Scientific Abstract Presentations: Top Residents Abstract Session 2 (Breast, Reconstructive) Thursday, September 26 Thu, Sep 26 8:00-9:30 a.m. PDT

Purpose: To evaluate how bariatric surgery modulates the risk of postoperative complications for obese patients prior to microvascular breast reconstruction.

Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases were queried for all patients undergoing bariatric surgery from January 2017 to December 2022. All patients with a body mass index (BMI) ≥35 kg/m2 undergoing gastric bypass or sleeve gastrectomy for therapeutic weight loss were evaluated. Patients with a BMI <35 kg/m2, receiving revision bariatric surgery, or with less than 1 year of follow-up were excluded. Preoperative variables included patient age, BMI, ASA status, and comorbidities (hypertension, diabetes, coronary artery or peripheral vascular disease, active smoking). Postoperative outcomes included BMI, ASA status, and status of comorbidities 1 year following bariatric surgery; hypertension was considered resolved once a patient was normotensive (SBP < 140 mmHg) while off antihypertensive medications, and type 2 diabetes was considered resolved with normalization of hemoglobin A1C (< 6.5%) while off oral diabetic medications and insulin. Paired Breast Reconstruction Risk Assessment (BRA) scores were generated for each patient utilizing preoperative and postoperative bariatric surgery variables. Patient BRA scores prior to and 1 year following bariatric surgery were analyzed to evaluate the potential impact of bariatric surgery on risk of 30-day complications following immediate microvascular breast reconstruction.

Results A total of 1,026 patients were included for analysis, with an average age of 47 (range 18 to 77 years) and preoperative BMI of 44.7 kg/m2 (range 35.0 to 156 kg/m2). Average preoperative ASA was 2.8. Preoperative comorbidities included hypertension (59%), type 2 diabetes (28%), coronary artery/peripheral vascular disease (1%), and smoking (7%). One-year outcomes after gastric bypass (65%) or sleeve gastrectomy (35%) included an average BMI of 32.7 kg/m2, ASA of 2.3, and resolution of hypertension (89/601, 15%) and type 2 diabetes (84/291, 29%). Paired BRA risk analysis for microvascular breast reconstruction prior to and 1 year following bariatric surgery showed a significant reduction in 30-day overall surgical complications (42% vs. 27%, Wilcoxon Signed-Rank P-value <0.0001), with an absolute risk reduction (ARR) of 15% and relative risk reduction (RRR) of 36%, exhibiting a number needed to treat (NNT) of 7. Rates of surgical site infection (31% vs. 16%, P <0.0001), seroma (11% vs. 6.9%, P <0.0001), wound dehiscence (20% vs. 11%, P <0.0001), reoperation (13% vs. 10%, P <0.0001), and flap loss (9.5% vs. 7.4%, P <0.0001) were significantly reduced 1 year following bariatric intervention. Linear regression analysis revealed that for each 1 kg/m2 reduction in preoperative BMI there was a 3.4% reduction in overall risk of 30-day surgical complications (r=0.73, r2=0.54, P<0.0001).

Conclusions: Our study suggests the potential efficacy of bariatric surgery in reducing complications following microvascular breast reconstruction in obese patients. While this approach may be limited in patients with active breast cancer needing immediate reconstruction, there remains a population of patients who could significantly benefit from this strategy.

Background: The accessibility and demand of reconstructive surgeries following mastectomy have significantly increased, leading to the consideration of their costs on the healthcare system. This study aimed to explore factors associated with increased hospitalization costs following autologous breast reconstruction.

Methods: This was a retrospective cohort study including patients undergoing free tissue postmastectomy breast reconstruction from 2005 to 2020 in the province of Ontario, Canada (population 14 million). Participants were women who underwent autologous breast reconstruction surgery with either a pedicled transverse rectus myocutaneous (TRAM) flap or free tissue transfer. Cost analysis was performed from the individual hospital perspective. The time horizon was from hospital admission to discharge after autologous breast reconstruction surgery. Generalized linear models with a gamma distribution were used to determine factors associated with of cost.

