The coronavirus disease of 2019 (COVID-19) pandemic has had an unprecedented impact on all facets of health care allocation and administration worldwide.1 2–9 10 11
Resident physicians have been actively involved with all aspects of COVID-19 patient care when needed, and medical centers developed a number of systems to support these efforts.12 , 13
Case volume and “hands-on” surgical education have been significantly reduced, reflecting Centers for Medicare and Medicaid Services and American Society of Plastic Surgeons recommendations to temporarily halt elective and nonurgent procedures and minimize nonessential personnel in the operating room.14 , 15 6 , 9
Plastic surgery training programs have also been confronted with a significant change in the way didactic education is conducted.16 , 17 18
The COVID-19 pandemic has created sudden stressors across numerous domains in plastic surgery. To endure the ongoing COVID-19 pandemic and its aftermath, the plastic surgery community must pay special attention to the safety of not only our patients but also ourselves and our community.19
In the context of a rapidly changing health care environment, there has been no investigation into the experiences of U.S. plastic surgery residents during the COVID-19 pandemic. Redeployment, social distancing, reduced caseload, virtual education, and risk for COVID-19 transmission may all have a substantial effect on the wellness and learning of plastic surgery residents. Resident perspectives on clinical team restructuring, engagement in alternative learning strategies, and future career plans are of substantial value going forward. The goal of this study was to understand the determinants of plastic surgery resident educational experiences during the COVID-19 pandemic.
METHODS
Study Population
The University of Washington Institutional Review Board granted exempt status for this project before enrolling any subjects (STUDY00010119). All trainees in a plastic surgery program within the United States were eligible to participate in the survey. Participants were excluded if they were not currently enrolled in a plastic surgery residency program (e.g., fellows, observers, medical students), or declined to participate in the study. The total number of plastic surgery residents for the 2019 to 2020 academic year for integrated and independent programs was 1190 as reported by the Accreditation Council for Graduate Medical Education and served as the target population for this study.20
Survey Instrument
A novel survey instrument was initially developed by an expert panel with experience in survey methodology, medical education, and wellness. The panel consisted of three plastic surgery residents (C.S.C., J.L., and S.D.M.) and two academic plastic surgeons (B.C.D. and J.E.J.) from four different institutions. Consensus agreement among the panel members resulted in the production of a draft instrument. Nine plastic surgery residents from six academic institutions in postgraduate years 1 through 9 (residents in both independent and integrated plastic surgery tracks) were selected to pilot the instrument, and their feedback was incorporated into the final survey. (See Figure, Supplemental Digital Content 1 , which shows the pilot study feedback for design of final study instrument, https://links.lww.com/PRS/E586 See Figure, Supplemental Digital Content 2 , which shows the final survey instrument distributed to U.S. residents, https://links.lww.com/PRS/E587 21–23
The anonymous survey consisted of three sections: a cover page providing an overview and purpose of the study, questions related to plastic surgery resident education and wellness during the COVID-19 pandemic, and a demographic component. Demographic information included residency program location, postgraduate year, training program type (integrated versus independent), living situation, and sex (questions 25 through 28 in Figure, Supplemental Digital Content 2 , https://links.lww.com/PRS/E587 Figure, Supplemental Digital Content 2 , https://links.lww.com/PRS/E587
The final survey was circulated in electronic format every 2 days for a 9-day period in April of 2020. An institutional Web-based survey tool was used as the platform for electronic survey circulation.24
Statistical Analysis
All data were coded for appropriate analysis. Ten percent of the data were reentered to check for errors in data entry, with none found. Statistical analyses were performed using Microsoft Excel (Microsoft Corp., Redmond, Wash.). Significance was set at p < 0.05. All variables were categorical; therefore, all bivariate analysis consisted of chi-square tests, unless any cell in the contingency tables contained fewer than five, in which case Fisher’s exact test was used.
RESULTS
A total of 668 plastic surgery residents responded to the survey request, corresponding to a 56.1 percent response rate. Of these respondents, 48 were only partially completed, thus a total of 620 surveys were included for final analysis (Fig. 1 ).
