Scientific Abstract Presentations: Reconstructive Session 7 Saturday, September 28 Sat, Sep 28 10:30 a.m.-12:30 p.m. PDT

Introduction: Targeted muscle reinnervation (TMR) has been demonstrated to be effective in the surgical treatment of neuropathic pain for amputees. (1, 2) However, data on the long-term postoperative pain course for patients that undergo Primary, prophylactic (<14 days since amputation), or Secondary (≥14 days) TMR surgery for preexisting pain, and their difference, remains insufficiently described. This study aims to describe the long-term postoperative pain course for these patients to aid in managing postoperative expectations.

Methods: Chart review was performed for major upper and lower limb amputees who underwent Primary and Secondary TMR and who were prospectively enrolled between January 2018 and January 2024, with a minimum follow-up up of 12 months. Pain scores reported on the Numerical Rating Scale (NRS, pain on a 0-10 scale) were collected up to latest follow-up. Mean NRS pain levels were compared between Primary and Secondary TMR cohorts. For Secondary TMR patients, it was assessed whether the difference in baseline and post-operative pain reached the Minimally Clinically Important Difference (MCID, ΔNRS=3.0). (3) Multilevel mixed-effects models were utilized to analyze the difference in pain and visualize average postoperative pain courses.

Results: A total of 144 amputees (60.4% male; 60.4% Secondary TMR patients) were included. The median follow-up was 2.4 years (IQR: 1.5-3.3). Primary TMR patients demonstrate a more rapid decline in pain, typically achieving average mild pain levels at 12 months (3.0, versus 4.1 for Secondary TMR patients (p<0.001)) before stabilizing. Secondary TMR patients demonstrate a less rapid, yet consistent decrease in pain, reaching an average mild pain level at the 36-month mark (NRS=2.7, versus 2.3 for primary TMR patients (p<0.001). The difference in pain between Primary and Secondary TMR patients is significantly different over the complete trajectory (p<0.001). On average, Secondary TMR patients reach the MCID at the 36-month mark, compared to pain at baseline (NRS=6.0 to NRS=2.7, ΔNRS=-3.3, p<0.001).

Summary: - Primary TMR patients illustrated a consistent postoperative decrease in pain score, reaching low levels of pain at 12 months before stabilizing. - Secondary TMR patients demonstrate slower but consistent decline in pain levels, and reach the MCID at the 36-month mark. - Primary TMR patients demonstrate lower pain levels over the whole trajectory. - These trends may assist in illustrating and understanding the long-term postoperative pain course and counseling patients in pain expectations following TMR. - This data reinforces the durability of both Primary and Secondary TMR over a long timeframe.

References 1. Mioton LM, Dumanian GA, Shah N, et al. Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees. Clin Orthop Relat Res. 2020;478(9):2161-2167. 2. Evelyn G Goodyear, Andrew L O'Brien, Julie M West, et al. Targeted Muscle Reinnervation at the Time of Amputation Decreases Recurrent Symptomatic Neuroma Formation. Plast Reconstr Surg . Published online May 18, 2023:Online ahead of Print. 3. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149-158.

PURPOSE: Malposition of the nipple areolar complex (NAC) is a non-optimal complication of nipple-sparing mastectomy (NSM) reconstruction, NSM that preserves the NAC and surrounding skin and results in both a more naturally appearing reconstructed breast and improved patient quality-of-life. NAC malposition may undermine these major reconstructive benefits, but there are various aspects of surgical technique that may potentially affect the NAC positioning: use of acellular dermal matrix (ADM), reconstruction type (direct-to-implant vs tissue expander), implant or tissue expander plane of placement, and mastectomy incision location. METHODS: To better understand NAC malposition and these potential surgical factors, measurements and data were recorded for 88 NSM reconstruction patients between January 2020 and May 2023. Statistical analyses comparing actual and ideal measurements were completed and demonstrated that, while patients' measurements strayed from the ideal at both pre-operative and post-operative timepoints, most patients had worsened malposition post-operatively compared to pre-operatively. Analyses of the surgical variables was performed using mixed effect regression models. RESULTS: Findings were significant for ADM usage (p=0.003 and p<0.001) and direct-to-implant reconstruction type (p=0.058 and p=0.029), being associated with NAC malpositioning along the vertical axis. Subpectoral placement of tissue expanders or implants (p=0.012 and p=0.011) and breast-splitting mastectomy incision type (p=0.003) were found to result in increased malposition. CONCLUSION: These findings demonstrate how certain NSM reconstruction surgical techniques may influence NAC positioning by highlighting which variables may have a higher risk of NAC malpositioning. These factors should be carefully considered with surgeons' operative planning and with patient counselling regarding reconstructive options.

Chronic Venous Insufficiency (CVI) commonly manifests as venous leg ulcers (VLUs), which account for approximately 70% of all persistent leg ulcers. Traditional treatments encompass chronic wound management, pharmacotherapy, utilization of compression garments, and surgical options such as debridement and skin grafting. However, these interventions frequently result in suboptimal skin graft adherence and high recurrence rates of ulcers. Additionally, patients often continue to experience refractory ulcers and enduring phleboedema, despite the surgical rectification of varicose veins and management of deep vein thrombosis.

In recent years, Lymphovenous Bypass (LVB) - a procedure that redirects lymphatic flow into the venous system - has emerged as a promising therapy for lymphedema. Given the symptomatic similarities between phleboedema (C3) and lymphedema, LVB presents a potential treatment strategy for phleboedema as well.