Results: This cohort included 2,634 patients of which 380 (14 %) underwent pedicled TRAM reconstruction and 2,256 (86 %) underwent free flap reconstruction. The median hospitalization cost was CAD 8,816 (interquartile range $793). Common drivers of cost identified in the univariate analysis included length of admission, free flap reconstruction, age, income quintile, laterality (unilateral vs bilateral), and emergency reoperation within seven days. Our adjusted multivariable analysis revealed type of reconstruction (free flap reconstruction: 13% cost increase, 95% confidence interval [CI] 1.05-1.22), age above 70 (31% increase, 95 CI% 1.07-1.61), income quintile (quintile 5 v. quintile 2: 10% increase, 95% CI 1.03-1.18), and bilateral reconstruction (11% increase, 95% CI 1.02-1.22) were all independently associated with increased costs. Factors such as type of hospital (teaching vs non-teaching hospital), geographic region, timing of reconstruction (immediate), preoperative radiation, Charlson Comorbidity Index, diabetes, and rurality did not impact hospitalization costs.

Conclusion: This study identifies key contributors to increased hospitalization costs in a publicly funded healthcare system, notably free tissue transfer, bilateral reconstructions, as well as lower socioeconomic status. Conversely, factors such as geographic location, timing of reconstruction, and patient comorbidities do not influence costs. These findings highlight opportunities for targeted policy development and resource allocation to manage expenses effectively in breast reconstruction services.

Purpose: The purpose of this study was to assess the impact of resident involvement on patient outcomes in reduction mammoplasty.

Design: Meta-analysis

Methods: This paper followed Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Two independent authors searched PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov from inception to January 2024 to find studies assessing the impact of resident involvement on patient outcomes in reduction mammoplasty. Included studies were all full-text articles that examined the effects of resident participation (no trainees at the fellowship level) in reduction mammoplasty procedures in single-center and ACS National Surgical Quality Improvement Program (ACS NSQIP) studies. Six patient characteristics and two patient outcomes that had multiple studies (≥ 3) for comparison were analyzed with and without resident involvement. Categorical data from studies were pooled to report odds ratio (OR) and 95% confidence intervals (95% CIs). Continuous data were analyzed to yield standardized mean difference (SMD) and 95% CIs. Study quality was assessed on the Newcastle-Ottawa Scale and ascribed a quality label per Agency for Healthcare Research and Quality standards by three independent authors.

Results: Five studies were included in this meta-analysis, comprising a total of 2,070 patients. (1-5) Among included studies, residents were involved in operations with more ASA Class 3 and 4 patients compared to the no resident group (OR, 1.41; 95% CI [1.27, 1.57], 3 studies (20,943 patients), I2=37%).(1,3,4) A significant increase in overall complications was observed in the resident group (OR, 1.76; 95% CI [1.52, 2.05], 3 studies (13,765 patients), I2=0%).(2,3,5) Perioperative steroid use (OR, 1.20; 95% CI [0.90, 1.59], 3 studies (20,943 patients), I2=0%) and operative time (SMD, 2.29; 95% CI [-6.20, 10.77], 3 studies (20,943 patients), I2=93%) demonstrated no significant variation between groups.(1,3,4)

Conclusion: Resident involvement in reduction mammoplasty has been associated with an increase in patient overall complications. However, this may be attributed to the fact that residents were involved in operating on sicker patients as demonstrated by the overall higher ASA scores. Further research is indicated to investigate these trends; this study was limited to mainly data with few high-quality studies with baseline patient characteristics adjusted for in in the study comparison groups. A major limitation of this research is qualification of resident involvement, as the degree to which a resident is involved will vary based on a particular program's policies as well as what year of residency they are in.

1. Fischer JP, Cleveland EC, Shang EK, Nelson JA, Serletti JM. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Article. Aesthetic Surgery Journal. 2014;34(1):66-73. doi:10.1177/1090820X13515676
2. Fischer JP, Wes AM, Kovach SJ. The impact of surgical resident participation in breast reduction surgery--outcome analysis from the 2005-2011 ACS-NSQIP datasets. Article. Journal of plastic surgery and hand surgery. 2014;48(5):315-321. doi:10.3109/2000656X.2014.882345
3. Malyar M, Peymani A, Johnson AR, Chen AD, Van Der Hulst RRWJ, Lin SJ. The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures: A Comprehensive Analysis of 9638 Patients. Article. Annals of plastic surgery. 2019;82(3):310-315. doi:10.1097/SAP.0000000000001714
4. Ourian AJ, Doval AF, Zavlin D, Chegireddy V, Echo A. Evaluating patient outcomes in breast and abdominal cosmetic plastic surgery procedures involving residents. Article. Aesthetic Surgery Journal. 2019;39(5):572-578. doi:10.1093/asj/sjy329
5. Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. Resident participation does not affect surgical outcomes, despite introduction of new techniques. Article. Journal of the American College of Surgeons. 2010;211(4):540-545. doi:10.1016/j.jamcollsurg.2010.06.008

Background: SARS-CoV-2 (COVID-19) infection has an increased risk of thrombosis; however, studies of its association with microsurgical free flap breast reconstruction thrombosis are limited. This study investigates postoperative complications in patients undergoing Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction, (1) pre- versus post-COVID pandemic period, (2) with and without history of COVID infection, and (3) within 40 days or > 40 days from COVID-19 vaccination or booster.

