Scientific Abstract Presentations: Reconstructive Session 1 Thursday, September 26 Thu, Sep 26 9:45-11:50 a.m. PDT

BACKGROUND Breast cancer is one of the most common types of cancer diagnosed worldwide which has allowed breast reconstruction to become a well-established part of patient care and recovery (1). However, following mastectomies, both with and without radiation, sensation is often lost, impairing patient satisfaction in multiple dimensions such as intimacy, body image, and the ability to discern harmful temperatures and pain (2,3). Despite growing interest in neurotization in breast reconstruction, there is limited research on the efficacy of maintaining or restoring protective sensation. This systematic review explores the outcomes of innervated autologous breast reconstruction and evaluates the influence of oncologic intervention on these results.

METHODS A PRISMA systematic search was conducted through Pubmed, Scopus, and Cochrane Library for original research articles between 2000 to 2021 (4). Eligible studies of innervated autologous oncoplastic breast reconstruction were extracted for risk of bias assessment, pre- and post- surgical interventions, as well as tactile, thermal, and nociceptive sensation evaluations.

Semmes-Weinstein Monofilament Test (SWMT): SWMT provides standardized scores, corresponding to applied force, for evaluating acuity of tactile sensation. Extrapolated from guidelines for the distal extremities, SWMT above the range of 4.56-6.45 suggests loss of protective tactile sensation (5). A conservative threshold of 4.56 was used to assess innervated and non-innervated flaps.

RESULTS Of 336 articles, 15 studies met the inclusion criteria and were extracted for flap type, radiation, donor and recipient nerves, method of sensation measurement, and demographic control. Eight studies included SWMT scores. The average score for non-innervated flaps was greater than 4.56 in contrast to innervated breasts which averaged consistently within protective range. Through a mixed model, adjusting for sample size, non-innervated flaps scored 0.91 units higher which was statistically significant (P < 0.001). Articles including thermal and pain sensation also suggested greater sensitivity but with limited statistical significance. Our analysis was also limited due to heterogeneity of data and risk of bias.

CONCLUSION Microsurgical nerve-grafting poses promising potential for restoring protective sensation in post-mastectomy patients. Despite the significant implications of restoring intimate and thermal senses and growing interest in microvascular breast reconstruction, current literature is limited in quantity and quality. This warrants future research with continued SWMT along with quantified thermal and pain measurements to further evaluate the efficacy of innervated autologous breast 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. 2019;173(2):267-274. doi:10.1007/s10549-018-5018-1 2.) Dogan ZA, Farhadi J. Evaluation of Sensation on Mastectomy Skin Flaps following Immediate Breast Reconstruction. J Reconstr Microsurg. 2020;36(06):420-425. doi:10.1055/s-0040-1702157 3.) Beugels J, Cornelissen AJM, van Kuijk SMJ, et al. Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction: Plast Reconstr Surg. 2019;144(2):178e-188e. doi:10.1097/PRS.0000000000005802 4.) Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. PLOS Med. 2021;18(3):e1003583. doi:10.1371/journal.pmed.1003583 5.) Manual: Baseline® TactileTM Semmes-Weinstein type monofilaments. Published online all rights reserved. Baseline and Tactile are trademarks of Goldberg 2017.

Background: The Facial Mohs micrographic surgery (MMS) is a precise surgical technique used for the removal of skin cancers, offering functional superiority and greater aesthetic outcomes than conventional techniques. While complications associated with periorbital MMS have been extensively documented in the literature, notable variances exist in reported rates. For instance, Michelotti et al. observed a complication rate as high as 23%, with 19% necessitating revision surgery [1]. Conversely, other studies have reported considerably lower complication rates, such as 0.72% [2]. This discrepancy underscores the complexity inherent in periorbital MMS and the need for comprehensive investigation into potential predictors that could provide some added value to current existing literature and clinical practice.

Purpose: The aim of this study is to identify potential predictors of complications and the necessity for revision surgery following MMS in the periorbital region. Our retrospective analysis stands apart as we endeavor to identify predictive factors for complications, particularly those necessitating revision surgery in periorbital cases. By delineating such factors, we aspire to furnish clinicians with enhanced prognostic tools, thereby facilitating the anticipation and potential mitigation of complication rates.

Methods: This retrospective study from 2014 to 2022 was approved and deemed exempt by our institution's Review Board. We analyzed data from 100 patients' charts who underwent Mohs reconstruction from the Mayo Clinic Database. Variables including defect zone, patient demographics, smoking history, Fitzpatrick skin class, Glogau scale of photoaging, history of skin damage, preoperative diagnosis, and immunosuppression status were assessed for their association with postoperative complications and revision surgery needs. The analysis was done using Fisher's exact test for count data. Instances where patients underwent multiple MOHS procedures followed by reconstruction for malignancies in different periorbital anatomic locations were treated as distinct cases.

Results: The overall complication rate was 22.5% following reconstruction of periorbital Mohs defects , with ectropion being the most common complication being (15.5%) followed by scar hypertrophy (5.6%), infection (2.8%), lagophthalmos (2.8%), and skin graft necrosis (1.4%). Analysis of the current cohort revealed no significant predictors of complications among the examined variables, except for immunosuppression status, which showed a significant association with an increased risk of complications (p=0.0351). Additionally, there was no discernible trend observed for the necessity of revision surgery, underscoring the unpredictable nature of surgical outcomes in the periorbital region. It is important to acknowledge the limitations of this study, particularly the relatively small sample size of 100 patients. Conclusion: While Mohs remains the go-to option for the treatment of skin cancers in the face region, immunosuppressed patients exhibited higher risk of postoperative complications within the periorbital region. The absence of reliable predictors for complications so far emphasizes the complexity of managing outcomes in this delicate area.

                                                           References

1. Michelotti B, Mathis R, Roberts J, Travelute C, Billingsley E, Wilkinson M. Periorbital Mohs reconstruction: characterization of tumor histology, anatomic location, and factors influencing postoperative complications. Dermatol Surg. 2014 Oct;40(10):1084-93. doi: 10.1097/DSS.0000000000000125. PMID: 25229782. 2. Cowan N, Goldenberg A, Basu P, Eilers R, Hau J, I Brian Jiang S. A Retrospective Analysis of Complication Rates in Mohs Micrographic Surgery Patients With Clinically Large Tumors and Tumors With Aggressive Subclinical Extension. J Drugs Dermatol. 2018 May 1;17(5):511-515. PMID: 29742181.

Background Burn injuries are a major cause of morbidity and mortality, often leading to nerve damage in the skin, resulting in debilitating pain and/or numbness. Numbness in burn scars can hinder protective sensation, increasing the risk of future injury. Strategies to enhance nerve regeneration post-burn injury are crucial. Previous research has identified antimuscarinic drugs as potential therapeutic targets for peripheral neuropathies, such as diabetic and chemotherapy-induced neuropathy. By blocking muscarinic receptors, these drugs have shown to promote sensory neuron growth and stabilization by enhancing cytoskeleton development and mitochondrial trafficking. This study aimed to investigate whether antimuscarinic drugs can impact neuronal regeneration following burn injury.