Between May 2021 and June 2023, a prospective study was conducted on patients with non-healing stasis ulcers following four weeks of conventional care, or those suffering from lower extremity edema that adversely affected their quality of life despite undergoing varicose vein treatments (Mueller phlebectomy or endovascular laser therapy). Exclusion criteria included severe peripheral arterial disease and untreated deep vein thrombosis or iliac vein compression. Data collected encompassed demographic information, the trajectory of wound healing, rates of ulcer recurrence, lymphoscintigraphy results, and responses to the Venous Leg Ulcer Quality of Life (VLU-QoL) questionnaires.

The cohort consisted of 31 patients who underwent LVB, with skin grafting performed as needed. The average age was 62.6 ± 14.7 years, with a predominance of male patients (20, 64.5%). The majority were classified as CEAP C6 (25, 80.6%). Postoperative observations included wound healing and phleboedema resolution within two months, with enduring outcomes observed in patients exhibiting a singular etiology of CVI over a minimum follow-up of one year. The VLU-QoL questionnaire, which had a 39.3% response rate, indicated enhancements in quality of life, including activities, psychological well-being, and symptom distress.

The employment of Lymphovenous Bypass for CVI management has demonstrated an elevated success rate in skin grafting, alleviation of wound pain/neuralgia, limb decompression, and enhanced wound healing, with sustained outcomes. Patient-reported outcome measures (PROMs) further underscore the potential advantages of LVB. To validate these findings, large-scale randomized controlled trials and pathophysiological investigations are imperative.

Background: An immediate lymphatic reconstruction (ILR) combining axillary reverse lymphatic mapping and lymphovenous anastomosis (LVA) has been gradually in the spotlight as a novel surgical technique to prevent lymphedema.[1] However, there is a counterargument that connecting small lymphatic vessels to large veins in the axillary region is not physiollogically reasonable given the pressure gradient.[2] Since it is difficult to decide whether to perform ALND preoperatively, our center perform not only ILR, but also distally based delayed lymphatic reconstruction (DLR). In this study, we will compare the incidence of postoperative lymphedema between the ILR treatment group and DLR treatment group during the same period.

Methods: In this retrospective cohort study, we analyzed 38 patients who had undergone mastectomy for node-positive unilateral breast cancer in our institution between November 2020 and October 2021. To compare the effect of preventive LR, we divided the patients into a ILR group (n=16) and a DLR group (n=22). For patients with at least 24 months of follow-up, we analyzed patient demographics and individual characteristics of patients who developed lymphedema.

Results: During a mean follow-up of 28 months, one patient (6.3%) was confirmed to have upper extremity lymphedema in the ILR group, whereas 5 out of 22 patients (22.7%) were diagnosed in the DLR group. In terms of individual LE patients, 5 out of 6 (83.3%) were treated with radiation, and were diagnosed between 7 and 21 months after lymphatic reconstruction (median = 18 month)

Conclusions: Our results suggested that ILR in the axillary region seems to have a better prophylactic effect than distally-based DLR. There is a need for larger studies with longer follow-up to confirm the findings obtained in our study.

References 1. Chung JH, Kwon SH, Jung SP, Park SH, Yoon ES. Assessing the preventive effect of immediate lymphatic reconstruction on the upper extremity lymphedema. Gland Surg. 2023 Mar 31;12(3):334-343. doi: 10.21037/gs-22-554.

2. Chen WF, Knackstedt R. Delayed Distally Based Prophylactic Lymphaticovenular Anastomosis: Improved Functionality, Feasibility, and Oncologic Safety? J Reconstr Microsurg. 2020 Nov;36(9):e1-e2. doi: 10.1055/s-0040-1716743.

Purpose: Video-capillaroscopy is a non-invasive imaging modality widely used in the field of rheumatology to evaluate microcirculation. We have previously reported successful capture of real-time blood flow in 1-mm superficial layer of flaps using video-capillaroscopy, leading to possible application of this device in intraoperative assessment of real-time blood flow in microsurgery. In this study, we used video-capillaroscopy to observe different tissue components of the donor and recipient sites in reconstructive microvascular surgery and lymphaticovenous anastomosis (LVA). Additionally, we report histological characteristics of the findings and the conditions limiting the use of this modality.

Methods: Twelve patients (7 males and 5 females) between the ages of 54 to 76 years underwent head and neck microvascular reconstruction from 2021 to 2024. The donor- and recipient-sites were evenly divided into four areas (quartiles) as observation points, and the central portion was observed using video-capillaroscopy (GOKO-BscanZD, GOKO Imaging Devices Co., Japan). Additionally, lymph vessels of 20 lower extremity lymphoedema patients between the ages of 32 to 83 years (mean age 61.7 years) in LVA surgeries from 2022 to 2023 were evaluated using this device.

Perforating branches of the donor-site were detected at the junction of blood vessels and fascia at a total of 42 locations for 12 patients (mean: 3.5 perforators). The muscle, fascia, skin surface, adipose tissue, and de-epithelialized skin were observed. At the recipient site, the cervical skin, mandibular periosteum, sternocleidomastoid muscle, and cervical adipose tissue were detected. In LVA surgery, lymph vessels in adipose tissue were observed. Blood flow was defined as clear detection of red blood cells movement and was assessed using a four-point evaluation scale. Zero points were given if there was no blood flow. One, two, three, and four points were given for blood flow found in <25%, 25-50%, 50-75%, >75% of the observed area, respectively. Papaverine hydrochloride was applied for preventing perforator spasm.