Methods: A retrospective review of a prospective database was performed of 469 DIEP flap breast reconstruction patients. Cohorts were divided into pre-COVID (January 23, 2017- January 19, 2020, n=236) and post-COVID (January 20, 2020 – present, n=233) groups. Patients within the post-COVID period were further divided into history of documented COVID infection (n=24) and no history of documented COVID infection (n=209). Sociodemographic and clinical variables, including history of COVID infection or vaccination and complications were analyzed.

Results: Median age was 50 years and mean BMI was 28.57 kg/m2. The post-COVID group had significantly more former smokers (74 vs 35, p=0.001) and more bilateral DIEP flaps performed (157 vs 126, p<0.891), but no significant differences in intraoperative anastomotic revisions or in major post-operative complications. In the post-COVID period, 24 patients (10.4%) had a COVID infection history pre-operatively and 178 (76.4%) patients had been vaccinated; 20 (11.3%) of whom had received COVID vaccination/booster within 40 days of surgery. Patients with a history of COVID infection or those who received vaccination/booster within 40 days of DIEP flap demonstrated similar rates of complications, including thrombotic-related complications, as those patients without history of COVID infection or vaccination within 40 days, respectively.

Conclusion: Major and minor post-operative complications were similar in pre- and post-COVID period patients. There were no significant differences in rates of major post-operative complications among patients with history of COVID infection preoperatively or those who received vaccination/booster ≤40 days before surgery.

References 1. Ho W, Köhler G, Haywood RM, Rosich-Medina A, Masud D. Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience. J Plast Reconstr Aesthetic Surg JPRAS. 2022;75(1):112-117. doi:10.1016/j.bjps.2021.09.007 2. Chen J, Chow A, Lee E, et al. Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic. J Reconstr Microsurg. Published online July 7, 2022. doi:10.1055/s-0042-1749677 3. Smadja DM, Yue QY, Chocron R, Sanchez O, Lillo-Le Louet A. Vaccination against COVID-19: insight from arterial and venous thrombosis occurrence using data from VigiBase. Eur Respir J. 2021;58(1):2100956. doi:10.1183/13993003.00956-2021 4. Mani A, Ojha V. Thromboembolism after COVID-19 Vaccination: A Systematic Review of Such Events in 286 Patients. Ann Vasc Surg. 2022;84:12-20.e1. doi:10.1016/j.avsg.2022.05.001 5. Sharifian-Dorche M, Bahmanyar M, Sharifian-Dorche A, Mohammadi P, Nomovi M, Mowla A. Vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis post COVID-19 vaccination; a systematic review. J Neurol Sci. 2021;428:117607. doi:10.1016/j.jns.2021.117607

Background: Infection is problematic in implant-based breast reconstruction. Explantation can be particularly challenging with nipple sparing mastectomy (NSM). Traditionally, infected implants are removed for several months resulting in delay of reconstruction and nipple malposition. The need for secondary nipple position adjustment has not been characterized. The purpose of this study is to evaluate the necessity of nipple location adjustment following implant removal with nipple sparing mastectomy.

Methods: A single-center retrospective review of breast cancer patients who underwent implant-based breast reconstruction following nipple sparing mastectomy between 2018 to 2022. Patients were included if they required removal of the tissue expander (TE) or implant because of infection or skin necrosis. Demographic data, comorbidities, mastectomy incision type, duration of being without reconstruction, subsequent operation after tissue expander loss, and nipple adjustment type were recorded. Outcome variables included postoperative infection (TE loss or hospitalization for intravenous antibiotics), skin necrosis rate, adjusted nipple location, and time to next operation.

