Phẫu Thuật Tạo Hình (Tập 1): Nguyên Lý Cơ Bản – Neligan (2018)

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CHAPTER 34 • Robotics in plastic surgery
structures is crucial. As the use of robotic microsurgery
expands, so will the refinement and development of new and
adapted instrumentation.
Conclusion
Minimally invasive techniques have long been known to
reduce postoperative pain, hospitalization duration, patient
recovery time, infection risks, and overall cost, increasing the
quality of care.65 Robotic technology is the next step in the
evolution of minimally invasive techniques, adding enhanced
precision and visualization that can augment the capabilities
of plastic surgeons and aid them in achieving safer and more
precise interventions. Additionally, these technologies can
enable surgeons to perform approaches never before possible,
such as the robotic LD harvest. Robotic instrumentation is also
expected to continue to improve and expand the range of
applications in various areas within plastic surgery, especially
microsurgery, leading potentially to the refinement of proce-
dures and wider adoption. The future of robotics in plastic
surgery is promising. With improved technology platforms,
improved training pathways and the inevitable decreases in
cost which accompany the democratization of all technology
revolutions, robotic plastic surgery will likely grow and
flourish.
potential for an unparalleled visual acuity for complex micro-
surgical procedures.
Other microsurgery-specific robotic instrumentation, of
potential interest to reconstructive microsurgeons, include the
flexible drop-in Doppler (Vascular Technology Inc., Nashua,
NH) designed specifically for use with the robotic platform.
It is easily manipulated by the robotic forceps, and allows the
surgeon to perform real-time Doppler monitoring of the sur-
rounding vasculature and tissue. Also, a robotically controlled
ultrasound transducer (Aloka Inc., Wallingford, CT) has
recently been developed and allows surgeons to obtain full
ultrasound imaging with real-time flow mapping.61 Another
potentially useful modality is hydro-jet dissection, utilizing a
thin, high-pressure stream of water for fine tissue dissection
while preserving vascular integrity; this technology can be
applied robotically with a pressure-adjustable device such
as the ERBEJET2 hydrodissector (ERBE Inc., Tuebingen,
Germany).62,63 Finally, CO2 laser dissection, which is currently
growing in popularity as it can provide effective ligation and
coagulation with less collateral thermal damage,64 has been
integrated into a flexible fiber-optic delivery system manipu-
lated with a robotic handpiece attached to a robotic arm
(FlexGuide ULTRA and BeamPath Robotic Fiber, OmniGuide,
Cambridge, MA). The fiber-optic CO2 laser might even sub-
stitute monopolar or bipolar cautery for microsurgical dissec-
tion, where maintaining the integrity of the surrounding
13. Bhayani MK, Holsinger FC, Lai SY. A shifting paradigm for patients
with head and neck cancer: transoral robotic surgery (TORS).
Oncology (Williston Park). 2010;24:1010–1015.
14. Genden EM, Kotz T, Tong CCL, et al. Transoral robotic resection
and reconstruction for head and neck cancer. Laryngoscope.
2011;121:1668–1674.
16. De Almeida JR, Park RCW, Genden EM. Reconstruction of transoral
robotic surgery defects: principles and techniques. J Reconstr
Microsurg. 2012;28:465–472.
19. Selber JC. Transoral robotic reconstruction of oropharyngeal defects:
a case series. Plast Reconstr Surg. 2010;126:1978–1987. This is the first
published clinical series of the use of trans-oral robotic surgery to
reconstruct large oropharyngeal defects created without a mandibulotomy.
It demonstrates that TORSS allows access and precision within the
oropharynx. It is also safe, and may expand minimally invasive resections
where reconstruction is not possible through traditional approaches.
23. Katz RD, Taylor JA, Rosson GD, et al. Robotics in plastic and
reconstructive surgery: use of a telemanipulator slave robot to
perform microvascular anastomoses. J Reconstr Microsurg.
2006;22:53–57.
28. Facca S, Hendriks S, Mantovani G, et al. Robot-assisted surgery of
the shoulder girdle and brachial plexus. Semin Plast Surg.
2014;28:39–44. This report describes the application of robotics in surgery
of the shoulder girdle and brachial plexus. Although the entire potential of
robotically assisted brachial plexus surgery was not attained (as an open
incision was still required), this paper demonstrates the ability to perform
successful robotic microneural repair, and stresses the importance of
developing finer instruments for further expansion of robotic
microsurgery.
38. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi
muscle harvest: a case series. Plast Reconstr Surg. 2012;129:1305–
1312. This is the first published clinical series of robotic harvest of the
latissimus dorsi muscle, as both a free and pedicled flap, for various
reconstructive purposes. It demonstrates that this novel technique is an
effective method of muscle harvest as it offers technical advantages over
endoscopic harvest and aesthetic advantages over the open technique.
43. Ibrahim A, Sarhane K, Pederson J, Selber J. Robotic harvest of the
rectus abdominis muscle: principles and clinical applications. Semin
Plast Surg. 2014;28:26–31. This paper describes the indications, key
advantages, and operative procedure of the robotic rectus abdominis
muscle flap harvest technique. It demonstrates its effective and safe use for
various reconstructive needs with a significant decrease in surgical-site
morbidity. It also shows how the robotic platform has increased the
versatility of this already highly useful and commonly performed flap.
51. Alrasheed T, Liu J, Hanasono MM, et al. Robotic microsurgery:
validating an assessment tool and plotting the learning curve. Plast
Reconstr Surg. 2014;134:794–803. This study demonstrates the usefulness
of the Structured Assessment of Robotic Microsurgery Skills (a valid
instrument for measuring microsurgical skill) in robotic microsurgical
education. This new evaluation system is the first on the road to
customized education, curricular design with individual assessment,
targeted feedback, and competency-based learning. Its ultimate aim is
disseminating robotic microsurgery teaching.
60. Brahmbhatt JV, Gudeloglu A, Liverneaux P, Parekattil SJ. Robotic
microsurgery optimization. Arch Plast Surg. 2014;41:225–230.
Access the complete reference list online at

656.e1
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2014;28:39–44. This report describes the application of robotics in surgery
of the shoulder girdle and brachial plexus. Although the entire potential of
robotically assisted brachial plexus surgery was not attained (as an open
incision was still required), this paper demonstrates the ability to perform
successful robotic microneural repair, and stresses the importance of
developing finer instruments for further expansion of robotic
microsurgery.
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Main. 2013;32:206–209.
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latissimus dorsi muscle, as both a free and pedicled flap, for various
reconstructive purposes. It demonstrates that this novel technique is an
effective method of muscle harvest as it offers technical advantages over
endoscopic harvest and aesthetic advantages over the open technique.
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rectus abdominis muscle: principles and clinical applications. Semin
Plast Surg. 2014;28:26–31. This paper describes the indications, key
advantages, and operative procedure of the robotic rectus abdominis
muscle flap harvest technique. It demonstrates its effective and safe use for
various reconstructive needs with a significant decrease in surgical-site
morbidity. It also shows how the robotic platform has increased the
versatility of this already highly useful and commonly performed flap.
44. Ibrahim AE, Clemens M, Sarhane KA, et al. Robotic surgery in breast
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of the Structured Assessment of Robotic Microsurgery Skills (a valid
instrument for measuring microsurgical skill) in robotic microsurgical
education. This new evaluation system is the first on the road to
customized education, curricular design with individual assessment,
targeted feedback, and competency-based learning. Its ultimate aim is
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35 
Telemedicine and simulation in
plastic surgery
Joseph M. Rosen and M. Lucy Sudekum
SYNOPSIS
■ This chapter describes the latest innovations in simulation and
telemedicine and their integration into plastic surgery practice.
■ Simulation will have its greatest impact on the teaching and
performance of plastic surgery. Simulation is used to train plastic
surgery students, residents and fellows in all procedures, and to train
senior surgeons on new procedures. Simulation provides an increase
in safety and reduction in medical errors, since trainees will effectively
“make mistakes” on a simulator, rather than on live patients.
■ Telemedicine will have its greatest impact on plastic surgery delivery.
Telemedicine can make use of simulation and new technology to
deliver medical care to a distant population, whether during everyday
life, in wartime, or following a disaster.
■ This chapter will provide plastic surgeons with a basic understanding
of how to apply current technologies to enhance their armamentarium
with solutions to clinical and surgical problems.
Introduction
Medical technology can help doctors to diagnose, heal, and
transcend traditional limitations of the human body, via tools
like pacemakers, ventilators, artificial hips, three-dimensional
(3D) body imaging, and even robotic arms. Plastic surgery, a
specialty that prides itself on approaching complex problems
with innovative solutions, has an opportunity to lead the
medical community in the responsible and creative use of
new technology.
Surgeons can enhance their practice with biological tech-
nologies, such as transplantation and tissue engineering,
covered in Chapters 12, 16, 30, 32, 33, or with nonbiological
technologies. This chapter discusses the latest innovations in
nonbiological technologies – simulation and telemedicine –
and their widespread integration into plastic surgery practice.
Simulation is used to train plastic surgery residents in common
procedures, and to train senior surgeons on new procedures.
Simulation promotes safety, as trainees will make initial errors
on a simulator before operating on live patients. Finally, access
to mobile sophisticated technology via smartphones has
placed telemedicine in the hands of a larger population than
has been previously imagined.1 This aspect of telemedicine
delivers medical care to a distant population, whether during
everyday life, in wartime, or following a disaster.
This chapter will provide plastic surgeons with a basic
understanding of how to apply current technologies to enhance
their armamentarium with solutions to clinical and surgical
problems. Technological tools can resolve needs that are not
met with current standards of care (for example, a potentially
concussed football player can consult with a neurologist via
telemedicine without leaving the playing field).2 However, it is
critical that both outcomes and costs be considered whenever
we evaluate new technology; the outcomes should be demon-
strable, and the cost–benefit ratio considerable.
Simulation
Access the Historical Perspective section and Fig. 35.1
online at

Introduction and definition of simulation
Simulation is increasingly utilized in surgery as the field
reacts to continued pressure to standardize training. The main
push for standardization comes from the desire to improve
patient safety. Simulation can be defined as “the imitative
representation of the functioning of one system or process by
means of the functioning of another.”9 This includes the use
of a model, whether physical or logical, over time, to gain
insight into the way the system or process operates in order
to evaluate and analyze it.7 This chapter’s focus is on com-
puter-based simulators that engage the learner and test cogni-
tive knowledge. Animation is a new feature that accompanies
some computer-based simulators. Trainees first watch ani-
mated computer films, to view the specific procedure and

657.e1
Simulation
Historical perspective
Simulation has been used for centuries in various arenas. One
early example includes military simulation in the sixth century
in the form of the chess game.3 Widespread use of simulation
across the aviation field draws the highest correlation with the
field of medicine. Link created the first flight simulator in 1929
with the goal to develop a safer, less expensive, easier method
to learn to fly.4 The US military served as the early investor of
Link trainers in World War II, and later spurred the propaga-
tion of more complex simulators for flight training upon the
advent of computer imaging.4 Later the National Aeronautics
and Space Administration (NASA) invented modern virtual
reality. These tools became ingrained in training regimens for
both pilots and other members of the flight crew, and also
Fig. 35.1  Early surgical planning using modeling
clay for nose flap. (Courtesy of Joseph Rosen, MD.)
served as a method for personnel evaluation. Contemporarily,
flight simulators have proven to be not merely safe, but cost-
effective, with cost ratio estimates of 1 : 40 for training with a
simulator versus training in an aircraft.5
The earliest record of surgical simulators from 600 BC in
India includes clay and leaf models for forehead-flap nasal
reconstructions (Fig. 35.1).6 Other early examples of simula-
tion in plastic surgery include Le Fort’s use of cadavers to
study facial fractures, and Rad Tanzer’s use of plaster ears
prior to completing reconstructive surgery on patients.7 Today
medical device companies and technology are merging to
create new horizons for simulating surgery and its modeling
– for example, plastic surgeons can 3D-print patient models
for precise surgical planning.8

658
CHAPTER 35 • Telemedicine and simulation in plastic surgery
surgery training; the AEIs aid this process with skills simula-
tors such as box trainers for suturing.14
As minimally invasive robotic surgery gains traction, simu-
lators are likewise utilized to train on specific operating tools,
such as the da Vinci system. The Mimic Technologies
dV-Trainer, a simulator for the da Vinci system, is a tabletop
virtual environment with a two-handed haptic device with
force feedback and tracking (Fig. 35.2). A study by Kenney
et al. revealed that the dV-Trainer had content, construct, and
face validity, which is a positive assessment of the simulator’s
realism by the novice user.15 Intuitive Surgical also offers the
da Vinci Skills Simulator, introduced in 2011. Designed to
offer an immersive virtual experience via the surgeon console,
the da Vinci simulator enables users to measure and track
skills assessment without the need for additional system
components, instruments, or skills models. The use of
become familiar with the relevant anatomy, before they prac-
tice the procedure on the computer-based simulator. This is
analogous to the “see one, do one” approach for traditional
surgical training.
Simulation can be implemented in three phases, based on
the American College of Surgeons (ACS) plan for general
surgery trainees: (1) it can be used to learn skills; (2) to practice
and understand procedures; and (3) to practice team training
in the operating room.7 Simulators, physical devices which
manifest simulation in the medical area, can take various
forms, including bench models, animal models, cadavers,
mannequins and computer and online simulators.7 Special-
ized surgical skill workshops have reduced the rate of com-
plications in endoscopic carpal tunnel procedures.10 Thus,
when applied to medical procedures, ethically and practically,
simulation provides an effective tool for both education and
planning in a variety of surgical specialties. In plastic surgery,
simulation has applications in residency training, maintenance
of certification, and patient-specific planning of procedures.
Simulation provides a safe and consistent way for plastic
surgeons to improve and verify technical skills, cognitive
knowledge, and teamwork.
Rationale for using simulation for plastic
surgery and evidence of its utility in surgical
training paradigms
Both the Accreditation Council for Graduate Medical Educa-
tion and American Board of Medical Specialties sanction the
common six core competencies for all surgeons: (1) medical
knowledge; (2) patient care; (3) interpersonal and communi-
cation skills; (4) professionalism; (5) practice-based learning
and improvement; and (6) systems-based practice.11 Despite
these aims, the Institute of Medicine reported that roughly
210 000–400 000 deaths in the US occur each year as a result of
medical errors – significant enough to deem it a public health
risk.12 These staggering statistics have prompted greater
concern for patient safety across the field. Furthermore, the
rising cost of healthcare has put pressure on medical centers
to alleviate costs. While operating room time has real costs up
to thousands of dollars per hour,13 simulation provides a safe
way for surgeons to practice procedures at a significantly
reduced cost.7
Using virtual reality and simulation, residents and attend-
ing surgeons can practice skills and procedures without risk
to the patient; it is a supplement to the “see one, do one, teach
one” paradigm. If a trainee can practice certain skills and
procedures on a simulator, operating room times can be
reduced, and potentially fewer mistakes made by trainees,
thereby increasing patient safety.
The role of simulation in plastic surgery
Training simulators
Simulation for training is growing in pervasiveness in plastic
surgery, with early use in residency programs. While the ACS
has pioneered the foundational structure for using simulators
for training through its Accredited Educational Institutes
(AEIs) consortium, the plastic surgery community has pri-
marily focused on developing procedural simulators specific
to the field. Technical skills are usually taught in general
Fig. 35.2  The Mimic dV-Trainer simulator for robotic surgery is designed to train
surgeons in how to use the da Vinci surgical system and to teach system
awareness, instrument manipulation, and basic skills such as needle handling and
energy management. (A) The Ring Walk exercise assists in refining dexterity,
moving an object with a linear constraint, using the camera to navigate around the
surgical field, and learning how to use the clutch with the instruments. (B) The
Energy Dissection exercise instructs the user in applying the use of cautery and
coagulation as part of dissection, as well as controlling blood loss. (Courtesy of
Jeff Berkley, PhD, and Gordon Nealy; copyright 2012 Mimic Technologies, Inc.)
A
B