Results: The mean score for the donor-site was ≤1 points for muscle, fascia, and de-epithelialized skin; and >3 points for other tissues. The mean scores at the recipient-site were 0 for muscle, 2.0 for bone periosteum, 2.7 for skin papillary, and 3.5 for adipose tissue. Evaluation for muscle and fascia using video-capillaroscopy was intractable due to poor LED penetration. De-epithelialized skin was challenging to observe due to damage within 1-mm depth from the skin surface. Likewise, assessment of skin papillary region near skin incisions was not possible. A total of 67 lymph vessels were observed at the time of LVA surgery with an average score of 2.6. The mean preoperative ICG stage of lymph vessels in which blood flow could not be observed was 3.5.

Conclusion: Video-capillaroscopy, a portable, non-invasive imaging modality, still has its limitations to application on muscles, injured areas within 1-mm depth, and lymph vessels with high ICG stage. However, consistent observation of abundant blood flow in the skin, adipose tissue, periosteum, perforators, and lymph vessels via video-capillaroscopy in our study demonstrates the hopeful efficacy of this device in microvascular surgery and LVA.

Introduction: The coverage of lower extremity soft tissue defects from trauma, cancer and deep seated wounds often requires complex free tissue transfer. The anterolateral thigh, gracilis, and radial forearm have been proven to be safe and effective means for limb salvage and functional recovery.1 Classically, a major drawback of the radial forearm flap is the high incidence of donor site morbidity.2 Raising an adipofascial (AF) forearm flap preserves skin at the donor site and its relative thinness makes it a versatile flap with minimal bulk over the ankle and foot. With the intention of improving donor site morbidity and aesthetics, we compare the radial forearm AF flap to the suprafascially-dissected fasciocutaneous (FC) flap for coverage of lower extremity soft tissue defects.

Methods: This is a retrospective review of 29 consecutive patients treated with free AF or FC radial forearm flaps to the foot and ankle between February 2018 and September 2023. Records were reviewed to determine the type of defect and preceding surgery, time to reconstruction, complications, and reoperations.

Results: Of the 29 patients, 7 underwent FC reconstruction and 22 AF reconstruction. There was no significant difference in patients age, BMI, and comorbidities between the AF and FC groups. In addition, there was no difference in operative time, dissection time, or hospital length of stay. There was a significantly lower rate of reoperation and donor site revision in the AF group compared to the FC group with a similar rate of recipient site complications. Four patients underwent reoperation in each group (FC 57.1%, AF 18.2%, p-value= 0.046), and 3 patients underwent donor site revision in the FC group compared to 1 patient in the AF group (FC 42.9%, AF 4.5%, p-value=0.0091).

Conclusion: In the author's experience, the radial forearm should be considered a workhorse flap in the reconstruction of lower extremity soft tissue injury. This series shows that the use of the AF flap resulted in improved functional and aesthetic outcome with a decreased need for reoperation and donor site revision.

1. Kozusko, SD, et al., Selecting a free flap for soft tissue coverage in the lower extremity reconstruction. Injury 2019; 50:S32-39.
2. Satteson ES, Satteson AC, Waltonen JD, Li Z, Wiesler ER, Apel PJ, et al. Donor-site outcomes for the osteocutaneous radial forearm free flap. J Reconstr Microsurg 2017; 33:544-8.

Aim: Reconstructive surgeons aim to provide durable solutions for complex wounds with exposed vital structures, emphasizing minimal donor site morbidity. While muscle and fasciocutaneous flaps are often the gold standard, their limitations sometimes necessitate additional interventions like skin grafts. Minimizing donor site morbidity is crucial in treatment planning, driving the search for solutions to avoid secondary flap or graft harvest. This abstract explores the use of decellularized fish skin grafts (FSG) as a regenerative matrix product to extend flap reach during transfer. Method: Ten patients requiring soft tissue coverage underwent reconstruction using muscle or fasciocutaneous flaps combined with decellularized FSG. FSG was utilized when flaps alone were unable to fully cover the wound or when minimizing tension on the surrounding structure, such as the lower eyelid, was desired. In these cases, FSG replaced traditional skin grafts or additional flaps. Results/ Discussion: FSG supported flaps involving various muscles and fasciocutaneous areas in all 10 patients, with successful tissue transfer and rapid FSG integration. Flaps supported in this way included the lateral gastrocnemius muscle, abductor digiti minimi muscle in addition to keystone, dorsal nasal, rotation advancement and filet of toe fasciouctaneous flaps. The wounds healed without further surgical intervention, and patient satisfaction was high. Conclusion: Decellularized fish skin grafts prove effective in extending flap reach while minimizing donor site morbidity. The rapid integration of FSG facilitates quick re-epithelialization and complete closure, demonstrating its utility in challenging cases.