Results: In our study period, 188 patients underwent nipple sparing mastectomy. Complications following surgery (infection or skin necrosis) occurred in 25 patients (46 total tissue expanders) who underwent nipple sparing mastectomy with immediate implant-based reconstruction. The average age was 48.2 ± 10.8 years old and body mass index (BMI) was 30.4 ± 6.4 kg/m2 of patients who develop complications after NSM. Total implant loss from either infection or skin necrosis was 13.3% (25/188). The infection rate leading to implant loss requiring intravenous antibiotics was 7.9% (15/188). The skin necrosis rate was 5.3% (10/188) of NSM patients that ultimately necessitated explanation. Nipple adjustment was required in 53% (8/15) of NSM patients who had infection and 50% (5/10) who had skin necrosis. Salvage with implant removal, placement of negative pressure wound vacuum therapy with instillation and dwell (NPWTi-d), and replacement of an implant while inpatient was performed in 3 patients. None had reinfection or required nipple repositioning. The average time that patients experienced without an implant/tissue expander was 4.3 ± 2.3 days in NPWTi-d patients compared to 135.7 ± 97.6 days in patients without NPWTi-d (p=0.0007). Radiation occurred in 20% (3/15) of patients after implant loss from infection who required had either deep inferior epigastric perforator flap (2 patients) or latissimus flap reconstruction (1 patient) as the next stage of operation. In patients with skin necrosis, there were 20% (2/10) who had radiation after implant loss who underwent deep inferior epigastric perforator flap reconstruction.

Conclusion: Nipple location may be preserved in nipple sparing mastectomy patients who receive NPWTi-d with faster reconstruction rates following infection compared to a matched control group. NPWTi-d may serve as a therapy adjunct in forming an algorithm following loss of a tissue expander.

Purpose: Implementation of Enhanced Recovery After Surgery (ERAS) programs, protocols designed to standardize and optimize perioperative medical care, have been shown to allow for same day discharge of patients undergoing immediate implant-based reconstruction following mastectomy. High-quality studies reporting ERAS implementation and subsequent outcomes in this patient population are lacking. The purpose of this study was to compare outcomes of patients undergoing mastectomy with immediate implant-based breast reconstruction discharged on the day of the surgery versus post-operative day one.

Methods and Materials: A randomized controlled trial was conducted at two hospitals including patients who underwent immediate implant-based breast reconstruction after mastectomy for prophylaxis or breast cancer. Patients were randomized to discharge either on the day of surgery or post-operative day one. All patients completed pre-operative validated surveys, and post-operative validated surveys at days 1 and 7. Surveys included the PROMIS-29, a quality-of-life survey and the QoR-15 Scale, an assessment capturing patient satisfaction with support, comfort and emotions. Higher scores in both surveys equate with better health. All patients recorded narcotic consumption for up to 30 days after surgery which were converted to morphine milligram equivalents (MME). Thirty-day post-operative outcomes were recorded including complications, emergency room visits, readmissions, and reoperations.

Results: A total of 203 breasts were reconstructed in 122 patients, with mean age of 48 years (range 23-75 years). Sixty patients were randomized to discharge on post-operative day 0 (POD0) and 62 patients were randomized to discharge on post-operative day 1 (POD1). Differences in the QoR-15 Scale scores were noted at baseline and post-operatively, with the post-operative group having higher scores; after adjustment for covariates and baseline differences, differences at follow-up were no longer significant (p=0.07). PROMIS-29 scores were higher in the POD1 group than the POD0 group for some domains, including physical function, while no significant differences were seen in other domains. There was no difference in post-operative MME consumption between the POD0 and POD1 cohorts, with median (IQR) MME consumption of 67.5 (15.0, 135.0) and 71.3 (18.3,133.1), respectively (p=0.78). No difference was observed in post-operative day 7 pain scores, with a median (IQR) of 4 (3-5) in POD0 and 4 (2-5) in POD1 (p=0.39). The most frequent complication was hematoma (3.3%), followed by mastectomy flap necrosis (2.5%), and cellulitis (1.6%). Ten patients presented to the emergency room within 30 days of discharge (POD0=6 vs POD1=4), with 4 patients requiring hospital admission. Six patients (5%) required reoperation (POD0=4 vs POD1=2). In the POD0 cohort, 3 patients required hematoma washout and 1 patient required device replacement due to infection. In the POD1 cohort, one patient no longer desired reconstruction, and the other patient required device replacement due to infection.

Conclusion: Our study showed that regardless of whether mastectomy patients undergoing immediate implant-based breast reconstruction are discharged on POD0 or POD1, complication rates are similarly low with no difference in narcotic consumption and similar patient satisfaction scores. ERAS pathways may be useful in optimizing patient care to allow for same day discharge while maintaining high-quality of care and reducing costs.

Purpose: This systematic review and meta-analysis aimed to investigate chronic pain in mastectomy alone, alloplastic reconstruction following mastectomy and autologous reconstruction following mastectomy, including: 1) overall chronic pain prevalence; and 2) character and location of chronic pain to determine the etiology; and 3) chronic pain intensity.

