Publications by authors named "Andres F Doval"

28 Publications

  • Page 1 of 1

Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique?

Cureus 2022 Jun 24;14(6):e26290. Epub 2022 Jun 24.

General Surgery, Parkview Health, Fort Wayne, USA.

Background Abdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown. Methods Using a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed.  Results A total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST. Conclusion CS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.
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http://dx.doi.org/10.7759/cureus.26290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9308972PMC
June 2022

Deep venous thrombosis in a 41-year-old female with May-Thurner syndrome following abdominoplasty and medial thigh lift.

J Surg Case Rep 2022 Apr 18;2022(4):rjac175. Epub 2022 Apr 18.

Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA.

Deep venous thrombosis (DVT) is a feared occurrence following body contouring surgery as it can result in pulmonary embolism. Acute presentation can range from lower extremity edema and pain to being totally asymptomatic. Surgical literature reports reveal many risk factors for developing DVT, and surgeons must risk stratify their patients to best prevent this outcome. However, there are conditions which place patients at risk that are difficult to account for when making such decisions as they can be undiagnosed and are not a part of standard screening protocols. We present a case of DVT in a 41-year-old female with undiagnosed May-Thurner syndrome following abdominoplasty and medial thigh lift for massive weight loss. The authors discuss the current literature as well as challenges faced by surgeons who strive to appropriately risk stratify their cosmetic surgery patients to avoid complications such as venous thromboembolism.
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http://dx.doi.org/10.1093/jscr/rjac175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9015771PMC
April 2022

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes.

Ann Plast Surg 2022 Feb;88(2):208-211

From the Institute for Reconstructive Surgery.

Background: Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute.

Methods: A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups.

Results: A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001).

Conclusions: More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.
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http://dx.doi.org/10.1097/SAP.0000000000002900DOI Listing
February 2022

Primary and Revision Rhinoplasty: A Single Surgeon Experience and Patient Satisfaction.

Plast Reconstr Surg Glob Open 2021 Sep 13;9(9):e3798. Epub 2021 Sep 13.

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Tex.

There is minimal information describing the common characteristics among patients seeking primary/revision rhinoplasty. Success is traditionally interpreted from the surgeon's viewpoint, without considering the patient's perspective. The study's aims were to (1) identify/compare anatomic and functional characteristics commonly found in patients seeking primary and revision rhinoplasties; (2) assess patient satisfaction using a survey; and (3) explore whether graft choice (auricular cartilage versus rib cartilage) affects patient satisfaction and outcome in revision rhinoplasty.

Methods: A retrospective review of all rhinoplasties by a single surgeon from June 2016 to January 2020 was performed, focusing on preoperative anatomic/functional characteristics and operative interventions performed. A survey was then used to assess patient satisfaction. Finally, survey outcomes were compared between patients who received auricular and rib cartilage grafts in revision rhinoplasty.

Results: A total of 102 rhinoplasties (53 primary and 49 revisions) were included. Primary rhinoplasties were noted to have more patients with "big" noses ( = 0.015) or humps ( < 0.010). Patients undergoing revision rhinoplasties more commonly exhibited middle vault collapse ( = 0.022). The survey response rate was 60%. Revision rhinoplasty patients had a higher incidence of dissatisfaction with their outcome.

Conclusions: Several features among patients seeking revision rhinoplasties could have been created in the primary operation. The rhinoplasty surgeon should be careful to not introduce new issues or create worse deformities than those seen following the initial operation. Survey-based outcome analysis demonstrated that revision rhinoplasty patients are more likely to have a greater rate of dissatisfaction following their operation.
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http://dx.doi.org/10.1097/GOX.0000000000003798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432634PMC
September 2021

Static Suspension of the Paralyzed Face Utilizing the Midfacial Corridor: Anatomic Evaluation and Surgical Technique.

J Reconstr Microsurg 2022 May 23;38(4):270-275. Epub 2021 Aug 23.

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell School of Medicine, Houston, Texas.

Background:  Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces.

Methods:  Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed.

Results:  A total of 22 patients were included with a mean age of 64.3 years (33-86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed.