Fig. 1.: Survey respondents.
Male and female respondents constituted 57.6 percent and 42.1 percent of respondents, respectively, and two respondents identified as transgender (Table 1 ). Approximately 80 percent were in integrated track and 20 percent were in independent track training programs. Resident level was well represented in the sample. Geographic location was also evenly divided between Northeast (26.9 percent), Midwest (24.8 percent), South (24.5 percent), and West (23.7 percent) U.S. Census regions. A majority of respondents reported living with at least one other individual (71.6 percent). One-third of residents reported living with an adult who also works in the health care field. Approximately 20 percent of residents live with a child and 1.6 percent live with an adult older than 65 years.
Table 1. -
Respondent Demographics
No. (%)
Sex
Female
261 (42.1)
Male
357 (57.6)
Transgender
2 (0.3)
Nonbinary/other
0 (0)
Postgraduate year
Integrated
513 (82.9)
Year 1
95 (15.3)
Year 2
89 (14.3)
Year 3
93 (15.0)
Year 4
75 (12.1)
Year 5
76 (12.3)
Year 6
74 (11.9)
Research/professional development
12 (1.9)
Independent
106 (17.1)
Year 1
37 (6.0)
Year 2
35 (5.6)
Year 3
34 (5.5)
Region
Northeast
167 (26.9)
Midwest
154 (24.8)
South
152 (24.5)
West
147 (23.7)
Living situation
Live alone
176 (28.4)
Live with an adult in the health care field
219 (35.3)
Live with an adult not in the health care field
203 (32.7)
Live with your child/children
123 (19.8)
Live with someone older than 65 yr
10 (1.6)
Nearly all plastic surgery trainees (97.1 percent) reported restructuring of their residency program during the COVID-19 pandemic; however, only 14.4 percent were personally redeployed to assist in the care of COVID patients, either directly or indirectly (Table 2 ). Ten percent of redeployed residents worked on more than one service. The majority of redeployments were to COVID-specific intensive care units (56.4 percent), and the remainder were to non–COVID-19 intensive care units (15.8 percent), general surgery services (10.9 percent), emergency departments (7.9 percent), medicine services (5.9 percent), and non-M.D. roles (3.0 percent) (Fig. 2 ). Male residents were more frequently redeployed than their female counterparts, although the difference did not reach statistical significance (16.7 percent versus 11.1 percent; p = 0.06). Similarly, integrated residents in their first 3 years of training were more likely to be redeployed as compared to integrated residents in their last 3 years or independent residents (18.8 percent versus 9.8 percent versus 13.2 percent, respectively; p = 0.03).
Table 2. -
Plastic Surgery Program Restructuring
No. (%)
p
Restructuring of residency
602 (97.1)
Redeployment
89 (14.4)
Area of redeployment*
Emergency department
8 (7.9)
Intensive care unit (non-COVID)
16 (15.8)
COVID intensive care unit
57 (56.4)
Medicine service
6 (5.9)
General surgery
11 (10.9)
Non-M.D. role†
3 (3.0)
More than one area
10 (9.9)
Sex and redeployment
0.06
Male
59 (16.5)
Female
29 (11.1)
Training level and redeployment
0.03‡
Integrated yr 1–3
18.8 (52)
Integrated yr 4–6
22 (9.8)
Independent
14 (13.2)
Research/professional development
1 (8.3)
* Calculated based on 89 residents redeployed and 10 redeployed more than once.
† Non-M.D. roles included respiratory therapy, personal protective equipment team, and scribe.
‡ Statistically significant.
Fig. 2.: Resident redeployment. The percentage of residents redeployed is shown within the pie chart, with the break-out bar graph illustrating the percentage of those redeployed to a given department. ICU , intensive care unit.
A majority of residents felt that the COVID-19 pandemic had either a somewhat negative (47.9 percent) or a very negative (10.2 percent) impact on their education (Table 3 ). One-fifth of residents reported a somewhat positive impact. Eighteen percent of residents reported mandatory research by their program during the COVID-19 pandemic.