Methods: MEDLINE, Embase, and Web of Science were searched for observational studies and randomized controlled trials from inception to October 9, 2023. Inclusion criteria required: (1) mastectomy with or without breast reconstruction for breast cancer, carcinoma in situ or risk reduction, (2) minimum three month post-operative follow up, (3) pain to breast, axilla, arm or donor site after breast surgery. Meta-analysis was carried out using a random-effects model to assess the pooled prevalence with 95% confidence interval (CI).

Results: 79 studies with 21,606 breast cancer patients were included. 13 different pain scales were used to describe chronic pain post-mastectomy. The reported prevalence of chronic pain ranged from 7.5% to 100%. Mean prevalence of chronic pain following mastectomy using the random-effects model was 44.57% [36.63, 52.51]. Mean prevalence of chronic pain following immediate alloplastic reconstruction was 52.99% [CI: 40.28, 65.70], following delayed autologous reconstruction was 42.81% [CI: -3.55, 89.17], and to the donor site following reconstruction was 25.35% [-11.31, 62.01]. One study reported delayed alloplastic reconstruction, with a reported prevalence of 34.44% for chronic pain.

Conclusion: Chronic pain following mastectomy and reconstruction is prevalent, with immediate alloplastic patients reporting the highest prevalence of pain. However, heterogeneity among studies remains high. Prospective studies that better characterize how timing and type of breast reconstruction affect chronic pain, using validated breast cancer specific pain assessment tools, are required.

The development of pathological scars is a common sequelae following acute management of thermal burns(1). The management of hypertrophic burn scars remains challenging despite various therapeutic modalities, such as compressive garments or silicone-containing sheets or gels(2,3). Since the initiation of laser therapy in the treatment of pathological scars secondary to burns, fractional CO2 laser therapy has emerged as a promising alternative(4,5). This prospective observational study aimed to evaluate the effectiveness of fractional ablative CO2 laser therapy in treating hypertrophic burn scars and to assess differences in outcomes based on initial debridement technique. A total of 24 pathological scars in 21 patients were treated with fractional CO2 laser therapy in our center between January 2022 and January 2024. Flame-related injuries were predominant. In acute management, bromelain-based enzymatic debridement was used in 45.8% of cases and skin grafting was required in 75% of cases. Laser was not applied until at least 6 months after epithalization. The mean follow-up duration was 19.98 months. Significant improvements were observed in scar characteristics, as measured by the Vancouver Scar Scale and Patient and Observer Scar Assessment Scales (POSAS), at 6, 12, and 24 months post-treatment compared to pre-treatment scores (p=0.001; p=0.003; p=0.011). Notably, there were no differences in scores comparing measurements at 12 and 24 months post-treatment. No significant differences were found in scar outcomes based on initial debridement technique. Fractional CO2 laser therapy demonstrated efficacy in improving hypertrophic burn scars, with sustained benefits observed starting from the 6th month of follow-up. Despite variations in initial debridement techniques, no significant differences in outcomes were observed, highlighting the potential utility of fractional CO2 laser therapy as a standalone treatment or in conjunction with other modalities for hypertrophic burn scars. Further research with larger cohorts and longer follow-up durations is warranted to confirm these findings and optimize treatment protocols. 1. Oosterwijk AM, Mouton LJ, Schouten H, Disseldorp LM, van der Schans CP, Nieuwenhuis MK. Prevalence of scar contractures after burn: A systematic review. Burns J Int Soc Burn Inj. 2017;43(1):41-49. doi:10.1016/j.burns.2016.08.002 2. Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. J Plast Reconstr Aesthetic Surg JPRAS. 2009;62(1):77-84. doi:10.1016/j.bjps.2007.10.052 3. O'Brien L, Jones DJ. Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2013;2013(9):CD003826. doi:10.1002/14651858.CD003826.pub3 4. Choi KJ, Williams EA, Pham CH, et al. Fractional CO(2) laser treatment for burn scar improvement: A systematic review and meta-analysis. Burns J Int Soc Burn Inj. 2021;47(2):259-269. doi:10.1016/j.burns.2020.10.026 5. Poetschke J, Dornseifer U, Clementoni MT, et al. Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled, standardized treatment approach. Lasers Med Sci. 2017;32(5):1031-1040. doi:10.1007/s10103-017-2204-z

Introduction: Management of distal upper extremity trauma with extensive soft tissue, nerve, and arterial involvement presents a challenge for reconstruction. The most common options for soft tissue reconstruction include the reverse radial forearm, posterior interosseous, groin, or free flaps. We present the case of an 11-year-old male following an ATV collision with a resulting grade 3 open distal radius and ulna fracture, 5x13 cm volar soft tissue defect with exposed flexor tendon, radial artery occlusion, and median nerve injury which was reconstructed with an ulnar-based transposition flap (UBTF) and sural nerve cable graft.