Conclusion:  Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.
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http://dx.doi.org/10.1055/s-0041-1731766DOI Listing
May 2022

Refining the Rib-sparing Approach in Microsurgical Breast Reconstruction: Keys to Success.

J Reconstr Microsurg 2022 May 17;38(4):263-269. Epub 2021 Aug 17.

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.

Background:  Free tissue transfer using microsurgical techniques is a popular option for breast reconstruction, and the internal mammary vessels remain the most popular recipient vessels for the anastomosis. Traditionally, ribs were resected for better access to these vessels in the intercostal space. However, rib resection has the potential for complications and adds a surgical step. Here, the authors evaluate and compare both techniques in a retrospective study as well as offer technical pearls.

Methods:  The 400 most recent consecutive patients who underwent microsurgical breast reconstruction by a single surgeon were retrospectively reviewed. 54 patients underwent the traditional rib-resecting approach. 346 patients underwent the rib-sparing approach, which was the preferred approach of the senior author, when possible. Patients requiring the rib-resecting approach were distributed evenly throughout the series. Primary outcomes were any immediate post-operative complications.

Results:  Between the two clinical groups, there was no difference between demographic or clinical details, the flap type, history of previous radiation, or timing of reconstruction. Complications of any kind as well as the subset of complications were significantly more frequent in the rib resection than in the rib-sparing group. Specifically, the rate of reanastomosis was higher in the rib resection group [10.6 vs 2.7%,  < 0.001] as was the frequency of return to the OR in the immediate post-operative setting [3.0 vs 0.3%,  < 0.001]. There is a 4.50 odds ratio of having a complication in a rib resection case versus rib sparing [CI: 1.97-10.30,  < 0.001]. All cases were initiated with the intent to perform a rib-sparing approach if possible, and they were converted to a rib-resection approach as needed.

Conclusion:  In the largest reported series to date, the rib-sparing approach is demonstrated to be both safe and efficacious in microsurgical breast reconstruction.
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http://dx.doi.org/10.1055/s-0041-1731762DOI Listing
May 2022

Dual Innervation of Free Functional Muscle Flaps in Facial Paralysis.

Facial Plast Surg Clin North Am 2021 Aug;29(3):431-438

Institute for Reconstructive Surgery, Houston Methodist Hospital, 6560 Fannin Street, Suite #2200, Houston, TX 77030, USA.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.
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http://dx.doi.org/10.1016/j.fsc.2021.03.006DOI Listing
August 2021

Comparing plastic surgery and otolaryngology surgical outcomes and cartilage graft preferences in pediatric rhinoplasty: A retrospective cohort study analyzing 1839 patients.

Medicine (Baltimore) 2021 Jun;100(25):e26393

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston.

Abstract: Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists.
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http://dx.doi.org/10.1097/MD.0000000000026393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238294PMC
June 2021

Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

Plast Reconstr Surg 2021 Jun;147(6):1271-1277

From the Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center at Houston; and the Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine.

Background: Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results.

Methods: A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications.

Results: No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation.

Conclusions: From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000007956DOI Listing
June 2021

Breast Implant Utilization Trends in USA versus Europe and the Impact of BIA-ALCL Publications.

Plast Reconstr Surg Glob Open 2021 Mar 19;9(3):e3449. Epub 2021 Mar 19.

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Tex.

Background: The goals of this study were to analyze and compare breast implant preferences between US and European surgeons in terms of size, shape, and surface texturing. Furthermore, we set out to investigate the impact of BIA-ALCL scientific publications on surgeon practice patterns.

Methods: Breast implant sales data from the USA and Europe dating from June 2013 to September 2018 were provided by one of the world's leading breast implant manufactures (Mentor Worldwide LLC). Change-point analysis was used to identify when significant changes in sales trends occurred. These changes were compared with dates of government announcements and publications of landmark scientific articles regarding BIA-ALCL.

Results: Our data demonstrate that US surgeons tend to prefer larger, smooth round implants compared with European surgeons, who prefer smaller, textured round implants. Despite these differences, medium-sized implants were still the most common size used between both regions. Sales trends illustrate an increase in smooth implants and a decrease in textured implants for both regions. Significant changes in trends align with publication dates of announcements and landmark scientific articles.