Table 3. -
Plastic Surgery Educational Effects of COVID-19
No. (%)
Overall effect on education
Very positive
22 (3.5)
Somewhat positive
138 (22.2)
No effect
100 (16.1)
Somewhat negative
297 (47.9)
Very negative
63 (10.2)
Mandated research during COVID-19 pandemic
Yes
112 (18.1)
No
508 (81.9)
Overall effect on operative experience
Maximally
62 (10.0)
Moderately
263 (42.4)
Minimally
295 (47.6)
Inability to achieve recommended case numbers
Yes
41 (6.6)
No
426 (68.7)
Unsure
153 (24.7)
Specific areas where case numbers will be affected*
Aesthetic
25 (61.0)
Extremity/hand
7 (17.1)
Breast reconstruction/microsurgery
6 (14.6)
Pediatrics/craniofacial
13 (31.7)
Burn
0 (0)
General surgery
2 (4.9)
* Calculated from 41 respondents who said they would be unable to achieve case numbers. Not mutually exclusive.
Ten percent reported a maximal negative impact on their operative experience, whereas 42.4 and 47.6 percent reported a moderate or minimal effect, respectively. Residents in their final year of training (integrated year 6 and independent year 3) reported a more significant impact on operative experience (Fig. 3 ). Overall, 7 percent of plastic surgery residents felt that they were not or will not be able to meet recommended case minimums secondary to COVID-related decreases in operative volume; however, this varied greatly by year and program type (Fig. 4 ). Approximately one-quarter of independent residents in their final year of training feared that they would not meet case minimums because of the postponement or cancellation of cases. Fewer than 10 percent of all other postgraduate years reported an inability to meet case minimums. Aesthetic cases (61.0 percent), followed by pediatric/craniofacial cases (31.7 percent), were the surgical categories where case numbers were most likely to be felt unmet.
Fig. 3.: Perceived effect of COVID-19 on operative experience. Percentage of residents who noted maximal, moderate, or minimal effect on operative experience by postgraduate level.
Fig. 4.: Inability to reach recommended operative case minimums. Percentage of residents who noted impacts on their ability to reach minimum recommended operative cases by postgraduate year.
Virtual education (e.g., online lectures, discussions) was the most favored learning modality, followed by reading, research, continuing work in the hospital, and lastly practicing surgical skills outside of the operating room (Table 4 ). The average number of virtual education sessions increased to an average of 4.2 per week during the COVID-19 pandemic compared to less than 1 per week before the emergence of COVID-19. Almost all residents reported having watched institutional and Society-sponsored lectures (Table 5 ). On average, residents found visiting professors lecture series, Society-sponsored lectures, Society-sponsored virtual education websites, and institutional lectures of the greatest educational value.
Table 4. -
Importance of Educational Mediums Used during COVID-19
*
Medium
Average Importance (SD)
Virtual education
1.8 (1.2)
Reading
2.5 (1.1)
Research
3.2 (1.2)
Continuing work in the hospital
3.3 (1.3)
Practicing surgical skills
4.2 (1.1)
* Based on a 1 to 5 ranking scale, with 1 being the most important to education.
Table 5. -
Utility of Educational Mediums for Plastic Surgery Residents
*
Medium
Average Utility (SD)
Institution-sponsored lectures1
2.4 (0.6)
Society-sponsored lectures2
2.6 (0.6)
Visiting professor lecture series3
2.6 (0.6)
Society virtual education websites4
2.4 (0.7)
Industry-sponsored lectures5
1.9 (0.7)
Watching live anatomical dissections6
2.1 (0.8)
Watching real-time operations7
2.2 (0.8)
* Ranked on 0 to 3, with 3 being extremely valuable. (1) 2.7% (17 respondents) not using this medium; (2) 5.3% (33 respondents) not using this medium; (3) 16.6% (103 respondents) not using this medium; (4) 14.0% (87 respondents) not using this medium; (5) 41.3% (256 respondents) not using this medium; (6) 70.3% (436 respondents) not using this medium; (7) 73.5% (456 respondents) not using this medium.
