Scientific Abstract Presentations: Top Residents Abstract Session 3 (Breast, Reconstructive) Thursday, September 26 Thu, Sep 26 8:00-9:30 a.m. PDT

Background Oncoplastic surgery (OPS) is an accepted breast conservation surgical option for the treatment of breast cancer. Extensive dissection and breast tissue resection provides a lower positive margin rate but also contributes to higher wound complication rates. Closed-incision negative pressure therapy at -125mmHg (cINPT) decreases the rate of wound complications but at a fiscal cost. Our aim was to examine the cost-utility of cINPT in oncoplastic surgery.

Study Design A literature review was performed to obtain the probabilities and outcomes for the treatment of unilateral breast cancer with OPS with cINPT or with standard dressing. Reported utility scores in the literature were used to calculate quality adjusted life years (QALYs) for each health state. A decision analysis tree was constructed with rollback analysis to determine the more cost-effective strategy. An Incremental Cost-Utility Ratio (ICUR) was calculated. Sensitivity analyses were performed.

Results OPS with contralateral symmetrizing operation and cINPT is associated with a higher clinical effectiveness (QALY) of 33.43 compared to without cINPT (33.42), and relative cost increase of $667.89. The resulting ICUR of $57432.93/QALY favored cINPT (Figure 1). In one-way sensitivity analyses, cINPT was the more cost-effective strategy if the cost of cINPT was less than $1,347.02, or if the probability of wound dehiscence without cINPT was greater than 8.2%. Monte-Carlo analysis showed a confidence of 75.39% that surgery with cINPT is more cost effective.

Conclusions Despite the added cost, surgery with cINPT is cost-effective. This finding is a direct result of the decreased overall wound complications with cINPT. These findings support current literature which promotes the use of cINPT in patients with an increased risk of wound complications (diabetes, smoking, etc.) and is the first to show its cost effectiveness in OPS. cINPT should therefore be considered in the oncoplastic population.

Introduction: Over the last 15 years, there have been novel approaches in breast cancer surgical care. Plastic surgery no longer applies only to post mastectomy reconstruction given newer techniques in oncoplastic surgery which involve reconstruction after breast conserving partial mastectomies. This study aims to provide a contemporary analysis of surgical trends using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) focusing on surgical options including partial mastectomy (PM), mastectomy without reconstruction (M), mastectomy with Autologous reconstruction (M+AR), mastectomy with implant reconstruction (M+IR), and Oncoplastic Surgery (OPS). Secondarily, this study investigates trends across all aspects of breast reconstruction, specifically Oncoplastic surgery.

Methods: A retrospective cohort analysis was conducted using the ACS-NSQIP database from 2008 to 2022. Patients were categorized into surgical groups based on current procedural terminology (CPT) codes for PM, M, M+IR, M+AR, and OPS (1). A subgroup analysis was conducted to elaborate on each reconstructive surgical group focusing on types of oncoplastic surgery performed, when applicable. Data analysis was conducted via Pearson's chi-squared test for demographics, linear regression, and a non-parametric Mann- Kendall test to assess a temporal trend and Sen's slope.

Results: The patient cohort consisted of 420,863 patients from the NSQIP database and of those patients, 6,585 did not meet inclusion criteria (i.e. inappropriate CPT or ICD codes). Annual breast surgery trends from 2008 to 2022 changed as follows: PM 39.3% to 46.4%, M 38% to 25.3%, M+IR 18% to 20%, OPS 1.3% to 4.8% (all p<0.01) and M+AR 3.4% to 3.5% (p>0.05). In the subgroup analysis, 119,096 patients had reconstructive surgery. Here we found reconstruction after mastectomy procedures declined aside from those receiving free flap reconstruction: Mastectomy + Implant placement 78.6% to 70.2%, Mastectomy + Latissimus Dorsi Flap 1.7% to 0.6%, Mastectomy + TRAM flap 7.9% to 0.4%, and Mastectomy + Free Flap 5.3% to 11.2%. The OPS group had a significant increase across all sub-categories: Level 1 OPS 1.6% to 9.5%, Level 2 OPS 3.2% to 6.2% and volume replacement OPS 0.9 to 1.4% (all p<0.01).

