More Healing Hands Through More Harmonized Voices: The SCALPEL Study.

Orbital floor fractures are among the most common facial fractures, yet no consensus guidelines exist for their management. Multiple surgeons from surgical specialties, including oculofacial plastic surgeons (OP), plastic surgeons, oral and maxillofacial surgeons, and facial plastic surgeons, routinely treat these injuries and may exhibit distinct clinical practice patterns. An anonymous electronic survey was distributed between 2022 and 2023 to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, the American Society of Maxillofacial Surgeons, the American Association of Oral and Maxillofacial Surgeons, and the American Academy of Facial Plastic and Reconstructive Surgeons. Respondents were queried about their clinical approaches to isolated orbital floor fractures. A total of 389 surgeons completed the survey. OP were significantly more likely to delay intervention until the development of clinically significant enophthalmos (P < 0.001) and favorited longer periods of observation across multiple clinical scenarios (P < 0.05). The most used surgical approach was transconjunctival preseptal approach (53.0%), and the most frequently selected implant material was porous polyethylene-titanium (49.6%). Most respondents did not routinely use intraoperative or postoperative imaging; OP were the least likely to do so (P < 0.001). OP were also the least likely to use prophylactic antibiotics (P < 0.001). Although general agreement exists among subspecialties regarding orbital floor fracture management, OP are more likely to delay surgery, forgo imaging, and avoid antibiotics. Areas of interspecialty variation highlight the opportunities for future research and the development of evidence-based guidelines.

Sir: It was with great pleasure that we read the informative article by Dr. Shah et al. entitled “Factors Affecting Women’s Success in Academic and Private Practice Plastic Surgery.”1 This article should inspire all readers to think about their career choice, especially female plastic surgeons. Students may wonder where to start their career after graduation. This article helps us realize that support and mentorship, negotiation, promotion, leadership opportunities, and institutional change are the five factors that we should take into account that can be used as work satisfaction evaluation indicators. Although every coin has two sides, we should treat the choice in a more objective way. First, as Dr. Shah et al. mentioned in the article, “females need to consider timing of pregnancy, duration of maternity leave … many women wait until after residency to start families…”. However, male counterparts are full of energy and have less stress in their lives. This may be the reason why more male junior faculty have a mentor compared with women. This timing and duration lead to women lagging behind in competition for hierarchy leadership positions.2 However, after that, women catch up soon. Second, the data from the American Association of Medical Colleges showed that 15 percent of all plastic surgeons are women.1 However, in another article,3 using data collected from the American Medical Association’s Fellowship and Residency Electronic Interactive Database Access System, the authors showed that among all full-time academic faculty, there are 935 academic plastic surgeons, 181 of whom are women. This proportion is more than 15 percent, so we can conclude that more women would like to work in an academic department. Also, 77.6 percent of these academic plastic surgeons received industry funding, and most (42.46 percent) of the academic plastic surgeons are assistants. Considering the gender parity in an academic department, we can infer that women received more funding in academic departments than in private practice. As the author says, “When at the professor and chair level, women are [just as] productive as men.” Then, women would have a greater chance to receive a promotion in an academic department. Last but not least, although private practitioners earn a higher lifetime income than academic surgeons across all surgical subspecialties, academic plastic surgeons have the smallest differences of only 2 percent in lifetime revenue between full professors and private practitioners.4 This means that the financial rewards need not be taken into consideration in choosing academic or private practice. In conclusion, the five factors that the author pointed out are really the key points for female plastic surgeons. Besides, we believe women should make a choice according to their needs and personal stages, such as whether to have time flexibility for work or a mentor who can give instructions that are good for their future career. DISCLOSURE The authors do not have any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this submitted communication. No funding was received for this communication. Jun Qi, M.DJie Luan, M.D., Ph.D.Plastic Surgery HospitalChinese Academy of Medical Sciences and Peking UnionMedical CollegeShijingshan DistrictBeijing, People’s Republic of China

Understanding and Getting Involved in the International Facial Plastic Surgery Community