Seventy percent planned to pursue fellowship training before the COVID-19 pandemic. Fewer anticipated starting directly in a group private practice (13.2 percent), employed physician/hospital-based practice (6.0 percent), solo private practice (4.7 percent), or academic practice (3.1 percent). Most respondents reported no change in career path because of COVID-19 (85.5 percent), whereas a minority of residents reported an effect on their career path or plans (Table 6 ). Transition to a virtual job or fellowship interview and, more concerning, the loss or potential loss of a job were the two most reported career-related effects of COVID-19 [26 responses each (4.2 percent each)]. Rates of career changes were much higher in the final 2 years of training, with nearly 20 percent of residents in their final year of training reporting actual or possible loss of their future job (Fig. 5 ). Six percent of residents now planned to pursue fellowship training as a result of the pandemic, and 3.9 percent planned to seek employment in a hospital-based practice. Overall, two-thirds of residents reported that job security was an extremely important determinant of career path.
Table 6. -
Effects of COVID-19 on Career Path (All Years)
No. (%)
Anticipated career path before COVID-19
Fellowship
434 (70.0)
Direct to academic practice
19 (3.1)
Direct to solo private practice
29 (4.7)
Direct to group private practice
82 (13.2)
Direct to employed physician/ hospital-based practice
37 (6.0)
Military
2 (0.3)
Not sure
17 (2.7)
Effect of COVID-19 on career path
Delay in fellowship interview/match
24 (3.9)
Transition to virtual job/fellowship interviews
26 (4.2)
Change in anticipated job start date
18 (2.9)
Loss or potential loss of job
26 (4.2)
Change in career path
24 (3.9)
Unsure
5 (0.8)
No change
530 (85.5)
Anticipated career path change because of COVID-19
Will not do fellowship
2 (0.3)
Will do fellowship
36 (5.8)
Going into academic practice
14 (2.3)
Going into private practice
16 (2.6)
Going into employed physician/ hospital-based practice
24 (3.9)
Consider alternate nonclinical career
2 (0.3)
Unsure
15 (2.4)
Will not change
530 (85.5)
Importance of job security in career path
Extremely important
414 (66.8)
Somewhat important
180 (29.0)
Not important
26 (4.2)
Fig. 5.: Effect of COVID-19 on career path. Residents in their final 2 years of training and their noted career path changes.
Of the residents that were redeployed, 88.8 percent felt they had adequate institutional support during this time. Of those that did not feel adequately supported, inadequate personal protective equipment (4.5 percent), psychosocial support (3.4 percent), and financial support (3.4 percent) were quoted. Most redeployed residents (84.8 percent) felt some impact on their wellness during this time. Psychological stress (37.1 percent), disruption of home life (28.8 percent), and strain to physical health (12.9 percent) were the most common. Nevertheless, 69.7 percent of those who were redeployed would welcome redeployment again (Table 7 ).
Table 7. -
Resident Experiences with Redeployment
*
No. (%)
Adequate institutional support
Yes
79 (88.8)
No
4 (4.5)
Not sure
6 (6.7)
Reasons for inadequate institutional support†
Inadequate PPE
4 (4.5)
Inadequate psychosocial support
3 (3.4)
Inadequate familial services
0 (0)
Inadequate financial support
3 (3.4)
Effect of redeployment on well-being†
No hardship
20 (15.2)
Disruption of home life
38 (28.8)
Financial burden
5 (3.8)
Psychological stress
49 (37.1)
Strain to physical health
17 (12.9)
Negative impact on training
3 (2.3)
Volunteer for redeployment again?
Yes
62 (69.7)
No
16 (18.0)
Unsure
11 (12.4)
* Calculated from 89 residents that were redeployed.
† Not mutually exclusive.