Conclusion: This study provides a comprehensive analysis of demographic profiles and surgical trends across common breast interventions and reconstructive surgeries. Understanding patient profiles, surgical eligibility and current trends in breast surgery are essential when counseling patients during the pre-operative decision making process to optimize surgical outcomes and improving access to breast cancer reconstruction.

References: 1. Jonczyk MM, Jean J, Graham R, Chatterjee A. Surgical trends in breast cancer: a rise in novel operative treatment options over a 12 year analysis. Breast Cancer Res Treat. 2018.

Introduction:
The risk factors for the development of breast cancer-related lymphedema (BCRL) have been well studied, but little is known about the effect of hand dominance (HD). As the treatment of BCRL involves movement and physical therapy of the affected limb, we postulated that the increased use of a dominant upper extremity may be protective against the development of lymphedema. The purpose of this study was to determine if there is an association between HD and the development of BCRL after mastectomy for unilateral breast cancer. We hypothesized that patients with HD ipsilateral breast cancer would develop post-mastectomy BCRL significantly less often than those with HD contralateral breast cancer due to the increased use of the dominant upper extremity.

Methods and materials: A retrospective cohort study was conducted involving women with breast cancer who underwent mastectomy at a single institution from January 2012 to June 2022. Patients <18 years old, with incomplete records, bilateral breast cancers, or unable to obtain HD information were excluded. BCRL diagnosis was confirmed by a certified lymphedema therapist. All patients had a minimum follow-up period of 1.5 years post-mastectomy. The laterality of hand dominance and breast cancer was categorized as ipsilateral (on the same side) or contralateral (on opposite sides). Univariable and multivariable analyses including linear ANOVA were performed.

Results: Two hundred sixty-six patients were included in the analysis, with 70 (26.3%) patients diagnosed with BCRL. Of the 196 patients without BCRL, 104 (53.0%) had HD ipsilateral breast cancer. Of the 70 patients with BCRL, 30 (42.9%) had HD ipsilateral breast cancer, and 40 (57.1%) had HD contralateral breast cancer. Univariable analysis demonstrated that there was no significant difference in BCRL development based on HD ipsilateral or HD contralateral breast cancer (P=0.14). There was no significant difference in BCRL development among those that underwent sentinel lymph node biopsy (SLNB) (P=0.48) or axillary dissection (P=0.50) when compared between HD ipsilateral and HD contralateral breast cancer groups.

Multivariable analysis of the study population was performed predicting for the development of BCRL. There was no significant association with the development of BCRL and HD ipsilateral breast cancer (P= 0.07), body mass index (P=0.63), and post-mastectomy reconstruction (P=0.56). There was a significant association between the development of BCRL and the number of lymph nodes removed (P<0.001), adjuvant chemotherapy (P=0.04), and adjuvant radiation therapy (P<0.001). There was a significant interaction with post-mastectomy reconstruction (P=0.01) when these variables were compared to HD ipsilateral breast cancer.

Conclusions The findings of this single-center retrospective cohort study indicate that there is no significant association with hand dominance and the development of BCRL after mastectomy for unilateral breast cancer. Known risk factors such as increased number of lymph nodes removed, adjuvant chemotherapy, and adjuvant radiation therapy demonstrated significant association with BCRL development. Further studies including larger and multicenter populations are needed to comprehensively elucidate the relationship between HD and BCRL development.

Background: There is currently inconclusive evidence on whether the intraoperative use of combination of liposomal bupivacaine plus bupivacaine hydrochloride (LB-BH) confers better post-lumpectomy analgesia than standard bupivacaine hydrochloride (BH) when used as a component of Enhanced Recovery After Surgery (ERAS) protocol. The aim of this study is to compare patient-reported pain control, adverse side effects, and reduced need for supplementary opioid prescription with use of either type of analgesic. Beside, ERAS protocol with BH alone can save costs for patients and hospitals, with BH priced significantly lower than LB ($0.34 per unit vs. $20.00 per unit).

Methods: This single-center, patient-blinded, prospective randomized control trial enrolled 76 participants who underwent lumpectomy between April 2023 and February 2024. Patients were randomized to receive either combination LB-BH or BH alone at time of surgery. Primary outcome was patient-reported pain on Numerical Rating Scale (NRS) of 1-10 at first postoperative telephone and clinic visit. Secondary outcomes included need for adjunctive opioid analgesia and adverse clinical outcomes. A per-protocol, equivalence test analysis evaluated clinical equivalence between groups.