Methods We performed a retrospective analysis using the TriNetX Research Database. Patients presenting with burn injuries were identified. We created an experimental cohort of burn patients that were taking one of the antimuscarinic drugs approved to treat overactive bladder at the time of their burn injury: darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine, and trospium. A control cohort consisted of patients not taking antimuscarinic medication. Patients with a history of skin sensation disturbance were excluded. Propensity matching was performed based on burn total body surface area (TBSA), anatomical burn location, age, sex, race, and diagnosis of overactive bladder and incontinence. Paresthesia development between 3 and 18 months post-injury was used as a proxy for nerve regeneration.

Results We identified 13,406 burn patients taking an antimuscarinic medication, along with 460,505 burn patients not taking an antimuscarinic medication. After propensity matching, 10,534 patients in each group were included for analysis. 3.98% of burn patients on antimuscarinic medication developed paresthesia between 3- and 18-months post-injury compared to 2.07% of matched controls (p < 0.0001). Patients taking an antimuscarinic medication had statistically significant higher odds of developing paresthesia (OR: 1.96; 95% CI: 1.66, 2.314).

Conclusion Burn patients taking antimuscarinic therapies were more likely to develop paresthesia following their injury. While paresthesia is an uncomfortable sensation for patients, it can also be a sign of regenerating sensory neurons. Improved regeneration and subsequent sensory recovery could help to treat abnormal sensations or numbness: significant causes of morbidity for burn patients. While questions remain about if this paresthesia translates to improved sensory recovery in burn patients where the normal architecture of the skin is damaged and potentially hostile to nerves, preliminary analysis suggests antimuscarinic therapies are impacting nerve regeneration after burn injury.

Purpose: Connective tissue diseases (CTDs) have a wide variety of impacts on patients' health including impaired wound healing (1). Although prevalence rates of CTDs vary between different patient populations, the overall prevalence is very low (2). There is currently a paucity of research examining postoperative outcomes in patients with CTDs who undergo microsurgery, especially following breast reconstruction. In this study, we assessed postoperative outcomes in patients with CTDs who underwent breast reconstruction with the deep inferior epigastric perforator (DIEP) flap.

Methods: We conducted a single-institution preliminary retrospective study of all patients that underwent breast reconstruction with DIEP flaps between the years 2020 and 2023. 318 DIEP flaps were performed on 184 patients. 7 of these patients, who underwent 13 DIEP flaps, were diagnosed with connective tissue diseases including Sjögren's, systemic lupus erythematosus, systemic scleroderma, undelineated ANA+ CTD, juvenile arthritis, and Kawasaki disease.

Results: The two groups with and without CTDs did not differ significantly with respect to age, BMI, smoking history, hypertension, and diabetes. Major complications including stroke, cardiac arrest, myocardial infarction, deep vein thrombosis, hematoma requiring takeback, and overall reoperations occurred at similar rates between groups. Minor complications including dehiscence, skin necrosis, ulcerations, epidermolysis, fat necrosis, and local infection at the surgical site also occurred at similar rates between groups. Patients with CTDs developed hematomas and seromas that were able to be managed outpatient at significantly higher rates than patients without CTDs (42.86% and 10.73% respectively, p=0.038).

Conclusion: Our data suggests that breast reconstruction using DIEP flaps is safe for patients who have CTDs. Patients with CTDs do not appear to be at an increased risk for major complications following the procedure; however, these results imply that they are at increased risk for minor hematomas and seromas that do not require significant intervention. Although our study is limited by the small sample size of CTD patients, this sample size reflects the low prevalence rates of these diseases.

References 1. Avishai E, Yeghiazaryan K, Golubnitschaja O. Impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. EPMA J. 2017;8(1):23-33. Published 2017 Mar 3. doi:10.1007/s13167-017-0081-y 2. Gaubitz M. Epidemiology of connective tissue disorders [published correction appears in Rheumatology (Oxford). 2008 Feb;47(2):234-5]. Rheumatology (Oxford). 2006;45 Suppl 3:iii3-iii4. doi:10.1093/rheumatology/kel282

Purpose The paramedian forehead flap stands as the gold standard in soft tissue nasal reconstruction for optimal aesthetic and functional results (1). Despite its widespread use for nasal defect correction, there remains a gap in research regarding its influence on nasal tip rotation. Brennen et al. examined nasal tip rotation before and after rhinoplasty, utilizing the nasolabial angle (NLA) as a metric, and observed a significant elevation in NLA immediately post-rhinoplasty (2). However, postoperative decreases in nasal tip rotation months after septorhinoplasty have also been described (3). We present a retrospective review of patients who received a paramedian forehead flap (MFF) for nasal reconstruction comparing the NLA pre- and post-MFF.

Methods We performed a retrospective review encompassing all patients who underwent a MFF by a single surgeon (J.F.T.) from January 2017 to January 2023. Inclusion criteria contained patients who underwent nasal reconstruction with a MFF and had studio photographs taken before MFF placement and after MFF division and inset, those who did not have studio photographs were excluded. The NLA was measured of these patients pre-MFF placement and post-MFF division and inset using Adobe Photoshop. The NLA was measured as the angle between line drawn through the midpoint of the nostril aperture and the line drawn perpendicular to the Frankfurt horizontal while intersecting the subnasale. A paired two sample t-test was used to evaluate a significance between pre-MFF placement and post-MFF division and inset NLA to determine if the forehead flap impacted nasal tip rotation.

Results A total of 28 patients were included in the study, with a mean age of 67.1 ± 13.6 years, and 75.0% of the patients were female. The primary etiology for the nasal defect was Mohs surgery for basal cell carcinoma resection, observed in 18 cases (64.2%). The average defect size was 12.0 cm2, ranging from 0.3 cm2 to 33.4 cm2. The mean NLA prior to MFF placement was 96.6° ± 8.3°, and the mean NLA after MFF division and inset was 95.5° ± 8.3° (p = 0.35). The average time between MFF placement and NLA measurement was 482.8 ± 397.0 days.

Conclusion Few studies exist regarding nasal tip rotation after paramedian forehead flap, but this study demonstrates that there was no significant difference in NLA pre- and post-MFF. Therefore, the current work serves as a proof of concept that forehead flap reconstruction may be effective at restoring and maintaining patient nasal tip rotation post-operatively. Further studies are needed to discern changes in NLA after paramedian forehead flap at standardized post-operative time intervals.