Conclusions: We demonstrate definitive differences in implant preferences between the USA and Europe. We encourage physicians to continue their pursuit of publishing because it seems these publications affect medical device selection.
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http://dx.doi.org/10.1097/GOX.0000000000003449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099399PMC
March 2021

Efficacy of Closed Incision Negative Pressure Wound Therapy on Abdominal Donor Site After Free Flap Breast Reconstruction.

Wounds 2021 Apr;33(4):81-85

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.

Introduction: Negative pressure wound therapy (NPWT) has been used to treat acute and chronic wounds in a variety of scenarios. Specifically, in autologous breast reconstruction, studies investigating the use of closed incision NPWT (ciNPWT) in breast surgery are lacking.

Objective: The aim of this study was to analyze the use of ciNPWT at the abdominal donor site following deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Materials And Methods: A retrospective cohort study was conducted over a 15-month period including patients who underwent abdominally based microsurgical breast reconstruction. Patients were divided into 2 groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT. Groups were compared in terms of demographic characteristics, perioperative variables, and abdominal donor site complications.

Results: A total of 42 patients were identified. Of these, 18 were included in the control group and 24 in the ciNPWT group. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and in 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none in the ciNPWT group (P = .429). Interestingly, 3 patients developed hyperpigmentation where the ciNPWT plastic drape was placed.

Conclusions: The use of ciNPWT on the abdominal donor site following DIEP flap breast reconstruction did not lower the incidence of wound dehiscence and wound infection. Different approaches are needed to decrease the incidence of donor site complications in abdominally based postmastectomy breast reconstruction.
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April 2021

Reoperative Cervical Endocrine Surgery: Appropriate Valuation for the Time and Effort?

J Surg Res 2021 07 27;263:155-159. Epub 2021 Feb 27.

Department of Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas.

Background: Controversies currently exist regarding the best way to appropriately quantify complexity and to benchmark reimbursement for surgeons. This study aims to analyze surgeon reimbursement in primary and redo-thyroidectomy and parathyroidectomy using operative time as a surrogate for complexity.

Methods: A retrospective analysis using the National Surgical Quality Improvement Program database was performed to identify patients who underwent primary and redo-thyroidectomy and parathyroidectomy. Calculations of median operative time work relative value units per minute and dollars per minute were compared between primary and redo procedures.

Results: Thyroidectomy cases represented 53.5% (22,521 cases), and the other 46.5% (19,596 cases) were parathyroidectomy cases. The median dollars per minute in primary thyroidectomy was $4.97 and for redo-thyroidectomy was $8.12 (P < 0.0001). By the same token, dollars per minute were higher in the redo cases with $15.40 when compared with primary parathyroidectomy cases with $13.14 dollars per minute (P < 0.0001).

Conclusions: By Current Procedural Terminology codes, surgeons appear to be appropriately reimbursed for redo-thyroid and parathyroid procedures indexed to first time parathyroidectomy based on the compensated operative time of these procedures calculated using a nationally representative sample.
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http://dx.doi.org/10.1016/j.jss.2021.01.034DOI Listing
July 2021

Parastomal Hernia Repair Using a Silo Biologic Mesh.

Ann Plast Surg 2021 11;87(5):e97-e102

From the Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX.

Background: A parastomal hernia (PSH) is an enlargement of the stoma's original opening through the abdominal wall's musculature around a colostomy, ileostomy, or urostomy. Its incidence can be up to 48%. The described methods for its repair have high recurrence rate.This article presents a 3-dimensional silo technique for PSH repair (PSH-R). The aims of this technique are to enhance the structural strength of the tunnel wall, to reinforce both the sidewalls and the fascia above and below the muscular opening, and to maintain a stable stoma opening.

Methods: All consecutive patients undergoing PSH-R with the silo technique between January 2009 and May 2018 by 2 plastic surgeons were included. The outcome parameters of interest were hernia recurrence and wound-related complications.