659
Simulation
advancement/distraction simulator. These new simulators
include features such as videos of live surgeries, to help
illustrate the procedure being simulated; audio voiceover, to
facilitate learning as the trainee practices; and 3D visualiza-
tion (Fig. 35.4). Simulators for other specialized procedures
include a simulator for latissimus dorsi myocutaneous flap
with tissue expander for breast reconstruction following
mastectomy (Fig. 35.5).
For example, the University of Wisconsin has developed an
Endoscopic Carpal Tunnel Release (ECTR) simulator that is
being used by resident subjects (Fig. 35.6). The subjects
are asked to take a pre-preparation test followed by random-
ization into simulation and non-simulation groups for
simulators for robotic surgery training is explained in more
detail in Chapter 34.
The American Council of Academic Plastic Surgeons
(ACAPS) Ad Hoc Committee on Virtual Reality and Simula-
tion for Plastic Surgery Education is committed to helping
develop and distribute simulators to educate residents on
plastic surgery procedures. The Committee is divided into
groups of experts in four plastic surgery subspecialties: (1)
craniofacial; (2) cosmetic; (3) reconstructive; and (4) hand
procedures. A survey completed by 85 ACAPS members in
February 2009 indicated that 93% were interested in using a
3D surgical simulator system for training residents in plastic
surgery. Today this is a reality.
The Committee’s goals are to adapt this advanced virtual
surgery simulation technology for standardized teaching,
and for procedures in the four aforementioned areas of exper-
tise. Using a process called cognitive task analysis, procedures
such as open carpal tunnel release and reduction mammo-
plasty are broken into steps, which are weighted according
to their relevance to the outcome of the procedure. For
instance, in the latissimus dorsi procedure, flap positioning
and chest closure are weighted at 20%, while dressing is 5%.
In this way, key teaching points are emphasized in the devel-
oped simulator.
BioDigital Inc. and the NYU Institute of Reconstructive
Plastic Surgery have undertaken the development of anima-
tors and simulators to educate residents in plastic surgery
procedures. Using a multidisciplinary team of plastic surgeons
as medical experts, artists to provide realism, and computer
scientists for technical development, the team has created a
library of training programs to teach craniofacial and breast
procedures. Table 35.1 summarizes the procedures for which
animations have already been completed.
The SmileTrain and BioDigital cleft lip and palate simula-
tor, developed under the leadership of Dr. Roberto Flores,
MD, is an online platform allowing the user to explore the
procedures in depth online (Fig. 35.3). Its CT-based patient
model enables the trainee to practice, record, and review
surgery in real time; to explore the anatomy at every tissue
layer; and to cut surfaces, create flaps, and transpose tissue.16,17
Simulators in the Interactive Craniofacial Surgical Atlas, created
under the direction of Joseph McCarthy, MD, include the
frontal orbital advancement simulator, the Monoblock
advancement/distraction simulator, and the Le Fort III
Table 35.1  Completed surgical animations for various surgical
procedures
Problem
Animated procedure
Bilateral cleft lip
Cutting bilateral procedure
Secondary cleft lip nose
Dibbell procedure
Unilateral cleft lip
Mohler procedure
Cleft palate
Furlow (primary palate)
Genioplasty
Sliding genioplasty
Jumping genioplasty
Prognathia
Bilateral sagittal split osteotomy
Vertical ramus osteotomy
Temporomandibular
joint ankylosis
Transport distraction
Maxillary hypoplasia
Le Fort I
Midface deformities
Le Fort III classic and distraction
Upper two-thirds
hypoplasia
Monobloc distraction
Monobloc classic
Craniosynostosis
Fronto-orbital advancement
Breast reconstruction
Pedicle TRAM reconstruction
DIEP flap reconstruction
Latissimus dorsi flap reconstruction
Free TRAM reconstruction
Tissue expander
DIEP, deep inferior epigastric perforator; TRAM, transverse rectus abdominis
myocutaneous.
Fig. 35.3  BioDigital Inc./SmileTrain cleft lip and palate simulator showing a simulated patient’s appearance (A) before and (B) during surgery. (Courtesy of SmileTrain and
BioDigital Inc. Available online at: )
A
B

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CHAPTER 35 • Telemedicine and simulation in plastic surgery
comparison. The simulation group uses the simulator, which
focuses on surgical indications, relevant anatomy, and proce-
dural steps, followed by a physical model simulation and a
post-preparation test. The non-simulation group prepares for
the case as they would for any other surgical operation. All
subjects undergo a real-time ECTR case with the senior author
and are assessed on a 20-point objective scoring measure:
operating set-up, anesthesia, tourniquet, procedure steps,
dressing application, etc. The subjects had different surgical
backgrounds but overall it was found that the simulator
group outperformed the non-simulatior group on post-
preparation test scores (89% vs 74%; p<0.001) and operative
scores (96% vs 79%; p=0.002). The subjects showed significant
improvement in all steps of the operation except for dressing
application. This study and those like it show the promise and
future of surgical training and its benefits (B. Mandel, personal
communication).
Arguably the most advanced simulation system available
to surgical trainees is the Wide Area Virtual Environment
(WAVE) that was developed by Alan Liu at the Val G.
Hemming Medical Simulation Center of the Uniformed Ser-
vices University of the Health Sciences (A. Liu, personal
communication). The WAVE is a 1000 sq ft immersive virtual-
reality training environment that combines 3D virtual envi-
ronments with patient actors, human patient simulators, and
the theatrical effects to provide comprehensive and unprece-
dented levels of realism (Fig. 35.7). As seen in Fig. 35.7A,
projectors are placed around the training operating theater
and triage area allowing for constantly changing scenarios.
Fig. 35.4  MyFace craniofacial virtual surgery simulator (A) bilateral sagittal split
osteotomy procedure and (B) LeFort I procedure. (Courtesy of MyFace, Joseph G.
McCarthy, MD, and BioDigital Inc. Available online at:
.com/#/.)
A
B
Fig. 35.5  BioDigital Inc. latissimus dorsi simulator. (Courtesy of BioDigital Inc.)
A
B
The WAVE is designed to support training scenarios of up to
96 hours in duration.18
Investigators at Dartmouth’s Thayer School of Engineering
have conducted team-training research to enhance communi-
cation and ensure safe patient handoffs between operating
room personnel and hospital staff. The envisioned system – a
computational team-training simulation – will seamlessly
monitor medical operations to reduce or prevent catastrophic
medical errors and to improve patient safety (E. Santos, per-
sonal communication). The Santos team models reasoning
among doctors, nurses, and patients,19 and simulates the
team’s clinical decision-making and reasoning prior to, during,
and after surgical procedures, to analyze inconsistencies or
gaps in the procedure – a key indicator of medical errors – with
the goal of alerting the team when any discrepancy occurs.
Surgical planning simulators
Plastic surgeons can use simulation not only to practice new
procedures on a virtual patient, but also for patient-specific
surgical planning. Prior to the first US near-total face trans-
plant procedure, performed by a surgical team led by Dr.
Maria Siemionow at Cleveland Clinic in 2008, the surgeons
used anatomical models made from the patient’s CT scans,

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Simulation
Fig. 35.6  Endoscopic Carpal Tunnel Release (ECTR) simulator. (A) Simulator set-up. (B) Detailed simulator set-up. (C) Simulator in use. (D) Comparative OR set-up.
(E) Simulator in use with simulator screen and OR comparison. (Courtesy of Benjamin Mandel, MD; Steve Kempton, MD; Jacqueline Israel, MD; A. Neil Salyapongse, MD.)
A
B
C
D
E
Fig. 35.7  The Wide Area Virtual Environment (WAVE). (A) WAVE overview. (B) A
virtual emergency room training scenario. (C) Combining 3D displays with human
patient simulators and props to simulate a combat rescue environment. (Courtesy of
Virtual Medical Environments Laboratory, Val G. Hemming Simulation Center,
USUHS.)
A
B
C

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CHAPTER 35 • Telemedicine and simulation in plastic surgery
Fig. 35.8  The stereolithic anatomical model based on the computed tomographic scan of the patient who had the first US facial transplant, performed by a team of
surgeons led by Dr. Maria Siemionow at the Cleveland Clinic in 2008. (A) Frontal view of the craniofacial defect after gunshot injury to the patient’s face, indicating damage
of the frontal and midface skeleton including the infraorbital floor and the nasal, zygomatic, and maxillary bones mixed with the metal pieces. (B) The left side of the defect,
with a significant tridimensional defect showing missing nose and nasal bones and upper jaw bony support. (C) Frontal view at 6 months after transplantation,
demonstrating complete restoration of the craniofacial defect by replacement of all missing bony components of the facial skeleton and soft tissues of the patient with the
composite facial allograft from the donor. (D) Left-side view after transplantation confirming restoration of the tridimensional defect of the craniofacial skeleton, including
nose and bony structures supporting the upper and midface skeleton. (Reproduced with permission from Siemionow MZ, Papay F, Djohan R, et al. First U.S. near-total
human face transplantation: a paradigm shift for massive complex injuries. Plast Reconstr Surg. 2010;125:111–122.)
A
B
C
D
showing the facial defect, as part of their surgical planning
(Fig. 35.8)20 (M. Siemionow, personal communication).
Prior to the second US facial transplant, performed by
microsurgeons at Brigham and Women’s Hospital in 2009
under the leadership of Dr. Bohdan Pomahac, the team also
used CT scans of the recipient’s head and facial defect to
generate a life-sized 3D model of the cranium, built in acrylic.
The team then generated a second 3D facial model, based
on a CT scan of normal facial anatomy, from which parts
were removed and transferred to the recipient’s model. This
allowed the surgeons to plan how much bone was needed
from the donor, as well as to anticipate the anatomical logistics
of the donor recovery procedure (B. Pomahac, personal
communication).
Future applications of simulation
A future vision must include simulation trainers in plastic
surgery plans universally, and also provide training for new
procedures as part of continuing education, in a safe, efficient,
and effective manner. As simulation centers are developed
in increasing numbers, and medical center and surgery cur-
ricula continue to incorporate simulation as a beneficial tool
for training, simulation will become more ingrained in the
field of plastic surgery for resident training, maintenance of
certification, and patient-specific practice. As simulators
become more advanced, they will be used at various levels in
practice, and may even incorporate a physical–behavioral–
genomics model of a human being, one that combines infor-
mation about a person’s cells, tissues, organs, vital signs,
biomechanics, physiology, behavior and genetic traits, com-
bined with the epidemiology of a larger population. Such a
comprehensive model might simulate and predict the indi-
vidual’s behavior and health (Fig. 35.9).
Telemedicine
Access the Historical Perspective section online at

Introduction
In the future, telemedicine will extend robotics and simulation
to make plastic surgery safer, simpler, more successful, and
more accessible. The patient–provider relationship and deliv-
ery of care will be transformed by telemedicine, as doctors
will not need to be physically present in order to care for their
patients. This section of the chapter defines telemedicine as a
clinical tool, explains the role of social networks in telemedi-
cine, presents potential challenges in its utilization for plastic
surgery, and explains current and future applications in plastic
surgery.
Definition and methods
Telemedicine refers to the application of telecommunications
technologies to a medical context. Telemedicine may be
defined as “a branch of e-health that uses communication
networks for delivery of healthcare services and medical
education from one geographical location to another”.31
Telemedicine may be as simple as faxing a copy of an X-ray,
or as complicated as multipoint video conferencing across
several continents with high-resolution image transfer. A
resident can ask an attending physician for advice; one phy-
sician can ask another physician for advice; or a patient can
ask advice of a doctor. Many components of current plastic
surgery consultation can be converted to a digital format,
including long-distance triage, remote consultation, telesur-
gery,32,33 postoperative assessments, patient education, con-
tinuing medical education for providers, and public health
education.
Worldwide, the need for telemedicine has only increased
as the gap in access to technology broadens between those
living in rural and urban areas. People living in rural areas
have less access to medical care generally, and in many cases,
to specialty care, with the exception of medical volunteerism
groups such as ReSurge International (formerly Interplast).34
ReSurge International is one of a number of groups that
provide temporary specialty care to remote areas on inter-
national surgical humanitarian trips, and supplement this
with visiting educators who provide direct, hands-on training
for local medical personnel. The interaction with local

662.e1
Telemedicine
Historical perspective
NASA helped pioneer telemedicine in the 1960s: when
humans began flying in space, physiologic parameters were
communicated between both the spacecraft and the space
suits during missions.21 Fifteen telemedicine projects were
active by 1975, with pioneering efforts in the US and world-
wide. The earliest-reported nongovernment applications of
telemedicine included a teleradiology effort at the Montreal
Neurological Institute and a telepsychiatry network at the
Nebraska Psychiatric Institute.21 Early projects using tele-
medicine in rural healthcare proved to have great beneficial
effects on survival and recovery of patients; as the cost and
size of the equipment came down and the technical quality
went up, telemedicine became feasible to use in different
applications, including maritime medicine and care in remote
locations, including Antarctica.22–26
Telemedicine has followed the enormous growth of com-
puting and the internet from 1980 to the present day. Whereas
in 1980 almost no one had a home computer or cell phone,
and the internet was in its infancy, now most people in devel-
oped countries have home computers, internet access, and
mobile phones, making it possible for people to work remotely
and telecommute; do online banking, travel reservations, and
web shopping; and use email and social networks. A similar
transformation occurred in medicine: it is now possible to link
from home or a small clinic or medical center using video
conferencing and other telemedicine technologies to access
specialists worldwide for consultation and even surgery.27–29
Telemedicine is increasingly benefiting from the technology
that allows us to collect and transmit medical information
using portable devices such as ultrasound monitors and cell
phones. For example, Remote Interaction, Consultation, and
Epidemiology (R.I.C.E.) uses SMS technology to track influ-
enza and diarrheal diseases in rural Vietnam.30 Networked
medical care has a great potential to improve both daily
patient care and also to allow clinicians to respond to various
medical disasters anywhere in the world at any time.

