Managed care's attempts to capture aesthetic surgery

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.     

After plastic surgery: adolescent-reported appearance ratings and appearance-related burdens in patient and general population groups.

The aim of this study was to determine the effects of appearance-related surgery on psychosocial functioning during adolescence. To this end, changes in bodily attitudes and appearance-related burdens in adolescents undergoing corrective (for aesthetic deformities) and reconstructive (for congenital or acquired deformities) surgery were compared with those in a general population sample.A group of 184 adolescent plastic surgery patients (corrective, n = 100; reconstructive, n = 84), and a comparison group of 83 adolescents at random selected from three municipalities (corrective, n = 67; reconstructive, n = 16), aged 12 to 22 years, were studied at two time points with a 6-month interval. The plastic surgical patients were studied presurgically and postsurgically. Using fully structured telephone interviews and postal questionnaires, adolescents' ratings of their appearance, bodily satisfaction and attitudes, and appearance-related burdens were obtained.All patients reported a significant decrease in burdens after surgery compared with the comparison group, indicating a much more prominent improvement in the patient sample compared with the developmental changes that may be expected to occur in adolescence. The corrective patient group reported least burdens after the operation. More specifically, the "breasts" group benefited most from the operation, indicating that breast corrections are rewarding interventions.The findings of this study imply that adolescents can be regarded as good candidates for plastic surgery. They gain bodily satisfaction, and they are relieved of many appearance-related burdens. Physical, social, and psychological burdens related to appearance satisfaction improve considerably in both corrective and reconstructive adolescent patients.     

Basics of immune responses in transplantation in preparation for application of composite tissue allografts in plastic and reconstructive surgery: part I

Currently, composite tissue allografts are applied only occasionally as a reconstructive option in the field of plastic and reconstructive surgery. Composite tissue allografts offer a unique potential for coverage of large multitissue defects. However, compared with the relatively homogenous tissue of solid organ transplants, the heterogenicity of tissue components of composite tissue allografts may generate high immunologic responses. Modern immunosuppressive agents significantly improve successful allograft acceptance. However, chronic allograft rejection and immunosuppressive drug toxicity are still major problems in the clinical practice of transplantation. The major goals of transplantation immunology are (1) to develop tolerance to allograft transplants and (2) long-term drug-free survival. A number of experimental protocols were designed to develop tolerance; however, none of them has been proven to induce tolerance in clinical transplantation. In this article, the authors outline the mechanisms of allograft acceptance and rejection and barriers to transplantation tolerance. Novel immunosuppressive protocols are discussed in this review. This basic immunologic knowledge of allograft acceptance and rejection will allow plastic surgeons to apply composite tissue allograft transplants to plastic and reconstructive surgery.     

Functional genomics of neural and behavioral plasticity

How does the environment, particularly the social environment, influence brain and behavior and what are the underlying physiologic, molecular, and genetic mechanisms? Adaptations of brain and behavior to changes in the social or physical environment are common in the animal world, either as short-term (i.e., modulatory) or as long-term modifications (e.g., via gene expression changes) in behavioral or physiologic properties. The study of the mechanisms and constraints underlying these dynamic changes requires model systems that offer plastic phenotypes as well as a sufficient level of quantifiable behavioral complexity while being accessible at the physiological and molecular level. In this article, I explore how the new field of functional genomics can contribute to an understanding of the complex relationship between genome and environment that results in highly plastic phenotypes. This approach will lead to the discovery of genes under environmental control and provide the basis for the study of the interrelationship between an individual's gene expression profile and its social phenotype in a given environmental context.     