Results: The mean participant age was 60.3 years; all were women. Baseline characteristics like chronic opioid use, intraoperative Toradol administration, and nodal surgery were balanced between both groups. Mean telephone visit occurred on postoperative day (POD) 2 (p = 0.961) and mean clinic visit occurred on POD 10 (p = 0.932) for both groups. Mean pain score was found to be clinically equivalent between study groups at telephone(raw mean difference, -0.059 [90% CI, -1.134 to 1.016]) and clinic visit(-0.145 [90% CI, -.851 to 0.561]. No patient in either study group requested additional opiate pain control at follow-up or emergency room visit within 30 days of surgery. There were no adverse side effects or functional outcomes reported by either group.

Conclusions: LB in conjunction with BH, and BH alone, were determined to be equivalent in providing postoperative pain control and facilitating recovery among patients undergoing lumpectomy. Given that BH is more cost-effective and has a shorter duration of action in the body compared to LB, resulting in fewer side effects, it represents the preferred form of analgesia for inclusion in ERAS protocols. Equivalence test results comparing pain score at postop call and visit between ERAS with LB-BH and Control ( ERAS with BH alone).

Introduction:

Patients with severe breast ptosis are often deemed poor candidates for NSM because of concerns that the results will be aesthetically unacceptable. One strategy for successful reconstruction of such patients is to perform a NSM with concomitant or delayed MSLD flap reconstruction. At a subsequent stage, nipple-areolar transposition can be performed based on a "neo-parenchymal" circulation, where the nipple-areolar complex (NAC) can be mobilized on the new blood supply provided by the flap.

Methods:

To find out how successful this strategy can be, we retrospectively reviewed our database of patients over the past 6 years. We identified all patients with breast ptosis who underwent NSM with MSLD flaps and who eventually had NPM.

Results:

42 patients (63 breasts) underwent the aforementioned procedures. There were no major complications. Two patients had ischemia of the NAC and suffered partial necrosis following NPM. All patients achieved successful reconstructions with superior aesthetic results as evidenced by patient satisfaction surveys and post-operative photographs.

Conclusion:

MSLD flaps and subsequent neo-parenchymal mastopexies are a highly successful strategy for autologous breast reconstruction following NSM in patients with severe breast ptosis.

Background: Surgical techniques employed in treatment of gynecomastia have evolved from subcutaneous mastectomy to include a combination of liposuction with or without direct excision and in the recent decade, addition of the arthroscopic shaver. Use of the latter has gained popularity due to its ability to break down dense breast connective tissue in a minimally invasive manner. In the military, its use has become increasingly prevalent given the implications of any elective surgical procedure on military readiness and the importance of ensuring timely and complete return to full duty status. The purpose of this study is to evaluate surgical outcomes following use of the arthroscopic shaver in the military population, particularly when compared to open excision with or without liposuction, and its potential implications on return to full duty status.

Methods: This was a retrospective cohort study evaluating patients that underwent surgical excision of gynecomastia between September 2017 and June 2022. Surgery was performed by 5 different surgeons who used two techniques: Open excision+ liposuction and liposuction +arthroscopic shaver. A Student's T-test and Chi Square tests were used to compare variables between both groups.

Results: A total of 114 male patients (221 breasts), 93 of which were active duty, were included in the analysis and were distributed by surgical technique into two groups: 125 breasts were treated with open excision and liposuction and 96 breasts were treated with liposuction and the arthroscopic shaver. Mean age was 27.4 ± 5.9 and mean BMI was 28.9 ± 3, with no significant difference between groups (p>0.05). The complication rate was 13.6%(n=17) for the open excision and liposuction group compared to 12.5% (n=12) in the liposuction and arthroscopic shaver group (p>0.05). Also,12.6%(n=14) of breasts treated via open excision and liposuction went on to undergo further surgical revision compared to 4.2%(n=4) in the liposuction + arthroscopic shaver group (p<0.05).

Conclusion: Overall, arthroscopic shaver use in conjunction with liposuction offers active duty patients, who must maintain high physical fitness standards and deployment readiness, a safe and effective minimally invasive approach. Implications of the arthroscopic shaver's utility in the military health care system is evident as demonstrated by the significant reduction in future surgical revisions and resulting implications on force readiness.