663
Telemedicine
Fig. 35.9  Physical–behavioral–genomics model. No model yet
exists that encompasses the physical body, behavior, and
biomarkers of an individual, but Dr. Joseph Rosen and colleagues
are developing such a model. A full human model could include
a person’s cells, tissues, organs, vital signs, biomechanics,
physiology, behavior and genetic traits, combined with the
epidemiology of a larger population. Such a comprehensive
model might simulate and predict the individual’s behavior and
health. (Courtesy of Joseph Rosen, MD.)
Population
Body
Cell
Physical
Behavioral
Biomarker
providers is such that surgeons in host countries can post
cases on a secure website to receive advice when ReSurge
International teams are not in-country. Specialist physicians,
such as plastic surgeons, are often a small percentage of the
overall physician workforce and tend to be concentrated in
urban centers. Through this networked-care mechanism, we
are moving toward more efficient use of specialists as their
time and expertise are available anywhere, anytime.34
Several technologies are commonly used in telemedicine
applications. The first, called store-and-forward, is used to
transfer digital images from one location to another. An image
is taken with a digital camera (store) and then sent (forward)
to another location for interpretation and analysis (Fig. 35.10).
This method is used for nonemergent situations, when a
consultation can be provided in the next day or few days, and
a patient’s wellbeing is not dependent on an immediate
response from a physician.
Another technology often used in telemedicine applica-
tions is called the synchronous model. This technology is
used when a face-to-face interaction is desired, and is used
between a patient/provider in one location and a specialist
in another location. It provides real-time relay of information
and can allow for review of information by on- and off-site
personnel (Fig. 35.11).35 In most cases, the patient/provider
pair is located in a rural environment and the specialist is
located in an urban center. These types of patient consults
are becoming commonplace in medical practice. Dartmouth-
Hitchcock Medical Center’s Division of Plastic Surgery is
developing a follow-up telemedicine program. Programs
like this one are only being used when a physician–patient
relationship has already been established. (See below for
telemedicine regulations and legal constraints.) Once the
relationship has been established, the patient can be screened
and enrolled in these programs to avoid follow-up appoint-
ments at the hospital. These telemedicine visits can take the
place of face-to-face clinical visits. This is both cost- and
time-efficient for the patients (Figs. 35.12 & 35.13). Video
conferencing equipment at both locations enables a live, real-
time consultation for the patient without having to travel
(Table 35.2).
Social networking
The future delivery of healthcare will not be limited to face-
to-face interactions. Online social networks, such as Patients-
LikeMe.com and CarePlace.com, already link patients with
similar conditions. Clayton Christensen, in The Innovator’s
Prescription, discusses facilitated networks as an important
part of a future healthcare system.36 The websites previously
mentioned already exist for patients as facilitated networks.
In the plastic surgery realm, is a
website where patients can find resources on weight loss
surgery, including a body mass index calculator, research,
forums, insurance assistance, pictures, providers, and stories.37
Facilitated networks can exist specifically for plastic surgeons,
creating a space where they share best practices and support
specific lines of work.
Table 35.2  Two telemedicine technologies and comparison
Type
Store-and-forward
Two-way interactive
Situations used
Nonemergent
Synchronous, often
urgent or in
postoperative
follow-up
Present uses
Teleradiology,
ultrasonography,
telepathology,
teleanesthesia,
teledermatology
Real-time
videoconferencing for
patient consultations
using otoscopes,
stethoscopes, or
presence of visiting
nurses
Advantages
Requires less
bandwidth
Real-time
Disadvantages
Takes longer
More expensive,
requires more
bandwidth

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CHAPTER 35 • Telemedicine and simulation in plastic surgery
Fig. 35.10  Wound clinic telehealth “store-and-forward model” timeline. The secretary who schedules the visit communicates with a registered nurse (RN) from the visiting
nurse association (VNA) to help plan and conduct the visit. The nurse then confers with a wound specialist to examine and treat the wound, and communicates back to the
secretary to close the loop.
Pre visit
Day of visit 1
tsilaic
e
p
s
d
n
u
o
W
N
R
A
N
V
yraterc
e
S
Schedule telehealth visit
Prepare for telehealth visit
Arrive at patient home
Set up telehealth equipment
Review medication and progress
Remove wound dressing
Take photo and collect clinical data
Send photo and clinical data
Perform wound care
Clean up and depart
Receive wound care instructions
for the next visit
Schedule next visits
Examine wound
Discuss wound care and plan
Change follow-up plan?
Send instruction and advice to VNA
Determine follow-up schedule
Complete visit documentation
Plastic surgery and telemedicine
Plastic surgeons have used telemedicine predominantly in
communicating about individual cases in the international
medical arena. Telemedicine can be used in the preoperative,
operative, and postoperative phases of a plastic surgical opera-
tion. Through organizations such as ReSurge International,
plastic surgeons anywhere in the world receive daily updates
about cases in developing nations where consultations are
requested.34 These surgeons can choose to log on to the online
system to provide their expertise on the case. They can view
patient diagnostics and past medical history, and write a case
report. This is a prime example of medical care at a distance.
The other major area in which telemedicine impacts
plastic surgery is in telesurgery. Using telesurgery, surgeons
can operate on patients who are geographically remote: for
example, a patient who cannot physically or financially
afford to travel to the doctor.32 In the future, surgeons might
remotely operate on an injured soldier on a battlefield,33 or
a victim of an earthquake, hurricane, pandemic, or other
disaster (Figs. 35.14 & 35.15). One major advantage of
telesurgery is that patients can remain in their own environ-
ment, where they can receive care and support from com-
munity or family members.
A brief description of the specific “tele” terms relating to
telesurgery may help the reader. The term teleoperation
means doing work at a distance. Telesurgery refers to doing
surgery across a distance. For example, a surgeon, in one
location, can control a surgical robot at a remote location
(known as telerobotics). Telerobotics is depicted in Fig. 35.14
with a schematically drawn robotic surgeon; though in prac-
tice, a telerobotics system might look more like the da Vinci
system (Fig. 35.16), with the surgeon using a control console
and viewing system at his or her site, directing the actual
operating robot at a remote site, which must also have a
camera to send back images to the surgeon of the robot’s-eye
view. Telepresence refers to being somewhere one is not
physically present: the best current example is videoconfer-
encing, which makes one “present” via two senses: sight and
sound. In the surgical example, telepresence could mean an
expert surgeon projecting his or her image into a remote
operating room, via two-way videoconferencing, to be a
mentor assisting the other surgeons in real time. The OR
surgeon(s) would see the remote mentor “appearing” on a

665
Telemedicine
Fig. 35.11  Wound clinic telehealth “synchronous model with video conferencing” timeline. This scenario is similar to Fig. 35.10 where the secretary communicates with
the registered nurse (RN) at the visiting nurse association (VNA), who in this case conducts a telemedicine video consultation (TVC) to communicate with the wound
specialist.
Pre visit
Day of visit 1
tsilaic
e
p
s
d
n
u
o
W
N
R
A
N
V
yraterc
e
S
Schedule telehealth visit
Prepare for telehealth visit
Arrive at patient home
Set up telehealth equipment
Review medication and progress
Remove wound dressing
Perform wound care
Review wound care instructions
Clean up and depart
Schedule next visits
Examine wound
Start TVC
Start TVC
End TVC
No
Yes
Discuss wound care and plan
Change follow-up plan?
Determine follow-up schedule
Complete visit documentation
Fig. 35.12  Telemedicine postoperative consult. (Courtesy of Dartmouth-Hitchcock/
Mark Washburn.)
Fig. 35.13  Telemedicine postoperative at-home consult. (Courtesy of Dartmouth-
Hitchcock/Bonnie Barber.)
monitor in the OR, and the mentor would likewise see an
image of the OR and surgical field. Virtual telepresence could
also be employed, in which a computer-generated surgical
mentor (perhaps from an animation or a simulator) would
project into the actual OR to help instruct the surgeons (see
Fig. 36.14).
Telemedicine for the plastic surgeon
Each state is adopting or creating its own regulations to monitor
and establish telemedicine practice. Physicians using telemedi-
cine must be licensed in the state of their established practice
and the state where the patient is located, if different.

666
CHAPTER 35 • Telemedicine and simulation in plastic surgery
Nationally, the American Medical Association’s Code of
Medical Ethics has been challenged to include telemedi-
cine because of a key issue: does telemedicine allow for a
patient–physician relationship? The current law in New
Hampshire allows physicians to establish a patient-physician
relationship and prescribe medications via telemedicine.
Prescribing drugs without such a relationship is not allowed,
except under certain conditions, including newly hospitalized
patients. Most controlled substances may not be prescribed
by telemedicine.38
Ubiquitous mobile telemedicine
There are significant barriers to overcome before telemedicine
can be incorporated ubiquitously. We must demonstrate its
cost-effectiveness; resolve insurance reimbursement issues;
resolve legal issues regarding licensing of physicians working
across state and international lines; and provide sufficient
internet connectivity and bandwidth. Telemedicine technol-
ogy will be important in the ongoing healthcare debate, as it
promises to provide a potentially higher quality of care at a
decreased cost.
Telemedicine has the potential to transform the role of the
plastic surgeon as a provider, by making access to care both
cheaper and faster as part of a networked healthcare system.
Providers will not have to receive teleimages over email or be
physically present in a room with expensive video conference
Fig. 35.14  Telesurgery and telepresence are two ways in which
a remote surgeon can assist in, and/or direct procedures in, an
operating room (OR) anywhere else in the world. In telesurgery,
the remote surgeon controls a robot that actually conducts the
surgery. In telepresence, the remote surgeon serves as a mentor
to instruct the surgeons in the actual OR, using two-way
videoconferencing (alternately, a computer-generated, animated
or simulated surgical mentor is projected into the actual OR). In
both telepresence and telesurgery, the remote surgeons see a
view of the actual OR with images collected by camera and
transmitted in real time.
Telesurgery
(telerobotics)
Surgeon can see real OR
and remotely control robot
Surgical mentor can see real OR,
and real OR can see and hear surgical
mentor via 2-way videoconferencing
Computer-generated (animated or
simulated) mentor – remote or
local to the OR – projects into real OR
Virtual (computer-
generated) telepresence
Telepresence
Remote location
Physical operating room
Fig. 35.15  Telesurgery via satellite using haptics and robotics. Image depicting
conceptualization of how surgeons might someday conduct surgery from Earth to
space. (Courtesy of Joseph Rosen, MD.)
Virtual information windows
Remote
manipulation
Head coupled
stereo camera
Tactile input feedback
telesurgery
Virtual interface environment

667
Telemedicine
Fig. 35.16  da Vinci Si high-definition robotic surgical system, showing two surgeon consoles, patient cart, and vision cart. (Courtesy of Intuitive Surgical and © 2012
Intuitive Surgical, Inc.)
Fig. 35.17  Smartphone medical applications. (Courtesy of Joseph Rosen, MD.)
equipment, but will be connected to a network through mobile
handheld devices that allow them to acquire data and diag-
nostics about a case, formulate a patient plan, supervise
surgery, and perform consultations in real time.
Technological convergence
The reconstructive ladder for the 21st century is one in which
the plastic surgeon is able to weigh the risks and benefits
associated with fixing a deformed limb or face with many
choices: through reconstructive surgery, using microsurgical
techniques; or through replacement using either robotic
prostheses, a human tissue transplant, regenerative medicine,
or tissue engineering.
Diagnostics, therapeutics, and networking are all being
supported by robotics, simulation, and telemedicine. These
technologies depend on information technology/information
management bandwidth, speed and processor power, all of
which will become better, faster, and cheaper. Given the
wide use of smartphones and the abundance of medical
“application” development, patients, physicians and plastic
surgery trainees can explore different aspects of healthcare at
their fingertips (Fig. 35.17). The website, iMedicalApps.com
reviews medical “apps” and telemedicine technology that
are at the forefront of innovation.39,40 The developers of
iMedicalApps.com have since developed iPrescribeApps.
com, a website that can allow physicians to prescribe an app
for patient use.40,41 We will be able to make diagnostic deci-
sions from smaller and smarter devices, linked to a larger
network, and these devices’ capabilities will increasingly
converge. It is now possible to access the Plastic and Recon-
structive Surgery Journal from a desktop computer, laptop
computer, and even an iPhone or Android device. In the
future, it will be downloadable on an iPhone and viewed
remotely while participating in telemedicine over the phone
or another handheld device.