Telemedicine use among otolaryngologists-head and neck surgeons and facial plastic and reconstructive surgeons has accelerated as a result of the COVID-19 pandemic. Yet, it is unclear what impact the increased adoption of telehealth will have on the doctor-patient relationship, patients' perceptions of individual practices, and the likelihood of patients proceeding with the next steps toward surgery. While an understanding of these complex questions is imperative for all otolaryngologists, it is extremely important for facial plastic surgeons who focus on elective procedures, particularly cosmetic/aesthetic operations. The use of telemedicine has the potential to reduce bias among patients seeking facial plastic surgery, especially cosmetic procedures. As reports of this phenomenon are anecdotal thus far, we recommend further study into the specific criteria that patients consider when selecting a facial plastic surgeon.

The Physician Payments Sunshine Act (PSSA) is a government initiative that requires all biomedical companies to publicly disclose payments to physicians through the Open Payments Program (OPP). The goal of this study was to use the OPP database and evaluate all nonresearch-related financial transactions between plastic surgeons and biomedical companies. Using the first wave of OPP data published on September 30, 2014, we studied the national distribution of industry payments made to plastic surgeons during a 5-month period. We explored whether a plastic surgeon's scientific productivity (as determined by their h-index), practice setting (private versus academic), geographic location, and subspecialty were associated with payment amount. Plastic surgeons (N = 4195) received a total of US $5,278,613. The median (IQR) payment to a plastic surgeon was US $115 (US $35-298); mean, US $158. The largest payment to an individual was US $341,384. The largest payment category was non-CEP speaker fees (US $1,709,930) followed by consulting fees (US $1,403,770). Plastic surgeons in private practice received higher payments per surgeon compared with surgeons in academic practice (median [IQR], US $165 [US $81-$441] vs median [IQR], US $112 [US $33-$291], rank-sum P < 0.001). Among academic plastic surgeons, a higher h-index was associated with 77% greater chance of receiving at least US $1000 in total payments (RR/10 unit h-index increase = 1.47 1.772.11, P < 0.001). This association was not seen among plastic surgeons in private practice (RR = 0.89 1.091.32, P < 0.4). Plastic surgeons in private practice receive higher payments from industry. Among academic plastic surgeons, higher payments were associated with higher h-indices.

The JAMA Facial Plastic Surgerymission statement, appearing on the masthead of every issue, reads as follows: “JAMAFacialPlasticSurgery isamultispecialtyjournalwhose keymission is toprovide facial plastic surgeons themost accurate and innovative information available to enhance their patients’ quality of life. JAMAFacial Plastic Surgerywill strive to • Promote the art and science of facial plastic surgery by publishing significant peer-reviewedarticles on all aspects of reconstructive and cosmetic surgery of the head and neck. • Promote the education and contributions of physicians worldwide. • Provide a forum to present important and relevant issues in ethics and public policy.” JohnS. Rhee,MD,MPH,whenhe assumed theposition of Editor, appointed the InternationalAdvisoryBoard (IAB) to focus on the facial plastic surgery community outside North America. The IAB is building from strength, and JAMA Facial Plastic Surgery is already the official journal of the International Federation of Facial Plastic Surgery Societies (IFFPSS) andconsistentlypublisheswell-cited articles fromaround the globe.1-9 Manuscript submissions, as expected, are more frequent from countries with larger populations and/or strong training programs in facial plastic surgery such as the United Kingdom,Switzerland,China,Germany,Brazil, Italy,Korea, the Netherlands, and Turkey. The current IAB members represent leaders in the scientific community fromNorthandSouth America, Asia, and Europe: • Peter A. Adamson, MD, Toronto, Ontario, Canada • Fazil Apaydin, MD, Izmir, Turkey • Yong Ju Jang, MD, PhD, Seoul, South Korea • Jose A. Patrocinio, MD, PhD, Uberlandia, Brazil • Santdeep Paun, MD, London, England • Abel-Jan Tasman, PD Dr, St Gallen, Switzerland The international community of facial plastic surgeons is both diverse and united. The best and brightest from around the world are attracted to our creative and challenging field. Theyarediverse in language,butmostareable toreadandwrite English albeit with additional effort for some. When I edited the theme issueonAsian facial plastic surgery, itwas clearhow much added effort someof the authors had to expend to publish an article that did justice to their innovative techniques. Nevertheless, with authors and editors working together, we brought to a global audience practical procedures to help our patients. English is a hurdle to be cleared but not an impossible one for authorswhoseprimary language is Chinese, Portuguese, Spanish, or any of myriad other languages. Another areaofdiversity is the socioeconomic levelsof the various countries in the IFFPSS. Some are at a level similar to the average in North America, but others are challenged by health systems with inadequate technology and physical resources, limited educational materials, limited patient resources tomake treatment possible, and other limitations. In thesecountries theproblemsencounteredby facial plastic surgeons are somewhat different than in wealthier nations, and the economics of medical publishing can also be daunting. Finally different surgical specialties perform specific procedures in various geographical areas. One may find oneself when traveling working with plastic surgeons, facial

