Scientific Abstract Presentations: Reconstructive Session 4 Friday, September 27 Fri, Sep 27 10:30 a.m.-12:30 p.m. PDT

Introduction Conventional healing methods following Mohs surgery such as secondary intention healing and local flap usage can prolong healing times and introduce secondary wounds/scars, respectively. Dehydrated human amnion/chorion membrane allografts such as Epifix (MiMedx, Marietta, GA), have emerged as promising adjuncts in this process by providing scaffolds that mimic the natural architecture of the skin allowing for more uniform re-epithelialization and decreased healing times. This study will evaluate the wound healing characteristics following Epifix usage in post-Mohs surgical wounds.

Methods 46 patients who underwent Mohs surgery had reconstructive procedures utilizing Epifix. A retrospective analysis of demographic information and operative variables including: age, cancer type, smoking history, body mass index, wound location, wound size, wound depth, healing time, number of treatments, graft usage, and graft size.

Results Of the 46 patients, 19 were women and 27 were men. The mean age was 73 years. 9 patients had squamous cell carcinoma and 37 had basal cell carcinoma. The mean wound size was 2.64 cm2. The mean number of Epifix treatments was 2.26. 34 of the 46 patients received full thickness skin grafts post treatment. The mean healing time from the date of Mohs surgery was 42 days. Statistical analysis using Fisher's exact test with a p <0.05, showed no significant differences regarding healing time when comparing by wound size, location, and depth. Wounds on the nasal tip had significantly more treatments than other locations.

Conclusion The application of Epifix following Mohs surgery provides favorable healing times when compared to previous methods. Nasal subunits such as the nasal dorsum and alar required significantly less treatments when compared to the nasal tip with no significant differences in wound healing time. Future studies will include larger cohorts with greater variation in wound size, location, and compare aesthetic outcomes of Epifix to other reconstructive methods.

Purpose: Traditionally, soft tissue reconstruction following internal hemipelvectomy is performed using pedicled contralateral vertical rectus abdominis myocutaneous (VRAM) flap, but this technique has significant donor site morbidity (Proctor et al., 2019). Applied in reverse, the principles of anterior component separation (Ramirez et al., 1990) create sufficient laxity to enable closure without a donor site. Here, we compare outcomes of reverse anterior component separation (RACS) technique with VRAM for soft-tissue reconstruction following internal hemipelvectomy at our institution.

Methods: Patients undergoing internal hemipelvectomy and reconstruction with either RACS or VRAM between 1994 and 2024 were identified using EMERSE, a full-text EMR search engine available to researchers at our institution (Hanauer et al. 2015). BMI, Charlson Comorbidity Index (CCI), smoking history, pre-operative oncologic treatment, operative details, complications, length of stay and best postoperative ambulatory status were collected from retrospective chart review and bivariate analysis was performed to compare patients undergoing RACS and VRAM. Fisher's exact testing was used for categorical variables and Wilcoxon rank sum testing was used for continuous variables.

Results: A total of 17 were included, of which 7 had reconstruction with RACS and 10 had reconstruction with VRAM. The mean age at surgery was 56.1 (SD 15.6), the mean BMI was 29 (SD = 6.6) and the mean CCI score was 4.47 (SD = 1.77), none of which varied significantly by type of reconstruction. No patients had a history of smoking. Among patients undergoing RACS, a total of three (42.9%) had any complication, compared with 8 (80%) patients who underwent VRAM, although this difference was not significant (p=0.16) One (14.3%) patient who underwent RACS required readmission, compared with 4 (40%) who underwent VRAM, although again this difference was not statistically significant (p=0.33). Of patients who underwent RACS, three (42.9%) were able to ambulate without assistance and 4 (57.1%) with assistance, compared with patients who underwent VRAM among whom three (30%) could ambulate without assistance and 7 (70%) could ambulate with assistance (p=0.48).

Conclusion: RACS enables soft tissue closure following internal hemipelvectomy while minimizing donor site morbidity. Compared with VRAM, RACS had lower complication rates, although these were not statistically significant, likely due to small sample size. Surgeons should recognize reverse anterior component separation as an alternative to VRAM in patients undergoing repair following internal hemipelvectomy.