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CHAPTER 35 • Telemedicine and simulation in plastic surgery
Fig. 35.19  Evolution of healthcare from hospital-centric to user/patient-centric network. (Reprinted with permission from Rosen JM, et al. Cybercare 2.0: meeting the
challenge of the global burden of disease in 2030. Health Technol (Berl). 2016;6:36.)
Private
healthcare
Public
healthcare
National
security
Physical
transport
Community
centres
Previous system 2000
Present system 2017
Future system 2030
Hospital
Community
Home
Distributed
healthcare
Hospital
Community
Home
H
H
H
H
H
H
Super
hospital
H+
Hospital
Community
Home
Fig. 35.18  Healthcare of the future as a network centering on Cybercare
development. EMR, electronic medical record. (Courtesy of Joseph Rosen, MD.)
Cybercare
EMR
Virtual
reality
Artificial
intelligence
Social
media
Augmented
reality
Telemedicine
Simulation
Robotics
Conclusion
Over the next ten years we will see a dramatic reduction of
cost in information technology and a steady increase in com-
putational power. This will result in a significant improvement
in the ease of using these technologies in our practices. Infor-
mation technologies will take many forms, from the two that
we have just discussed, simulation and telemedicine, to many
others. We use the term “Cybercare” to encompass the many
different information technologies in medicine that will
impact plastic surgery (Fig. 35.18).
At present, each of our practices and institutions are incor-
porating electronic medical records. These initial systems
have created significant barriers to our practices with respect
to cost and time. In the future, these information systems will
incorporate both simulators and telemedicine. They will also
incorporate intelligent agents and artificial intelligence to
improve our ability to do our jobs and increase our safety.
Intelligent agents can be incorporated within these systems to
follow a lab value and make sure that we see this result and
respond to it in an appropriate manner. Artificial intelligence
can aid us in making the right decision about which antibiotic
to use, and make sure that we do not give the wrong

669
Conclusion
Fig. 35.20  The clinic visit of the future where the patient and the physician can
visualize and interpret medical records via virtual reality lenses. (Reprinted with
permission from Rosen JM, et al. Cybercare 2.0: meeting the challenge of the
global burden of disease in 2030. Health Technol (Berl). 2016;6:36.)
Bonus images for this chapter can be found online at

Fig. 35.1 Early surgical planning using modeling clay for nose flap. (Courtesy
of Joseph Rosen, MD.)
medication to a patient who may have an adverse reaction to
that drug. For example, Watson by IBM is challenging how
we diagnose and treat cancers.42
Our practices will shift from the hospital to clinics to the
home. Plastic surgery has been the leader in providing
high-quality surgical care in an outpatient setting. This trend
will continue. And instead of the patient coming to the hos-
pital, information and decision-making will shift from the
hospital to the clinic to the home (Fig. 35.19). Care will follow
a network and patients will share information on social media
and the internet. This should result in improved care at a
decreased cost. A physician can provide care anywhere within
this network through telemedicine, by phone, by teleconfer-
ence, by wearing a virtual reality interface, or by being within
a virtual reality WAVE (see Fig. 35.7).
The physician of the future may see a patient using a virtual
reality interface, like Google Glass. When additional informa-
tion is provided through this interface, we call it augmented
reality (Fig. 35.20). This will provide additional information
about the patient from the electronic medical record, outside
records and up-to-date literature. And at the same time the
patient can wear an interface to help them to better under-
stand the planned procedure. The patient interface could have
a simulation of the procedure that explains the procedure to
the patient step-by-step.
Over the next ten years, the delivery of healthcare and
plastic surgery will be transformed by information technol-
ogy. It will take many forms, and it will have a learning curve
that each provider will face, but eventually there will be an
improved system that provides better outcomes for the patient
with increased safety.
Acknowledgments
We also wish to extend thanks to the various doctors and product devel-
opers who helped review the chapter and provided comments, content,
and images.
1. Al-Hadithy N, Ghosh S. Smartphones and the plastic surgeon. J
Plast Reconstr Aesthet Surg. 2013;66:e155–e161.
7. Rosen JM, Long SA, McGrath DM, et al. Simulation in plastic
surgery training and education: the path forward. Plast Reconstr
Surg. 2009;123:729–738. This paper describes the American College of
Surgeons’ resident training program for simulation in general surgery and
how it might be applied to plastic surgery training programs.
11. Sachdeva AK, Pellegrini CA, Johnson KA. Support for simulation-
based surgical education through American College of Surgeons-
accredited education institutes. World J Surg. 2008;32:196–207.
17. BioDigital SmileTrain Cleft and Palate Viewer. Available at: smiletrain.biodigital.com/#/>.
30. Katona LB, Rosen JM, Vu NC, et al. A new paradigm for disease
surveillance in Vietnam. Telemed J E Health. 2014;20:493–495.
31. Sood S, Mbarika V, Dookhy R, et al. What is telemedicine? A
collection of 104 peer-reviewed perspectives and theoretical
underpinnings. Telemed J E Health. 2007;13:573–590.
32. Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted
telesurgery. Nature. 2001;413:379–380.
36. Christensen CM, Grossman JH, Hwang J. The Innovator’s
Prescription: A Disruptive Solution for Health Care. New York:
McGraw Hill; 2009:24.
42. Keim B. IBM’s Dr. Watson will see you … someday. IEEE Spectrum.
2015. Available at: <
diagnostics/ibms-dr-watson-will-see-yousomeday>.
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diagnostics/ibms-dr-watson-will-see-yousomeday>.

36 
Digital technology in plastic surgery
Lynn Jeffers, Hatem Abou-Sayed, and Brian Jeffers
Introduction
Advances in digital technology have impacted and will con-
tinue to impact plastic surgery. This chapter will explore the
effects of current and future technology on the patients’ and
doctors’ experiences: (1) prior to the plastic surgery consulta-
tion, (2) during the patient encounter(s), (3) in the operating
room and during the perioperative period, and (4) during
long-term follow-up. The chapter will also discuss the impact
of digital advances on education, research, medical devices,
patient monitoring, “Big Data” analytics, and registries.
Digital technology before the first
consultation
Introduction
Digital advances have expanded the base of knowledge avail-
able to patients such that even before consulting with a doctor,
patients can become well informed about procedures, the
selection of available surgeons, and the methods used to make
an appointment. A plethora of informational websites are
available to educate patients on procedures, postoperative
recovery, surgical limitations, and other information needed
to ensure the patient arrives at the consultation prepared and
knowledgeable.
Information on procedures
Using online databases and websites, patients can learn more
about the procedures they might undergo before speaking
with a physician. Informational websites and applications can
allow patients to compare and differentiate between various
procedures. By examining the descriptions and exact proce-
dures of different operations, patients can analyze the inherent
risks and dangers. Websites such as
com can aid patients in choosing a procedure, understanding
potential complications, and even finding a surgeon whose
office is geographically convenient to the patient. The avail-
ability of this information can produce a more informed
patient and a more efficient and effective consultation with
the plastic surgeon. Some applications allow the patient to
visualize simulated results through 3D animation and may
produce full 3D models through the interpolation of several
2D pictures, which can be uploaded by the patient to the
website before seeing the plastic surgeon. The patient must
visit the physician to see the 3D images. Online content on
plastic surgery websites often includes animations designed
to educate patients on the conduct of surgical procedures in
an abstract manner for those who may not be able to tolerate
video content documenting real surgery.1,2 For patients seeking
more detailed video content on planned procedures, many
surgeons create custom video content and post it to YouTube.
com or other sites, along with links from the surgeon’s website
to the videos.
Plastic surgeons can also permit prospective patients to
access certain office documentation to save time in the office
for both patients and the surgeon’s staff. These documents
may include office policies and procedures, general consents
to treatment, HIPAA privacy notifications, Patient Bill of
Rights documents, intake questionnaires, menus of services,
pricing lists, surgeon biographies, procedural brochures,
financial policy disclosures, and others. By having prospec-
tive patients fill out these forms online or print them out and
bring to the visit, the intake process at the initial consultation
becomes more streamlined and more efficient for all involved.
Consequently, the patient may arrive for a consultation having
extensively researched the plastic surgeon’s practice and the
local marketplace dynamics, prepared with preliminary forms
and materials, and armed with numerous questions and an
idea of what he or she desires.
Choosing a surgeon
Patients considering plastic surgery can search the internet for
detailed information on surgeons and their practices, their

671
Digital technology before the first consultation
granted access (Fig. 36.1). Photo galleries can represent a
meaningful component of plastic surgery marketing while
also serving an educational purpose for the public. Some
plastic surgeons who do not favor placing patient photos
online nonetheless may provide guidance to prospective
patients to contact the office for an in-person consultation,
where these photos, deployed either in bound albums or
using digital tools (tablets, large screens in viewing rooms,
waiting-room results reels in PowerPoint presentations), are
available for viewing in a controlled environment.
After selection
Once a patient has selected a plastic surgeon’s office for a
possible consultation, the online experience can be augmented
with real-time chat tools on the surgeon’s website and calen-
dar integration via sites that permit the patient to find open
appointment timeslots in the surgeon’s office schedule and
book visits online, with the appointments automatically popu-
lating the office practice management software system12 or via
the patient portal of some electronic health records (EHRs)
with this capability.13 Voice-over-Internet-Protocol (VoIP)
systems allow offices to communicate with patients even
asynchronously to open office hours, from most mobile
devices and from most locations, obviating the need for fixed
landline telephone systems. Online maps with directions
shareable to mobile devices or in-dash navigation systems in
automobiles streamline the process of finding the doctor’s
office, with dynamic updates on traffic patterns available
in apps like Waze (now a part of the Google Maps toolkit).
Patients wishing to travel for surgery and those who
have limitations on the ability to see a physician in the office
during convenient office hours may benefit from applications
credentials, price estimates for procedures, patient satisfaction
testimonials and outcomes culled from review sites, and gal-
leries of preoperative and postoperative photos.
Patients often research a plastic surgeon’s credentials and
reputation before choosing a surgeon by reviewing the prac-
tice’s website as well as a number of review sites.3–7
These sites not only provide patients with a forum to share
their perceptions of the quality of the surgical outcome, but
also the quality of customer service, the appearance of the
office, and the friendliness of the staff, etc. These sites can give
patients significant influence on the reputation of the doctor
or practice, which can be detrimental or advantageous.
However, the entirety of the surgeon’s online presence includ-
ing videos, media appearances, blogs, Facebook, etc. help to
shape the surgeon’s and practice’s brand8 and, thus, it is
important that the surgeon continually monitor his or her
presence on the web either with a third-party service or by
setting targeted Google alerts.
Patients may seek procedure pricing information to com-
parison shop among practices by soliciting online fee sched-
ules and can compare menus of services where available. This
information is occasionally available directly on a practice’s
website or can be explored on specific apps and portals.9 One
study demonstrated that patients were more likely to book
surgery at the time of the initial office visit if they knew the
price of the procedure before arriving for the consultation.10
Patients can also evaluate a surgeon’s results by evaluating
before-and-after photos that the surgeon displays online.
These galleries of before-and-after photos provide real
examples of the surgeon’s work and are often categorized by
body location and procedure. Some programs11 allow galleries
to be accessed only via a password-protected patient portal
that requires prospective patients to register before being
Fig. 36.1  Menu screen of the patient portal allowing access to educational content and before-and-after galleries in a password-protected patient portal that the patient can
review with any internet connection. (© 2015 TouchMD, an ALPHAEON Company. Used with permission. All Rights Reserved.)

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CHAPTER 36 • Digital technology in plastic surgery
both time and money. Physicians and office staff may experi-
ence challenges in implementation and training with new EHR
systems, sometimes with a considerably steep learning curve,
requiring significant allocation of staffing time before the EHR
is fully operational for the office’s needs. Thus, the choice of
EHR can be crucial. Below are some key considerations regard-
ing the EHR itself that should be taken into account when
choosing an EHR system.
Certification
Determining whether the chosen EHR is certified by the ONC
(Office of the National Coordinator of Health Information
Technology) is important, especially if the plastic surgeon is
planning on participating in certain government incentive
programs. Certification is meant to assure that the EHR system
offers the capability, functionality and security to meet the
Meaningful Use (MU) criteria established by the Centers for
Medicare and Medicaid Services (CMS).35 The Meaningful
Use program is in the third of three “stages” of implementa-
tion along an 11-year timeline (culminating in the final Med-
icaid incentive payments being slated for 2021), with penalties
to be levied against practices which see significant Medicare
or Medicaid volume and fail to demonstrate compliance with
MU. Certification provides one level of reassurance that the
EHR system allows entry of data necessary to achieve MU
compliance and is a toolkit for submission of reports to CMS
for validation and incentive processing. For plastic surgeons
not interested in participating in the Meaningful Use program,
certification may provide some level of assurance that the
program meets certain standards of functionality, security,
and interoperability, and probably is more likely to survive
consolidation than other non-certified programs.
Server on site or off site or subscription model (SAAS
– Software As A Service)
There are three principal models through which an EHR
program can be provided to users. Some EHR vendors can be
deployed all three ways. The most traditional model of soft-
ware delivery houses the program and data on a server in the
office owned by the physician/group. The physician has
complete control of the data, but is responsible for hardware
maintenance, back-ups, insurance, and security, as well as
manual updating of the software. Access from a remote loca-
tion or satellite offices is also maintained by the physician’s
practice, and may involve high-speed data access lines (T1 or
fiber-optic cable, for example), virtual private networks
(VPNs), and other remote logging programs. This model may
require higher upfront costs for hardware infrastructure and,
depending on the size of the practice, one or more IT special-
ists outsourced or employed in-house. Another model
involves using a server that is housed off-site, maintained by
a third-party vendor. The physician/group still maintains
complete control of the data but leases space in a remote
server. Updates frequently still require manual effort, but
responsibility for servers, back-ups, and insurance is assumed
by a third-party vendor.
Finally, the Software-As-A-Service (SAAS) model is a sub-
scription service in which the program and data are maintained
and updated by the EHR vendor, with the software accessed
via the computers/devices in the practice – much like the way
Gmail, Yahoo! Mail, Dropbox, and other online programs
that facilitate virtual consultation.14–21 One Harris poll com-
missioned by a prominent telemedicine vendor in 2014 indi-
cates that 64% of consumers are willing to see physicians via
video consultation.22,23 The Federation of State Medical Boards
has issued model legislation aimed at encouraging standards
in the credentialing and licensure oversight for providers of
telemedicine services in participating states.24 Some states do
not permit telemedicine consultations, and insurance reim-
bursement models and legal considerations are undergoing
significant debate. Nonetheless, the promise of mobile tech-
nologies in the field of telemedicine is substantial and in 2013,
three companies alone hosted 400 000 to 500 000 doctor−patient
interactions.25 For the plastic surgeon, there are opportunities
to potentially rule out poor candidates for surgery before they
incur the expense of traveling to the surgeon’s office, or to
permit office staff to begin the intake and preoperative workup
process for remote patients, or to provide a more personal
introduction as part of marketing outreach to bring in more
patients.
Patients who require urgent but non-emergent care (for
example, for minor burns or other minor trauma) also have
tools for finding local clinical resources via applications
similar to “sharing economy” tools like Uber. Some innova-
tive apps26–28 provide logistics for connecting patients with
available providers on demand, creating a digital platform to
reimagine the “house call” of old, or allowing patients to
bypass costly points of care like emergency rooms and arrange
services in the office.29
Digital technology during the
office visit
During the consultation encounter, digital technology can
enhance: (1) patient information gathering and archiving in
the form of electronic medical records including patient data,
medical information, photographs, and documents; (2) patient
education via digital materials; and (3) clinical information
and decision-making.
Medical records
Choosing an electronic health record (EHR)
The Health Information Technology for Economic and Clinical
Health (HITECH) Act, enacted as part of the American Recov-
ery and Reinvestment Act of 2009, was signed into law on
February 17, 2009. Starting in 2011, eligible professionals could
receive incentive payments up to a total of 5 years if they could
demonstrate “meaningful use” of certified electronic health
records (EHRs). Providers faced up to 5% penalties if they did
not demonstrate meaningful use beginning in 2015. As a result,
adoption of electronic health records increased during this
time.30–34 Even plastic surgeons who do not treat many Medi-
care patients have increasingly adopted electronic health
records and practice management software. The EHR market
continues to evolve. The market is anticipated to consolidate,
as rules, regulations and functionality demands increase in this
space. However, many EHRs were designed with the primary
care physician in mind and thus can be lacking in key features
desired or required by the average plastic surgeon. In addition,
many programs require a significant upfront investment of