Results: This study reports 22 patients (9 male, 13 female) with a mean age of 66.7 years and an average body mass index of 29.2. The variety of ostomy types included 10 colostomies, 7 ileostomies, and 5 urostomies. Postoperatively, there were 3 surgical site infections, 1 seroma, and 2 wound healing delays. Six patients were readmitted, 3 of those because of small bowel obstruction. These 3 cases all required reoperation, in addition to 1 operative revision for stoma retraction. During our average follow-up of 19.9 months, 3 cases of PSH recurrence were diagnosed for a recurrence rate of 13.6%.

Conclusions: This silo technique is associated with favorable complication and low recurrence rates compared with the available techniques in surgical literature. In our practice, it has established itself as a new and safe technique for complex or recurrent PSHs and should be considered in a surgeon's armamentarium. This technique has become our standard for treatment of recurrent PSHs.
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http://dx.doi.org/10.1097/SAP.0000000000002681DOI Listing
November 2021

How to Maximize Aesthetics in Autologous Breast Reconstruction.

Aesthet Surg J 2020 11;40(Suppl 2):S45-S54

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX.

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.
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http://dx.doi.org/10.1093/asj/sjaa223DOI Listing
November 2020

Incidental Findings in CT and MR Angiography for Preoperative Planning in DIEP Flap Breast Reconstruction.

Plast Reconstr Surg Glob Open 2020 Oct 23;8(10):e3159. Epub 2020 Oct 23.

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Tex.

Background: Autologous breast reconstruction with deep inferior epigastric perforator flaps is considered a standard of care in the treatment after mastectomy, yet vascular anatomy is highly variable and perforator selection remains challenging. The use of preoperative imaging can influence surgical planning and assist intraoperative decision-making. However, this imaging can inevitably uncover incidental findings. The purpose of this study was to analyze incidental findings, evaluate correlation with patient factors, and examine effects on overall care.

Methods: A retrospective review was performed on 350 consecutive patients who received magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) as a preoperative evaluation for deep inferior epigastric perforator flap breast reconstructions done between August 2015 and June 2019. Radiology reports were analyzed for incidental findings. Patient charts were reviewed for patient history, genetic history, cancer treatment, and type of reconstruction.

Results: Of the 350 patients meeting the criteria, 56.9% were noted to have incidental findings on preoperative imaging, 12.9% received additional imaging, and 4.0% underwent additional interventions. There was no difference in the percentage of patients with incidental findings between immediate and delayed reconstructions or between CTA and MRA. Five patients were found to have malignancies.

Conclusions: Preoperative CTA and MRA is a valuable tool to optimize outcomes and efficiency in breast reconstruction with abdominal perforator flaps. However, this imaging can also be beneficial to the overall wellness of the patient. With the high prevalence of incidental findings on preoperative imaging, it is important to counsel patients and adjust surgical plans, if necessary.
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http://dx.doi.org/10.1097/GOX.0000000000003159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647637PMC
October 2020

Is Our Effort Appropriately Valued? An Analysis of Work Relative Value Units in Immediate Breast Reconstruction.

Plast Reconstr Surg 2020 09;146(3):502-508

From the Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine; and Texas A&M College of Medicine, Texas A&M University.

Background: The work relative value units system was developed as a quantifier of physician labor, technical skill, and training time required to complete surgical procedures. Thus, more complex surgical procedures that require greater technical skills and are more time consuming should yield a greater compensation. It is known that prosthetic breast reconstruction reimburses more per hour than autologous breast reconstruction. However, there are limited data comparing work relative value units and operative times in breast reconstruction procedures. Therefore, this study aims to compare mean operative times and work relative value units per minute across three different modalities of breast reconstruction.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing implant-, pedicle-, and free flap-based reconstruction over a 6-year period. Calculation and comparison of median operative times, work relative value units, and dollars per minute was performed.

Results: A total of 3135 patients were included in the analysis: 2249 (71.7 percent) underwent immediate implant-based reconstruction, 745 (23.8 percent) underwent immediate free flap-based breast reconstruction, and 141 (4.5 percent) underwent immediate pedicle flap-based reconstruction. Patients were distributed in unilateral and bilateral cases. Consistently, median operative time was greater for free flap breast reconstruction, followed by pedicle flap- and implant-based reconstruction (p < 0.0001). However, work relative value units per minute and dollars per minute were found to be higher for prosthetic reconstruction in all comparisons (p < 0.0001).