Methods: The patient underwent several debridements until a clean wound bed was achieved. Integra was used for initial wound closure, and an UBTF and cable graft were employed for definitive management. Median neurolysis and debridement demonstrated a 6 cm nerve gap, which was repaired using a 26 cm sural nerve autograft in a cable fashion. Soft tissue reconstruction with a UBTF was achieved by making a curvilinear incision on the volar surface of the forearm, transposing the flap to the most distal and radial aspect to cover the defect. Split-thickness skin grafts were placed on the antecubital fossa and the distal aspects of the wrist to decrease tension on flap inset.

Results: The patient reported full flexion and extension at digital joints with excellent opposition to the thumb and progressive paresthesia of the thumb, index, and long fingers in the first month of intervention. After five weeks, the patient received physical therapy. After eight weeks, there was an improvement in wrist flexion from 60 to 65 degrees and in wrist extension from 25 to 35 degrees. The patient has regained sensation in the thumb, index, and long fingers, and has returned to all activities of daily living with good grip strength at the five-month follow-up.

Conclusion: Reconstructing nerves in the distal upper extremity can be a significant challenge, especially when the distal radial artery is blocked due to injury. Achieving functional nerve restoration and soft tissue coverage is crucial in such cases. The UBTF reduces donor site morbidity and can be an alternative choice for reconstruction in cases of compromised radial arteries. We utilize a unique flap for soft tissue coverage in situations where conventional flaps cannot be used, while decreasing the donor site morbidity.

Background: Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there remains a notable gap in understanding how elevated BMI specifically impacts functional outcomes after post-traumatic lower extremity (LE) free flap reconstruction. Consequently, this study aims to elucidate the relationship between elevated BMI and ambulation following LE-flap reconstruction. In doing so, we hope to enhance patient care and preemptively address potential complications within this specific patient population.

Methods: A retrospective review was performed at a level 1 trauma center between 2007-2022 of patients who underwent post-traumatic LE reconstruction with free flap tissue transfer and microvascular anastomoses. Demographic data, flap and wound details, complications, and ambulatory outcomes were recorded. Patients were stratified into BMI categories as defined by the Center for Disease Control (CDC). The primary outcomes were ambulation status, (ambulatory, assistance device, wheelchair) and time to final ambulation, which were modeled with multivariate logistic and linear regression. Secondary outcomes included postoperative complications.

Results: A total of 398 patients were included in the study with an overall average BMI of 28.2 ± 5.8. There were no significant differences with regard to prior ambulatory status between any of the obese classes and the remaining non-obese cohort. Patients who were ambulatory at final follow-up had a significantly lower BMI than those who still required a wheelchair or assistance device (27.6 vs. 28.6, p=0.049). There were no differences in ambulation outcomes between patients in class I or class II obesity compared with the remaining cohort. However, patients with class III obesity were significantly less likely to be ambulatory at final follow-up. Multiple logistic regression demonstrated that when controlling for age, smoking status, flap type (local vs. free and myocutaneous vs. fasciocutaneous), class III obese patients were significantly less likely to be ambulatory (OR: -1.3, 95% CI -2.6 - -.072, p=.038). At final follow-up, less than a third of patients with class III obesity were ambulatory (30.1%), with the remaining requiring either wheelchairs (42.3%) or assistance devices (26.9%).

Conclusions: This study highlights the significant impact of elevated BMI on post-traumatic LE reconstruction outcomes, particularly regarding ambulatory function. The findings underscore the importance of considering BMI as a critical factor in patient care and surgical decision-making in the context of lower limb reconstruction. Moving forward, further research is warranted to explore interventions aimed at optimizing outcomes for patients with higher BMI undergoing LE-flap reconstruction, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.

Introduction: Post-operative hyperglycemia (POHG) has been associated with higher rates of complications, prolonged hospitalization, and increased costs of care after numerous surgical procedures (1,2). In patients undergoing free tissue transfer for head and neck reconstruction, POHG has been shown to be associated with increased rates of surgical site infection and wound healing complications (3,4). However, the effect of POHG on surgical outcomes in patients undergoing microvascular free tissue transfer for limb salvage has not been studied.