1. Menick FJ. Nasal reconstruction with a forehead flap. Clin Plast Surg. 2009;36(3):443-459. doi:10.1016/j.cps.2009.02.015
2. Brennan TE, Trujillo O, Sina M, Vandenberg KN, Myers O, Pearlman SJ. Change in Columellar-Philtral and Nasolabial Angles Over Time Following Rhinoplasty. Facial Plast Surg. 2022;38(4):411-418. doi:10.1055/s-0042-1742452
3. Pou, J. D., Ziegler, J., Patel, K. G., & Oyer, S. L. (2022). Preserving Nasal Tip Rotation and Projection in Open Septorhinoplasty. Ochsner J, 22(3), 218-224. https://doi.org/10.31486/toj.22.0006

Purpose: There is a disproportionate incidence of disability secondary to lower limb trauma in Sub-Saharan Africa (SSA) (1). Disability-adjusted life years (DALYs) are the standard unit used by the Global Burden of Disease Study to quantify the morbidity and mortality due to disease (2). The World Health Organization (WHO) recommends that cost-effectiveness of an intervention be measured based the ratio of procedural cost to GDP/capita (3). This study provides the first known assessment of the cost-effectiveness of free flaps for lower extremity reconstruction in SSA.

Methods: We performed a retrospective review on all patients who received an anterolateral thigh (ALT) free flap for lower extremity reconstruction by a single surgeon at an institution in rural Kenya from November 2022 to November 2023. Billing Information for all patients was retrieved. DALYs were calculated based on the database of the Global Health Cost-Effectiveness Analysis Registry using a disability weighting of 0.173 for a long-term untreated amputated lower limb, a discount rate of 0.03 and an age weighting parameter of 0.04.

Results: Ten patients (9 male) received ALT free flaps for lower extremity reconstruction. Average age was 43.3-years. The most common indication for flap was traumatic fracture with soft tissue defect. Average cost of hospital admission was $864. The average DALY per lower extremity reconstruction was 7.14. The GDP/capita for Kenya is $2,070. The average cost per DALY averted was $121.

Conclusions: Interventions performed for less than three times the GDP/capital per DALY are considered cost-effective by the WHO. Interventions performed for less than one GDP/capita per DALY are very cost-effective. In our setting, ALT free flaps for lower extremity reconstruction are very cost effective as they can be performed for 5% of the GDP/capita per DALY. Efforts should be made to increase microsurgical capabilities in SSA.

1. Bach O, Hope MJ, Chaheka CV, Dzimbiri KM. Disability can be avoided after open fractures in Africa-results from Malawi. Injury. 2004;35(9):846-851. doi:10.1016/j.injury.2003.11.014
2. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380(9859):2197-2223. doi:10.1016/S0140-6736(12)61689-4
3. Hutubessy R, Chisholm D, Edejer TTT. Generalized cost-effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc. 2003;1(1):8. doi:10.1186/1478-7547-1-8

Background: Postoperative care following microsurgical autologous reconstruction varies greatly among institutions. Goals of close in-house postoperative monitoring include early identification of any flap complications requiring intervention or operative takeback. Even though most thrombotic complications take place within the first three postoperative days, they could still occur up to the first week post-operation. Therefore, early postoperative discharge may theoretically result in early readmission with comparatively late microvascular complications. In the current study, we evaluate nationwide trends in postoperative length of stay (LOS) for deep inferior epigastric perforator (DIEP) flaps for autologous breast reconstruction to determine whether a longer postoperative admission reduces the risk of early readmission, presumably due to anastomotic compromise.

Methods: Unilateral and bilateral DIEP flap breast reconstructions from October 2019 to January 2024 were reviewed from the Vizient Clinical Database. A Spearman's rank correlation coefficient analysis was performed to evaluate the relationship between LOS and 7-, 14-, and 30- day readmission rates.

Results: 28,079 DIEP surgeries were recorded, with 59.8% bilateral, 19.9% right-sided and 20.2% left-sided procedures. Mean length of stay was 3.9 ±1.4 days for bilateral and 3.7 ±1.3 days for unilateral DIEP procedures. We found no significant correlation between LOS and 7-, 14-, or 30- day readmission rates for both bilateral and DIEP reconstructions with correlation coefficients 0.014, 0.060, and 0.109, respectively. There was no difference when subdivided by unilateral or bilateral reconstruction.

Conclusion: Longer postoperative stay may not reliably protect against early readmission for vascular compromise following DIEP flap breast reconstructions. In a first use of the Vizient clinical database for plastic surgery related outcomes research, we demonstrate that it may be more cost effective to discharge uncomplicated DIEP flaps on postoperative day 3 or 4.

Background
Socioeconomic status (SES) and race have been implicated as factors that predict health inequities. Low median household income (MHI) has been shown to correlate with increased complications in implant-based reconstruction. However, limited data exists regarding the effect of SES on free flap breast reconstruction.(1) We aimed to determine the impact of SES and self-identified race on surgical outcomes in autologous breast reconstruction.
Methods This was a single-center, retrospective study of patients who underwent free flap breast reconstruction between 2013 to 2023. SES variables included US Census Bureau reported MHI, US Department of Agriculture food insecurity data, neighborhood area deprivation index (ADI), and insurance provider. Demographics, 30-day postoperative complications, and the number of elective revisions were recorded. Univariate analysis and multiple linear regressions were performed. Findings were considered statistically significant for p<0.05.
Results 221 patients were included with an average age of 51±9.7 years, average body mass index (BMI) of 31±5 kg/m2, and an average Charlson Comorbidity Index of 3.3±1.5 points. Most patients underwent bilateral reconstruction (116/221, 52.4%) and the most common flap was a DIEP (196/221; 88.6%). Our population had MHI of $71,303, well below the Virginia average of $87,249. Average neighborhood ADI was 5.7±2.4, with a median of 6 (our state's median is 5).(2) For ADI, higher values indicate lower SES. 88 patients (40%) had either public or no insurance, while 133 (60%) had private insurance. There were no differences in demographics between groups, except for self-reported race. The public insurance group had 48% White and 45% Black patients, while the private insurance group had 62% White and 28% Black patients (p < 0.05). Average neighborhood ADI was significantly worse in the public insurance group (6.2±2.3 versus 5.3±2.5, p < 0.05) and MHI was lower ($69,052 versus $73,997, p = 0.09). There was a trend toward longer time between mastectomy and free flap reconstruction for the publically insured (603 versus 429 days, p = 0.1). Publically insured patients had significantly fewer elective revisionary operations (1.4±0.8 versus 2.1±0.7 revisions per patient, p < 0.05). There were no differences in postoperative complications, including infection, hematoma, seroma, unplanned reoperation, and flap loss (p > 0.05). On multivariate analysis controlling for SES revealed that age and race played a significant role in elective revisions, with an increase by 0.01 in number of revisions per patient year of age (p = 0.0055), and a decrease of 3.6x for Black compared to White patients (p = 0.0029).
Conclusions: Our results suggest autologous free flap breast reconstruction outcomes are not negatively influenced by patient SES. However, age and self-identified race may have a significant impact on the patient's choice to pursue free flap reconstruction or later revision. Further investigation into the best estimations of SES and patient-reported outcome measures is warranted to understand barriers to reconstruction.

1. Martin MS, Kebede S, Saad OA, Baker NF, Losken A. Impact of socioeconomic status on breast reconstruction outcomes. Ann Plast Surg. 2022;88(5 Suppl 5):S481-S484. doi: 10.1097/SAP.0000000000003124.