Although most residents felt their institutions offered psychosocial support, 7.6 percent felt there was minimal psychosocial support during the COVID-19 pandemic. Of note, 14.8 percent noted childcare support was offered and 6.3 percent noted additional financial support (i.e., hazard pay) was offered (Table 8 ). On bivariate analysis, only female residents (p = 0.06) had a trend toward feeling less psychosocial support from their institutions (Fig. 6 ).
Table 8. -
Psychosocial Support during the COVID-19 Pandemic
No. (%)
Institutional psychosocial support
Maximal
306 (49.3)
Moderate
267 (43.1)
Minimal
47 (7.6)
What support was offered?*
Financial support
36 (6.3)
Childcare support
85 (14.8)
Physical wellness
113 (19.7)
Psychosocial wellness
246 (42.9)
Reduced clinical responsibilities
498 (86.9)
Regular administration updates
25 (4.3)
Other†
7 (1.2)
* Calculated from 573 respondents who noted their institution was maximally or moderately supportive of psychosocial well-being. Not mutually exclusive.
† Responses included virtual learning opportunities (n = 5), gift cards for food (n = 1), and paid parking (n = 1).
Fig. 6.: Differences in perception of psychosocial support. Only female residents had a trend toward feeling less institutional psychosocial support.
A significant portion of residents (82.6 percent) felt isolated from their colleagues during the COVID-19 pandemic. Video conferencing was the most common way residents maintained contact with their colleagues (92.7 percent). Eight percent of residents (47 respondents) said they were still having in-person contact with colleagues without appropriate social distancing (Table 9 ).
Table 9. -
Feelings of Isolation among Plastic Surgery Residents
No. (%)
How often do you feel isolated from colleagues?
All the time
55 (8.9)
Most of the time
192 (31.0)
Sometimes
265 (42.7)
Rarely
69 (11.1)
Never
39 (6.3)
Mediums used to maintain contact with colleagues*
In-person with appropriate social distancing
253 (40.8)
In-person without appropriate social distancing
47 (7.6)
Video conferencing
575 (92.7)
Telephone (calls or text)
494 (79.7)
E-mail/social media
283 (45.6)
Not staying in contact
2 (0.3)
DISCUSSION
Education
Surgical education is a core tenet of residency training and consists of several different facets of learning, both technical and nontechnical.25 26
Our results demonstrate that academic medical centers and plastic surgery residency programs quickly responded to the limitations the COVID-19 pandemic inherently imposed on training and education. Expectedly, a large proportion of plastic surgery residents felt COVID-19 negatively impacted their education. Some residents were concerned about meeting recommended case minimums, and a considerable percentage in their final 2 years of training noted potential or actual loss of a prospective job. Such an effect would represent one of the most significant single events to affect the plastic surgery job market in recent decades.
Although almost all plastic surgery residents reported restructuring of their training programs, several residents were redeployed to other services, specifically, COVID-19 intensive care units. Plastic surgery residents may be uniquely suited for redeployment. This may be partly attributable to a broad clinical exposure, with many plastic surgery residents having critical care experience as part of their general surgery training. Furthermore, many plastic surgery residents may have been available because of clinical team reorganization and reductions in elective case volume. The highest proportion came from junior-level integrated residents (postgraduate years 1 to 3; 19 percent), which may be a factor of their broad-based training during their early years of residency. Senior residents were likely more critical to their assigned plastic surgery service and less likely to be redeployed.
A majority of plastic surgery residents reported that changes secondary to COVID-19 precautions had a negative effect on their education. From cancellation of in-person conferences to reduction in elective operative experiences to loss of patient interaction, plastic surgery residents were impacted in several different ways. More than half of plastic surgery residents noted a maximal or moderate effect on operative experience during the COVID-19 pandemic. Chief residents (i.e., integrated clinical year 6 and independent year 3) felt this impact to a greater degree than their more junior colleagues. Factors such as reduced resident cohorts paired with cancellation of senior-resident level clinical experiences (e.g., chief resident cosmetic clinic, community aesthetic cases, microvascular reconstructions) may be driving this sentiment. There may also be a greater perceived loss of surgical experience for those soon to be entering practice or fellowship training. More tangible is the fact that many residents —including one-quarter of independent residents in their final year of training—feared an inability to achieve the recommended Accreditation Council for Graduate Medical Education case numbers. Unfortunately, these findings suggest that the COVID-19 pandemic may have substantially impacted the training of chief residents. The implications may be even broader than the findings demonstrated in this study. For example, if graduating chief residents are less confident in their skill set in early practice, this may ultimately alter the caseload they undertake as “fully” trained plastic surgeons.