A new educational role for plastic surgery in the fourth year of medical school

At most medical schools, students are offered limited or sporadic experiences in plastic surgery. This is unfortunate because all physicians need to possess the knowledge and skills to evaluate skin lesions and participate in wound management. Also, students who are considering a career in plastic surgery do not have adequate information to make informed decisions. With the restructuring of plastic surgery training programs, career decisions of individuals interested in plastic surgery are being made earlier than ever before in the education continuum, and the aforementioned problem assumes greater magnitude both for the students and the faculty. At MCP-Hahnemann School of Medicine, basic plastic surgery experiences have been integrated into the third-year surgery clerkship as a requirement for all students, and a Plastic Surgery Pathway has been designed in conjunction with the school's pathway system for fourth-year students. The Pathway provides a framework for the student to select a combination of rotations that will best provide an appropriate broad-based education in preparation for training in plastic surgery, and it provides extensive guidance by faculty members in the discipline to assist with career decisions, rotation selection, and preparations for the residency application process. Students in the Plastic Surgery Pathway are required to take rotations in medicine, neurology, and plastic surgery. The remaining rotations are selected from a list of options based on the student's individual learning needs, interests, and career aspirations. Early experience with the Plastic Surgery Pathway has shown that it has been well received by students and faculty, has assisted students with their career decisions, and has led to an increased student awareness of the importance and relevance of the specialty.     

基于AHP与Rough Set的农业节水技术综合评价

由于不同区域自然条件的差异,农业节水技术自身特点及对应用环境条件的要求,导致不同农业节水技术的应用效果存在很大差异,有较大的不确定性,因此,如何筛选合理的评价指标,构建科学、全面的农业节水技术综合评价方法具有十分重要的意义。根据对农业节水技术应用效果的实地调研,应用Delphi法从调查获得的20项评价指标中筛选出了9项农业节水技术综合评价指标。其中节水率、积温和土壤肥力属于生态因子,产投比、劳动力投入和经济投入属于经济因子,可靠性、推广程度和农民认可度为社会因子。基于以上9项指标,构建了农业节水技术综合评价指标体系.综合评价方法(ARM)通过引入经验因子α对应用层次分析法(AHP)和粗糙集(Rough Set)所获得指标权重进行修订,使指标权重更加合理化。同时,分别应用AHP、Rough Set和ARM对甘肃省武威市的地膜覆盖、秸秆覆盖和常规畦田灌溉在大田中的应用效果进行了综合评价。评价结果显示,在对地膜覆盖技术评价中,AHP法过分强调了经济效益的作用(0.44),Rough Set法则强调的是生态效益(0.33)和社会效益(0.32),弱化了经济效益(0.05),ARM修正了以上2种方法的评价结果,获得地膜覆盖的经济效益、生态效益和社会效益,分别为0.36、0.20和0.13。在对秸秆覆盖评价中,与其它两种方法相比,Rough Set法的评价结果存在显著性差异,ARM修正获得的经济效益、生态效益和社会效益,分别为0.09、0.18和0.06。在对常规畦田灌溉评价中,Rough Set法强调了生态效益(0.28),经过修正获得的经济效益、生态效益和社会效益,分别为0.24、0.01和0.13。ARM的评价结果表明,采用地膜覆盖的经济效益最佳;同常规畦田灌溉相比较,地膜覆盖、秸秆覆盖的生态性指数分别比之高0.19和0.17,主要是由于秸秆覆盖具有保墒、增加土壤有机质以及在作物生长后期调节地温的作用,地膜覆盖具有节水、提高苗期土壤温度和促进提前出苗的作用;同秸秆覆盖相比,地膜覆盖和常规畦田灌溉的社会性指数分别高112.12%、18.18%,说明这两种技术在河西半干旱地区具有良好的社会基础。可见,在西北半干旱地区地膜覆盖用于种植玉米的效果最佳,而秸秆覆盖尽管其生态效益较高,但经济效益较低,推广应用存在一定的难度。     

The economics of plastic surgery practices: trends in income, procedure mix, and volume