Conclusion: In the authors' analysis, more complex and time-consuming procedures resulted in a lower reimbursement in dollars and work relative value units per minute for the procedure.
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http://dx.doi.org/10.1097/PRS.0000000000007054DOI Listing
September 2020

Role of CTA in Women with Abdominal Scars Undergoing DIEP Breast Reconstruction: Review of 1,187 Flaps.

J Reconstr Microsurg 2020 May 28;36(4):294-300. Epub 2020 Jan 28.

Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Background:  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes.

Methods:  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs).

Results:  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15-2.87,  = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0-1.94,  = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22-2.12,  < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times.

Conclusion:  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars.
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http://dx.doi.org/10.1055/s-0039-1701040DOI Listing
May 2020

Readability and Understandability Analysis of Online Materials Related to Abdominal Aortic Aneurysm Repair.

Vasc Endovascular Surg 2020 Feb 13;54(2):111-117. Epub 2019 Oct 13.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Background: Patients commonly use online materials as a source of health information. Since poor health literacy has been shown to correlate with negative outcomes, it is recommended that patient-directed materials be written at a sixth-grade reading level. This study evaluates the readability and understandability of commonly accessed online materials pertaining to both endovascular and open repair of abdominal aortic aneurysm.

Methods: Searches for "endovascular repair abdominal aortic aneurysm" and "open repair abdominal aortic aneurysm" were performed on both Google and Bing, and the top 10 websites from each search engine were identified. Relevant websites (total N = 28, endovascular n = 15, open n = 15, and 2 redundant sites) with patient-directed content were analyzed. Readability was assessed using 9 established methods, and understandability was assessed using the Patient Education Materials Assessment Tool scoring system.

Results: The average reading grade level for all sites was 12.8. Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 to 15.6. Open-repair websites had a grade-level average of 12.1 with a range from 9.9 to 14.1. Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of -0.551 ( = .003). No website was written at or below the recommended sixth-grade reading level.

Conclusions: Patient-directed online health information pertaining to open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level. Increasing complexity of health literature correlates with poor understandability. Modifications such as shorter sentences, fewer words with more than 6 letters, and increasing usage of clear visual aids can increase readability and understandability.
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http://dx.doi.org/10.1177/1538574419879855DOI Listing
February 2020

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

Plast Reconstr Surg Glob Open 2019 Mar 13;7(3):e2180. Epub 2019 Mar 13.

Institute of Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Tex.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467626PMC
March 2019

Safety Profiles of Fat Processing Techniques in Autologous Fat Transfer for Breast Reconstruction.

Plast Reconstr Surg 2019 Apr;143(4):985-991

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School.

Background: Autologous fat transfer is common in breast reconstruction because of its versatility for use in contour deformities. The authors examined three different fat grafting processing techniques for complications and safety profile using their institutional database.

Methods: Retrospective review was performed of patients from a single institution who had undergone autologous fat transfer following breast reconstruction from 2012 to 2016. Individuals were separated into three cohorts according to fat harvest technique: (1) centrifugation, (2) Telfa gauze, or (3) Revolve. Complications between the groups were assessed.

Results: A total of 267 cases of autologous fat transfer were identified (centrifugation, n = 168; Telfa, n = 44; and Revolve, n = 55). Grafting by means of centrifugation was associated with the greatest incidence of oil cysts (12.5 percent; p = 0.034), postoperative adverse events observed in the clinic (13.7 percent; p = 0.002), and total complications (25.6 percent; p = 0.001). The use of Telfa resulted in the lowest rates of oil cyst formation (0 percent; p = 0.002) and total complications (2.3 percent; p = 0.001). Grafting by means of centrifugation was also associated with the highest frequency of repeated injections among the three techniques after initial grafting (19.6 percent; p = 0.029). In contrast, Revolve demonstrated a repeated injection rate of just 5.45 percent, significantly lower when independently compared with centrifugation (p = 0.011). Multivariate analysis demonstrated that higher total graft volume (p = 0.002) and the use of centrifugation (p = 0.002) were significant risk factors for adverse events seen in the clinic postoperatively.