References: Proctor MJ, Westwood DA, Donahoe S, et al. Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis. 2020;22(5):562-568. doi:10.1111/codi.14909

Ramirez OM, Ruas E, Dellon AL. "Components Separation" Method for Closure of Abdominal-Wall Defects: An Anatomic and Clinical Study. Plast. Reconst. Surg. 1990;86(3):519.

Hanauer DA, Mei Q, Law J, Khanna R, Zheng K. Supporting information retrieval from electronic health records: A report of University of Michigan's nine-year experience in developing and using the Electronic Medical Record Search Engine (EMERSE). J Biomed Inform. 2015 Jun;55:290-300. PMID: 25979153.

Purpose: Open vascular surgery procedures involving the groin carry a high risk of complications that can compromise the vascular graft or repair and the associated extremity. Muscle flaps, including the sartorius muscle flap (SMF), over revascularization sites are known to reduce complications (1). However, little is known about how many times the SMF can be elevated and re-inset safely in patients who undergo repeat procedures in the same groin region.

Methods: A retrospective cohort study was performed on all patients who underwent vascular procedures of the groin with SMF plastics closure over a six-year period at a single institution. Surgical cases involving SMF closure were classified according to the number of re-insets involved (primary SMF closure, first SMF re-inset, or second SMF re-inset). A mixed-effects multivariable logistic regression model with a random intercept accounting for clustering by patient was used to evaluate the association between the number of SMF re-insets and all-cause surgical complications. Complications included hematoma, seroma, lymphocele, infection, wound breakdown, flap loss, and unplanned return to the operating room.

Results: There were 348 separate vascular procedures involving SMF closure performed on 228 unique patients. Two hundred eighty-two (81%) procedures were primary SMF closures, 60 (17%) were first SMF re-insets, and 6 (1%) were second SMF re-insets. Compared to primary SMF closures, cases involving first SMF re-insets were associated with lower odds of all-cause surgical complications (adjusted odds ratio [aOR] = 0.24, 95% CI = 0.08–0.69, p = 0.008). Cases involving second re-insets were not associated with surgical complications when compared to primary SMF closures (aOR = 0.39, 95% CI = 0.03–5.18, p = 0.475). Obesity (i.e., BMI > 30) was also independently associated with increased odds of surgical complications (aOR = 3.19, 95% CI = 1.26–8.09, p = 0.015).

Conclusion: Re-insetting the SMF for closure of vascular procedures of the groin can be performed safely at least once in patients undergoing reoperation in this region. In fact, SMF re-insetting may be a superior option to alternative closure types for repeat groin procedures given its low complication rate. Identification of obesity as a risk factor for complications may guide pre-operative risk assessment and management strategies in these patients. Future research should investigate whether additional SMF re-insets can be reliably performed to inform surgical decision-making.

References: 1. Wallace AB, Piper ML, Holland M, Lee S, Orringer M, Eichler C, Kim EA, Hansen SL. Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin. Ann Vasc Surg. 2022 Jan;78:77-83. doi: 10.1016/j.avsg.2021.05.049. Epub 2021 Aug 22. PMID: 34433093.

Introduction: Defined in 2009 by the European Hernia Society, flank hernias are a subclass of lateral abdominal wall hernia. Surgery involving the spine, aorta/IVC, retroperitoneum, and organ transplantation can lead to weakening of the lateral abdominal wall and subsequent herniation. Despite the reference to a seemingly generic anatomic location, flank hernias represent a specific subset of hernias that are lateral to the rectus and within three centimeters of the umbilicus, distinct from lumbar, iliac and subcostal defects. Less commonly reported than incisional/midline hernia, outcomes are poorly defined and there exists no consensus abdominal wall closure technique. Herein, we examine flank hernia repair and patient outcomes.

Methods: A retrospective review of all ventral hernia repairs between October 2013– August 2022 performed by the senior authors was conducted. Operative reports were used to identify flank hernias. All other ventral hernias were excluded. Demographic, comorbidity, perioperative, and surgical outcome-related information was collected.  