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Digital technology during the office visit
point of sale management of product lines, prepayment for
services (e.g., deposits and prepayment for cosmetic surgery
or package pricing for lasers, etc.), photo archiving with rich
search and display features (see below), patient management
(see section below), and others. Contracts and user agree-
ments that are contingent on the development or enhancement
of a feature or functionality should have clearly agreed-upon
language in the contract with timelines and benchmarks,
along with consequences for missed milestones.
Support and implementation
Implementation, training and support are critical services
provided by vendors. Important considerations include the
length, complexity, cost and responsibilities for the installa-
tion process as well as the amount of initial and ongoing
training included and available. Guaranteed limits on outages
and unavailability of the software during updates, bug fixes
and other interruptions should be sought and practices should
seek clear terms regarding the support resources available in
such instances, especially after normal business hours. Even
something as seemingly trivial as the time zone of the ven-
dor’s support headquarters may have an impact on office
productivity if the practice experiences bugs, slow data pro-
cessing, access problems or other issues during normal busi-
ness hours in another time zone. Many vendors provide
extended hours or offer “premium” support (typically at a
surcharge) to cover such contingencies. Most experts recom-
mend that a busy practice anticipate a decrease of 50% in both
productivity of office staff as well as physician volume during
the implementation period of the EHR (which in some cases
can last months to a year or more).38 One study estimated an
average of 611 hours required to prepare for implementation
of the EHR, and 134 hours needed by end-users (physicians,
clinical and non-clinical staff, etc.) to become sufficiently
familiar with the EHR system to feel comfortable using it
regularly with patients.39
Contracting considerations
As with most contracts, it is advisable to have an attorney
familiar with such transactions review the EHR vendor’s
contract, including (where appropriate and provided)
Master Services Agreements, Statements of Work, and User
Agreements/Terms of Use. Some specialty society and state
medical societies also offer resources on this topic. Some basic
considerations to delineate include:
1. Who owns the data?
2. Does the contract grant the EHR company permission to
access the physician’s patient data and, if so, is it in a
de-identified and aggregate form and is the company
permitted to sell the data to other parties?
3. Is there a required duration of contract? If so, what
constitutes a breach of contract to allow the physician to
terminate the agreement early (e.g., excessive downtime,
lack or loss of certification by ONC, failure to create
agreed-upon features, etc.)
4. When the physician changes vendors, what is the
process to decrypt the data and provide it into a usable
format such that it can be used in another EHR? What is
the cost of the data conversion and agreed-upon
timeline and redress for failure to deliver the data in a
timely fashion?
work. The updates are usually real-time and performed auto-
matically by the EHR company, often without disrupting the
software’s availability. The server function, back-ups, and
security of the server is assumed by the EHR company.
Depending on the contract, the physician/group may incur
fees to have the data extracted into a usable format when
changing vendors. Some contracts and user licenses permit the
EHR company access to or ownership of the data. In some
cases, de-identified data (records that have been stripped of
identifying personal or demographic information) can be used
by the vendor for purposes of research, product development,
or aggregation and commercialization. This model usually
boasts lower upfront costs for hardware purchase and instal-
lation, and delivery through a cloud infrastructure facilitates
easier access from remote locations and satellite offices.
Increasingly, both professional and consumer software is
being delivered through the SAAS model, with support, train-
ing and updates bundled into the subscription costs and
availability provided “anywhere, anytime and on any device”.
Stability in the market
A search of the ONC-approved comprehensive EHR list as of
2015 shows 648 approved programs,36 a number that is prob-
ably unsustainable. Even in 2012, 75% of users of EHR
products were concentrated among the top 6 vendors serving
hospitals and the top 15 serving outpatient venues.37 Accord-
ingly, an important consideration when choosing an EHR is
whether the product is anticipated to survive an expected
consolidation of the market among sustainable leading
vendors. Such vendors often have the advantages of consis-
tent revenue from the installed user base along with scalable
physical and human resources that may allow them to fulfill
further governmental or other regulations better and to make
updates and improvements to their programs. On the other
hand, larger EHR companies may be somewhat less respon-
sive to suggestions by users to improve the usability or
functionality of their programs or to add features that are
crucial to only a small subset of their users. As plastic surgery
is a relatively small specialty, this can sometimes be an issue
impeding the timely selection of an EHR with essential fea-
tures needed by the average plastic surgeon.
Features and functionality
Most certified EHRs can adequately accomplish the genera-
tion of a satisfactory progress note, problem list, medication
list, etc. More important is the ease of use of the software. The
usability of many programs is hampered by the requirement
for multiple clicks, non-intuitive navigation, and a cumber-
some maze of windows and menus. It is critical to request a
detailed demonstration of the functioning program and to
engage with current users of the system who are reference
clients of the vendor. One way to accurately experience the
ease (or difficulty) of use and functionality is to have the
demonstration performed in a manner that follows the prac-
tice’s current workflow from initial patient contact, schedul-
ing, registration, intake, note generation, billing, reporting,
follow-up, etc.
As discussed above, many EHRs in the market were not
designed with plastic surgeons in mind. Practices should care-
fully vet those features that may not be accessed by a general
provider, including cosmetic quote generation, inventory and

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CHAPTER 36 • Digital technology in plastic surgery
augmentation consultation, tissue expander visit, encounter
for injectables, etc. Most EHRs permit the templates to include
not only the current chief complaint(s) and history of present
illness with associated relevant physical exam, but also the
typical discussion, treatment plan options, orders, and medical
coding. These work best when there are visit categories which
are more frequent for the practice, and some EHRs will build
these templates at the time of implementation based on the
practice’s current EHR documents or paper forms being used
in the practice. Certain visits might best be recorded with a
visual form or on anatomic images, with annotations typed
or drawn as appropriate, as is commonly done when record-
ing injection sites for botulinum toxin and filler treatments. It
is important to assess whether the EHR allows the physician
or other user to create custom templates to fit the practice’s
regular workflows or the user’s personal preferences, as
opposed to requiring that requested changes or templates be
submitted to the EHR company. Customization can be key to
effective use of an EHR system.
With less common or complicated encounters, templates
may be less helpful as real-time text editing becomes neces-
sary. Some physicians find it helpful to enter prelim summary
notations to be further clarified after the patient encounter,
with the note being text-edited at a later date or the provider
utilizing speech-to-text transcription in a program like Dragon
Medical. Some surgeons prefer to utilize medical scribes who
can enter all the appropriate information at the time of the
encounter, recording observations rapidly into the EHR while
the physician focuses on direct patient care and face-to-face
interaction. The scribes can be the physician’s employees
physically present in the examination room, or may be at a
remote location. One vendor11 offers HIPAA-compliant scrib-
ing services via Google Glass technology, allowing the scribe
to see and hear the patient encounter while transcribing from
a remote location. Newer EHR products are leveraging the
widespread availability of mobile technologies and Wi-Fi to
facilitate less disruptive ways to use an EHR in the patient
encounter (Fig. 36.2).
Alerts
Many EHR products also allow custom setting of alerts to
assist with clinical decision-making or with business practice.
5. What is the process to gain support for downtime of the
program? There should be a maximum percentage set
for downtime and a maximum time for resolution.
6. Is there an agreement to work with other vendors to
allow for interfacing or integration of different programs
(e.g., photo archiving or morphing programs, patient
management systems, third party billing clearinghouses,
etc.)?
7. Are there additional costs to add providers, support
staff or satellite offices? Some EHR programs charge per
user, others per physician (or provider, including nurse
practitioners and physician’s assistants), still others per
computer terminal workstation license.
8. Who is responsible for installing and ensuring the
functionality of the EHR program?
9. What capabilities exist for interoperability of systems
– i.e., does it link to laboratory vendor data, radiology
systems (PACS or DICOM viewers), other EHRs, etc.,
and is there an implementation or maintenance cost for
these services?
Using the EHR
A comprehensive primer on the use of EHRs is beyond the
scope of this chapter. However, this section illustrates some
suggestions to help enhance the effective use of EHRs in a
plastic surgery practice.
Intake and entry of information via patient portals
and on site
ONC-certified EHRs are required to furnish a patient portal
that allows patients to access limited portions of their medical
record and results as well as interact with the office. Patient
portals which allow the patient to enter demographic and
clinical information prior to the office visit can improve office
efficiency by minimizing the amount of data entry at the time
of the visit. Some programs allow different questionnaires
and intake documents to be created which can be tailored
to specific physicians’ practice preferences, or keyed to the
patient category (e.g., the surgeon is likely to be interested in
different information when seeing a hand surgery patient vs.
a facelift patient). Demographic entry by patients permits
them to update contact information and privacy permissions
in a more timely and well-documented manner. Alternatively,
such intake forms can be completed in the office with staff
members assisting the patient with the appropriate electronic
forms or performing a transcribing function for patients who
have difficulty working with digital devices. Bubble forms
(similar to Scantron standardized test forms but printed by
the practice on regular paper) can be created and used in some
EHRs40,41 which scan the responses into digital format directly
into a progress note. Advances in optical character recognition
(OCR) and natural language processing (NLP) are likely to
further enhance the intake of medical information into struc-
tured medical records.
Data entry at the time of the patient consultation
Copious entry of free text at the time of the patient consulta-
tion is neither feasible nor desired. Typically, EHRs make use
of a library of templates created for various patient encoun-
ters, e.g., initial breast reconstruction consultation, breast
Fig. 36.2  Modernizing Medicine EMA Plastic Surgery. (© 2015 Modernizing
Medicine, Inc., used with permission. All rights reserved. Modernizing Medicine and
Electronic Medical Assistant are registered trademarks of, and EMA is a trademark of
Modernizing Medicine, Inc.)

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Digital technology during the office visit
limit manual entry and increase efficiency and flow with
automatic templates, linked fields, and automated alerts and
tasks. Taking the time to familiarize oneself with the features
of the program and configuring the system to allow the office
to take full advantage of the software will encourage further
efficiencies and decrease frustration in the long term. Physi-
cians should expect to take time off (both physician and staff)
for appropriate training and implementation, and should
expect decreased productivity for many months, possibly
years. Interestingly, though, some studies have shown that
despite the frequent reduction in clinical volume that many
practices encounter even years after EHR implementation,
revenues have increased, presumably due to better capture of
revenue with more accurate billing and coding, and more
efficient workflows on the practice management side.
Photo system
Most plastic surgeons will find the photo systems offered by
their EHRs to be inadequate, as they cater to primary care and
other physician specialties. Accordingly, plastic surgeons may
find it better to purchase or subscribe to a dedicated photo
management program that links with the EHR.11,42 Ideally, the
system should allow direct uploading from the tablet device,
camera or smartphone without needing to first download to
a hard drive or needing to upload and assign to correct
patients at the end of the day. Categorizing photos with
metatags for demographics, surgeon, facility, diagnosis,
procedure(s), and other considerations like implant size and
position can provide important context for building dynamic
galleries without having to duplicate photos. The process for
assigning tags to the image should not be laborious and tags
should be easily searchable. Certain tags such as photo date
and patient demographics should be automated, especially if
linked to the EHR. In such a system, it would be feasible, for
example, to search for all 6-month postoperative pictures of a
female breast reduction patient between the age of 28 and 40
years old who had at least 600 g of reduction. Some photo
systems also allow the physician to immediately annotate the
image and save the annotated image as a separate (“flat-
tened”) file. This is an effective patient education and risk
management tool as well. When a patient can see her asym-
metries or other issues visually marked or the proposed
procedure illustrated (especially when done in real time by
the surgeon on a tablet and broadcast to a large screen in the
examination room, creating an immersive educational experi-
ence), it may increase her understanding of the limitations
while simultaneously increasing her comfort with the proce-
dure. The manner in which the photos are presented to the
patient is also important. Ideally, the program should permit
before and after images to be shown side-by-side and saved
as such and printed with a specified number of images per
page. Access to the patient’s images should be enabled via a
laptop or desktop computer, tablet device, or smartphone.
Some programs11 allow the physician to give patients access
to some or all of their images via a patient portal, and others
allow patients to upload their own images to their account as
well. This shared access may encourage happy patients to
share their experiences with prospective patients.
When transferring the photos for use on a website or
PowerPoint presentation, authorized individuals with access
to the photos must be vigilant that proper consent has been
For example, some systems allow the user to set an alert
which pops up whenever a specific patient chart is opened to
display, for example, that this patient needs to retake her
photos or pay for her most recent treatment. Most EHRs also
provide alerts for medication contraindications, drug–drug
interactions, and/or disease process considerations when
prescribing medication. Some programs may allow the user
to customize action items that only display when specific
criteria are met. For instance, if a female patient is older than
50 years old and has not had a mammogram in the last year,
the EHR may prompt the user to consider ordering a mam-
mogram, and may even provide computer provider order
entry that generates a printable requisition or transmits the
order electronically to a radiology center.
Document and forms management
Most EHRs enable the user to upload forms that are required
by various vendors and facilities, such as the OR scheduling
sheet at the surgeon’s local hospital or the order form for a
frequently prescribed product or durable medical equipment.
Some EHRs will allow the user to mark directly on the image
of the form and save it as a document. Others will also allow
the form to be set up to capture each blank in a form as
structured data (e.g., smart PDF forms) that can later be used
to generate reports or used in a mail-merge document.
Integrated systems
As much as possible, arrange for integration of the various
programs that will be used in the practice. Many vendors of
EHR products now offer integrated software suites that
include medical records, billing, practice management, labo-
ratory and diagnostic study results, revenue cycle manage-
ment, inventory, operating room compliance documents,
consent forms and surgical quotes. These systems may also
feature direct data integrations or single-sign-on interfaces to
the products of other vendors. For instance, a vendor of an
EHR which does not offer a practice management module
may nonetheless build “data bridges” to commonly used
practice management software products, allowing practices to
mix and match products that may better suit the practice’s
needs, budget, and profile. Not uncommonly, one EHR
product may not fit all the needs of a practice, and a separate
photo management product (see below), patient education
system (see below), or digital simulator program may be
desired. Ideally, these should also be integrated as much as
possible, even when provided by competing vendors. Integra-
tion reduces the requirement for double or triple entry of
patient demographics in each program and can obviate the
need to open multiple screens and programs with different
sign-ons and user interfaces. One positive result of the more
widespread adoption of EHR programs among physicians
and hospitals is the potential (although as yet unrealized)
promise of long-needed progress in interoperability among
multiple vendors of medical record and other health informa-
tion technologies. Market demand is likely to drive further
innovation in this area.
Upfront investment of time – know your EHR
Overall, it is advisable that the plastic surgeon, office manager,
and key staff members take the time to understand the capa-
bilities of the EHR and consider how it can best be used to