Background: The nasolabial flap is widely used to reconstruct the nasal ala, because of several advantages of nasolabial tissue, including its location, color-match, excellent blood supply, minimal donor deformity, absence of hair, and ease of transfer (1). Different nasolabial flap variations have been advocated, including two-staged (2) and single-staged flaps (3-5). However, when to choose which variation remains unclear. The performance of nasolabial flap variations was analyzed and compared to other reconstructive options. Methods: Consecutive alar reconstructions performed during a 10-year period (January 2012 to December 2021) were studied retrospectively. Charts and surgical reports were reviewed for defect size, reconstructive technique, cartilage grafts, surgical complications, and secondary procedures. Patients were followed-up clinically at 3, 6 and 12 months. Aesthetic outcomes were evaluated using standard digital photographs. Results: 148 alar reconstructions were performed in 84 female and 64 male patients (mean age, 69 years; range, 19-89 years). Average defect diameter was 1.6 centimeters, involving the right and left ala in 70 and 78 cases, respectively. 110 reconstructions (74 percent) were performed with nasolabial flaps, 90 single-staged and 20 two-staged, including 68 nasolabial-cheek flaps, 32 nasolabial island flaps and 10 nasolabial transposition flaps. 38 reconstructions (26 percent) employed other flaps in 20, skin-fat grafts in 14, and direct closure in four cases respectively. Alar rim grafts (95 primary and 5 secondary) were used in 100 patients. Complications occurred in 42 patients (28 percent), including hematoma, delayed wound healing, flap necrosis, vestibular stenosis and alar crease obliteration. Planned secondary procedures were performed in 20 nasolabial island flaps and 12 paramedian forehead flaps. Unplanned secondary procedures were performed in 42 single-stage nasolabial flaps (47 percent). None of the other single-stage flaps or skin-fat grafts were revised. Conclusions: Single-stage and two-stage nasolabial flap variations provide a versatile and safe means for reconstruction of the nasal ala, pending adherence to specific principles of flap design, harvest and inset. They are particularly suitable for patients with a well-developed nasolabial fold and excess cheek skin. Two-stage flaps are advantageous for patients with a pronounced alar crease and thick nostrils as well as younger patients, while single-stage flaps are more suitable for patients with a flat alar crease and thin nostrils as well as older patients. Scars should be placed at the borders of anatomical subunits, in existing folds or creases and over convex contours in areas with light reflections, whenever possible. With the right indication, single-stage nasolabial flaps produce aesthetically pleasing results and compare favorably to two-stage flaps. However, unplanned secondary surgery is frequent. References: (1) Cameron RR, Latham WD, Dowling JA. Reconstructions of the nose and upper lip with nasolabial flaps. Plast Reconstr Surg. 1973;52;145-150. (2) Climo MS. Nasolabial flap for alar defect. Plast Reconstr Surg. 1969;44:303-304. (3) Hagerty RF, Smith W. The nasolabial cheek flap. Am J Surg. 1958;24:506-510. (4) Field LM. Design concepts for the nasolabial flap. Plast Reconstr Surg. 1983;71:283-285. (5) Zitelli JA. The nasolabial flap as a single-stage procedure. Arch Dermatol. 1990;126:1445-1448.

Purpose

Lymphedema is an important complication, impacting quality of life and increasing healthcare burdens. Early prediction and intervention are crucial for effective management of this condition. In this study, we aim to develop and validate an artificial intelligence (AI) model, specifically the eXtreme Gradient Boosting (XGBoost) algorithm, to predict the occurrence of lymphedema after immediate lymphatic reconstruction to enhance clinical decision-making and surgical outcomes.

Methods

A comprehensive dataset comprising 131 patients who had undergone immediate lymphatic reconstruction was analyzed. The dataset was systematically divided into training (70%), validation (20%), and testing (10%) sets to optimize and validate the AI predictive model. The XGBoost algorithm, an AI algorithm, known for its efficiency and accuracy in handling structured data, was employed as the cornerstone of our predictive model. The model's performance was rigorously evaluated through cross-validation on the training and validation sets, followed by a final assessment on a set aside test set.

Results

AI model demonstrated remarkable predictive accuracy, achieving an accuracy metric of 0.8620 on the test set, indicating its robustness and reliability. These results underscore the precision of the XGBoost model in identifying patients at risk of developing lymphedema following immediate lymphatic reconstruction.

Conclusion

The findings of this study highlight the significant potential of AI predictive models in predicting lymphedema after immediate lymphatic reconstruction. The high accuracy achieved by the XGBoost model underscores its applicability in clinical settings.

Background: The DIEP flap is a dependable technique for microvascular breast reconstruction with low revision needs. Prior NSQIP data shows a readmission rate of 5.6%, LOS of 3.9 days, and complication rates for hematoma, vascular reoperation, and dehiscence at 3.68%, 1.99%, and 2.8%, respectively, with infection rates at the recipient site at 0.4% and medical complications at 6.4%. (1-3) Our study expands on these metrics using a larger US database to examine readmissions, mortality, morbidity, and LOS.

Methods: We conducted a retrospective study using 2017-2020 Nationwide Readmissions Database data, focusing on patients with DIEP flap reconstruction. Our primary measure was 30-day readmission, and secondary metrics included mortality, readmission causes, complications, and resource use, adjusted for confounders through multivariate analysis.

Results: A total of 32,019 DIEP flaps were identified in the overall cohort, with a median age of 51 years. The most common indication for breast reconstruction was following mastectomy. The rates of in-hospital, 30-day, and calendar-year mortality were all less than 1% (confidence interval 1.29-3.99), indicating low mortality rates associated with DIEP flap reconstructions respectively. The 30-day readmission rate was 5.8% (CI: 5.4%-6.3%), with infection being the most common cause of readmission, which had not been previously reported in the literature, with a rate of 2.0%. The main causes of readmission were infection (2.0%), wound dehiscence (0.19%), pulmonary embolism (0.19%), sepsis (0.18%), and hematoma (0.18%). Reoperation rates within the same admission were 7% during the index hospitalization and 11% during readmission. The average length of stay for patients undergoing DIEP flap breast reconstruction was 3.7 days (CI 3.65-3.82), consistent with current literature. In terms of the financial aspect, the mean adjusted hospitalization total charge was found to be $133,939 (CI: $128,021-$139,856), representing the listed price for the services rendered. The mean cost, reflecting the actual expenses incurred, was calculated to be $35,252 (CI: $34,029-$36,475). These findings emphasize the significant difference between charges and costs in healthcare, highlighting the financial complexities associated with DIEP flap reconstructions.