Conclusions: Significant differences in postoperative outcomes exist between varying fat transfer techniques. Autologous fat transfer by means of centrifugation harbored the highest rates of complication, whereas Telfa and Revolve exhibited similar safety profiles.

Clinical Question/level Of Evidence: Therapeutic, III.
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April 2019

A Comparative Multimetric Assessment of English and Spanish Carpal Tunnel Syndrome Materials.

J Surg Res 2019 06 8;238:64-71. Epub 2019 Feb 8.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Spanish-speaking Hispanics living in the United States utilize the internet as a primary means to obtain health information. Accurate, accessible information is important for English speakers; however, it could have even greater utility for Spanish speakers who have lower health literacy levels. The aim of this study was to evaluate and compare online English and Spanish carpal tunnel surgery materials provided by using a multimetric approach.

Materials And Methods: A web search using the English term "carpal tunnel surgery" was performed. The first 10 institutional/organizational websites that provided carpal tunnel surgery information in English and Spanish were included. All relevant online materials were evaluated using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL) to assess understandability and actionability, cultural sensitivity, and readability, respectively.

Results: There were no statistically significant differences in understandability or actionability scores between Spanish and English materials. Average cultural sensitivity scores for Spanish materials were significantly lower than English materials (P = 0.015). The average reading grade level of online English materials was greater than that for Spanish materials (P = 0.011). Both mean values were above the recommended sixth-grade reading level.

Conclusions: Online patient-directed information regarding carpal tunnel surgery exceeded the recommended reading grade level for both English and Spanish-speaking populations. Most Spanish materials were often direct translations and were not contoured to the elevated literacy needs of this demographic. Institutions must caution their authors to tailor their web material in a way that is sensitive to their target population to optimize understanding.
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http://dx.doi.org/10.1016/j.jss.2019.01.032DOI Listing
June 2019

A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema.

Ann Plast Surg 2019 03;82(3):255-261

From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.

Background: Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources.

Methods: A web search using the Spanish term "linfedema" was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined.

Results: Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters.

Conclusions: Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.
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March 2019

Evaluating Patient Outcomes in Breast and Abdominal Cosmetic Plastic Surgery Procedures Involving Residents.

Aesthet Surg J 2019 04;39(5):572-578

Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX.

Background: Hands-on training and exposure to cosmetic surgery is an integral part of plastic surgery residency. However, resident participation in cosmetic surgical cases is often limited in many training programs. Furthermore, the effect of resident participation in cosmetic surgery is poorly defined.

Objectives: The aim of this study was to analyze the impact of resident involvement on outcomes in cosmetic plastic surgery procedures, with a focus on breast and abdominal surgeries.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing cosmetic breast and abdominal surgical procedures by plastic surgeons over a 4-year period (2009-2012). Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes.

Results: A total of 6982 patients were included in the analysis. Cases with resident involvement had higher rates of superficial surgical site infection (P < 0.0001), wound dehiscence (P = 0.014), and an increase in mean length of hospital stay (P = 0.001). Multivariate analysis revealed that the increased rate of superficial surgical site infection was associated with a higher body mass index and with the involvement of a resident during the surgical procedure.

Conclusions: This study provides further evidence to support the claim that resident involvement in cosmetic surgery is safe, with little effect on the rates of major complications. Any increase in minor complication rates must be critically analyzed with respect to the valuable surgical experience gathered by the next generation of surgeons.

Level Of Evidence: 2:
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April 2019

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Women With Previous Abdominal Incisions: A Comparison of Complication Rates.

Ann Plast Surg 2018 11;81(5):560-564

Division of Plastic Surgery, Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA.

Background: The deep inferior epigastric artery perforator (DIEP) flap is currently the most widely used method for autologous microsurgical breast reconstruction. There are mixed data in the literature regarding the impact of previous abdominal surgery on DIEP flap success in breast reconstruction. With this study, we take a closer look at the effect of prior abdominal surgery on DIEP flap and donor-site complications, with a particular focus on the different types of incisions and their influence on surgical outcomes.