More residents noted that they now planned to pursue a fellowship or employment in a hospital-based practice as a result of COVID-19. These influences were undoubtedly multifactorial, but our results and analysis could not exclude the impact of operative experience on senior resident career decisions. More striking is that approximately 20 percent of those in their last 2 years of training noted potential or actual job loss. This may represent institution-wide hiring freezes in which contracts are withheld. With the significant financial stress faced by a large proportion of residents on completing residency (e.g., educational loans, family obligations), job instability further compounds these stressors.27
Although operative experiences have suffered, other new educational opportunities have become available and previous ones more readily adopted.28 29
Wellness
Wellness for those at the frontlines of the pandemic is often overlooked, especially in those that are already at high risk for burnout.30 31 , 32
Our results revealed that many residents felt redeployment was a source of psychosocial stress (37 percent) and disruption to their home life (38 percent). These findings are quite compelling given that, at baseline (e.g., before the pandemic), prior studies have revealed that residents are at high-risk for burnout and stress.30 , 33 27 , 34 , 35 36
Redeployment to emergency departments/intensive care units and clinical areas less familiar for plastic surgery trainees can be a source of stress. Anxiety over one’s own personal safety or loved ones, particularly with data emerging regarding airborne transmission, exposure risk from asymptomatic carriers, and conflicting advice regarding level of personal protective equipment, is well warranted. In addition, guilt and grieving associated with taking care of COVID-19 patients can be difficult for trainees that may have less experience with loss/death. Fortunately, our study also revealed that most redeployed residents believed that they had adequate institutional support (89 percent). In fact, if given the option, most redeployed residents (62 percent) revealed that they would redeploy again, likely revealing either the empathy and social mission of plastic surgery residents or the rigorous training of plastic surgery trainees. Furthermore, given that the respondents revealed a reduction in clinical responsibilities (87 percent), the stress and anxiety of redeployment may be ameliorated by reduced working responsibilities and institutional support by means of wellness initiatives and childcare support. This survey importantly reveals that such institutional efforts promoting wellness must continue to assist trainees cope with the ongoing crisis.
However, it is important to note that the bivariate analysis revealed that female residents tended to endorse less psychosocial support from their institutions. Multiple studies have revealed that there is an implicit bias toward women in surgical specialties, including lower levels of promotion, decreased pay, and less representation at national society levels.37–41
Our study also revealed that during the COVID-19 pandemic, plastic surgery residents experienced high levels of isolation. Isolation, especially in fields with constant human interaction, can negatively impact wellness and mental health. With decreased clinical responsibilities, residents may feel withdrawn from their colleagues, further worsening the psychosocial stress caused by the pandemic. However, embracing technology, especially in the form of video conferencing, was supported by residents to maintain contact with each other. With the increase in virtual conferences during the pandemic, the ability to maintain contact and interact on a regular basis is a significant benefit extending beyond education. As many institutions are exploring the utility of virtual education and cross-institutional collaboration, our ability to interact with colleagues throughout the United States will also be enhanced. Video conferencing may become an important portion of future educational and collaborative endeavors in addition to technological resources that are already established.28
Limitations
As with any survey-based study, our survey was limited in several ways. First, this project was a cross-sectional study and the long-term changes and impacts on resident education and wellness were not explored. Nevertheless, this study gives us an initial, insightful understanding of plastic surgery resident adaptation to a changing educational environment. Second, this survey was constructed using multi-institutional expert panel input with pilot studying, but not reliability testing. However, this survey is strengthened by the substantial response rate (56.1 percent) from plastic surgery residents across the country supporting the generalizability of these findings.