Conclusion: Our study provides significant insights into patient outcomes and complication rates in DIEP flap breast reconstruction. Notably, we discovered that the infection rate requiring readmission from DIEP flap reconstruction is 2.0%, which has not been previously reported in the literature. Additionally, we observed a higher reoperation rate (7% vs 5.6%) and a lower dehiscence rate (0.2% vs 2.8%) based on data from the largest nationally representative readmission database in the United States. Importantly, our investigation showed comparable reoperation rates and length of stay.

1. Arnautovic A, Karinja S, Olafsson S, et al. Optimal Timing of Delayed Microvascular Breast Reconstruction after Radiation Therapy. J Reconstr Microsurg. 2023;39(03):165-170. doi:10.1055/s-0042-1750125
2. Chishom TA, Andersen ES, Juan HY, Lele S, Coots LB, Mountziaris PM. Impact of Intraoperative Hypothermia on Autologous Breast Reconstruction. Ann Plast Surg. 2023;90(6S):S342-S349. doi:10.1097/SAP.0000000000003458
3. Tan MYL, Onggo J, Saleh S, Phan K, Dusseldorp JR. Deep inferior epigastric perforator (DIEP) flap safety profile in slim versus non-slim BMI patients: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2022;75(7):2180-2189. doi:10.1016/j.bjps.2022.04.046

Introduction: The Autologous Skin Cell Suspension (ASCS) technology is a new addition to the plastic surgery toolbox that can expand the regenerative potential of donor split-thickness skin defects after reconstructing full-thickness skin defects. Over the past year, our plastic surgery team has used the ASCS technology in the reconstruction of a wide range of wounds. Here, we review our outcomes and report on our experience using the aerosolized skin spray technology for soft tissue reconstruction.

Methods: A one-year audit was conducted to retrieve all cases involving epidermal autografting at our institution, from January 2023 to January 2024. Patients of all ages were included. From the electronic medical records, the perioperative protocols followed for application of the epidermal autographing, patient demographics, and long-term clinic follow-up reports were obtained. Given the range of applications across the 4 senior plastic surgeons retrieved in our audit, 2 representative cases for each indication were selected for in-depth review of the protocols used, complications, and long-term clinical outcomes.

Results: A total of 32 cases involving epidermal autografting were conducted, and 8 cases (age range 5 to 77 years, 3 females) were selected for discussion grouped into following indications were: oncological reconstruction, traumatic reconstruction (degloving, limb salvage), infection or wound dehiscence, and cosmetic resurfacing. ASCS application varied significantly, with the aerosolized skin spray being; combined with a split-thickness skin graft (STSG, meshed either 2:1 or 3:1), applied over free or pedicled flaps (reverse sural artery, latissimus dorsi, omental), onto donor flap donor sites, either directly onto freshly debrided wound beds or onto neodermis established using dermal matrices (as a one- or two-stage surgeries). Wound locations included the toes, dorsal foot, lower leg, thigh, chest, posterior shoulder, arm, and calvarium. ASCS preparation involved additional intraoperative steps, but these steps could be integrated to the operative workflow and did not notably increase operative time. Primary dressings were either non-adherent porous transparent dressings followed by petroleum gauze, or petroleum gauze directly. Secondary dressings almost always included a negative pressure wound vacuums. There was no noted association between dressing choice and postoperative outcomes (graft take, durability, or cosmesis). The longest follow-up was 12-months and all patients to date had 100% graft take. There were no reports of postoperative infections or need for re-debridement or revision surgeries. Patients were agreeable to reconstruction with the technology and pleased with the outcomes. The durable reconstructions exhibit early repigmentation.

Conclusion: Our findings underscore the expansive utility of ASCS across a wide range of wound types commonly encountered in plastic surgery. Long-term patient follow-up remains imperative to assess sustained outcomes. Despite a modest increase in procedure duration, the technology poses no additional risks while offering substantial benefits. The aerosolized ASCS technology offers a promising advancement in wound care and may augment both the functional and cosmetic aspects of surgical reconstruction.

Purpose: Pain at amputation sites can often lead to considerable disability and decrease in quality of life. Our prior research indicates promising early outcomes with fat grafting to address soft-tissue deficiencies and enhance local tissue quality in lower extremity amputations. (1) This prospective, single-center clinical trial aimed to evaluate the effectiveness of autologous fat grafting at amputation sites for impacting pain and function in amputees. Methods: Under an FDA approved protocol and Department of Defense funding, and with strict eligibility criteria, we prospectively enrolled subjects with lower extremity amputation experiencing pain that limited prosthesis fitting and use, despite multiple attempts to refit the prosthesis and/or change its design. All subjects received autologous fat grafting, and were randomized into either the Enriched Group, using autologous adipose stromal cell-enriched fat grafting (minimum 2 x 10(6)) cells per cc of injectate), or the Standard Group, using standard autologous fat graft. Outcomes encompassed biological cell properties, limb volume appearance, CT scan-measured limb volume, pain assessment, functional outcome measures with prosthetics, and measurements related to quality of life. Results: Participants in the Enriched group totaled 3 (all male, average age 46±18), while the Standard group comprised 7 individuals (4 male, average age 56±13). The most common adverse events reported were bruising and pain at the liposuction site. SVF cell viability was measured 82.7±3.6% in the Enriched. Throughout the trial, all participants experienced significant improvement in residual limb pain and phantom pain, compared with baseline, and enduring for 24 months (p value?). Pain relief occurred earlier in the Enriched group at two months post-procedure compared to the Standard group at three months post-operatively (p=0.02). Six participants ceased pre-treatment analgesics after fat grafting. Furthermore, there was a notable enhancement in self-rated satisfaction and functional outcomes related to prosthetic use, along with a suggestive improvement in freedom from pain (p<0.05). Discussion: Fat grafting is a safe and effective intervention to alleviate pain, hypersensitivity, and improve prosthesis tolerability for lower limb amputation patients. Enrichment with adipose stromal cells shows potential for accelerating pain relief and expediting recovery, although fat grafting with and without SVF enrichment was effective in this study.