Understanding the perspectives and opinions of facial plastic surgeons on opioid dependence is critical in a national epidemic of opioid overuse. Findings may encourage surgeon education so that facial plastic surgeons may be able to judiciously prescribe opioids, improving patient outcomes and reducing healthcare opioid-related spending. The objective of this study is to understand facial plastic surgeons' perspectives on opioid dependence in rhinoplasty patients. A key secondary objective was to quantify facial plastic surgeons' opioid prescribing patterns. This was a prospective survey study. A nine-question survey was sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery in July of 2018, and analysis of the data was completed in August of 2018. The primary study outcome measurement was surgeon perspectives on opioid dependence. This was measured by an online survey. A total of 164 facial plastic surgeons responded to the survey (response rate: 6.6%). The majority were experienced surgeons in practice for more than 10 years (61.96%) who perform less than five rhinoplasties per week (84.15%). Of the facial plastic surgeons, 89.51% prescribe some variation of opioids following rhinoplasty. Most surgeons believe that opioid dependence is not a problem in rhinoplasty patients (86.96%), but that it is a problem among surgical patients in general (61.11%). The majority (52.45%) of surgeons prescribe between 11 and 25 tablets of opioids following rhinoplasty, with 25.17% of surgeons prescribing > 25 tablets of opioids. Facial plastic surgeons do not believe opioid dependence to be a problem among rhinoplasty patients. Resultantly, many facial plastic surgeons can prescribe more than 25 tables of opioids following rhinoplasty. The findings suggest that facial plastic surgeons may require further education and complete more research regarding opioid dependence among the rhinoplasty population. Additionally, the findings are important for health policy in that they encourage the creation of rhinoplasty specific opioid prescription guidelines.

Perspective: committed to excellence.

Social media is an important tool for networking, recruitment, and promoting clinical practice. No study has specifically assessed which FPRS practitioners have professional social media accounts, how they utilize them, and what barriers or resources exist to their use. This study aims to examine differences in social media use based on provider demographics and practice setting, and identify resources and barriers to professional social media use. This cross-sectional analysis was an anonymous survey sent to AAFPRS members. Data collected included demographics, practice setting, resources, and barriers encountered to use of professional social media. Most facial plastic surgeons (80%) use professional social media, notably Instagram and Facebook, and mostly post patient photos and stories (67.9%). Social media is more commonly utilized in private practice (56% vs 23%, P = .0016), where there are less institutional barriers (10% vs 40%, P = .02) and more resources available (82.5% vs 12.5%, P = .01). Social media is widely used in FPRS. Working in private practice is associated with increased availability of resources for support, and a reduction in institutional barriers to maintaining a social media presence. With this understanding, facial plastic surgeons can be better equipped for networking, marketing, and promoting the field of FPRS.