Introduction: As of a 2023 study, the most common anatomic region targeted in gender affirmation surgery (GAS) is the chest. In chest masculinization surgery, double-incision mastectomy with free nipple grafting allows for freedom of nipple placement and places transverse incisions on the chest wall. There are a wide variety of surgical designs regarding scar placement and layout, and nipple-areola complex (NAC) shape and placement, that may be offered on a patient-by-patient basis. Given this wide variability in surgical options, patients may have difficulty imagining or finding photos for certain chest configurations. And for many patients, including nonbinary patients, masculinization goals exist on a wide spectrum, with great variation in patient needs and wants. These factors may make it difficult for patients to communicate their specific chest configuration goals to surgeons.

Purpose: To create a novel web-based visualization tool for chest masculinization that allows patients to customize graphics based on Fitzpatrick scale, body habitus, and NAC design; and to perform a pilot test of the logistical feasibility and ease of use of the tool in a clinical context.

Methods: An initial web-based virtual graphical tool was created. Surgeons and staff at a 6-surgeon gender affirmation surgical practice tested the tool to generate multiple possible chest configurations, then completed a questionnaire regarding the implementation and perceived usefulness of the tool in a clinical setting. A preliminary 2-week pilot was conducted , in which patients undergoing pre-operative consultation or about to undergo chest masculinization surgery were provided with the tool, along with an explanation. Patients who consented received access to the tool and were surveyed about its use.

Results: Four surgeons and two PAs used the tool and completed the associated survey. 67% of the surgical staff surveyed strongly agreed that the tool would improve their understanding of a patient's desired surgical outcomes. All staff agreed that the tool would be more valuable than photos brought by patients. Free-text feedback expressed concern regarding potential influence on patient expectations towards results impossible to achieve with the patient's individual anatomy. Surgeons also requested a modifiable lateral view of the chest, to allow patients to demonstrate the target degree of flatness; as well as a modifiable incision pattern selection. Clinic staff felt the tool was efficient and easy to implement, especially if the final configuration could be uploaded as part of patient intake paperwork.

Five patients used the tool and commented positively. One patient completed the survey, with all fields ranked positively; free-text response stated that the tool was easy to use, with a simple efficient interface.

Conclusions: This novel virtual tool for chest masculinization surgery planning was received positively by surgeons, clinical staff, and patients. Responses were generally positive and future implementation was felt to be feasible and useful for patient care. Based on feedback provided, the tool has already been revised to include scar placement, and a lateral chest view module is being designed. The full study regarding its use and implementation will proceed after its completion.

Purpose Androgens and estrogens are known to affect wound healing. One study showed that application of topical estrogen can increase wound healing in both men and women1, while another showed that 5alpha-dihydrotestosterone (DHT) inhibits re-epithelization in wounds2. Biopsies of keloid tissue have demonstrated elevated androgen receptor levels3. More recently, the role of androgens on wound healing has become a topic of interest among surgeons who offer gender-affirming surgery, whose patients may be taking exogenous testosterone. Reiche et al. demonstrated that exogenous testosterone in a mouse model at levels comparable to human clinical therapeutic doses significantly impairs wound healing4. However, Rysin et al recently examined a cohort of 170 transgender men who underwent gender-affirming mastectomies and found no statistically significant association between testosterone and increased surgical complications5. We aim to evaluate patients who have undergone gender-affirming mastectomy to identify the role of testosterone on their complication rates.

Materials/Methods Included are 104 consecutive patients who were assigned female at birth who underwent chest-masculinizing surgery at our institution. Patients underwent: double-incision mastectomy with or without free nipple graft, periareolar incision, or circumareolar incision. Surgical technique was selected based on breast size, ptosis grade, and nipple position as a shared decision between the surgeon and patient. Bilateral 15-French drains were placed universally, and all were placed in a post-op compression vest for 1 week regardless of their surgical technique and presence or absence of free nipple graft. Drains were removed when output was less than 30 mL in a 24-hour period for two days in a row. Major complications included reoperation within 30 days, total and partial nipple necrosis, and hematoma. Minor complications included infection requiring antibiotics, delayed wound healing, seroma, and nipple revision not related to necrosis. Scar revisions included steroid injection or laser treatment. Patients who were taking exogenous testosterone at the time of surgery were compared to those who were not. With regard to gender identity, patients who identified as they/them were considered nonbinary, those who identified as both they/them and she/her were considered nonbinary/feminine, and those who identified as both they/them and he/him were considered nonbinary/transmasculine. Patients who identified as he/him were considered transgender men for this analysis.