Background: Facial vascular composite allografts (fVCA) offer innovative solutions to severe facial injuries, aiming for functional restoration and social identity reclamation. Despite the evolution of face transplants over 18 years, patient-reported outcome measures (PROMs) for fVCA recipients are notably lacking. In a unique case of partial face and whole eye transplant, established surveys were utilized to gauge patient-reported outcomes (PROs).

Methods: A 46-year-old male, severely injured by high-voltage electricity, underwent a partial face and whole eye transplant. The patient consented to periodic surveys assessing psychological and social health, administered pre and post-operation using four validated scales: Derriford Appearance Scale (DAS), Body Image Disturbance Scale (BIDS), Rosenberg Self-Esteem Scale (RSES), Social Desirability Scale (SDS). To maintain reproducibility and minimize confounding variables, surveys were administered by an independent third-party without providing clarifications to the patient's inquiries.

Results: The survey results show an overall increase in self-esteem and self-perception of image. RSES score increased from 10 (low self-esteem) pre-operatively, to 16 (moderate self-esteem) at 8 months post-operative. There was a decrease in scores across all subcategories of DAS from pre-op to 8 months post-op, as well as improvement in BIDS score. Finally, the SDS remained consistent from pre-op to 8 months post-operative with the subject in the "Average Scorers" category.

Discussion: This case highlights the significant psychosocial improvements post-facial and eye transplant, assessed using established PROMs. The findings advocate for the development of VCA-specific PROMs and broader incorporation of PROMs in protocol evaluations to enhance patient-centered care, post-operative interventions, and overall quality of life for VCA recipients.

Introduction: Burn injuries pose a significant global health concern, standing as the 4th most common traumatic injury worldwide (1). Despite advances in medical technology, severe burns persist as a challenge with often grim prognoses, underscoring the importance of unraveling mortality risk factors. This study seeks to identify these factors specifically in Appalachian burn patients within West Virginia's sole burn intensive care unit with the hope of offering insights into refining treatment approaches and resource allocation strategies. Methods: Retrospective analysis of patient data from Cabell Huntington Hospital's burn intensive care unit from January 2010 to June 2023 was conducted. Demographic and clinical variables were collected and analyzed using descriptive statistics, chi-square, Fisher's exact test, and logistic regression models to assess predictors of survival. Statistical significance was defined at p < 0.05. Results: In the study involving 1,104 patients, significant differences emerged between survivors and deceased individuals. Deceased patients were notably older (mean age 66 vs. 39, P<0.001) and had longer hospital stays (mean 13 vs. 9 days, P=0.022). A higher prevalence of COPD (30% vs. 14%, P<0.001) and inhalation injuries (47% vs. 9.7%, P<0.001) was observed among deceased patients. Survivors had a lower mean Total Body Surface (TBS) burned (7 vs. 32, P<0.001) and a higher proportion of 2nd-degree burns (70% vs. 26%, P<0.001) compared to deceased patients. Conversely, deceased patients had a higher prevalence of 3rd-degree burns (74% vs. 30%, P<0.001). Logistic regression analysis revealed age, COPD, inhalation injuries, TBS, and degree of burns as significant predictors of mortality. Each one-year increment in age was associated with a 1.07 times higher risk of mortality (P < 0.001). Patients with COPD had 2.64 times higher odds of mortality (P = 0.001), while those with inhalation injuries had 8.34 times higher odds (P < 0.001). Additionally, each one-unit increase in TBS increased the odds of mortality by a factor of 1.1 (P < 0.001). Patients with 3rd-degree burns had 6.45 times higher odds of mortality compared to those with 2nd-degree burns (P < 0.001). Conclusion: This study underscores the importance of recognizing specific risk factors associated with burn mortality, including age, comorbidities like COPD, inhalation injuries, TBS, and degree of burns. These findings offer critical insights for early detection and tailored interventions to improve outcomes in burn patients. By allocating resources efficiently and effectively based on identified risk factors, healthcare facilities can enhance patient care, minimize complications, and ultimately improve survival rates among burn patients in the Appalachian regions only BICU. Future research should continue to explore strategies for optimizing resource allocation and refining treatment approaches to further enhance outcomes in this patient population.

1) MD, Peck M. Epidemiology of burns throughout the world. part I: Distribution and risk factors. Burns. Published July 29, 2011. Accessed February 12, 2024. https://pubmed.ncbi.nlm.nih.gov/21802856/

BACKGROUND: Coverage of open wounds is challenging in certain regions of the body, as both wound contraction and its impact on range of motion must be considered. Inclusion of the dermal layer in skin grafts not only minimizes contraction, but also provides a reticular scaffold to support cell infiltration and graft integration during wound healing while improving the tensile strength and stability to the repaired skin. However, the use of full thickness autologous skin grafts is limited by donor site morbidity. Allogenic acellular dermal matrices obviate the need for an autologous donor site while maintaining the benefits of reduced contraction and improved wound healing.

PURPOSE: To present the evaluation of a meshed human reticular acellular dermal matrix (HR-ADM) in soft tissue restoration and wound healing in a series of wounds.

METHODS: Adult patients with open wounds participated in the study at a single academic institution. Patient demographics, wound etiology and duration were collected. Wound dimensions were recorded before and after application of meshed HR-ADM grafts, along with post-operative complications. The number of patients requiring secondary autologous skin grafting was noted as well as ultimate skin graft adherence, when used. Standard skin punch biopsies were taken from the wound bed pre-operatively (t=0) and 3-weeks post-operatively, and histological staining (H&E, CD31, laminin) was conducted to assess granulation and neovascularization.