2. QuickFacts: Virginia. US Census Bureau Web site. https://www.census.gov/quickfacts/fact/table/VA/PST045223. Accessed 2/22/, 2024.

Background: Many breast cancer patients have ovarian hormone-positive cancer and therefore undergo prophylactic bilateral salphingo-oophrectomy (BSO) and/or total abdominal hysterectomy (TAH) to decrease the risk of breast cancer recurrence and gynecologic cancer development. The timing and safety for performing autologous breast reconstruction (ABR) with gynecologic procedures is under debate. Sequential operations can introduce abdominal scar tissue and multiple operating room visits, while simultaneous operations can increase operative time and have been speculated to increase complications. This study aims to determine the effect of concurrent abdominally-based ABR and gynecologic procedures on complication rates and patient-reported outcomes.
Methods: Female patients over the age of 18 who underwent abdominally-based ABR at a tertiary academic medical center from 2010 to 2023 were retrospectively evaluated. We compared three groups: 1) ABR patients who underwent ABR and TAH and/or BSO on the same day, 2) patients whose ABR and TAH and/or BSO were performed on separate days, and 3) patients who underwent ABR without TAH and/or BSO. Outcomes of interest included presence of any complication, return to the operating room, and BREAST-Q Physical Well-being of the Abdomen scores (assessed preoperatively and at 6 months and 1 year postoperatively). Multiple imputation was used to account for missing BREAST-Q scores. Results: Overall, 2,288 patients met criteria for inclusion in our study, with 66 patients in Group 1 (2.88%), 256 patients in Group 2 (11.19%), and 1,966 patients in Group 3 (85.93%). Patients in Group 1 were more likely to undergo bilateral breast reconstructions (82% vs. 68% vs. 44%; p<0.001) and were younger (median 45 [IQR: 41, 50] vs. 48 [43, 53] vs. 52 [45, 58]; p<0.001) than patients in Groups 2 and 3. Patients who underwent additional gynecologic procedures (Groups 1 and 2) were more likely to have history of psychiatric comorbidities than patients in Group 3 (64% and 65% vs. 53%; p<0.001). BREAST-Q Physical Well-being of the Abdomen scores were not significantly different at preoperative, 6-month, and 1 year postoperative time points between all cohorts (72 [60, 86] vs. 65 [54, 81] vs. 69 [58, 81]; p=0.7). The proportion of patients in all cohorts who developed complications (38% vs. 47% vs. 43%; p=0.3) and returned to the operating room (14% vs. 13% vs. 16%; p=0.4) did not significantly differ. No statistically significant differences in BREAST-Q scores, complication rates, and return to the operating room emerged during pairwise comparisons. Conclusions: Our findings suggest that patients who undergo BSO and/or TAH at the same time as abdominally-based ABR have similar complication rates and short- and long-term Physical Well-being of the Abdomen as those who undergo sequential operations or do not undergo gynecologic surgery. Although additional investigations with a larger sample size are necessary, the present study suggests ABR and concurrent BSO and/or TAH safely combine risk-reducing procedures for hormone-positive breast cancer patients without any added morbidity.

Background: Patients with or at a high risk of breast and gynecological cancers often undergo mastectomies with breast reconstruction and risk-reducing gynecological surgeries, either in a staged or combined manner, to treat the existing cancer, prevent potential future cancers, and manage their overall risk (1,2). Previous studies have illustrated mixed results regarding complication rates associated with combined procedures, however, conclusions were limited by sample sizes or study design (e.g., de-identified database analyses) (3,4,5). The objective of this study was to compare the incidence of complications in combined versus staged procedures.

Methods: We conducted a retrospective review of patients undergoing staged or combined mastectomy with breast reconstruction and gynecological procedures at Beth Israel Deaconess Medical Center, RUSH University Medical Center, and the University of Colorado Anschutz Medical Campus from September 2007 to October 2023. Bivariate analyses were conducted to compare patient demographics and ninety-day breast-related complication rates between the cohorts. Complications of interest included emergency department visits, need for reoperations, and readmissions. All p-values equal to or less than 0.05 were considered significant.

Results: A total of 246 patients were identified who underwent combined or staged mastectomy with breast reconstruction and risk-reducing gynecological surgery, with 88 patients in the combined group and 158 patients in the staged group. The mean age in the population was 46±9 years with no significant difference (p=0.7) between the cohorts. The median BMI was significantly different between the groups with 27 kg/m2 (interquartile range: 8) in the staged group and 25 kg/m2 (interquartile range: 5) in the combined group (p=0.01). More patients in the staged group had history of radiation when compared to the combined group (41% vs. 24%, p=0.04), while there was no significant difference for the other comorbidities examined. There was no significant difference in breast-related complications between the staged and combined cohorts, however, patients in the staged group had significantly more reoperations (17% vs. 8%, p=0.04), readmissions (16% vs. 7%, p=0.037) and ED visits (18% vs. 8%, p=0.036) when compared to the combined group.

Conclusion: Contrary to previous studies, our findings suggest that patients undergoing combined mastectomies with breast reconstruction and risk-reducing gynecological procedures are not at increased risk of postoperative complications. This data is pertinent to patients' informed decision-making when considering combined management of breast and gynecological cancers.

References:

1. Berek JS, Chalas E, Edelson M, et al. Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. Obstet Gynecol. Sep 2010;116(3):733-743. doi:10.1097/AOG.0b013e3181ec5fc1
2. Ludwig KK, Neuner J, Butler A, Geurts JL, Kong AL. Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review. Am J Surg. Oct 2016;212(4):660-669. doi:10.1016/j.amjsurg.2016.06.010
3. Henn D, Barrera JA, Sivaraj D, et al. Combining Breast and Ovarian Operations Increases Complications. Plast Reconstr Surg. May 1 2022;149(5):1050-1059. doi:10.1097/PRS.0000000000008984
4. Tevis SE, Steiman JG, Neuman HB, Greenberg CC, Wilke LG. Postoperative complications in combined gynecologic, plastic, and breast surgery: An analysis from National Surgical Quality Improvement Program. Breast J. Nov 2019;25(6):1111-1116. doi:10.1111/tbj.13429
5. Vemuru SR, Bronsert M, Vossler K, et al. Postoperative Outcomes After Staged Versus Coordinated Breast Surgery and Bilateral Salpingo-Oophorectomy. Ann Surg Oncol. Sep 2023;30(9):5667-5680. doi:10.1245/s10434-023-13630-0

Background: Deep sternal wound infection (DSWI) is a serious and life-threatening complication of open cardiac surgery. Debridement and flap reconstruction has become standard of care, but the presence of a DSWI is associated with significant morbidity and mortality. The aim of this study is to investigate national patterns of flap-based management and outcomes for DSWI following coronary artery bypass grafting (CABG).