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CHAPTER 36 • Digital technology in plastic surgery
coding and bill based on time and complexity of the encoun-
ter. Many EHRs provide tools to assist in selection of the
appropriate CPT and ICD codes, and may even automate
the process based on anatomic and clinical data entered in
the course of the progress note’s creation. After the claim is
generated, most systems have a process called claims “scrub-
bing”, in which the claims are checked for errors prior to
submission. When available, the claim can be sent either
directly to a third-party payor or more commonly to a billing
clearinghouse, which then sends the claims to the appropri-
ate third party. Ideally, the interfacing of the practice man-
agement program with the clearinghouse will automatically
send secondary claims to the supplemental insurance payors,
where applicable, and even generate paper statements to
patients as needed for billing the patient’s out-of-pocket
component. Automation of this process reduces the depen-
dency of a practice’s revenue on the caliber and dedication
of personnel in the office, and when set up appropriately,
reduces the frequency of missed or denied claims.
Reports
Popular practice management systems also allow access to
customizable reports that help the practice track outstanding
unpaid claims, revenues per facility, revenues per claim,
revenues per employee, volume by procedure, etc. Histori-
cally, many such reports were difficult to obtain and were
rarely generated in real time. With more sophisticated systems,
practice managers and physicians can assess the viability and
efficiency of their practice on demand.
Theft prevention
Practice management programs may also help decrease the
risk of theft, embezzlement and similar issues by allowing
books to be “hard-closed” at the end of each day. When the
hard close is performed, monetary amounts and transactions
can no longer be added, removed, or altered. Additionally,
robust inventory management systems help track how many
products have been sold, by whom, and how many products
should remain in inventory, helping to mitigate against “lost”
inventory, to prompt timely restocking, and to facilitate more
accurate tracking of revenue generation from the sale of each
unique product stock-keeping unit (SKU).
Customer relation management
Newer systems also feature customer relation management
(CRM) modules for tracking leads, following patients for
recurrent revenue opportunity, and engaging patients with
appropriate marketing materials. Some of the common fea-
tures of CRM products include the ability to send targeted
timely emails or letters based on patient demographics,
procedure types, time elapsed from prior appointment dates,
etc. Properly used, CRM can be deployed even before
the patient comes into the practice. The system can start
engaging the patient the moment an inquiry is made on a
website, a subscription to the practice’s electronic newsletter
is enrolled, or a patient appointment call is made. When these
inbound communications are received from prospective
patients, automated customized emails or letters can be sent
prepopulated with appropriate information and on a prede-
termined schedule. For example, in the case of a new breast
obtained from the patient for online use, and that identifying
information has been removed. This includes the metadata
tags assigned to the photo (such as patient name, gender, date
of birth, procedure, date, etc.) which may remain associated
with the photo and “readable” to a web search engine like
Google. Consequently, if a plastic surgeon is unaware that this
metadata must be removed from the photo, a well-meaning
friend of a patient may Google her friend’s name only to be
directed to a set of images in a plastic surgeon’s online breast
augmentation gallery. If identifying features like tattoos are
easily recognized, this can add to the risk of privacy viola-
tions. Similarly, some of this same information can sometimes
be viewed inadvertently when the mouse is rolled over the
image. These incidents may not only lead to loss of business
from disgruntled patients but may lead to charges of HIPAA
violations or other legal and financial liabilities.
As is true with the EHR, it is equally important with a
vendor of photo management systems to delineate in the
contract who owns the data/images, who bears the responsi-
bilities for maintenance and what are the conditions for and
obligations following termination of the contract (see discus-
sion in Contracting considerations section, above).
Practice management
Integrated single-vendor software products may include
components for practice management, scheduling, billing,
clinical documentation, and follow-up marketing. An increas-
ing emphasis on interoperability of healthcare information
systems provides practices with more choices and the ability
to bring together digital tools from a variety of vendors. While
there is often much discussion by physicians about the docu-
mentation and note-generating aspects of an EHR, perhaps
more important to the overall health of the office is the practice
management system used. Traditionally, practice manage-
ment systems focused mainly on the billing and coding
process and tracking accounts receivable. However, sophisti-
cated modern practice management systems can streamline
workflows and reporting and increase revenue capture while
potentially reducing costs.
Billing
Even in the traditional arena of billing, some newer practice
management programs will automatically check patient eli-
gibility information, including verifying that the patient’s
insurance is still active, identifying the amount of the
deductible and how much has been met, listing benefits for
in- and out-of-network visits and for inpatient and outpa-
tient procedures, cataloging copays for studies and labs, and
furnishing formularies and benefits explanations for pre-
scription medications. This information may facilitate the
collection of appropriate copays and deductibles at the time
of the visit or more accurate decision-making regarding
procedures and orders. Some systems have an E/M (Evalua-
tion and Management) calculator which helps the clinician
code the appropriate billing level for the office visit based on
the information gathered in the progress note. For example,
a sophisticated EHR using a structured data model can use
Medicare E/M coding guidelines to determine the number
of history, physical examination and review of systems
bullets that have been satisfactorily documented, as well as
provide the physician a way to override the automated

677
Digital technology during the office visit
enhancement patient, the process may be set up as follows:
an initial welcome message is sent after the patient has sched-
uled an appointment, an appointment reminder is delivered
via SMS or email one week after inquiry and again 3 days
before the scheduled appointment (with a request for the
patient to acknowledge receipt and confirm the appointment
time with a quick text or reply which is automatically regis-
tered in the system), a “thank you for coming” message with
a succinct visit summary is delivered the day after the patient
is seen, a follow-up message is issued asking if the patient
desires more information if an appointment for surgery has
not been scheduled within 4 weeks, and so on until after the
surgery is completed. Reminders for postoperative appoint-
ments, due dates for neurotoxin and filler treatments, special
promotions and events can all be delivered and tracked with
sophisticated CRM tools.
On-site patient education
Using digital technology for patient education can enhance
patient comprehension of complex medical information, and
modern devices and software products can make this a highly
interactive experience. When used effectively, such technol-
ogy can increase the patient’s confidence not only in the
treatments selected, but also in the surgeon whose competence
may be reflected in the selection of state-of-the-art modern
tools used in the office.
Digital educational materials
The office encounter may be enhanced by interactive infor-
mational videos or materials that patients can be viewing in
the reception area or in the examination room as they are
waiting to see the physician (Fig. 36.3). These may include
slide presentations, animations, video tutorials and other
media, and may be professionally developed, licensed from
third parties, or generated in-house by the physician’s prac-
tice. Digital information on other available procedures and
products may open the door to further discussion on a topic
or procedure about which the patient was previously
unaware. As stated previously, during the encounter the
real-time use of photographs and illustrations that can be
annotated may help the surgeon explain the procedure in
detail or show asymmetries and other considerations that
are specific to the patient.11 More elaborate programs allow
the annotated images to also be saved seamlessly to the
patient’s chart. Some tablet EHR products also boast highly
detailed virtual anatomic atlases featuring multiple touch-
sensitive zones, allowing explanation of pertinent anatomy
and techniques with multiple views and layers (Fig. 36.4).
The initial consultation is often a prime opportunity for
plastic surgeons to showcase their artistic skills with quick
sketches of procedural steps, incision locations, etc., drawn
before the patient’s eyes in real time.
Digital simulation
Digital simulators may also allow the surgeon to better dem-
onstrate to the patient and companions the possible outcomes
of a procedure, and may also assist in surgical planning. Most
of these are stand-alone systems that in some cases can be
linked to the practice’s EHR. Some require special hardware
and a dedicated area of the office designated as an image
capture room.43 Other systems44 only require an iPad, camera
phone, or regular camera to capture three traditional-position
images (frontal, right lateral and left lateral) in any room (Fig.
36.5). With sophisticated computer algorithms, the photos are
interpolated into a three-dimensional image that can then be
manipulated in the software. The same system also allows
three-dimensional scanning with a commercially available
sensor attachment for the iPad (Fig. 36.6). The resultant image
can then be manipulated to help the patient visualize possible
outcomes and provide useful feedback about specific aesthetic
goals (Fig. 36.7). For breast augmentation planning, virtual
breast implants selected from a menu categorized by manu-
facturer, size, shape, and dimensions may be added and dif-
ferent implant choices may be viewed side-by-side. With
multiple views and what-if scenarios, the patient can assess
differences in projection, shape and width. For example,
three-dimensional modeling can help the patient better
understand the difference between a shaped or round implant
and help her to decide whether the projected result is worth
the added expense. For a patient seeking breast reduction,
digital simulation may help to show the patient a representa-
tive image of what a reduction of 500 g of breast volume (as
may be required by her particular insurance) would look like,
to help her decide if she would like to commit to insurance
coverage, or instead pay out-of-pocket for a more limited
breast reduction that preserves more volume. The program
allows for differential subtraction of volume on each side
which can be helpful in planning secondary breast revision
cases and post-mastectomy reconstruction. In the evaluation
of the mastectomy patient for post-mastectomy reconstruc-
tion, this feature may permit the surgeon to subtract the entire
volume of the breast and then place a variety of virtual
implants to assess the best direct-to-implant choices for the
patient. When counseling candidates for augmentation mas-
topexy, who often have difficulty understanding the necessity
of both components in their surgical plan, the simulation
helps to illustrate what the breast may look like with an
implant alone without the mastopexy and vice versa. With
facial and body images, the programs allow the surgeon to
simulate various procedures including reshaping, retexturing,
and filling with a variety of topical treatments, injectable
products, laser and energy devices, liposuction systems, etc.
The surgeon can also model widening/narrowing, advancing/
recessing, and raising/lowering of various structures such as
the chin, brows, nose, eyes, cheeks, etc. One vendor’s software
fabricates full facial replicas with 3D-printing technology, and
integrates with some 3D camera systems used for other clini-
cal simulation tasks to create an even more comprehensive
visual and tactile representation of the patient’s features for
more detailed modeling.45
Some programs allow the patient to upload pictures
securely from home to the physician’s website (Fig. 36.8).
The photos are incorporated into simulation software, and
patients are then encouraged to schedule an office visit to see
these simulations and discuss treatment options with the
surgeon. In so doing, these tools move beyond education and
may serve as a means of differentiating the surgeon in the
market and recruiting prospective patients. Finally, some
programs allow patients secure online access to a portion or
all of their images remotely, as determined by the physician,
and some offer easy social media sharing options. Thus,
happy patients may share their results with friends (Fig. 36.9).