Ehlers-Danlos syndromes (EDSs) are a group of heritable connective tissue disorders. Patients with EDSs can develop excessive facial rhytids, nasal deformities, and facial scarring, for which they may seek consultation with a facial plastic surgeon. Ehlers-Danlos syndromes can be associated with serious surgical complications and should be identified preoperatively to facilitate optimal treatment. To our knowledge, no management guidelines for patients with EDSs exist in the facial plastic surgery literature. We present a review of the literature and management recommendations for the facial plastic surgeon. We performed a PubMed/MEDLINE search for all publications in the English language related to surgical experience in patients with EDSs. A total of 37 publications (including reviews and case series) were included. Ehlers-Danlos syndromes are more common than appreciated, with an overall point prevalence between 1 in 2500 and 1 in 5000 according to existing literature. There are 6 main subtypes of EDSs that have significant phenotypic heterogeneity. Patients with classic type and hypermobile EDS (the 2 most common subtypes) can typically undergo elective facial plastic surgery without major complications. However, specific preoperative, intraoperative, and postoperative issues, as outlined in this review, must be taken into consideration. Vascular EDS should serve as a contraindication to elective surgery given its potential for life-threatening complications. Because of their skin laxity, patients with EDSs may present more frequently to facial plastic surgeons' offices. Simple screening questions can help the surgeon identify potential patients with EDSs. Treatment should be individualized and performed with extreme care to ensure optimal outcomes.

Although the practice of medicine is built on a foundation of ethics, science, and common sense, the increasing complexity of medical interventions, social interactions, and societal norms of behavior challenges the ethical practice of aesthetic surgeons. We report a survey of the opinions, practices, and attitudes of experienced and novice facial plastic surgeons. The survey consisted of 15 clinical vignettes addressing ethical quandaries in aesthetic rhinoplasty. The vignettes are based on the experience and observations of the senior author (P.A.A.) over nearly 30 years of practice and teaching. Fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed anonymously. Five of the 15 vignettes demonstrated significant differences between the responses of the fellowship directors and the fellows. No single vignette had a unanimous consensus in either group. Aesthetic rhinoplasty surgeons encounter ethical issues that should be reflected on by both experienced and inexperienced facial plastic surgeons, preferably before being faced with them in practice. We present a practical approach to ethical issues in clinical practice. Our survey can also be used as a stimulus for further discussion and teaching. Karimi and coauthors present a practical approach to ethical issues in clinical practice of facial plastic surgery. Their survey can also be used as a stimulus for further discussion and teaching.

How to Leverage Social Media in Private Practice

Although the practice of medicine is built on a foundation of ethics, science, and common sense, the increasing complexity of medical interventions, social interactions, and societal norms of behavior challenges the ethical practice of aesthetic surgeons. We report a survey of the opinions, practices, and attitudes of experienced and novice facial plastic surgeons. The survey consisted of 15 clinical vignettes addressing ethical quandaries in aesthetic rhinoplasty. The vignettes are based on the experience and observations of the senior author (P.A.A.) over nearly 30 years of practice and teaching. Fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed anonymously. Five of the 15 vignettes demonstrated significant differences between the responses of the fellowship directors and the fellows. No single vignette had a unanimous consensus in either group. Aesthetic rhinoplasty surgeons encounter ethical issues that should be reflected on by both experienced and inexperienced facial plastic surgeons, preferably before being faced with them in practice. We present a practical approach to ethical issues in clinical practice. Our survey can also be used as a stimulus for further discussion and teaching.

Since the theory of selective photothermolysis was described, the field of facial plastic surgery has advanced the science behind laser: tissue interactions. Particular advances in skin cooling, hair removal, intense pulsed light, and uses for aesthetic and nonaesthetic skin problems are described in this review. Continued basic science research in lasers has led to improvements in current technology available to the facial plastic surgeon. Advances in skin cooling have allowed for wider use in all Fitzpatrick skin types without concomitant adverse reaction. Our understanding of laser science continues to expand our knowledge in basic laser: tissue interaction. An improvement in various laser mediums and adjunctive devices provides the facial plastic surgeon with instruments to treat a wider patient population. The benefit is a successful clinical and aesthetic result with improved safety.

The ultimate goal for most facial plastic surgeons is to develop a successful practice. For those currently owning a practice and those planning on developing a practice, the skills and training necessary to establish and manage a facial plastic practice are not taught in medical school, residency, or most fellowships. The goal of this article is to underline the key principles of running a successful business. This article does not replace an MBA, but it allows you to be aware of potential challenges that all businesses encounter.