Methods: We queried the National Inpatient Sample (NIS) from 2016 to 2018 for patients with DSWI who underwent CABG. The outcomes of interest were reception of flap reconstruction and in-hospital mortality. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Sociodemographic and clinical variables that differed significantly (p<0.20) on univariate analysis were incorporated into binary logistic regression (p<0.05).

Results: There were 120,440 patients who underwent CABG procedures, of whom 1,399 (1.2%) were diagnosed with DSWI and included for analysis. Among these SWI patients, 113 (8.1%) patients were treated with a flap procedure during their stay (Table 1). There were 134 (9.6%) patients who died during admission. Higher yearly plastic surgery facility volume predicted a higher probability of flap reconstruction (OR: 1.002, 95% CI: 1.001-1.002, p=0.0013). Female sex (OR: 0.68, 95% CI: 0.55-0.84, p<0.001) and rural (OR: 0.32, 95% CI: 0.13-0.79, p=0.013) or urban non-teaching (OR: 0.39, 95% CI: 0.27-0.56, p<0.001) hospital status predicted lower probability of flap reconstruction. Older age (OR: 1.028, 95% CI: 1.019-1.037, p<0.001) and higher comorbidity burden (OR: 1.026, 95% CI: 1.021-1.030, p<0.001) predicted higher risk of in-hospital mortality. On average, patients with in-hospital mortality were associated with a $316,155 increase in total hospital charges when compared to those without mortality (p<0.001).

Conclusion: DSWI encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. Given that flap reconstruction has been associated with improved outcomes, reduction in total hospital stay, and costs, the findings of this study indicate that patients with DSWI are best served at high-volume plastic surgery facilities. The rate of flap reconstruction is significantly lower than expected for management of SWI in some demographic groups. Our analysis highlights a gap in the consistency of practice patterns for DSWI management, with decreased flap reconstruction rates noted in females, rural hospitals, and urban non-teaching hospitals.

Background Postoperative respiratory complications and adverse airway events are potentially life-threatening events that can occur following abdominal wall reconstruction. Clinical and physical risk factors including medical comorbidities, hernia volume, and increased intra-abdominal pressure have been proposed to increase patient risk for these complications. The purpose of this study was to determine the risk of respiratory complications in adults undergoing abdominal wall reconstruction and factors affecting complication rates using a national database.

Methods This is a retrospective cohort study performed with the TriNetX database collecting case data from 61 healthcare organizations. Adult (age ≥18 years) patients undergoing abdominal wall reconstruction with component separation were included based on CPT codes (49560, 49561, 49565, 49566, and 15734). Respiratory failure occurring within 90 days was determined by ICD-10 codes (J96.00, J95.82, J95.3, J95.821, J95.2, J95.3, Z99.11, and J96. 20). Patient demographics, medical comorbidities, and complications were compared using single-variable analysis. Risk factors were stratified by system or specific pathology. Propensity score-matched analysis was applied to each risk factor to assess the risk of respiratory failure. Statistical significance for each analysis was set to p < 0.05.

Results The database returned 12,788 cases of abdominal wall reconstruction meeting inclusion and exclusion criteria. The average age at reconstruction was 57.3 (±12.8) years. White (77%) non-Hispanic (78%) females (55%) were the most common demographic. We identified 1,263 cases with no risk factors and 11,525 cases having any of the outlined risk factors present. Propensity score-matching yielded cohorts of 1,252 cases each, and analysis showed that having multiple (≥2) risk factors (odds ratio [OR], 4.693 (2.9-7.59); P=0.0001) or history of COVID-19 and additional (≥1) risk factors (OR, 4.80 (3.2-7.19); P=0.0001) demonstrated a higher risk of respiratory complications. A diagnosis of obesity increased risk independently of other comorbidities (OR, 2.464 (1.28-4.76); P=0.0057). Other chronic conditions (anemia, chronic kidney disease, diabetes, cardiovascular disease, pulmonary disease, or hepatic disease) did not demonstrate statistical significance.

Conclusions Respiratory failure following abdominal wall reconstruction is a serious complication. Obesity and the presence of multiple chronic medical comorbidities are independent risk factors for respiratory failure following abdominal wall reconstruction. This data can be used to further risk-stratify patients preoperatively and facilitate postoperative monitoring.

Introduction Implant-based reconstruction (IBR) is the most common form of post-mastectomy breast reconstruction in the United States, the majority of which are performed in a two-stage manner (expander-to-implant). While IBR has historically been performed predominantly in the subpectoral plane, prepectoral implant positioning with use of an acellular dermal matrix (ADM) may offer relative benefits including mitigation of animation deformity, improved chest-wall positioning, and fewer muscle spasms. This prospective cohort study aims to compare prepectoral and subpectoral two-stage IBR through interval administration of patient reported outcome measures (PROMs) up to 12 months after the first stage of surgery.

Methods Patients undergoing two-stage IBR at a single institution from November 2021 to December 2023 were identified pre-operatively and recruited for enrollment. Females at least 18 years of age undergoing two-stage IBR using ADM following mastectomy were included. Enrolled patients were administered a set of BREAST-Q scales (Satisfaction with Breasts, Satisfaction with Implants, Breast Sensation, Breast Symptoms, Animation Scale, Physical Wellbeing-Chest) and the EQ-5D-5L pre-operatively and post-operatively at 6 weeks, 3 months, 6 months and 12 months. Chart review was performed to gather demographic and clinical variables. Comparative analysis of PROMs between the prepectoral and subpectoral cohorts was performed independently at each timepoint; within-group time dependence analysis and regression pending.

Results A total of 281 patients consented to participate in the study, of whom 191 have completed two-stage IBR (123 prepectoral and 68 subpectoral) and were included in analysis. Prepectoral and subpectoral patients completed surveys at the following timepoints, respectively: Baseline (77, 39), 6 weeks (59, 36), 3 months (64, 43), 6 months (74, 38), 12 months (71, 46). Baseline characteristics including age, race/ethnicity, BMI, smoking history, diabetes, indication for surgery, and history of chemotherapy and radiation did not significantly differ between the two treatment groups (p>0.05). A greater proportion of subpectoral patients had hypertension (9 [7.3%] vs. 14 [21%]; p=0.007), and a greater proportion of prepectoral patients underwent bilateral reconstruction (99 [80%] vs. 44 [65%]; p=0.016).

Between the prepectoral and subpectoral cohorts, there was no significant difference in BREAST-Q and EQ-5D-5L scores at any time point (p>0.05). The only significant difference in PROMs between cohorts at any point was that a greater proportion of subpectoral patients endorsed swelling of the arm (lymphedema) ipsilateral to their reconstruction (9 [27%] vs 3 [5.8%]; p=0.016) at 6 months post-op; this difference resolved by 12 months (7 [19%] vs 10 [18%]; p>0.9).

Conclusions This prospective study offers preliminary evidence that prepectoral and subpectoral two-stage IBR offer comparable patient reported outcomes up to 12 months post-operation. Across all timepoints evaluated, there was no significant difference between prepectoral and subpectoral IBR patients with respect to breast satisfaction, satisfaction with implants, breast sensation, breast symptoms, breast animation, physical wellbeing of the chest, and quality of life. Data acquisition is ongoing, so results may be subject to change.