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CHAPTER 36 • Digital technology in plastic surgery
Fig. 36.3  Interactive brow lift (A) and rhinoplasty (B) informational screens with access to videos, illustrations and other educational content. (© 2015 TouchMD, an
ALPHAEON Company. Used with permission. All Rights Reserved.)
A
B

679
Digital technology during the office visit
However, consideration should be given to whether the simu-
lated image can be misconstrued as an implication of a
guaranteed result – all images and all sessions should empha-
size that the images are not a guarantee and are estimates only
to be used for educational purposes. Printing a disclaimer to
this effect on any image that the patient is able to view outside
the office or which goes into the medical record may serve an
important role in setting expectations and documenting the
limitations of digital simulation tools.
On-site clinical information and
decision-making
Digital technology may also assist the surgeon in clinical
information and decision-making. As mentioned in the previ-
ous section, digital simulation is not only a patient education
tool but can be used to help patients and surgeons plan and
choose appropriate techniques, breast implants or other pro-
cedural components at the time of the office encounter.
Fig. 36.4  Illustrations that can be annotated and saved for the patient to access
later via their portal can be an effective patient education tool. (© 2015 TouchMD,
an ALPHAEON Company. Used with permission. All Rights Reserved.)
Fig. 36.5  Some systems allow images to
be captured either with a traditional camera
or mobile device in three views and
uploaded for automatic 3D reconstruction.
(Image courtesy of Crisalix.)
Fig. 36.6  Image processing systems may also allow for images to be captured
with the Structure sensor scanner on an iPad, creating instantaneous reconstruction.
(Image courtesy of Crisalix.)
Digital technology may also allow access to a specific
specialist consultation from a remote location. This may be in
the form of an intra-specialty or inter-specialty consultation.
With newer products that are HIPAA-compliant and with the
use of high definition video camera systems, the remote
consultant can see and hear the interaction and advise in real
time during the patient encounter. This may bring needed
expertise to aid in the care of patients in a remote or under-
served region with limited services or may facilitate additional
expert opinion for complex cases. Military battlefield triage
and surgical stabilization may be aided by similar telesurgery
technologies.
Digital tools have also granted easier access to services
during a visit that were previously unavailable. For example,
translation services are available via a smartphone app44
where the patient’s language is selected, a translator calls
the phone and provides translation for the entire interaction
from a remote location. This is also available for patients
requiring sign language interpretation via an online platform,

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CHAPTER 36 • Digital technology in plastic surgery
speed, chip memory, cloud storage infrastructure, and mobile/
wireless technologies evolve, a fully integrated operative suite
with a system of interconnected devices and programs is not
only feasible, but may become the norm in the near term.
Preoperative work-up
Assessing photographs in preoperative planning
The preoperative workup for a patient often begins during,
or shortly after, the initial consultation. Properly captured
patient history and physical information in an electronic
medical record can be reviewed along with digital photo-
graphs that are marked to the patient’s chart. As described in
increasing accessibility and decreasing the cost to the office of
hiring an in-person sign-language interpreter for compliance
with the American Disabilities Act (ADA).46,47
Perioperative digital technology
Digital technology is increasingly playing a role in the preop-
erative, intraoperative and postoperative phases of patient
care. Following initial consultation and establishment of a
patient’s candidacy for surgery, a number of digital tools,
including devices and software systems, are available to prop-
erly plan, execute, and immediately monitor patients after
complex procedures. As capabilities advance and processor
Fig. 36.7  A 3D reconstruction of the breasts can be manipulated to choose different implant brands, size, shape, texture, pocket position. Options for mastopexy and
implant/volume subtraction also exist. Sample before and after view. (Image courtesy of Crisalix.)
Fig. 36.8  Some programs allow the patient to upload pictures securely from home.
The patient is then encouraged to schedule an office visit in order to see the
simulations and discuss treatment options. (Image courtesy of Crisalix.)
Fig. 36.9  Some systems offer patients remote online access to designated
reconstruction images with social media sharing options. (Images courtesy of
Crisalix.)

681
Perioperative digital technology
the Photo system section above, sophisticated EHR tools and
photography archiving systems allow for categorizations of
patient photos with metadata tagging for properties like
procedure type, date of procedure, diagnosis, body location,
patient age, gender, insurance type, place of service, operative
phase (pre-, intra-, or postoperative), etc. A dynamic registry
that contextualizes the patient’s photographs can allow the
surgeon to view a patient’s preoperative photos among those
of other patients with similar demographic, anatomic or other
characteristics, to build a tailored operative plan. For example,
the surgeon planning a rhinoplasty on a 30-year-old African-
American patient may label her photographs with tags like
“dorsal hump reduction”, “African-American”, “30–35”,
“open tip”, etc. The surgeon could compare this index patient’s
photos to those of other patients whose photos were similarly
tagged. The surgeon’s pictorial record database becomes
richer and more easily mined for the kinds of photos needed
in any given context by being able to filter and sort through
images based on these kinds of tags. Some standalone applica-
tions48 provide such searchable metatagging and cataloguing
of photo galleries on tablet devices (Fig. 36.10).
Digital simulation in preoperative and
intraoperative planning
Additionally, photography archiving software programs
equipped with morphing and annotation tools allow the
Fig. 36.10  MyAppwoRx.com images. (© 2015 AppwoRx, used with permission. All rights reserved.)
A
B
surgeon to non-destructively mark up a set of preoperative
photographic images to incorporate preoperative planning
ideas. This is commonly performed in rhinoplasty and breast
surgery, where unmarked and marked reference photographs
obtained prior to the onset of swelling and other intraoperative
changes can serve as a continuous guideline throughout the
conduct of an operation. It is particularly useful to have the
ability to tag photographs with appropriate metadata asyn-
chronously to the patient visit, so that additional pertinent
information can be annotated to an image set even after the
patient has left the office. Accessing photographic records
remotely via cloud-based systems or virtual private networks
(VPNs) allows the surgeon to be reminded of the surgical
plan, to add information that may be generated after contacts
with the patient, and to print or view photos when delivering
care at a remote point of service (for example, when perform-
ing surgery at a hospital using a different, on-site record
system).
Preoperative quotes and informed consent
Estimating financial responsibility for patients for aesthetic
and reconstructive procedures is an equally integral part of
plastic surgery office workflow, and the process of obtaining
informed consent is, of course, critical to proper patient care,
serving as a safeguard for proper procedure selection and as
a legal record of the information provided to the patient.

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CHAPTER 36 • Digital technology in plastic surgery
surgeon and patient information, etc., between the component
modules. In some cases, this allows customized “workflow
ladders” of task assignment and accountability chains to be
configured in the software, where specific tasks involved in a
preoperative or postoperative protocol for a patient can be
assigned to individual staff members and the “baton” handed
between them as steps in the protocol are completed. Well-
integrated systems also allow these steps to be documented
into the EHR, memorializing the date, time, responsible staff
member and any notes pertinent to the workflow. As mobile
technologies mature further, secure messaging and task
recording on mobile devices help facilitate truly paperless
office workflows.
Preoperative risk assessments and tools
In some cases, automation can also be applied to algorithms
for preoperative risk assessment and management. For
example, data entry tools in EHR programs can permit calcu-
lation of a Caprini DVT risk score, along with peer-reviewed
evidence-based recommendations for appropriate prophy-
laxis. Calculation of ASA score, Fitzpatrick Scale, and other
metrics is feasible with protocols coded into software for the
perioperative patient evaluation. Some EHR vendors provide
customization tools that allow practices to digitize their exist-
ing forms for such purposes, often working in tandem with
the surgeon and staff in a collaborative development process.
Such systems can help surgeons and facilities maintain
compliance with documents required by AAAASF (American
Association for Accreditation of Ambulatory Surgery Facili-
ties) and other accreditation bodies, by permitting digitization
of the necessary surgical checklists and other forms.
Preoperative modeling
Patients requiring more elaborate preoperative workups for
craniofacial, microsurgical or other complex procedures can
also benefit from digital technologies. While its necessity is
not clear in all cases, digital angiography is commonly utilized
as part of the preoperative assessment of patients undergoing
perforator flap reconstruction and other microsurgical
procedures. With the advent and increasing popularity of
3D printing, custom moulages and cranial prosthesis for
complex, composite craniofacial reconstructions for trauma,
oncology, or craniosynostosis can be architected, utilizing 3D
reconstructions of CT, MRI and other radiographic data along
with digital photography to model the multi-dimensional
topography of the patient’s current or anticipated defect.
Sophisticated CAD/CAM tools51–53 can be used to create the
anatomic models from which implantable constructs of
titanium, methylmethacrylate (MMA), acrylics, hydroxyapa-
tite (HA), bioceramics, polyetheretherketone (PEEK), and
other materials can be machine-fabricated. Whole structure
implants such as custom mandibular titanium plates may also
be designed and manufactured. Composites of biologic and
inert substances incorporating dermal matrices, stem cells,
bone graft, chondrocyte scaffolds and other materials can
also be designed and modeled. The availability of custom
tissue engineering products from companies like Organovo
and relatively inexpensive consumer-focused 3D-printing
devices like the MakerBot holds promise for considerable
ongoing innovation in preoperative design and prototyping
for complex procedures.
Many EHR systems incorporate consent and quoting modules
that automatically populate from information documented
into the EHR from the clinical encounter, in some cases gen-
erating ICD-9 and ICD-10 codes, CPTs and fee schedules
automatically. One of the earliest programs with this function-
ality was a client-server software program that created custom
surgical quotes and informed consent booklets prepared for a
specific patient based on procedures proposed and selected
by the surgeon or appropriate office staff for populating the
document outputs.49 Many new software tools allow the
patient to be sent quotes and consent forms via privacy-pro-
tected portals (often the same portals created for the patients
to access pre-consultation educational materials and intake
forms), so they may be reviewed by the patient, shared by the
patient with family or caretakers, and, in some cases, com-
pleted. HIPAA-compliant online systems like DocuSign may
be used to capture electronic signatures if deemed appropri-
ate by the surgeon. The American Society of Plastic Surgeons
(ASPS) informed consent library is available in CD and digital
download format for surgeons to print and use in the office;
some EHR systems allow pre-existing forms to be converted
into smart PDF or other formats that allow signatures to be
captured in the EHR application as well. Alternatively, other
EHRs facilitate copy-and-paste functionality that allows the
content of other consent forms to be “digitized” into the
EHR’s library of forms.
Preoperative labs and studies
In addition to surgical quotes and consent tools, preoperative
planning includes the ordering and reviewing of laboratory,
radiographic, or other clinical data, as well as provision
of prescriptions for perioperative medications. Most EHR
systems in the United States are equipped with capabilities
for electronic prescribing through Surescripts or similar plat-
forms which connect to most pharmacies, reducing the
requirement for generation, signing, scanning and faxing of
paper prescriptions. Similarly, electronic computer provider
order entry for laboratory and radiographic studies is built
into many EHR programs. In many cases, these provide a
means for the direct electronic transmission of orders to labo-
ratory centers like Quest and LabCorp as well as for the
receipt and filing of the results into the patient’s record. This
automation holds some promise for accelerating the process
of ordering and reviewing labs for the surgeon and office staff,
and, where available, can be applied both preoperatively
and postoperatively. Radiographic images viewable in PACS
systems can sometimes be directly incorporated into the
medical record along with the radiologist’s reports.
Automated preoperative workflows
The wide array of integrations between healthcare informa-
tion technologies, often employing the Health Level 7 (HL7)
language of data transmission, holds promise for additional
methods of automating workflows.50 Already, many practice
management (PM) systems are integrated with the EHR
programs of other vendors, allowing a “mix-and-match”
approach to selecting office software solutions. Some vendors
offer all-in-one solutions with EHR, PM, inventory and other
features with internal integrations allowing automatic transfer
of data such as diagnosis, date of service, procedure codes,

683
Digital technology between patient visits (including long-term follow-up)
combat field hospitals, developing countries, rural locations,
and other points of service may be facilitated through these
POV technologies, which permit a remote surgeon to provide
guidance and instruction to treating providers on site, possi-
bly providing improved patient stabilization, triage, and
second opinion consultation. Already there have been numer-
ous publicly reported examples of surgeons utilizing Google
Glass in surgery, including augmented reality overlays of
surgical illustrations and procedural steps that are superim-
posable upon the patient’s anatomy to help guide the conduct
of a procedure.57–59
Intraoperative tools for surgical decision-making
Surgeons working closely with pathologists on intraoperative
pathology reporting may have access to sophisticated inte-
grated digital pathology solutions incorporating smart digital
scanning, image processing, archiving and analysis.60 The
surgeon engaged in microsurgery may utilize operating
microscopes equipped with digital optics and video record-
ing systems, and implant digitally monitored implantable
Doppler probes to assess anastomotic patency. Tissue perfu-
sion quality may be ascertained with the use of technology
allowing intraoperative decision-making for debridement of
tissue at risk for necrosis or interrogation of threatened vas-
cular pedicles.61
Postoperative digital technologies
As a surgical procedure nears completion, continuation of
perioperative workflow checklists can resume in the EHR.
Geolocation systems employing protocols like global posi-
tioning system (GPS), radio-frequency identification (RFID),
near-field communication (NFC), Bluetooth, wi-fi, internet
protocol (IP), and uplink-time difference of arrival (U-TDA)
cellular technology, can potentially track the whereabouts of
the patient and staff members for accurate recording of surgi-
cal times, allocation of beds and human resources, and other
location-based services. The intraoperatively placed Doppler
probes can provide ongoing postoperative flap monitoring,
and vital sign applications can stream continuous physiologic
data to the physician’s smartphone. Numerous additional
uses of digital technologies can be envisioned and designed
by innovative plastic surgeons in collaboration with engineers,
software developers, and other clinical providers.
Digital technology between patient
visits (including long-term follow-up)
Introduction
With advanced practice management/customer relationship
management programs, monitoring with wearable technol-
ogy and accessories, and online and other digital forms of
patient and community engagement, physicians will be able
to track and customize their engagement with their patients
and community throughout their lifetime.
Direct patient communication
Communication in the form of HIPAA-compliant apps62 is
already possible and widely available. The technology allows
Day of operation
Immediate preoperative digital technology
Once the patient has arrived for surgery, a number of tools are
available for the immediate preoperative assessment. Many
bedside digital vital sign monitors now include Bluetooth
connectivity as well as integration directly into EHRs. Addi-
tionally, remote home vital sign monitoring is available from
a variety of application vendors, with biometric parameters
tracked by tools like HealthKit from Apple or Google Fit.
Certain EHRs can pull forward medical history contained in
prior clinical notes for the surgeon, anesthesiologist or other
providers to review in the preoperative holding area. Immedi-
ate preoperative patient education can be enhanced similar to
the initial office consultation, with streaming video content
available through Apple TV, Google TV, and other wireless
devices broadcast to video screens in private holding rooms.
Preoperative checklists for the operating room staff can be put
into clinical workflows in the EHR with electronic signing and
attestation available for the appropriate staff members.
Intraoperative monitoring
The operating room is another venue for integration of digital
technology in the care of the plastic surgery patient. Digital
anesthesia monitoring is available in many operating rooms,
although direct integration of the data into EHRs remains a
challenge for many vendors. Often, this continuously acquired,
streaming data is condensed into photographic summaries
which serve the purposes of documentation but may be limit-
ing in terms of data analysis capabilities. More direct integra-
tion of data from these systems into EHRs is anticipated and
promoted by the FDA, Center for Medical Integration and
other organizations, consistent with the HITECH Act’s goal
of promoting interoperability.54 Other digital innovations may
further improve patient safety; for example, radio-frequency
identification (RFID) technology is being used to monitor lap
sponges in the operating room. Companies are currently
working on the concept of data fusion, which integrates
various inputs such as imaging modalities and software
algorithms that allow a hybrid 3D output, for example, or an
integrated display of all relevant clinical information that
could be real-time, streamed on mobile platforms, and poten-
tially allowing for the superimposing of data and other image
on a surgeon’s visual field, either through a screen monitor or
a wearable platform for real-time feedback/imaging during a
procedure.55
Intraoperative communication and collaboration
The surgeon in the operating room can also take advantage
of certain digital technologies where appropriate. Digital
point-of-view (POV) camera devices like the GoPro camera56
and Google Glass can facilitate education of students and
residents in the OR or at remote sites, providing the surgeon’s
vantage point to interested observers, allowing recording of
surgical procedures for educational, marketing or quality
assurance purposes, and providing a clearer picture of
hard-to-see small spaces, like the nasal vault during rhino-
plasty. Some surgeons utilize such technologies to engage in
additional hands-free communication as necessary with staff
and other parties outside the operating room. Telesurgery in