Methods: A retrospective cohort study was conducted over a 6-year period. Five hundred forty-four consecutive DIEP flaps were divided into a control group (321 flaps) without previous abdominal surgery and an incision group (223 flaps) with previous abdominal surgery. A comparison between both groups was made in terms of flap and donor-site complications followed by a subgroup analysis based on single types of abdominal incisions.

Results: There were no significant differences between both groups in terms of age, body mass index, flap weight, smoking history, prior radiotherapy, diabetes, and coagulopathy (P > 0.05). The most common incision was low transverse incision (n = 116) followed by laparoscopy port (n = 103) and midline (n = 46) incisions. We found no significant differences between the control group and incision group in terms of flap complications. Subgroup analysis revealed that none of the 3 types of incision increase the flap or donor-site complications. Smoking and flap weight were the only 2 independent predictors for donor-site complications.

Conclusions: The results from this large series of consecutive DIEP flaps from our institution confirm that autologous breast reconstruction with DIEP flap can be safely performed in patients who have had previous abdominal surgeries; however, counseling patients about smoking is critical to avoid potential donor-site complications.
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November 2018

Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction?

Plast Reconstr Surg 2018 06;141(6):805e-813e

Boston, Mass.

Background: The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. As breast cancer patients undergoing microsurgical breast reconstruction are often receiving hormone therapy, it is unclear whether this increased thrombotic risk is associated with increased flap loss.

Methods: A retrospective review was performed on patients undergoing abdominally based microsurgical breast reconstruction at an academic institution from 2004 to 2015. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including complete or partial flap loss and overall complications, were compared and analyzed using univariate and logistic regression models.

Results: Among a total of 853 patients (1253 flaps), 193 patients (269 flaps) were receiving hormone therapy and 660 patients (984 flaps) were not. Patients on hormone therapy had higher rates of previous breast surgery, advanced cancer stage, chemoradiation before reconstruction, and delayed and unilateral reconstruction. There were no statistically significant differences between hormone therapy patients and nontherapy patients in complete flap loss (1.0 percent versus 1.1 percent) and partial flap loss (2.2 percent versus 1.5 percent). Hypertension and previous breast surgery were the only independent risk factors for minor complications (adjusted OR, 2.1; 95 percent CI, 1.3 to 3.6; p = 0.005; and adjusted OR, 1.8; 95 percent CI, 1.2 to 2.7; p = 0.009, respectively) and overall complications (adjusted OR, 2.2; 95 percent CI, 1.3 to 3.7; p = 0.004; and adjusted OR, 1.9; 95 percent CI, 1.3 to 3.0; p = 0.003, respectively).

Conclusions: Hormone therapy was not associated with a higher incidence of complete or partial flap loss or overall complications. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors.

Clinical Question/level Of Evidence: Therapeutic, III.
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June 2018

A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer.

J Reconstr Microsurg 2018 Nov 7;34(9):685-691. Epub 2018 May 7.

Duke University School of Medicine, Durham, North Carolina.

Background:  Breast implant placement is the most common method for postmastectomy reconstruction. For patients who develop complications associated with implant-based reconstruction, additional surgeries may be challenging. This study examined implant-based reconstruction failure in patients undergoing salvage with abdominal free tissue transfer.

Methods:  We conducted an Institutional Review Board approved, multicenter retrospective study of patients with implant-based primary breast reconstruction followed by implant removal and subsequent abdominal free tissue transfer between 2006 and 2016. Patient demographics, treatment details, and complications were evaluated. Severity of implant failure was graded as either (1) not severe (delayed salvage reconstruction) or (2) severe (immediate salvage reconstruction).

Results:  Between 2006 and 2016, 115 patients with 180 mastectomy defects underwent primary implant-based reconstruction with subsequent implant removal and abdominally based free tissue reconstruction. Of these, 68 were delayed and 47 were immediate salvage reconstruction. Factors leading to elective removal were capsular contracture, asymmetry, and implant malposition. Factors leading to obligatory removal were infection, delayed wound healing, and implant extrusion. Postmastectomy radiation was significantly associated with immediate salvage reconstruction ( < 0.001, odds ratio = 3.9) as were large volume implants ( = 0.06). Deep inferior epigastric perforator flaps comprised 78.3% of all abdominally based free tissue reconstructions, while muscle-sparing transverse rectus abdominus myocutaneous flaps comprised 18.3%. Overall flap failure rate was 2.6% (2.94% delayed and 2.13% immediate salvage reconstruction;  = 1.0).