Introduction: Heterotopic ossification (HO) can form after extremity amputation and may cause pain and functional impairment, and prevalence has been described, but mainly in military populations. (1-2) Also, the association of HO and symptomatic neuromas has been described. (3) Therefore, we aimed to describe the prevalence of HO in a civilian population of transtibial amputees. Moreover, we hypothesize that amputees who underwent prophylactic active nerve surgery (Targeted muscle reinnervation or Regenerative Peripheral Nerve Interface) at time of amputation will show a lower rate of HO formation. (4)

Methods: Adult patients undergoing transtibial amputation at a tertiary care center between 2000 and 2023 were included. Patient data were collected through medical chart review. The most recent post-amputation X-ray of the residual limb was assessed for HO presence, according to the Walter-Reed classification, by two researchers, and confirmed by 5 clinicians independently. (5) Multivariable regression was conducted to identify factors associated with HO presence.

Results: In total, 665 of 632 patients were included. HO was identified in 354 X-rays (53.2%), and was commonly present on the distal residual tibia (67.2%) and the distal residual fibula (68.7%). Floating HO, which was not attached to the distal residual limb but present in the soft tissue envelope, was identified in 7.9% of X-rays. Pain in the affected limb was reported in 53.2% of patients with HO. In patients who underwent passive (traditional) nerve surgery at time of amputation, HO was identified in 55.1% of cases. This was significantly higher compared to patients who underwent active nerve surgery at time of amputation (36.8%, p=0.009). Also, symptomatic neuromas were significantly more common in patients for whom HO was identified (68.2%), versus patient that did not show HO on X-ray (31.8%) (p=0.012). Both passive (traditional) nerve surgery (OR:2.3, p=0.003) and the presence of a symptomatic neuroma (OR: 2.2, p=0.001) were independently associated with a higher prevalence of HO following multivariable analysis.

Summary: - HO is a common finding in transtibial amputees, and does not occur in the military population. - Avoiding symptomatic neuroma formation, using prophylactic nerve surgery during amputation, might aid in decreasing HO prevalence and should be considered.

1. Edwards DS, Clasper JC. Heterotopic ossification: a systematic review. J R Army Med Corps. 2015;161:315-321.
2. Potter BK, Forsberg JA, Davis TA, et al. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am. 2010;92 Suppl 2(SUPPL. 2):74-89.
3. Minarelli J, Davis EL, Dickerson A, et al. Characterization of neuromas in peripheral nerves and their effects on heterotopic bone formation. Mol Pain. 2019;15.
4. Eberlin KR, Ducic I. Surgical algorithm for neuroma management: A changing treatment paradigm. Plast Reconstr Surg Glob Open. 2018;6(10):1-8.
5. Hoyt BW, Roach WB, Lundy AE, D'Alleyrand JC, Forsberg JA, Potter BK. Reliability of the Walter Reed Classification for Heterotopic Ossification Severity in Amputees. J Orthop Trauma. 2020;34(12)

Background: Risk factors that increase the likelihood of developing lymphedema following axillary lymph node dissection (ALND) are well-described in the literature. However, this information is based on varying and arbitrary cutoffs for lymphedema diagnosis, such as a 10% volume change in the extremity. Further, many studies do not include patients use of compression. This can decrease the reported incidence of lymphedema based on volume criteria due to a reduction in arm swelling with compression use. Therefore, perhaps instead of examining risk factors for development of lymphedema, we should examine factors that contribute to normal lymphatic function. This study aims to identify protective factors associated with normal lymphatic function after ALND for treatment of breast cancer. Methods: This was a prospective study of women treated with unilateral ALND for breast cancer at a single tertiary cancer center between 2020 and 2023. The patients were randomized to a control arm or treated with immediate lymphatic reconstruction (ILR) at the time of ALND. Patients with normal lymphatic function were defined as meeting all of four criteria: <10% arm volume change from baseline, <10 bioimpedance change from baseline, no compression use, and stage 0 on indocyanine green lymphography at one year follow up. All other patients were classified as having abnormal lymphatic function. Two sample T-test, Fisher's exact test, and Pearson's Chi-squared test compared characteristics groups. Univariate and multivariate logistic regression were used examine variables possibly associated with normal lymphatic function. Variables of interest included age, BMI, race, neoadjuvant chemotherapy, adjuvant chemotherapy, radiation of chest wall/breast, radiation to the axilla, number of axillary lymph nodes removed, number of nodes positive for malignancy, and if immediate lymphatic reconstruction (ILR) was performed at the time of ALND. Results: Of 112 patients with one year follow up, 34 patients (30.4%) had normal lymphatic function and 78 patients (69.6%) had abnormal lymphatic function. As expected, one year volume change from baseline, bioimpedance change from baseline, compression use, and ICG stage significantly differed between patients with normal and abnormal lymphatic function (p<0.005). A higher percentage of patients underwent ILR in the normal lymphatic function group compared to the abnormal group (68% vs 42%, p=0.014). Other factors were not significantly different between groups. On univariate analysis, ILR was the only variable significantly associated with normal lymphatic function. The odds of normal lymphatic function in patients who had ILR were 2.85 times higher than that of patients who did not (OR=2.85, 95% CI=1.24 to 6.85, p=0.015). Conclusion: ILR is significantly associated with normal lymphatic function one year after ALND. These findings suggest that undergoing ILR may be protective against developing breast cancer-related lymphedema.

BACKGROUND: Skin cancer patients who undergo Mohs surgery may require subsequent reconstruction. Reconstructive rhinoplasty for large nasal defects that affect the nasal frame typically requires cartilage grafts for structural support. Autologous cartilage is the primary source of supporting grafts for reconstructive rhinoplasty. However, autologous grafts require a donor site with an added risk of complications. Irradiated allografts have been introduced but are reported to have higher rates of infection, resorption, and tissue necrosis. A newer type of graft, fresh frozen cadaveric costal allograft (CCA), offers the benefit of not requiring a donor site, thus reducing operating room time and possible donor site complications. Furthermore, the use of CCA may lead to reduced costs, given that the product costs approximately $400 to $600 and the reduction in surgical expenses often far exceeds this price. The purpose of this study is to evaluate the safety and efficacy CCA for reconstructive rhinoplasty after skin cancer removal.

METHODS: We retrospectively reviewed the medical history and operative data of sixteen patients who underwent reconstructive rhinoplasties using CCA after basal cell carcinoma resection. CCA underwent a process of sterilization without irradiation. The cadaveric cartilages were stored in frozen conditions (-40℃ to -80℃), and temperature was maintained using dry ice during shipment. Pre and postoperative photographs of the patients were obtained, and anthropometric measurements were taken from 2D photos to evaluate nasal tip projection. Adverse events including infection, tissue necrosis, resorption, and reoperation were evaluated.