Methods: A retrospective review of all patients who underwent microvascular free tissue transfer for upper or lower limb salvage at a single academic medical center from 2013 to 2023 was conducted. Outcome measures such as rates of surgical site infection, wound healing complications, venous/arterial thrombus, partial/complete flap loss, length of hospital stay and readmission were compared between patients with POHG (defined as ≥ 165 mg/dL within 48 hours of surgery) and those who were normoglycemic.

Results: 141 patients (68.79% male, mean age 46.74 years) who underwent free tissue transfer for upper or lower limb salvage were included. 75.18% (n=106) of patients were normoglycemic while 24.82% (n=35) experienced POHG. 15.10% (n=16) of normoglycemic patients had surgical site infections, versus 31.43% (n=11) in the POHG group (p=0.033). 20.75% (n=22) of normoglycemic patients had wound healing complications, versus 45.71% (n=16) of patients POHG (p=0.004). The mean length of hospital stay was 33.14 days in the normoglycemic group and 45.32 days in the group with POHG (p=0.019). The rates of readmission within 30 days for the normoglycemia and POHG groups were 9.43% (n=10) and 28.57% (n=10) respectively (p=0.005). There were no significant differences in rates of surgical re-exploration, venous/arterial thrombus, hematoma, seroma, or partial/complete flap loss.

Conclusions: POHG is associated with increased length of hospital stay, and with higher rates of surgical site infection, wound healing complications, and readmission. There is no association with higher rates of surgical re-exploration, partial flap loss, or complete flap loss. Normoglycemia should be maintained in the early post-operative period after free tissue transfer to optimize patient outcomes.

References: 1. Vogel TR, Smith JB, Kruse RL. The association of postoperative glycemic control and lower extremity procedure outcomes. J Vasc Surg. 2017 Oct;66(4):1123-1132. doi: 10.1016/j.jvs.2017.01.053. Epub 2017 Apr 19. PMID: 28433336; PMCID: PMC5625331. 2. Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008 Oct;248(4):585-91. doi: 10.1097/SLA.0b013e31818990d1. PMID: 18936571. 3. Offodile AC 2nd, Chou HY, Lin JA, Loh CYY, Chang KP, Aycart MA, Kao HK. Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects. Oral Oncol. 2018 Apr;79:15-19. doi: 10.1016/j.oraloncology.2018.02.009. Epub 2018 Feb 14. PMID: 29598945. 4. Bollig CA, Spradling CS, Dooley LM, Galloway TL, Jorgensen JB. Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction. Head Neck. 2018 Jun;40(6):1196-1206. doi: 10.1002/hed.25097. Epub 2018 Mar 1. PMID: 29498137.

Background: As the aging population increases, so does the incidence of frailty amongst head and neck cancer (HNC) patients. The utility of the modified frailty index-5 (mFI-5), a scale based on five variables in the ACS-NSQIP database, to predict adverse outcomes in patients who have undergone both pedicled and microvascular free tissue transfers for reconstruction in the setting of HNC is unclear. Methods: The ACS-NSQIP database (2017-2022) was used to identify HNC patients undergoing pedicled or microvascular free tissue transfers. Baseline characteristics/comorbidities were compared among the individual mFI-5 score groups. Kaplan-Meier curves and multivariable Cox regression analyses were performed to investigate associations of infections, bleeding, readmissions, reoperations, major adverse cardiovascular events (MACE), and all-cause mortality within the first postoperative month for each mFI-5 group with mFI-5=0 as reference. Results: A total of 5,573 patients (median age: 64, 31.5% female) were included. Univariate analyses demonstrated associations between increasing mFI-5 scores and long hospital stays, infections, MACE, and all-cause mortality. Cox regression analyses showed a 25% relative risk increase for infections in patients with an mFI-5 score of 2 and a 51% increase for a score ≥ 3 (adjusted HR: 1.25 and 1.51; p=0.01 and p=0.02). Additionally, mFI-5≥3 was associated with a 2.5-fold risk increase for MACE (adjusted HR: 3.56; p<0.05). Conclusion: In a nationwide cohort of adult HNC patients who underwent reconstruction with pedicled or microvascular free tissue transfers, higher mFI-5 scores were associated with postoperative infections and MACE but not with bleeding, readmission, reoperation or all-cause mortality.