RESULTS: 18 patients were enrolled between January 2023 and December 2023. There were 4 males and 14 females, with mean age 59 (34-84). Etiology included acute trauma and postsurgical wounds (e.g., status post fasciectomy or cancer resection). 17 wounds were acute, one wound was chronic, and the average size was 64.5 cm2 (4-322 cm2). Histologically, there is increased soft tissue (granulation) within the interces and infiltration into the dermal structure which demonstrate host integration with meshed HR-ADM. Histological staining revealed robust granulation (more laminin) and neovascularization (CD31) at 3 weeks compared to baseline (t=0). Notably, there is host cell infiltration into the dermal tissue structure confirming graft integration and increased laminin and CD31 within the interces, which can support stabilizing the area for skin grafting. 17 wounds (94%) underwent secondary skin grafting at 3 weeks and graft adherence was 100%. One wound healed without skin grafting. The average wound size decreased over time: 64.5cm2 (t=0), 13.6cm2 (t=3 weeks), 10.6cm2 (t=6 weeks). Final follow-up of 6 weeks was achieved in all patients. No flexion contractures were observed, and full range of motion was preserved in extremity wounds. There were no complications or adverse reactions to the meshed HR-ADM allograft.

CONCLUSIONS Meshed HR-ADM allografts provided a reticular scaffold for tissue ingrowth and helped optimize the wound bed to support soft tissue restoration and improved skin graft take. Clinically and histologically, increased granulation and neovascularization was observed in the wound bed. All the patients benefitted from the improved wound bed yielding successful autologous skin grafting and wound closure. It represents a valuable tool where avoidance of contracture is paramount and should be added to the armamentarium of reconstructive surgeons for treatment of open wounds.

Patients with a history of elective abdominoplasty face unique limitations when pursuing autologous-based reconstruction, as prior surgical intervention precludes them from the conventional deep inferior epigastric perforator (DIEP) flap procedure due to inadequate lower abdominal tissue. With the emergence of profunda artery perforator (PAP) flaps and lumbar artery perforator (LAP) flaps as viable alternative autologous options, patients with prior abdominoplasty procedures can now pursue reconstructive options beyond implant-based reconstruction. This study seeks to explore advancements made in autologous reconstructive options by comparing the outcomes of patients with and without a history of abdominoplasty who underwent subsequent autologous breast reconstruction.

This study utilizes data collected from a retrospective chart review of patients with and without history of abdominoplasty between January 2011 and May 2023 prior to presenting for breast reconstruction. 63 patients with a history of abdominoplasty were analyzed, of which 45 pursued autologous-based reconstruction and 18 pursued implant-based reconstruction. The 45 autologous patients with history of abdominoplasty were analyzed against 1355 autologous patients without history of abdominoplasty. Data including patient demographics, comorbidities, complications, and revisions were also analyzed. Complete BREAST-Q responses, including postoperative satisfaction with breasts, psychosocial well-being, physical well-being of chest, and sexual well-being, were tabulated and compared between groups. The LAP and PAP cohort BREAST-Q response rate was 38% and 43% respectively. All data was managed with REDCap electronic data capture tools. Statistical analysis was completed with SPSS statistical software. P-values of less than 0.05 were considered statistically significant.

There were no significant differences in age, race, BMI, and comorbidities between groups (p>0.05). A significantly higher proportion of patients without history of abdominoplasty underwent DIEP flaps (p<0.001) while a significantly higher proportion of abdominoplasty patients underwent PAP (p<0.001) and LAP flaps (p<0.001). Beginning in 2018, there was a notable increase in utilization of LAP flaps relative to PAP flaps in patients with a history of abdominoplasty. There were no significant differences in flap complications between groups (p>0.05). Patients treated with LAP flap reconstruction relative to PAP flap reconstruction had significantly higher BREAST-Q scores of post-operative satisfaction with breast, post-operative psychosocial well-being, and post-operative physical well-being of chest (p<0.001).

This retrospective analysis highlights the unique considerations and challenges encountered in breast reconstruction by patients with a history of abdominoplasty. Our findings emphasize the importance of patient-specific factors, especially prior surgeries, in guiding the selection of appropriate reconstructive techniques. The increasing preference for LAP flap procedures among patients with a history of abdominoplasty, alongside significantly higher LAP BREAST-Q scoring, supports a need for adaptable and innovative surgical approaches tailored to individual patient anatomy and medical history. Our study contributes to a growing body of evidence supporting personalized, patient-centric care in microsurgical breast reconstruction by advocating for a comprehensive assessment of patient characteristics to optimize outcomes and minimize postoperative complications and revisions.

Background Simultaneous symmetrizing surgery at the time of unilateral deep inferior epigastric perforator (DIEP) flap reconstruction has been described as a method to facilitate single stage breast reconstruction. However, the impact on cost and number of additional procedures is not well described.

Methods Patients who underwent unilateral DIEP reconstruction were identified in the MarketScan administrative claims database from 2017-2021 and followed for one year. Patients were stratified into immediate (DIEP at time of mastectomy) or delayed (DIEP remote from mastectomy) reconstruction groups, then further stratified into groups that underwent simultaneous symmetrizing surgery (SSS) defined as mastopexy or reduction or no simultaneous symmetrizing surgery (nSSS). Thirty-day outcomes included wound disruption, surgical site infection, thromboembolism, seroma/hematoma, and transfusion. Initial hospitalization cost, follow up surgery cost, and total cost were calculated. Deferred symmetrizing surgeries within one year were identified. In both immediate and delayed reconstruction groups, characteristics, outcomes, and cost between patients undergoing SSS vs. nSSS procedures were assessed using Chi-square and Fisher exact tests for categorical variables and Wilcoxon test for continuous variables.