RESULTS: The average age was 73 years (range 59 to 90). The average duration of follow-up was 7 months (range 3 to 15 months). Types of grafts used included: Alar batten graft (n=9, 56.3%), nasal tip graft (n=6, 37.5%), and alar batten graft with nasal tip graft (n=1, 6.2%). Measurements taken from the 2D photos of the patients showed no significant resorption or deviation at 6-month or 12-month follow-up. No significant complications related to the use of the cartilage were noted.

CONCLUSION: Our study highlights a low complication rate and positive surgical outcomes following the use of non-irradiated CCA for reconstructive rhinoplasties after skin cancer resection. Further investigation involving a larger sample size and greater variation in types of rhinoplasty grafts would add to the existing data supporting the efficacy of CCA over other grafting materials.

Background: Despite numerous studies exploring the monetary costs of lymphedema care, there remains a gap in our understanding of treatment-induced distress, or "financial toxicity" (FT), in lymphedema patients. This study aims to (1) categorize the degree of FT in our cohort of patients, (2) evaluate current disparities in lymphedema care using Area-Deprivation Index (ADI), and (3) identify the association between FT and lymphedema disease progression.

Methods: This is a single-institution prospective study of adult patients with chronic lymphedema. Surveys were administered at the time of evaluation in our multidisciplinary lymphedema clinic. FT was measured using an adaptation of the comprehensive 11-item COST-FACIT instrument. A secondary-cost survey was also distributed to obtain patient demographics, clinical history, and lymphedema spending history. Surveys were logged into RedCap, patients were anonymized and given a unique identifier to link responses for later analyses.

Results: 38 patients were interviewed and 36 met inclusion criteria and were included in the final analysis. 7 (19.4%) patients were male, and 29 (80.6%) were female. 23 (63.9%) patients had government-based insurance such as Medicare/Medicaid, and 13 (36.1%) patients had private, employer-based, or individually-purchased insurance. 17 patients (47.2%) had upper-extremity lymphedema, 19 (52.8%) had upper-extremity lymphedema; all patients with upper-extremity lymphedema were breast-cancer related lymphedema. Patients with advanced stage lymphedema (Stage 3) had the lowest COST-FACIT scores (indicating higher FT) of 18.90, compared to lower disease stages (Stage 0, 1, and 2) which results in higher COST-FACIT scores (indicating lower FT) (21, 23.5, and 26.63, respectively). A Spearman Ranked Correlation test was performed and resulted in a weak indirect association between lymphedema disease stage and COST-FACIT scores (p=0.36). Patients from higher ADI neighborhoods (indicating most disadvantaged) were significantly strongly associated with having a lower COST-FACIT score (indicating higher FT) compared to those from lower ADI neighborhoods (indicating least disadvantaged) (p<0.008). A Pearson Correlation test was computed to assess the linear relationship between COST-FACIT scores and patient-reported disability through the Lymphedema Life Impact Scale (LLIS) assessment. There was a strong, negative indirect correlation between the two variables (p<0.001) indicating that patients with lower COST-FACIT scores (indicating higher FT) were significantly correlated with having a higher level of patient-reported disability on the LLIS.

Conclusions: Lymphedema imposes a substantial financial strain on patients. Solely evaluating the monetary aspect of lymphedema care fails to unveil the "true cost" burden of this chronically debilitating disease for patients. Patients from highly disadvantaged neighborhoods are more likely to experience FT, have more advanced lymphedema staging, and report higher levels of disability. Capturing the financial burdens pressuring patients is essential to understanding treatment-induced stress known as FT.

Background: Previous attempts at whole eye transplantation (WET) were ultimately deemed unsuccessful due to both technical and immunologic limitations. Since the first face transplant (FT) in 2005, significant strides have been made in our understanding of both, with multiple groups establishing technical feasibility of FT. Coinciding with this, an improved understanding of immunologic processes and rejection affords the opportunity to revisit WET, especially given its unique immune properties.

Methods: We report on a 46-year-old male who sustained a high voltage electrical injury resulting in severe facial injuries and left eye enucleation. With a cPRA of 32%, following identification of an appropriate donor, the patient underwent a combined partial face and WET with optic nerve coaptation and immune induction using rituximab and anti-thymocyte globulin. Notably, donor derived CD34+ stem cells were injected, locally, at the site of optic nerve coaptation for their potential role in immunomodulation.

Results: Operation time was approximately 22 hours with a total ischemia time of 2 hours and 59 minutes. Initial induction immunosuppression consisted of thymoglobulin at a total dose of 6mg/kg and 1000mg rituximab. Intraoperative administration of isolated donor derived CD34 hematopoietic stem cells directly at the optic nerve coaptation was performed. No postoperative complications were observed during the initial hospital course. Mycophenolate, tacrolimus, and prednisolone were used to maintenance immunosuppression. Now, more than nine months days postoperatively, no evidence of acute rejection, dnDSA, or adverse events have been observed.

Conclusion: Following a combined partial face and whole eye transplantation, our patient's postoperative course has been notably free of acute rejection or adverse events over nine months. This period of stability, following transplantation surgery involving optic nerve coaptation and local CD34+ stem cell application, suggests potential advancements in the management and viability whole eye transplants.

-Background: Supraclavicular fasciocutaneous flaps are a staple choice in face and neck reconstruction due to their location, skin thickness, mobile pedicle, and diverse vascular supply.(1) Gradually pre-expanding these flaps results in reduced donor skin thickness, ensuring a closer match with the recipient site's skin thickness while also decreasing donor site morbidity.(2) Supercharging involves dissecting an additional arterial supply with a given flap, then performing anastomosis with a recipient site artery to decrease the risk of postoperative flap ischemia, necrosis, or failure.(3) Because these problems are common in supraclavicular flaps, especially when pre-expanded, the following flap was supercharged using paravertebral dorsal vessels and the temporal artery. Three cases were performed using the supercharged and expanded supraclavicular fasciocutaneous flap (SSFF), and the results are described here. -Methods: In a retrospective review, three cases were identified in which the expanded SSFF was used for face and neck reconstruction following long term post-burn sequelae. All cases were performed at the Hospital do Servidor Público de São Paulo between 2017 and 2018. The cases consisted of two stages: During stage 1 of the procedure, the tissue expander was carefully positioned and the donor flap was gradually expanded, allowing for controlled tissue growth in preparation for subsequent flap rotation. Stage 2 involved reconstruction using the pre-expanded SFF, which was supercharged via anastomosis between the dorsal paravertebral perforator and the temporal artery. Indications included 1) a 16 y/o male with severe thermal burns to the face, anterior neck, chest, and right upper extremity at age 10, 2) a 16 y/o male with severe thermal burns encompassing the entire face at age 10, and 3) a 41 y/o male with severe thermal burns to the neck and chest at age 11. -Results: In the clinical cases, flap sizes varied based on defect correction needs, and ranged from 297 cm2 to 1984 cm2. Donor sites were closed primarily, and there was no full-thickness necrosis or flap loss. Complications during tissue expansion included one instance of an expander site hematoma, which resolved spontaneously. Complications after reconstruction included epidermolysis of distal flap edges and post-operative flaccidity, which were corrected operatively, and fibrotic band formation on flap edges, which was corrected via z-plasty revision. -Conclusions: Large face and neck reconstructions are complicated by the diverse morbidities associated with post-burn scar contractures, as well as the unique qualities of the recipient skin. Pre-expanding a SFF increases the flap size for reconstruction, and ensures a closer match between the flap thickness and the unique thickness of facial and cervical skin. Additionally, anastomosing the dorsal paravertebral perforator to the temporal artery enhances flap survival. More cases are needed to prove significant risk reduction compared to traditional SFF face and neck reconstruction.