Purpose: Common peroneal nerve (CPN) palsy is the most common lower extremity nerve injury. Palsy results in detrimental gait consequences. There is a paucity of literature clarifying the intraneural topography and branching pattern of the CPN. This information can help surgeons with distal nerve transfers and fascicular reconstruction of the CPN and its major deep (DPN) and superficial (SPN) branches. Methods: The CPN was dissected through an anterolateral exposure in six lower leg cadavers starting proximal to the fibular head and ending distally to its motor and sensory branches. Branches were labeled and measurements were recorded in-situ to determine the distance between branch points and the fibular head, which served as our surgically relevant landmark. The nerve and its branches were then removed, and cross-section samples were prepared and stained for histologic review. Four specialty stains were performed – ChAT, CGRP, Laminin, and Neurofilament – along with H&E staining. The histology slides were analyzed and cross-referenced to determine the fascicular architecture of the CPN at various levels focusing on the CPN proximal, within, and distal to the fibular tunnel. Results: The CPN was identified within the fibular tunnel deep to the leading edge of the peroneus longus (PL) in all specimens. The bifurcation of CPN into DPN and SPN was found distal to the fibular tunnel in all specimens. There is marked variability in the branching pattern of CPN, DPN, and SPN. Regarding clinical relevance, the tibialis anterior branch point ranged from 6 to 14 cm from the fibular head making it the most distal motor branch of DPN. Despite the variability of branching patterns, the fascicular topography of the CPN within the fibular tunnel was consistent. Proximal to the tunnel, the nerve has three major fascicles which include the SPN motor, common sensory, and DPN motor fascicles from lateral to medial. Within the tunnel the topography consolidates into two major divisions – SPN lateral and DPN medial – with the motor axons anterior and sensory axons posterior. The individual motor branches begin to split according to the variable branching patterns of each specimen. Conclusion: Surgical interventions for CPN palsy range from fibular tunnel release and neurolysis to nerve transfers and nerve grafting. The data presented is clinically relevant information for the peripheral nerve surgeon. Fascicular reconstruction of the nerve and neurolysis should focus on the anterior half of the nerve to restore motor function. Proximal to the fibular tunnel, fascicles are divided into three major fascicles compared to two distally. Injuries at the level of the fibular tunnel can be reconstructed with distal nerve transfers from the tibial nerve motor branches to the DPN or tibialis anterior motor branch through an interosseous septal window. The branching patterns and measurements within this study will help surgeons identify the appropriate surgical procedure for each patient.

Human face transplantation (FT) is now in its second decade, and we have witnessed a number of successful cases since the first operation took place in 2005. However, despite significant improvements in techniques and outcomes over the years(1,2), acute rejection (AR) of the graft remains one of the most frequent complications, occurring in more than 80% of FT patients within the first postoperative year (3). Failure to identify AR in a timely fashion can lead to significant damage and potential loss of the graft. To date, we have limited tools for acute rejection monitoring and rely on late clinical signs as well as invasive graft punch biopsy for diagnosis. It is known that as acute rejection occurs and allograft cells undergo apoptosis, its fragmented DNA become systemically present in the FT recipient bloodstream and is a direct proxy of graft apoptosis. This study draws from this principle and aims to establish the utility of donor-derived cell free DNA (ddcfDNA) as a novel mechanism to assess and diagnose acute rejection following FT.

Hemifacial transplants were performed in a rat model and animals were allowed to undergo acute rejection. At different time points, allograft tissue samples were assessed by immunofluorescence and H&E staining for presence of inflammation and ulceration. Concurrently, blood samples were obtained for DNA extraction and next generation sequencing for cell free DNA analysis.

Acute rejection was achieved within an average of 5.3±2 days following FT, and confirmed on H&E and immunostaining staining, showing significant increase in inflammatory infiltrates and skin ulceration. Genomic analysis revealed detection of ddcfDNA in the blood of transplanted rats correlating with rejection. In addition, we have identified small nucleotide polymorphisms and haplotypes specific to the allograft. Our results demonstrate a correlation between skin changes, rejection markers and genetic changes and establish the potential for cell free DNA as a marker for acute rejection following FT.

1. Dubernard, J.-M. et al. Outcomes 18 Months after the First Human Partial Face Transplantation. New England Journal of Medicine 357, 2451–2460 (2007).
2. Rifkin, W. J. et al. Achievements and Challenges in Facial Transplantation. Ann Surg 268, 260–270 (2018).
3. Petruzzo, P., Sardu, C., Lanzetta, M. & Dubernard, J. M. Report (2017) of the International Registry on Hand and Composite Tissue Allotransplantation (IRHCTT). Curr Transplant Rep 4, 294–303 (2017).