Results There was no significant difference in age or BMI between cohorts. Unsurprisingly, the no testosterone cohort was significant for opting out of free nipple graft (p<0.001) as well as identifying as nonbinary (p<0.001). Overall major complication rates were low, 5.8%. The no-testosterone cohort included only one patient who experienced a major complication, compared to the testosterone cohort who had six patients experiencing major complications. 12% of patients in the no-testosterone cohort experienced minor complications, compared to 21.5% of the testosterone cohort. Neither the comparison of major or minor complications were statistically significant. Scar revisions occurred in 5.1% of the testosterone group and none within the no testosterone group.

Conclusion Our preliminary data suggests no statistically significant difference in complication or revision rates among patients who were on testosterone at the time of chest masculinization surgery compared to those who were not.

References: 1. Ashcroft GS, Greenwell-Wild T, Horan MA, Wahl SM, Ferguson MW. Topical estrogen accelerates cutaneous wound healing in aged humans associated with an altered inflammatory response. Am J Pathol. 1999 Oct;155(4):1137-46. doi: 10.1016/S0002-9440(10)65217-0. PMID: 10514397; PMCID: PMC1867002. 2. Gilliver SC, Ruckshanthi JP, Hardman MJ, Zeef LA, Ashcroft GS. 5alpha-dihydrotestosterone (DHT) retards wound closure by inhibiting re-epithelialization. J Pathol. 2009 Jan;217(1):73-82. doi: 10.1002/path.2444. PMID: 18855875. 3. Schierle HP, Scholz D, Lemperle G. Elevated levels of testosterone receptors in keloid tissue: an experimental investigation. Plast Reconstr Surg. 1997 Aug;100(2):390-5; discussion 396. doi: 10.1097/00006534-199708000-00017. PMID: 9252606. 4. Reiche E, Tan Y, Louis MR, Keller PR, Soares V, Schuster CR, Lu T, O'Brien Coon D. A Novel Mouse Model for Investigating the Effects of Gender-affirming Hormone Therapy on Surgical Healing. Plast Reconstr Surg Glob Open. 2022 Nov 29;10(11):e4688. 5. Rysin R, Skorochod R, Wolf Y. Implications of testosterone therapy on wound healing and operative outcomes of gender-affirming chest masculinization surgery. J Plast Reconstr Aesthet Surg. 2023 Jun;81:34-41. doi: 10.1016/j.bjps.2022.11.057. Epub 2023 Feb 9. PMID: 37084532.

Background: The growth of the jaw holds significant importance in the context of pediatric mandibular reconstruction, as any complications arising from unsuccessful reconstruction procedures have the potential to significantly impact the patient's overall quality of life.(1) Osteocutaneous fibular flap is the first choice for mandibular reconstruction for some. It has the possibility to reconstruct the loss of bone and soft tissue simultaneously, creating mandibular bone contour, and low rates of donor site morbidity.(2) Nevertheless, there is currently no existing literature that has documented the capacity of a vascularized bone flap to undergo growth following mandibular reconstruction. In this retrospective case series, we explore the functional and quality of life outcomes of pediatric patients who underwent mandibular reconstruction using free fibular flap.

Methods: This study looked at pediatric patients under the age of 13 who had mandibular reconstruction with free fibular flap and had not received another operation in the previous 6 months. The eating, swallowing, speech function, and quality of life are evaluated with EORTC QLQ-H&N35 after the mandible growth spurt has occurred.

Results: A total of 7 patients were included in this study with operation ages ranging from 6 years 1 months to 12 years 2 months. The etiology of malignant tumor was found in two patients and benign tumor in five patients. The mandibular defect distribution consists of one class Ic, one class II, two class IIc, two class III, and one class IVc. All patients reported no swallowing or speech difficulties. However, transient eating trouble was seen in one patient due to the extensive defect size that causes tooth loss. Only one patient received dental rehabilitation. The patients displayed an overall good quality of life with an average score of 2.857.

