13 (22.4%) breast reduction. The most popular information sources prior to the first surgical appointment were Internet searches (56.9%) and family/friends/other patients (39.7%). After the initial appointment, the most useful sources were plastic surgeons (84.5%), and the Internet (36.2%). Most patients (73.5%) still sought outside information after their appointment.On a Likert-type scale of helpfulness, plastic surgeons ranked 4.28/5, followed by the web-based patient education platform, 3.73 and the Internet, 3.6. A total of 63% of participants listed plastic surgeons as their single most important source of information.In ordinal logistic regression analysis, non-white race was significantly associated with higher rank of surgeon helpfulness (p < 0.05). Relative to low-income patients, income $50-100k (p < 0.05) and $100k+ (p < 0.05) were associated with lower rank of surgeon helpfulness.ConclusionsMost patients seek outside information prior to visiting with a surgeon from the Internet, social media, or family and friends. Patients consider plastic surgeons their most valuable information source overall, though still in need of supplementation for varying reasons. Additionally, certain demographic differences affect patient perception of information sources, and this is an important factor for surgeons to consider as they approach educating patients.

Background In the last decade, a number of studies have demonstrated the utility of indocyanine green (ICG) angiography in predicting mastectomy skin flap necrosis for immediate breast reconstruction. However, data are limited to investigate this technique for autologous breast reconstruction. Although it may have the potential to improve free flap outcomes, there has not been a large multicenter study to date that specifically addresses this application. Methods A thorough literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted. All studies that examined the use of intraoperative ICG angiography or SPY to assess perfusion of abdominally based free flaps for breast reconstruction from January 1, 2000, to January 1, 2020, were included. Free flap postoperative complications including total flap loss, partial flap loss, and fat necrosis were extracted from selected studies. Results Nine relevant articles were identified, which included 355 patients and 824 free flaps. A total of 472 free flaps underwent clinical assessment of perfusion intraoperatively, whereas 352 free flaps were assessed with ICG angiography. Follow-up was from 3 months to 1 year. The use of ICG angiography was associated with a statistically significant decrease in flap fat necrosis in the follow-up period (odds ratio = 0.31, P = 0.02). There was no statistically significant difference for total or partial flap loss. Conclusions From this systematic review, it can be concluded that ICG angiography may be an effective and efficient way to reduce fat necrosis in free flap breast reconstruction and may be a more sensitive predictor of flap perfusion than clinical assessment alone. Future prospective studies are required to further determine whether ICG angiography may be superior to clinical assessment in predicting free flap outcomes.

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Overall, patients undergoing plastic surgery procedures are adequately informed and have a high degree of satisfaction regarding their patient education. The addition of a Web-based informed consent tool did not make a demonstrable difference in informed consent.