Anecdotally, plastic surgeons have complained of working harder for the same or less income in recent years. They also complain of falling fees for reconstructive surgery and increasing competition for cosmetic surgery. This study examined these notions using the best available data. To gain a better understanding of the current plastic surgery market, plastic surgeon incomes, fees, volume, and relative mix of cosmetic and reconstructive surgery were analyzed between the years 1992 and 2002. To gain a broader perspective, plastic surgeon income trends were then compared with those of other medical specialties and of nonmedical professions. The data show that in real dollars, plastic surgeon incomes have remained essentially steady in recent years, despite plastic surgeons increasing their surgery load by an average of 41 percent over the past 10 years. The overall income trend is similar to that of members of other medical specialties and other nonmedical professionals. The average practice percentage of cosmetic surgery was calculated and found to have increased from 27 percent in 1992 to 58 percent in 2002. This most likely can be explained by the findings that real dollar fees collected for cosmetic surgery have decreased very slightly, whereas those for reconstructive procedures have experienced sharp declines. This study demonstrates that plastic surgeons have adjusted their practice profiles in recent years. They have increased their case loads and shifted their practices toward cosmetic surgery, most likely with the goal of maintaining their incomes. The strategy appears to have been successful in the short term. However, with increasing competition and falling prices for cosmetic surgery, it may represent a temporary bulwark for plastic surgeon incomes unless other steps are taken.     

Teaching plastic surgery from different perspectives

Just as everyone has a different learning style, teachers too approach the task from different perspectives. There are five basic teaching perspectives or styles: transmission, apprenticeship, developmental, nurturing, and social justice. The acronym BIAS is useful to describe the beliefs, intentions, assessments, and strategies associated with each perspective. The authors present a hypothetical 1-week rotation in plastic and reconstructive surgery in which a student encounters instructors who embody the five basic teaching perspectives. By presenting these perspectives, the authors introduce valuable teaching techniques that can benefit all those charged with the education of learners along the spectrum from premedical to continuing education venues. Educational objectives include the following: (1) explain and illustrate different approaches to effective teaching in plastic surgery; (2) introduce readers to the Teaching Perspectives Inventory as a means of determining their primary teaching style; and (3) argue for a "plurality of the good" in teaching.     

The effect of increased plastic surgeon supply on fees for aesthetic surgery: an economic analysis

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.     

Unemployment,deindustrialization, and ‘community economy’ in eastern Germany

Drawing from an evening of fieldwork at an eastern German Protestant churchin the rapidly deindustrialized city of Leipzig, this article finalyzes a discussion among church leaders, former ‘dissidents,’ and unemployed workers on the subject of ‘community economy’ (Gemeinschaftsökonomie), a concept people interpret to represent a potential solution to the crisis of mass unemployment. Such local debates on unemployment offer a frame for understanding the re-negotiation of labor and social welfare in eastern Germany following socialism's end. finalyzing this discussion within the context of theoretical debates on ‘civil society,’ I follow Burawoy's and Gramsci's lead in fillustrating that the imagined economic sphere of ‘community economy’ is an ideological battle ground, where hegemonic discourse supporting economic neoliberalism may be either reinforced or subverted.     

Plastic value chain and performance metric framework for optimal recycling

Despite the promotion of plastic recycling to sustainably manage plastic waste and advance the circular economy, existing plastic recycling systems globally are largely experiencing low performance and growth. To transition to world-class plastic material recycling and circularity, defining the metrics that impact the performance of a plastic recycling system is crucial. Bringing together existing literature, this study developed a conceptual framework, comprised of eight key performance metrics, for benchmarking recycling success or assessing the degree to which the performance of any plastic recycling system is optimal. Through a value chain approach, the specific performance metrics relevant to each stage of the plastic recycling system, their objectives, and the actors characterizing the system were analyzed in detail. Also, specific maturity models were developed to measure the performance of any plastic recycling system. This framework provides essential knowledge for related stakeholders to inform further development of plastic recycling and a circular economy.     