Survey responses are also limited in that they capture the disposition and attitudes of participants at a single point in time. As the crisis continues to evolve, education and well-being may change substantially. Further studies will be necessary to determine the true extent of this pandemic on plastic surgery training and careers.
CONCLUSIONS
This cross-sectional, national survey of plastic surgery residents reveals that most residents felt the COVID-19 pandemic has had a deleterious impact on their plastic surgery education and their personal well-being. Although the operative experience of plastic surgery residents suffered, virtual education emerged as an educational adjunct that was well received by most plastic surgery residents and may very well persist after precautions are lifted.
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APPENDIX. RESIDENT COUNCIL WELLNESS AND EDUCATION STUDY GROUP
The following are members of the Resident Council Wellness and Education Study Group: Arya A. Akhavan, M.D. (Division of Plastic Surgery, Department of Surgery, University of North Carolina Hospital, Chapel Hill, N.C.); Brendan J. Alleyne, M.D. (Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio); Spencer R. Anderson, M.D. (Department of Orthopaedic and Plastic Surgery, Wright State University, Dayton, Ohio); Ersilia L. Anghel, M.D. (Division of Plastic Surgery, Department of Surgery, Oregon Health Sciences University, Portland, Ore.); Sofia Aronson, M.D. (Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.); Mona Ascha, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio); Said C. Azoury, M.D. (Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Hospital, Philadelphia, Pa.); Alain J. Azzi, M.D., M.Sc. (Division of Plastic Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada); Pablo A. Baltodano, M.D. (Division of Plastic Surgery, Department of Surgery, Albany Medical Center, Albany, N.Y.); Ravinder Bamba, M.D. (Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind.); Christopher A. Bobbitt, M.D. (Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, Calif.); Michael D. Borrero, M.D. (Section of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Science Center, New Orleans, La.); Sterling E. Braun, M.D. (Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Mo.); Owen H. Brown, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.); Ronald D. Brown, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, N.Y.); Timothy P. Bruce, M.D. (Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Chicago, Ill.); Anna R. Carlson, M.D. (Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Hospital, Durham, N.C.); Katherine H. Carruthers, M.D., M.S. (Division of Plastic, Reconstructive, and Hand Surgery, Department of Surgery, West Virginia University School of Medicine, Morgantown, W.Va.); David Chi, M.D., Ph.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University Medical Center, St. Louis, Mo.); Katherine F. Chiasson, M.D. (Division of Plastic Surgery, Department of Surgery, University of Alabama School of Medicine, Birmingham, Ala.); Salih Colakoglu, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo.); Douglas Dembinski, M.D. (Division of Plastic, Reconstructive, and Hand Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio); Sagar Deshpande, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn.); Miguel I. Dorante, M.D., M.B.E. (Department of Plastic and Reconstructive Surgery, Lahey Hospital and Medical Center, Burlington, Mass.); Matthew P. Fahrenkopf, M.D. (Division of Plastic Surgery, Department of Surgery, Spectrum Health/Michigan State University, Grand Rapids, Mich.); Jordan D. Frey, M.D. (Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y.); Jeffrey B. Friedrich, M.D., M.C. (Division of Plastic and Reconstructive Surgery, University of Washington School of Medicine, Seattle, Wash.); Jared W. Garlick, M.D. (Division of Plastic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah); Natalie Godfrey, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.); Samuel Golpanian, M.D. (Division of Plastic Surgery, Department of Surgery, Temple University Hospital, Philadelphia, Pa.); Austin Y. Ha, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University Medical Center, St. Louis, Mo.); Matthew C. Hagan, M.D. (Division of Plastic Surgery, Department of Surgery, University of Illinois Hospital, Chicago, Ill.); Jordan N. Halsey, M.D. (Division of Plastic Surgery, Department of Surgery, Rutgers-New Jersey Medical School, New Brunswick, N.J.); Kristy L. Hamilton, M.D. (Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas); Adam