References: 1. Ismail, H., Elshobaky, A. Supraclavicular artery perforator flap in management of post-burn neck reconstruction: clinical experience. Ann Burns Fire Disasters. 2016;29(3):209-214. 2. Karacaoglan, N., Uysal, A. Reconstruction of postburn scar contracture of the neck by expanded skin flaps. Burns. 1994;20(6):547-50. 3. Ogawa, R., Hyakusoku, H., Iwakiri, I., Akaishi, S. Severe neck scar contracture reconstructed with a ninth dorsal intercostal perforator augmented "Super-Thin Flap". Ann Plast Surg. 2004;52(2):216-9.

Purpose Pulsed-dye laser (PDL) therapy is the treatment of choice for capillary malformations (CM). Patients with extensive CMs, or ones located on the face, frequently require anesthesia during treatment. However, the vasodilatory effects of sevoflurane can reduce blood flow through the malformation thus reducing the laser's ability to capture the hemoglobin chromophore. At our institution, we have started using a normotensive anesthesia protocol because we believe it improves treatment response due to the maintenance of blood pressure. The following study aimed to compare the efficacy of laser therapy between our novel anesthetic protocol with standard inhalation anesthesia.

Methods This was a prospective study of pediatric patients with CMs who were treated with PDL therapy. Patients received the traditional anesthetic technique of inhaled sevoflurane gas (SEVO) or our non-hypotensive protocol of inhaled nitrous oxide for peripheral intravenous catheter placement, followed by total intravenous anesthesia (TIVA) of ketamine, dexmedetomidine, and fentanyl boluses. The erythema of the CM and adjacent normal tissue were measured using a handheld spectrophotometer prior to induction, post-induction, at the end of the case, and at their post-operative appointment. Patient heart rate (HR), systolic, and diastolic blood pressures (SBP, DBP) were recorded at the time of the 4 color measurements. Tissue perfusion was evaluated by comparing the mean difference between pre-induction versus post-induction vitals and erythema. Treatment response was then assessed by the difference in erythema between the CM and normal tissue prior to induction and at their follow-up appointment.

Results Ten patients underwent a total of 24 rounds of laser ablation. The 10 patients (41.7%) in the SEVO group had a mean reduction in their DBP of 19.56 ± 6.44 mmHg (p = 0.02) and erythema of their CM by 11.40 ± 4.29 (p = 0.03) following induction. Whereas the 14 patients (58.3%) in the TIVA group had a mean reduction in their DBP of 3.80 ± 6.10 mmHg (p = 0.56) and erythema of their CM by 2.59 ± 3.74 (p = 0.50). Fourteen of the 24 cases (58.3%) had follow-up measurements taken after a median of 56 (40, 66) days from treatment. Patients in the TIVA group exhibited a reduction in the erythema of their CM by -8.0 (-10.7, 5.3), compared to those in the SEVO group who had an increase in erythema of 9.3 (-6.5, 14.3) following treatment (p = 0.15).

Conclusion Patients that received the SEVO protocol experienced a significant reduction in their DBP and the erythema of their CM following induction. While patients in the TIVA group had a modest decrease in these measurements, they subsequently exhibited a better color response following therapy. Although not all patients undergoing PDL therapy for CMs need anesthesia, our data indicates that the ones that do should use a normotensive protocol to improve treatment efficacy.

Purpose: Autologous breast reconstruction, regarded as the gold standard post-mastectomy approach, faces remaining challenges in loss of breast and nipple sensation with suboptimal patient-reported outcomes (1). In an effort to preserve sensation, neurotization of autologous breast flaps has become a highly investigated topic (2). Previously, flap neurotization relied on surgeons identifying sensory nerves of adequate length to allow for direct coaptation or harvesting an autograft from a donor site, but the introduction of nerve allografts has allowed for increased candidacy for neurotization without donor site morbidity. In this study, we sought to investigate sensory and BREAST-Q outcomes in patients receiving deep inferior epigastric perforator (DIEP) flap reconstruction neurotized via direct coaptation and allografts.

Methods: Patients with direct nerve coaptation DIEP reconstruction who underwent neurosensory testing with a pressure-specified sensory device and/or completion of a BREAST-Q survey were retrospectively identified and matched to patients with allograft-neurotized DIEP flaps with similar follow-up times. Primary outcomes were cutaneous sensitivity of nine different breast areas and BREAST-Q scores for the four scales qualified by the U.S. Food and Drug Administration (Physical Well-being (Chest), Psychosocial Well-being, Sexual Well-being, and Satisfaction with Breasts) and the Sensation Module (Breast Sensation, Breast Symptoms, and Quality of Life impact of sensation loss). Statistical analysis was performed in R, comparing baseline patient information and outcomes of interest between the two groups.

Results: 29 women (52 flaps) were included in this study, with 17 flaps reconstructed with an autograft and 34 flaps reconstructed with an allograft. The two cohorts were similar in age, comorbid conditions, reconstruction sequence and breast cancer therapy. Sensation outcomes were analyzed in 11 autograft DIEPs with average follow-up time of 92.67 months and 12 allograft DIEPs with average follow-up time of 84.79 months. No significant differences in cutaneous sensitivity were found between the two groups at any breast area (p > 0.05). BREAST-Q surveys were returned by 11 patients receiving an autograft with average follow-up time of 94.42 months and 16 patients receiving an allograft with average follow-up time of 61.56 months. The two groups had comparable scores for all survey scales included in this study (p > 0.05).

Conclusions: Our results demonstrate comparable sensory and BREAST-Q outcomes in DIEP flaps neurotized by direct coaptation and nerve allografts. These findings suggest that the foreign material of allografts does not impede long-term sensory recovery, despite the presumed superiority of native nerves. Nerve allografts circumvent the requisite donor-site morbidity of autografts, provide "off-the-shelf" reliability and predetermined graft length, and potentially present a more cost-effective option due to shorter operation time.

References: 1.Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125(3):818-829. 2.Shiah E, Laikhter E, Comer CD, Manstein SM, Bustos VP, Bain PA, Lee BT, Lin SJ. Neurotization in Innervated Breast Reconstruction: A Systematic Review of Techniques and Outcomes. J Plast Reconstr Aesthet Surg. 2022 Sep;75(9):2890-2913.