Results A total of 1136 patients were identified (43.8% immediate, 56.2% delayed). 11.8% of delayed reconstruction patients had a simultaneous reduction or mastopexy. There were no significant differences in patient characteristics or 30-day complications. Within one year of index procedure, 29.3% of SSS patients had a revision vs. 50.6 % of nSSS patients (p=0.001). Patients in the nSSS group were proportionally more likely to undergo at least one additional procedure versus those who underwent SSS. (57% vs. 36.0%, p<0.001). Median total cost of reconstructive encounters and follow up surgeries was significantly lower for SSS patients ($36,123, IQR: ($22,526 - $66,118) vs. $ 51,200, IQR: ($35,364 - $79,297), p=0.005). Among immediate reconstruction patients, 12.7% underwent SSS and there were no significant differences between groups who underwent SSS or nSSS in outcomes (30-day or 1 year), or costs.

Conclusions Patients undergoing delayed unilateral DIEP and simultaneous symmetrizing surgery (SSS) on the contralateral breast ultimately had fewer revisions and additional procedures as well as a lower total cost of reconstruction than those who did not have a simultaneous symmetrizing procedure (nSSS). Patients undergoing mastectomy, DIEP and symmetrizing contralateral surgery all at once did not experience an increase in cost or complications. In the appropriately selected patient, a symmetrizing procedure at the time of delayed unilateral autologous reconstruction may decrease overall cost and stages of reconstruction.

Purpose: The supraclavicular artery island flap (SCAIF) has recently reemerged as a reliable and versatile means of reconstruction for complex head and neck defects as an alternative to the traditional free flaps or pedicled pectoralis flap. SCAIF has several advantages including good color match, reduced flap bulk, minimal donor site morbidity and short harvest time. Prior studies show SCAIF has similar complication rates to free flaps. Our study seeks to describe our experience with the supraclavicular flap for head and neck oncologic reconstruction and identify comorbidities associated with major postoperative complications to enhance the plastic surgeon's options for head and neck reconstruction.

Study Design: Retrospective chart review

Setting: Tertiary academic oncologic medical center

Methods: A retrospective review of twenty three patients who underwent supraclavicular flap reconstruction for oncologic defects was performed. Patient demographics, comorbidities, surgical parameters, and postoperative outcomes were assessed.

Results: The mean age of patients in the study was 70.17 (range 44-92), with 16 males and 7 females. Average BMI was 28.74 (range 15-52.5). Mean length of admission was 7.43 days (range 2-37) and 1.74 days in the ICU (range 0-15). The average length of follow up was 823 days (range 18-2176 ). Average defect size was 75.98 cm 2 with supraclavicular flap area of 80.32 cm 2 (range of 20-180 cm 2). Average operative time including oncologic resection was 8.89 hrs (range 1.15-18.08 hrs).

One (4.35%) patient experienced total flap failure requiring a secondary flap reconstruction. Six (26.09%) patients had minor flap necrosis or delayed healing which was managed by local wound care. No patients suffered from shoulder contracture, salivary leak, fistula, hematoma, or infection postoperatively. Mortality was seen in 6 patients (26.09%), all of these occurring beyond 1 year post operation.

Adjuvant radiation was associated with greater postoperative complications overall. Patient history of diabetes, co-existing thrombotic complication (DVT, PE), was significantly associated with delayed wound healing at the flap site. Older age and higher BMI were correlated with longer hospital and ICU stays.

Conclusion: SCAIF is a reliable and safe flap for complex head and neck reconstruction, with a low rate of complications necessitating surgical revision. It represents an alternative reconstruction option for patients who are poor candidates for free flaps and has the advantage of being performed without microsurgical experience. SCAIF may also allow earlier ICU discharge and reduced hospital stay in comparison to more complex types of head and neck reconstruction. SCAIF is a versatile flap that can be utilized in select patients with benefits of quick harvest, reliable blood supply, and expedited recovery.

Background: Large traumatic extremity soft tissue defects pose a difficult reconstructive challenge. These are often treated with large or multiple free flaps resulting in the need for a skin grafted donor site, multiple donor sites, and/or multiple anastomoses.

Methods: We reconstructed four limb defects with a modification to the classic scapular-latissimus dorsi chimeric flap. Extension of the cutaneous paddle to include lateral chest and axillary tissue increases the size of the skin paddle, allows for harvest of both flaps through a single incision with primary closure of the donor site, and a single anastomosis. The skin paddle and muscle flap can be oriented independently during inset to cover near-circumferential limb wounds. We refer to this modification as the extended chimeric fasciocutaneous scapular flap and latissimus dorsi muscle flap (ECS-LDF).

Results: Four patients underwent ECS-LDF for reconstruction of three lower extremity defects and one upper extremity defect. The average ECS-LDF size was 416.75 cm2. One patient's flap included a vascularized segment of scapular bone measuring 20 cm2. One patient had partial necrosis of the distal latissimus dorsi muscle that required debridement and skin grafting, but otherwise there were no flap related complications. Primary donor site closure was successful in all four patients. There were no donor site complications.

Conclusion: Four ECS-LDF flaps successfully resurfaced massive upper and lower extremity defects. This is due to the unique flexibility of the ECS-LDF, which represents an excellent addition to the reconstructive microsurgeon's armamentarium.