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CHAPTER 36 • Digital technology in plastic surgery
wearables have gained popularity in recent years, including
the Jawbone UP systems for portable heart monitoring, Fitbit
activity trackers, and the Apple Watch. Third-party apps can
integrate physiologic, nutritional and other activity data from
multiple devices and wearables into single portals where
patients can confer with caregivers and advisors to craft
personalized wellness plans. Future advances might include
sensors incorporated into implants, wound dressings, or
directly into tissue. These could offer feedback and remote
monitoring of the wearer of the implant, status of the wound,
infection, malignancy, etc., with the capability to transmit the
information for remote access via a mobile app or a physician
portal. The use of long-term monitoring and patient engage-
ment between encounters is still in its infancy in terms of
technology and adoption, but the potential of a major para-
digm shift in healthcare delivery appears promising.
Patient community engagement online
Postoperative patient care, much like patient lead generation,
has been impacted by the popularization of social media, with
patients regularly sharing results, testimonials and detailed
descriptions of their patient care experiences through a variety
of media vehicles, including Facebook, Twitter, Instagram,
Snapchat, blogs, and other interactive forums. Newer “crowd-
sourcing” sites for discussion of practice paradigms and
medical advice sharing have proliferated, affording a venue
for dynamic discussions between patients and other patients
or between patients and providers. Engaging in such forums
requires the surgeon and office staff to be ever mindful of
HIPAA and other privacy considerations, but nonetheless can
provide important education for patients recovering from
procedures. One of the more popular and heavily trafficked
crowdsourcing sites for medical recommendations and advice
in the aesthetic plastic surgery field7 entails many surgeons
responding regularly to inquiries from prospective patients as
well as those who have undergone procedures by other pro-
viders. Many surgeons actively curate their profiles and
activities on that and other sites as part of a general social
media and marketing strategy; a number of additional crowd-
advice sites have steadily gained in popularity.14,70 Patient-
centric forums71 that focus on specific disease experiences
have also given patients as consumers of healthcare an impor-
tant role in patient referral patterns, treatment evaluations,
and clinical trial design. The digitally empowered patient can
have an important influence on a surgeon’s reputation, search
engine optimization, and word-of-mouth marketing success
via online review sites.3–7
Digital technology in plastic surgery
education and training
Perhaps nowhere is there more promise for impactful utiliza-
tion of digital technology than in the arena of medical educa-
tion and training. A new era in training capabilities has dawned
with the advent and popularization of highly sophisticated
virtual and augmented reality simulators. The Oculus Rift72,73
and other74 systems have both shown great promise for creat-
ing highly immersive, multi-sensorial experiences incorporat-
ing photorealistic 360° video environments, accompanying
audio and, perhaps when combined with wearable sensors,
for real-time, video, chat, and picture-sharing capabilities, as
with the virtual consultations discussed previously.
Surgeons wishing to discard pagers and arcane answering
systems may still provide round-the-clock phone contact
accessibility to patients, hospitals and emergency rooms using
free services such as Google Voice. The service can be set up
such that, when the patient calls the plastic surgeon’s Google
Voice number, it will ring any combination of land lines,
mobile numbers, desktop computers, etc., simultaneously.
The phone call can be screened, answered, or sent to a cloud-
based voicemail. Voicemails can be transcribed and emailed
and/or texted to the plastic surgeons. Alerts can be set to ring
with different tones and set to different answering messages
depending on the number calling. In addition, the plastic
surgeon can use Google Voice to return the call to the patient
without revealing their home phone or mobile number. The
plastic surgeon may also choose any area code for their Google
Voice number. To the patient, the Google Voice number is like
any other number. Google Voice also allows free landline and
mobile number calls to the entire US, Canada and Mexico. Of
course, it may be necessary to have a back-up system such as
a very basic answering service plan, to mitigate in the event
of natural disaster, or other possible disruptions to the sur-
geon’s access.
Other postoperative patient engagement tools are designed
specifically to track adherence to postoperative care protocols
and field inquiries from patients during their recovery. In
addition to the telemedicine applications described above,
plastic surgery offices can take advantage of mobile applica-
tions with secure messaging, patient compliance question-
naires, and private photo sharing. The patient or caretaker can
send photos of healing incisions or body locations of concern
for a quick triage regarding the urgency of follow-up.
Enhanced postoperative recovery protocols that include
step-by-step guidance for recovery (e.g., “Walk 10 steps every
3 hours on postoperative day one; advance from a clear liquid
diet to a low salt diet on postoperative day 2, etc.”) can be
built into checklists or messaging sequences with automated
callbacks and alerts when patients are not responding affir-
matively to requirements.62–66
Patient monitoring with wearables
and accessories
Follow-up after the immediate postoperative period may
sometimes be achieved with virtual visits and wearable or
portable technology for monitoring. Current technology
already enables EKG tracings, noninvasive blood sugar moni-
toring, heart rate, and dermascope readings at the hands of
the patient. Portable ultrasounds and heart rate monitors,
and pulse oximeters are also available as attachments to
smartphones.
There is great potential for innovation in the field of patient
wearables for monitoring. For example, in the area of wound
care, one project is developing wearables that include multiple
sensors to detect pressure, monitor for infection, and adjust
negative pressure applied to chronic wounds.67 Newer prod-
ucts68 can provide real-time feedback on plantar foot pressure
to aid in the prevention of ulcers in diabetics and patients with
other forms of neuropathy. One company69 offers a wearable
device that provides gait, balance and other postural analysis
to assist in physical rehabilitation. Numerous consumer health

685
Digital technology for the advancement of plastic surgery (research and clinical outcomes and advocacy)
Plastic surgeons and residents interested in additional
education and training in information sciences have numer-
ous opportunities in both degree-granting and executive
education certificate programs focusing on bioinformatics/
medical informatics, information systems, technology-
enhanced education, device and software innovation and
entrepreneurship. Master’s degrees in bioinformatics or
information systems often may be obtained on a part-time
basis, with limited time disruption on other professional
obligations or clinical practice momentum. Many MBA pro-
grams, both part-time and at the Executive MBA level, offer
coursework in technology innovation as well. There are
also numerous industry symposia, both sponsored within
the plastic surgery professional organizations and within the
digital health space, focusing on technological innovation
pertinent to patient engagement, medical records, photo-
documentation, telemedicine and telesurgery, practice man-
agement software, concierge-level wellness coaching, device
design, bench-to-market strategy, venture financing, etc.
Several professional societies, including the Healthcare
Information and Management Systems Society (HIMSS),
the American Medical Informatics Association (AMIA), and
others provide annual meetings and educational opportuni-
ties that afford physicians exposure to a wide array of vendor
products and services, key opinion leaders, advocacy pro-
grams, regulatory guidelines and other offerings. Many of
these symposia and meetings provide formal Continuing
Medical Education credits and serve as professional network-
ing venues. At the intersection of innovation, venture funding,
and clinical applications are several organizations that provide
online newsfeed content as well as sponsorship of such meet-
ings; examples include Singularity University’s Exponential
Medicine conference, VentureBeat and its associated Health-
Beat conference, Digital Health Summit, and many more.
Digital technology for the advancement
of plastic surgery (research and
clinical outcomes and advocacy)
The advent of inexpensive and highly scalable storage and
processing capabilities, along with the ubiquity of handheld
mobile technology and wireless communications, has opened
up numerous opportunities to mine and analyze large data­
sets for trends and outcomes information.
Residents training in surgery, as well as board Diplomates
who participate in Maintenance of Certification programs,
may participate in data registries such as the Tracking
Outcomes in Plastic Surgery (TOPS) and ABPS board collec-
tion modules. Other plastic surgeons are required to partici-
pate in the DataHub for accreditation of their ambulatory
surgery facilities by AAAASF.80 Clinically targeted registries
such as the National Breast Implant Registry81 and the Patient
Registry and Outcomes for Breast Implants and Anaplastic
Large Cell Lymphoma (ALCL) Etiology and Epidemiology
(PROFILE) registry82 (both cooperatively developed between
the Plastic Surgery Foundation and the FDA), and the General
Registry of Autologous Fat Transfer (GRAFT)83 have also been
developed out of the recognition that real data is needed to
answer important questions of safety, efficacy, and long-term
outcomes.
tactile feedback. The conceivable applications of such technolo-
gies for simulation of surgical procedures, resident skills
assessments with feedback looping, microsurgical training
replete with tremor reduction and highly detailed magnifica-
tion, and other applications are myriad. Similar to the intra-
operative applications of augmented reality cited above, other
vendors75–77 are exploring methods to incorporate CT and
other radiographic data into simulations, in combination
with instrumentation that provides verisimilitude to the tactile
experience of handling real tissues. While not a substitute for
direct intraoperative experience, these tools could provide
important adjuvant learning and preparation toolkits for stu-
dents and residents, particularly in early years of training.
Some institutions have begun using surgical simulation as a
core component of residency training, with intraoperative
feedback provided during the simulation and procedures
recorded for subsequent debriefing. The intraoperative use of
point-of-view (POV) technologies such as Google Glass and
the GoPro camera can provide the ability to communicate
from the operating room in real time with images, video and
chat tools to enhance the education of residents and other
surgeons. It may enhance the perspective of a resident who
may or may not be physically present as another surgeon
performs the procedure or, alternatively, it may augment the
viewpoint of the attending surgeon who may or may not be in
the same room, while the resident performs the procedure.
With routine use, POV systems can help facilitate the curation
of a large educational surgical video library that can be
streamed remotely on demand.
These technologies, in addition to other simple HIPAA-
compliant apps that allow real-time chat, video, and audio, can
also enhance communication and education in the emergency
department or during other consultations where a picture or
video is much more effective than a verbal description. This
can be extremely helpful in the appropriate triage and staging
of patients with lacerations and complex wounds, some of
whom can be appropriately managed in the emergency room
(by emergency department staff or the plastic surgeon) while
others require care in the operating room. They can also be
used for assessment and education of practicing plastic sur-
geons who are learning either in a simulation or by evaluation
of the surgeon’s actual cases. Larger scale review of various
surgeons’ procedures could also lead to formulation of best
practice guidance for operating efficiency that can enhance
resident education and continuing medical education.
Even the classic anatomic atlas has experienced digital
innovation: several products78,79 provide multilayered and
multi-view anatomic images, allowing a walk-through of
every layer of the human body and individual organs, holding
some promise to potentially decrease the need for human
cadaver-based dissection, or to provide educational resources
to supplement cadaver prosections. Coursework in medical
school and lecture series during residency can benefit from
digitally deployed course syllabi using numerous e-learning
and distribution programs, with surgical textbooks as well as
articles from plastic surgery journals and assorted relevant
periodicals available in electronic format for reading on iPad,
Amazon Kindle, or other handheld e-readers and tablets.
Continuing medical education is facilitated by online articles,
quizzes, Inservice exams, and conference webinars, with
participants being able to attend, rate and claim credits for
certain such activities on any web browser-enabled device.

686
CHAPTER 36 • Digital technology in plastic surgery
wearable technology, patient genomics, and other sources of
individualized data.
Furthermore, as reimbursements from third-party payers
becoming increasingly tied to value-based compensation, and
as healthcare policy-makers increasingly regulate medical
practice, the access to and analysis of Big Data will help plastic
surgeons and their specialty societies substantiate anecdotal
evidence of efficacy, safety, cost-effectiveness and other end-
points. Prospective data may also help mitigate against
unsubstantiated panic with every potential question of safety,
or alternatively, may identify safety issues before they trigger
a national crisis.
Crowdsourcing of clinical workflows and outcomes data
may allow the physician community to converge on best
practices which maximize patients’ safety, longevity and
satisfaction. Digital platforms that are easily accessed,
easily shared among providers, and easily analyzed may also
help plastic surgeons collaborate to conserve resources,
streamline workflow, decrease redundancies across practices,
and improve practice efficiencies. Some physicians are utiliz-
ing technology to create virtual group practices which main-
tain independent practice identity and autonomy while
maximizing the efficiency, negotiating power, and influence
of a collaborative group.
Some EHR platforms allow case information entered into
the clinical record to be directly integrated into certain registry
programs, reducing the need for double data entry and pro-
viding a natural method to track case volume and complica-
tions. Surgeons participating in state public health registries
and alert systems may sometimes take advantage of direct
EHR data exports through the Fast Healthcare Interoperability
Resources (FHIR) or Direct Protocols for health information
exchange that allow automatic uploading of data transfer
with other programs, registries and systems. As EHR adop-
tion increases, it is hoped that even more seamless interfaces
with automatic information transfer and portable data models
will ease the administrative burden on physicians and their
office staff.
Gathering of large-scale volumes of data is facilitated by
improvements in automated technology. When combined
with structured data architecture and natural language pro-
cessing, these aggregates, often called “Big Data”, hold sig-
nificant promise for assisting the evolution of healthcare from
evidence-based medicine to precision medicine, in which data
informing the likely outcomes specific to a subset of a popula-
tion or an individual can be utilized to facilitate better clinical
decision-making and treatment protocols. Precision medicine
can be informed by clinical information furnished through
medical records, healthcare claims, crowdsourcing sites,
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