T. Hauch, M.D. (Division of Plastic Surgery, Department of Surgery, University of California, San Diego, San Diego, Calif.); David A. Hill, M.D. (Houston Methodist Institute for Reconstructive Surgery, Houston Methodist Hospital, Houston, Texas); Ashley L. Howarth, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic–Arizona, Scottsdale, Ariz.); Michael S. Hu, M.D., M.P.H., M.S. (Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.); Lauren E. Hutchison, M.D. (Division of Plastic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill.); Michael Ingargiola, M.D. (Division of Plastic Surgery, Department of Surgery, Icahn School of Medicine at Mt. Sinai, New York, N.Y.); Lindsay Janes, M.D. (Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.); Charles C. Jehle, Jr., M.D. (Department of Plastic and Reconstructive Surgery, Brown University Alpert Medical School, Rhode Island Hospital, Providence, R.I.); Heidi H. Johng, M.D., M.P.H. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn.); Walter Joseph, M.D. (Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.); Shana S. Kalaria, M.D., M.B.A. (Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, Texas); Melissa D. Kanack, M.D. (Department of Plastic Surgery, University of California, Irvine School of Medicine, Orange, Calif.); Steven D. Kozusko, M.D., M.Ed. (Division of Plastic Surgery, Department of Surgery, Cooper University Hospital, Camden, N.J.); Casey T. Kraft, M.D. (Department of Plastic Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio); Ryan Kunkel, M.D. (Divison of Plastic and Reconstructive Surgery, Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, N.M.); Jasmine Lee, M.D. (New York University Grossman School of Medicine, New York, N.Y.); Rachel Lentz, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco School of Medicine, San Francisco, Calif.); Jeffrey L. Lisiecki, M.D. (Section of Plastic Surgery, University of Michigan School of Medicine, Ann Arbor, Mich.); Nicholas F. Lombada, M.D. (Division of Plastic Surgery, Department of Surgery, Texas A&M Health Science Center College of Medicine, Baylor Scott & White Medical Center, Temple, Texas); Jorge Lujan-Hernandez, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.); Zeshaan N. Maan, M.D., M.Sc. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, Calif.); Eric J. Maiorino, M.D. (Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Texas Health Science Center, Houston, Texas); Maridelle Millendez, M.D. (Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, D.C.); Pablo L. Padilla, M.D. (Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, Texas); Shimul S. Patel, M.D. (Division of Plastic Surgery, Department of Surgery, Tulane School of Medicine, New Orleans, La.); Lacey R. Pflibsen, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic–Arizona, Scottsdale, Ariz.); Irene J. Pien, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif.); Benjamin D. Schultz, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, N.Y.); Arman T. Serebrakian, M.D. (Division of Plastic Surgery, Department of Surgery, Brigham & Women’s Hospital, Boston, Mass.); John T. Smetona, M.D. (Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.); Jesse R. Smith, M.D., M.S. (Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Chicago, Ill.); Brian W. Starr, M.D. (Division of Plastic, Reconstructive, and Hand Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio); David M. Straughan, M.D. (Division of Plastic Surgery, Department of Surgery, Tulane School of Medicine, New Orleans, La.); Thomas M. Suszynski, M.D., Ph.D. (Department of Plastic Surgery, University of Texas Southwestern Medical School, Dallas, Texas); Shoichiro A. Tanaka, M.D., M.P.H. (Division of Plastic Surgery, Department of Surgery, Summa Health, Akron, Ohio); Sami P. Tarabishy, M.D. (Division of Plastic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, S.C.); Erin M. Taylor, M.D. (Division of Plastic Surgery, Department of Surgery, Brigham & Women’s Hospital, Boston, Mass.); Krishna S. Vyas, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.); Andrew L. Weinstein, M.D., M.S. (Division of Plastic Surgery, Department of Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, N.Y.); Erik M. Wolfswinkel, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, Calif.); Suma Yalamanchili, M.D. (Division of Plastic, Reconstructive, and Hand Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio); and Matthew R. Zeiderman, M.D. (Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, Davis School of Medicine, Sacramento, Calif.).