Conclusion:  Our findings suggest that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based breast reconstruction failure. Patients with severe implant failure were more likely to have received radiation. Surgeons should remain cognizant of this during care of patients.
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http://dx.doi.org/10.1055/s-0038-1641680DOI Listing
November 2018

Literacy Analysis of Spanish Online Resources for Breast Reconstruction.

Ann Plast Surg 2018 04;80(4 Suppl 4):S189-S195

Background: Health literacy studies indicate that literacy skills are linked to access to information and health outcomes, potentially contributing to health disparities. In the United States, minority and immigrant populations are more likely to have lower literacy skills than are other population groups. The aim of this study is to evaluate web-based health information prepared in Spanish for Hispanic women considering breast reconstruction surgery.

Methods: A search for the term reconstrucción de seno (translation: breast reconstruction) was conducted using Google. The 10 most easily accessible institutional/academic websites and media/private websites were identified. Each website was assessed for readability, understandability/actionability, suitability, cultural sensitivity, numeracy, and for website content organization and navigation. Two independent raters evaluated understandability/actionability, suitability, and cultural sensitivity.

Results: Readability analysis revealed higher than recommended scores (above ninth grade) for institutional/academic and media/private websites with no significant difference. When comparing institutional/academic and media/private websites, scores were adequate with no differences for understandability (50.6% and 47.1%, respectively; P = 0.53), suitability (50.2% vs 49.7%, respectively; P = 0.92), and cultural sensitivity (P = 0.31), whereas actionability scores were low at 18% and 14%, respectively (P = 0.67). In terms of numeracy analysis, most websites were in the less complex area of the hierarchy matrix.

Conclusions: Available breast reconstruction online resources for the Spanish-speaking population are rated too high for readability. Suitability, understandability, and cultural sensitivity scores are adequate; however, actionability scores are low, indicating potential areas for improvement. These findings demonstrate an opportunity to correct disparities in the literature on breast reconstruction for the Spanish-speaking population.
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http://dx.doi.org/10.1097/SAP.0000000000001411DOI Listing
April 2018

Identifying Sources of Funding That Contribute to Scholastic Productivity in Academic Plastic Surgeons.

Ann Plast Surg 2018 04;80(4 Suppl 4):S214-S218

Background: Scholastic productivity has previously been shown to be positively associated with National Institute of Health (NIH) grants and industry funding. This study examines whether society, industry, or federal funding contributes toward academic productivity as measured by scholastic output of academic plastic surgeons.

Methods: Institution Web sites were used to acquire academic attributes of full-time academic plastic surgeons. The Center for Medicare and Medicaid Services Open Payment database, NIH reporter, the Plastic Surgery Foundation (PSF), and American Association of Plastic Surgeons (AAPS) Web sites were accessed for funding and endowment details. Bibliometric data of each surgeon were then collected via Scopus to ascertain strengths of association with each source. Multiple linear regression analysis was used to identify significant contributors to high scholastic output.

Results: We identified 935 academic plastic surgeons with 94 (10.1%), 24 (2.6%), 724 (77.4%), and 62 (6.6%) receiving funding from PSF, AAPS, industry, and NIH, respectively. There were positive correlations in receiving NIH, PSF, and/or AAPS funding (P < 0.001), whereas industry funding was found to negatively associate with PSF (r = -0.75, P = 0.022) grants. The NIH R award was consistently found to be the most predictive of academic output across bibliometrics, followed by the AAPS academic scholarship award. Conventional measures of academic seniority remained predictive across all measures used.

Conclusions: Our study demonstrates for the first time interactions between industry, federal, and association funding. The NIH R award was the strongest determinant of high scholastic productivity. Recognition through AAPS academic scholarships seemed to associate with subsequent success in NIH funding.
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April 2018
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