Howard, Michael A.

Background: Delivering ethical care in global plastic surgery is challenging due to the unique complexities of resource-limited settings. Additionally, the rise of medical tourism has highlighted the importance of informed consent and awareness of the potential risks that are associated with seeking medical care in foreign countries. This article aims to consider core medical ethics principles and apply them in the context of delivering global plastic surgery. Methods: This article examines the application of the four core medical ethics principles in a framework set forth by Beauchamp and Childress, namely autonomy, beneficence, nonmaleficence, and justice, in the context of delivering plastic surgery in international settings. A literature review was performed, where all potential global plastic surgery articles were reviewed to better understand the application of the four core medical ethics framework in this context. Results: Increased communication between visiting surgeons and local healthcare providers; heightened education of surgeons traveling to low-to-middle-income countries regarding local medical practices, resource availability, and cultural norms before providing surgical education; and a greater emphasis on collecting and publishing data analyzing short- and long-term outcomes in low-to-middle-income countries are all likely to improve the success of international medical missions, ensuring that all patients receive medical treatment in a manner that upholds Beauchamp and Childress’ four core medical ethics principles. Conclusion: Providing plastic and reconstructive surgery abroad can be done ethically if the four main principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) are used.

Background: Over the past 10 years, smartphones have become ubiquitous, and mobile apps serve a seemingly endless number of functions in our everyday lives. These functions have entered the realm of plastic surgery, impacting patient care, education, and delivery of services. This article reviews the current uses of plastic surgery mobile apps, app awareness within the plastic surgery community, and the ethical issues surrounding their use in patient care. Methods: A scoping review of electronically available literature within PubMed, Embase, and Scopus databases was conducted in two waves in November and May 2022. Publications discussing mobile application use in plastic surgery were screened for inclusion. Results: Of the 80 nonduplicate publications retrieved, 20 satisfied the inclusion criteria. Articles acquired from the references of these publications were reviewed and summarized when relevant. The average American Society of Plastic Surgeons evidence rating of the publications was 4.2. Applications could be categorized broadly into three categories: patient care and surgical applications, professional development and education, and marketing and practice development. Conclusions: Mobile apps related to plastic surgery have become an abundant resource for patients, attending surgeons, and trainees. Many help bridge gaps in patient care and surgeon-patient communication, and facilitate marketing and practice development. Others make educational content more accessible to trainees and performance assessment more efficient and equitable. The extent of their impact on patient decision-making and expectations has not been completely elucidated.

Background In response to the opioid epidemic, the United States declared a public health emergency in 2017. We evaluated pain medication prescribing practices among plastic and reconstructive surgeons, assessing pain medication prescription rates and opioid-related mortality both nationally and regionally within the United States. Methods A retrospective analysis of Medicare Part D prescriber data among plastic surgeons from 2013 through 2017 was conducted. Pain medications were categorized as opioid and nonopioid medications. Trends in surgeon prescribing habits were evaluated using the Cochrane-Armitage trend test. Results A total of 708,817 pain medication claims were identified: 612,123 claims (86%) were for opioid pain medications and 96,694 claims (14%) were for nonopioid pain medications. Total pain medication claims decreased from 44% of all medications in 2013 to 37% in 2017 (P < 0.001). Opioid medications decreased from 37% of total medication claims to 32% (P < 0.001). The overall opioid prescription rate fell from 1.53 claims per beneficiary in 2013 to 1.32 in 2017 (P < 0.001). Nonopioid pain medications decreased from 7% in 2013 to 6% in 2017 (P < 0.001); nonsteroidal anti-inflammatory drug claims increased by 44%. The prescription rate of nonopioid medications decreased from 2.40 claims per beneficiary in 2013 to 2.32 in 2017 (P < 0.001). An overall increase in opioid-related mortality was observed. Trends in pain medication prescriptions varied significantly among US regions and divisions. Conclusions Plastic surgeons are prescribing less opioids and relying more on nonopioid pain medications. Increased adoption of multimodal pain treatment approaches among surgeons is a likely explanation for this trend in face of the current opioid crisis.

Background: The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for 30 abdominal wall reconstruction surgical procedures over a 20-year period (2000 to 2020). Methods: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was used for each of the 30 included current CPT codes, and reimbursement data were extracted. Monetary data were adjusted for inflation to 2020 U.S. dollars using changes to the United States consumer price index. The R2 values for the average annual percentage change and the average total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures. Results: After adjusting for inflation, the average reimbursement for all procedures decreased by 17.1% from 2000 to 2020. The greatest mean decrease was observed for CPT code 49568 (the implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of débridement for necrotizing soft-tissue infection, −34.4%). The only procedure with an increased adjusted reimbursement rate throughout the study period was CPT code 20680 (+3.9%). From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 0.85% each year, with an average R2 value of 0.78, indicating a stable decline throughout the study period. Conclusions: Reimbursement rates are declining when adjusted for inflation. Increased awareness of these trends is helpful to maintain access to optimal abdominal reconstruction care in the United States.

Background: Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma. Methods: The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021. Results: From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at −48.7% and −48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at −1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year. Conclusions: To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.

Background: Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. Methods: A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. Results: A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. Conclusions: LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.

Background: Plastic surgeons regularly perform injections for both cosmetic and functional purposes. This article examines the most common injections utilized by plastic surgeons under Medicare and how their usage and billing has changed between 2012 and 2019. Methods: Using the earliest and latest data available on the Centers for Medicare and Medicaid Services’ Provider Utilization and Payment Data File, we first determined Healthcare Common Procedure Coding System injection codes most billed to Medicare in 2012 and 2019. The number of services, amount of Medicare beneficiaries, and reimbursement rates were collected and analyzed for each Healthcare Common Procedure Coding System code from the Provider Utilization and Payment Data File for years 2012 and 2019. We compared the change in reimbursement rate for each injection to the rate of inflation in US dollars over the same period. Results: The unadjusted Medicare reimbursement rate for eight included injection types increased an average of 31.63% during the study period. This was not significantly different from the rate of inflation during the same period (+11.33%, P = 0.311). When all Medicare reimbursement data were adjusted for inflation to 2019 dollars, the average percentage change in reimbursement for all included injections in this study increased by 17.58% from 2012 to 2019. Conclusions: The findings from our study suggest that injections administered by plastic surgeons appear to be unique in their general stability in reimbursement rates as compared to rates in other fields. Further research should be performed to better understand the driving factors for usage and reimbursement changes.