Conclusion: These findings underscore the efficacy of free fibular flap reconstruction in pediatric patients who have not yet reached their mandibular growth peak, emphasizing both functional rehabilitation and psychosocial well-being. Further research with expanded cohorts and extended follow-up periods is warranted to consolidate these outcomes and refine therapeutic approaches in pediatric craniofacial reconstruction.

References: 1. Shahzad F. Pediatric Mandible Reconstruction: Controversies and Considerations. Plastic and Reconstructive Surgery Global Open [Internet]. 2020 [cited 2023 Nov 21];8(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787291/ 2. Castellon L, Jerez D, Mayorga J, Gallego A, Fuenzalida C, Laissle G. Mandibular Reconstruction for Pediatric Patients. J Craniofac Surg. 2018;29(6):1421–5.

Introduction

Follow up after surgical procedures is a crucial step in ensuring patient safety and positive outcomes. Patients with low socioeconomic status have extra burdens of inadequate health resources and additional barriers to follow up. Meanwhile, widespread access to text messaging, email, and social media is transforming the landscape of patient contact. Understanding patients' perceived difficulties with follow up and their preferred methods of communication can help direct efforts to help vulnerable populations and allocate limited resources towards solutions like transportation, effective reminders, or telehealth outreach.

Materials and Methods

A patient survey was conducted at a major safety net hospital over a 7-month period. Patients attending the reconstructive plastic and burn surgery clinics as outpatients were surveyed. Patients were queried regarding preferences regarding hospital communication, how likely they were to attend future appointments, what challenges they anticipated to follow up, and interest in support groups. Corresponding patient records were queried for demographic data and procedure type. Data were summarized using frequency for categorical variables and mean for continuous variables. Associations between categorical variables was assessed using Pearson's chi-squared or Fisher's exact test, as appropriate. Difference in continuous variables were assessed using Wilcoxon rank sum test. All tests were two-sided and a p-value <0.05 was considered statistically significant.

Results

A total of 160 patients were surveyed (51% burn and 49% reconstructive plastic), of whom 74.7% were Hispanic or Latino and 40.8% were Spanish speakers. 89.9% were insured, with Medical(Medicaid) (79.9%) and Medicare (5.3%) being the most frequent insurers. In response to "How would you like to be contacted?" patients responded: Call = 66.3%, Text = 65.7%, Email = 28.4%, Social Media = 3.6%.

Hispanic patients stated that they had no access (13.0%) or inconsistent access (6.1%) to Wi-Fi or cellular data, vs 0% and 7.5% of their non-Hispanic counterparts, respectively (p = 0.024). 16.1% of Hispanic patients access social media on a laptop versus 47.5% of non-Hispanic patients (p = <0.001). Both Hispanic (60.2%) and non-Hispanic (62.5%) patients anticipated similar difficulty in following up (p = 0.794), citing reasons such as difficulty with transportation = 20.7%, trouble taking time off work = 14.2%, language barrier = 6.5%, cost or insurance coverage = 12.4%, too busy = 6.5%, forget to schedule = 14.2%, and other = 8.3%.

Conclusion

Patients at safety net hospitals may receive initial treatment but struggle with follow up and continued care. At our institution, 61% of patients anticipated problems following up, and 15% stated that they do not have consistent access to Wi-Fi or cellular data. Identifying and addressing modifiable factors (such as lack of transportation or preferred communication method) in advance may ease pressure on patients and help shape outreach and aid for the most vulnerable.