Quality Assessment and Circularity Potential of Recovery Systems for Household Plastic Waste

Plastic recycling is promoted in the transition toward a circular economy and a closed plastic loop, typically using mass‐based recycling targets. Plastic from household waste (HHW) is contaminated and heterogeneous, and recycled plastic from HHW often has a limited application range, due to reduced quality. To correctly assess the ability to close plastic loops via recycling, both plastic quantities and qualities need to be evaluated. This study defines a circularity potential representing the ability of a recovery system to close material loops assuming steady‐state market conditions. Based on an average plastic waste composition including impurities, 84 recovery scenarios representing a wide range of sorting schemes, source‐separation efficiencies, and material recovery facility (MRF) configurations and performances were assessed. The qualities of the recovered fractions were assessed based on contamination and the circularity potential calculated for each scenario in a European context. Across all scenarios, 17% to 100% of the generated plastic mass could be recovered, with higher source‐separation and MRF efficiencies leading to higher recovery. Including quality, however, at best 55% of the generated plastic was suitable for recycling due to contamination. Source‐separation, a high number of target fractions, and efficient MRF recovery were found to be critical. The circularity potential illustrated that less than 42% of the plastic loop can be closed with current technology and raw material demands. Hence, Europe is still far from able to close the plastic loop. When transitioning toward a circular economy, the focus should be on limiting impurities and losses through product design, technology improvement, and more targeted plastic waste management.     

Victor von Bruns (1812-1883) and his contributions to plastic and reconstructive surgery

Victor von Bruns was an active surgeon in Germany during the nineteenth century. His work is accompanied by many illustrations, and a selected few are presented in this survey. His original contributions to plastic and reconstructive surgery are notable, mainly in lip and cheek reconstruction. These are still valid today and have been adopted by many plastic surgeons. His books dealt not only with plastic surgery, but with almost every surgical event, such as amputation, larynx surgery, galvanosurgery, and war surgery. His publications and illustrations give an excellent picture of the advances made by him and other plastic surgeons during the second half of the nineteenth century, thus making him an important contributor to the renaissance of plastic surgery.     

早期整形手术在深Ⅱ度烧伤患者治疗中的作用

为了探讨早期整形外科手术治疗对深Ⅱ度烧伤创面愈合后瘢痕挛缩畸形及功能障碍的影响,本研究选择深Ⅱ度烧伤患者60例作为研究对象,对患者进行早期功能性部位整形手术,其中研究组34例,对照组26例。对照组患者使用常规治疗和功能锻炼;研究组在对照组的基础上,使用瘢痕组织切除术、中厚皮肤移植术和术后功能锻炼,比较2组治疗后疗效的差异。研究结果表明,研究组34例烧伤患者接受整形手术后,各部位平均植皮成活率均达90%以上。术后第3个月和半年2组关节功能恢复效果不显著。研究组患者术后1年的关节功能恢复和疗效均显著优于对照组(p<0.05)。初步结论表明,研究组总有效率(100%)显著高于对照组(81.25%, p<0.05)。深Ⅱ度烧伤患者创面愈合后进行早期功能部位整形手术治疗能有效改善患处瘢痕挛缩导致的关节功能障碍。     

Discount cosmetic surgery: industry trends and strategies for success

Discount cosmetic surgery is a topic of interest to plastic surgeons. To understand this trend and its effects on plastic surgeons, it is necessary to review the economics of cosmetic surgery, plastic surgery's practice environment, and the broader business principles of service industries.Recent work looked at the economics of the plastic surgery market. This analysis demonstrated that increased local density of plastic surgeons was associated with lower adjusted fees for cosmetic procedures. A survey of plastic surgeons about their practice environment revealed that 93 percent categorized the majority of their patients as very or moderately price-sensitive. Fully 98 percent described their business climate as very or moderately competitive and most plastic surgeons thought they lost a sizable number of cosmetic patients within the last year for reasons of price.A standard industry analysis, when applied to cosmetic surgery, reveals the following: an increased number of surgeons leads to lower fees (reducing their bargaining power as suppliers), patients are price-sensitive (increasing their bargaining power as buyers), and there are few barriers to entry among providers (allowing potential new entrants into the market). Such a situation is conducive to discounting taking hold-and even becoming the industry norm.In this environment, business strategy dictates there are three protocols for success: discounting, differentiation, and focus. Discounting joins the trend toward cutting fees. Success comes from increasing volume and efficiency and thus preserving profits. Differentiation creates an industrywide perception of uniqueness; this requires broadly positioning plastic surgeons as holders of a distinct brand identity separate from other "cosmetic surgeons." The final strategy is to focus on a particular buyer group to develop a market niche, such as establishing a "Park Avenue" practice catering to patients who demand a prestigious surgeon, although this is likely a small segment of the overall patient population. Plastic surgeons that buck the trend toward discount cosmetic surgery must take concrete and potentially costly steps to implement a plausible strategy for distinguishing their practices within the crowded cosmetic surgery market.     

The integral role of the plastic surgeon at a level I trauma center

The role of plastic surgery in urban level I trauma centers in the United States has been largely undefined, despite the undeniable historical involvement of plastic surgery in reconstruction of posttraumatic defects. To explore and define this role, case data were prospectively collected during a 29-month period following initiation of a full-time plastic surgery position at an established urban level I trauma center. Referring and/or interacting surgical service, anatomical area of interest, and procedure data were tabulated. A total of 1009 operative reports comprising 1104 procedures were recorded. The most common interacting surgical services were orthopedics and general/trauma surgery; however, interaction occurred with a total of 10 surgical specialties. The upper extremity was the most common anatomical area operated on followed by head and neck, lower extremity, trunk, urogenital, and breast. A wide variety of procedures were performed in each anatomical area, demonstrating the broad scope of reconstructive surgery practiced in a trauma setting. Three hundred and twenty-four procedures involved expertise in microsurgery, flaps, and burn or frostbite care. Additional procedures commonly performed demonstrated considerable overlap with other fields of surgical specialization. This overlap in skills proved advantageous in distribution of facial trauma call and hand surgery coverage. Data presented in this study reinforce the idea that plastic surgery is a specialty defined by concept rather than anatomical area, and also demonstrate a significant role for plastic surgeons in a level I trauma center.     

Vilray P. Blair, his surgical descendants, and their roles in plastic surgical development.

Perhaps one of the most historically well-known plastic surgeons is Vilray P. Blair. As commander of the U.S. Army corps of head and neck surgeons during World War I, he became well known for his work in posttraumatic reconstruction. Blair's efforts in the early part of this century helped to develop plastic surgery as a distinct surgical subspecialty in the United States. His prowess as a surgeon allowed him to build one of the largest plastic surgery centers in the country and to train many of the top young American surgeons. Blair excelled as a teacher. He produced academic surgeons such as James Barrett Brown and Bradford Cannon, who took the lead in the care of wartime injuries during World War II. At Valley Forge General Hospital, Blair's trainees dedicated themselves to the reconstruction of injured patients and trained other young plastic surgeons in the care of postwar trauma. This exceptional level of patient care resulted in the U.S. government recognizing plastic surgery as a subspecialty following World War II. Since that time, Blair's surgical descendants at Washington University have led the country in the development of new training concepts and ideals and have gone on to become leaders in plastic surgery worldwide.     

Factors determining the ultimate fate of a plastic surgery applicant

Plastic surgery residency program directors are frequently interested in predictors of future career direction in their applicants. Many programs strive to train leaders in academic plastic surgery. To determine what factors may predict the ultimate fate of graduating plastic surgery residents, the authors reviewed the application files of 33 former residents from a single, major plastic surgery training program. The data from 29 residents were available for analysis. Nearly half of the residents graduating from the plastic surgery training program went into private practice. Two factors, the number of years taken off for research before entering the plastic surgery residency and the presence of children, were found to be indicative of a candidate's future career path. Of particular note, there was no difference between academic graduates and nonacademic graduates with regard to their intentions in their letters of recommendation and personal statements. This information is useful to both academic program directors and resident applicants.     

Priorities in plastic surgery

The study of historical priorities in plastic surgery must be based on established principles in the field instead of mere chronology. Examples of application of these principles to two landmarks in plastic surgery are given. The reader is commended to adhere to these principles in the study of other developments in plastic surgery.