Introduction: Microsurgical techniques utilizing free flaps have broadened therapeutic possibilities, offering refined procedures with both functional and aesthetic benefits for conditions ranging from oncological to congenital and post-traumatic. 1 Despite the decrease in the incidence of free flap failures (FFF), identifying the associated risk factors remains a challenge for surgeons 1,2 Hence, an examination of prevalent factors within our institution's cohort could aid in mitigating FFF in clinical practice. Objective: To assess the frequency and associated risk factors of FFF at our institution. Materials and Methods: We analyzed an electronic database encompassing 123 cases of free flap surgeries conducted between January 2015 and December 2021. Demographic, preoperative, perioperative, and postoperative data were evaluated, and risk factors related to FFF were identified and described using descriptive statistics. Results: Among elective and emergency/traumatic free flap surgeries, 22 cases out of 123 (17.88%) resulted in free flap failure. Despite prevalent literature reports, factors such as age, smoking, comorbidities3, preoperative transfusion, and hemoglobin levels, in our experience, did not exhibit a higher frequency in failed cases, nor did they outline significant statistical differences. However 18 cases (81%) among FFF had preoperative platelet counts exceeding 200,000/uL, 4 (18%) required postoperative transfusion, and 14 (63%) underwent flap revision. The mean surgical time for failed cases was 476 minutes vs 426 minutes for successful free flap SFF. Conclusions: Factors associated with FFF at our center included prolonged surgical operative time, free flap revision, postoperative transfusion, and elevated preoperative platelet counts being common among failed cases. These findings can aid surgeons in refining candidate selection for free flaps, optimizing surgical operative time, minimizing post-op transfusions, and implementing intraoperative strategies to reduce the need for flap revision and subsequent failures.

1. Kohlert S, Quimby AE, Saman M, Ducic Y. Postoperative Free-Flap Monitoring Techniques. Semin Plast Surg. 2019;33(1):13-16.
2. Khouri RK. Avoiding free flap failure. Clin Plast Surg. 1992;19(4):773-781.
3. Rosado P, Cheng HT, Wu CM, Wei FC. Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: a systematic review and meta-analysis. Head Neck. 2015;37(4):615-618.

Introduction: The LYMPHA (Lymphatic Microsurgical Healing Approach) is a preventative microsurgical technique performed at the time of axillary lymph node dissection (ALND) to reduce the risk of developing lymphedema in oncologic patients. Physical therapy (PT) is recommended as part of the postoperative course to reduce the risk of axillary contracture, promote upper extremity range of motion, and stimulate lymphatic drainage. While studies have shown that PT through a certified lymphedema therapist is effective in reducing excess volume of the operative limb, little is known about how the stimulation of lymphatic flow impacts the volume of the contralateral limb. This study aims to determine if any changes in contralateral limb volume occur during postoperative PT for LYMPHA patients.

Methods: A retrospective review was performed of n=104 patients who underwent LYMPHA from January 2020 to January of 2024 and had PT at our institution. Inclusion criteria were patients who underwent LYMPHA and ALND and had measurements of the operative or contralateral limb circumference at initial therapy intake and at a repeat appointment (minimum of 3 months). Patient demographics, functional status, LLIS (Lymphedema Life Impact Scale), QuickDash impairment, limb volume, limb ratio, and limb circumference measurements taken at 8 cm intervals proximal to the wrist were recorded.

Results: N=104 patients had measurements available of the operative limb and n=20 had measurements available of the contralateral limb circumference at initial and final PT evaluation (mean duration 12.29 months). The sum of limb circumference measurements increased in the contralateral limb by 8.18 cm (5.59%) with a decrease of the limb circumference of the operative limb of 6.22 cm (3.05%). Changes across the entire cohort over the duration of PT included improved LLIS (15.25 to 13.94, p=0.0309) and QuickDash impairment, (48.91% to 27.98%, p=0.0132). The overall limb volume of the operative limb improved by 21.8% and the limb ratio decreased by 0.032. When comparing limb circumference measurements at different intervals, the change in measurements taken 40-48 cm proximal to the wrist on both the operative and contralateral limb were significantly greater than distal measurements, with a change in the contralateral limb at the wrist of -0.5769, 8-16 cm proximally to the wrist of 1.207, 24-32 cm proximal of 0.9107, and 40-48 cm proximal of 2.100 (p=0.04079). Changes in limb circumference of the operative limb at the wrist was -0.1100, 8-16 cm proximally to the wrist -0.05570, 24-32 cm proximal -0.1337, and 40-48 cm proximal -1.073 (p=0.0319).

Conclusions: Based on these results, the contralateral limb of patients undergoing PT for lymphedema may experience an increase in volume, which may be due to transient lymph fluid influx from the affected side. Changes in limb circumference on both sides were most appreciable 40-48 cm proximal to the wrist. Based on these findings, lymphedema therapy techniques may benefit from the inclusion of central lymphatic drainage techniques and consideration of the contralateral limb during therapy after LYMPHA.