Results: A total of 39 flank hernias (19 male, 20 female) were included in this study. The average age was 60 years [26 years, 83 years] and average BMI was 31.3. Roughly 33% of the cohort were former smokers (having quit within 30 days), and most patients (56.8%) were classified as ventral hernia wound group (VHWG) 2. Patients had a mean 2.2 prior abdominal surgeries and 0.79 prior hernia repairs. One patient had prior mesh infection, and four had prior wound infections. There were 23 patients that underwent a concurrent abdominal procedure (59%), and 22 hernia repairs involved lysis of adhesions (considered distinct from concurrent procedures). The average hernia defect size was 219.95 cm2. One defect was closed primarily. The remaining 38 repairs incorporated mesh, with plane placements as follows: 15 onlay, four sublay, and 16 underlay. Mesh types included synthetic (19), biosynthetic (16) and biologic (2). Two patients experienced post-operative cellulitis (5.1%), five had a surgical site infection (SSI) (12.8%), and three encountered delayed healing (7.7%). There was a total of 11 recurrences (28.9%), with average time to recurrence of 724 days [203 days, 2022 days]. Mean follow-up was 2.7 years [18 days, 9.5 years].

Conclusion: Flank hernias represents a unique and challenging situation for reconstruction. Defect size, location, and proximity of surrounding structures are driving factors in its repair. We describe 39 flank hernia repairs, with an average follow-up of 2.7 years with a recurrence rate of 29%. Recurrence rates described in the literature, though decreased, reflect more ideal patient populations with frequent retromuscular and/or bone-anchored mesh repairs. Although this represents a limited cohort, outcomes analysis of flank hernias are sparse, and future investigations are warranted.

Purpose: Delays from presentation to soft tissue coverage within 72 hours in patients with lower extremity open fractures are associated with better outcomes. Orthoplastic teams should know how long flap coverage can be safely delayed from internal fixation, rather than presentation, because these procedures can be coordinated. We compared infection rates of patients with flap coverage delays within 24 hours, 24-72 hours, and over 72 hours of internal fixation.

Methods: This is a retrospective cohort study of adult patients in a Level 1 trauma center from 2011 to 2021. Patients sustained lower extremity open fractures and received free or local flaps after internal fixation. Infection rates among patients with various delays of flap coverage were compared. A multivariate logistic regression model (including patient demographics, flap composition, bone fixation technique, perioperative antibiotic use, the three aforementioned time intervals, the time from presentation to flap coverage, and time from fixation to flap coverage) was created to determine the predictors of wound infections.

Results: A total of 274 patients were included, and 76 (27.7%) developed a surgical site infection. The average time between fixation and flap coverage was 84.9 hours in non-infected patients and 106.6 hours in infected patients (p=0.074). The infection rates among the time intervals were (23.2%, 25.0%, and 31.5%, respectively; p=0.40). A positive correlation was found between the length of delay and infection rate in the multivariate logistic regression. Time from fixation to flap coverage was the only significant predictor of wound infection (p=0.04).

Conclusion: Time from fixation to flap placement is an effective predictor of infection rate. Although the infection rate of the >72 hours group did not reach significance, we believe a larger cohort would yield statistical significance. Early flap coverage of open fractures is ideal to mitigate infections as indicated by the trend in the data. More studies using fixation as the starting time point are warranted to further establish a "safe" time frame.

Background: Diabetes and PAD are the top causes of non-traumatic amputation in the US (1). The debate on optimal criteria for limb salvage or amputation persists, especially in complex cases (2). Lower extremity (LE) free tissue transfer (FTT) is an efficacious reconstructive tool aiding successful limb salvage (3). Despite efforts, comorbid patients remain at risk of amputation (2). This study aims to identify amputation risk factors following microsurgical FTT in the nontraumatic chronic wound population.

Methods: A single-institution, retrospective review of LE FTT patients (June 2011 to December 2023) collected demographics, medical history, Charlson Comorbidity Index (CCI), preoperative laboratory testing, preoperative angiogram details, microsurgical details, complications, and long-term outcomes. Patients who progressed to amputation (AMP) were compared to patients with successful limb salvage (LS). Variables conferring future amputation risk were examined using univariate logistic regression.

Results: 300 LE FTT patients had a 12.7% (n=38/300) amputation rate at a median of 168 (IQR:220) days. Of the 38 amputations, 63% were attributed to infection, 13% to flap failure, 11% to critical limb ischemia, 3% to hematoma, and 11% to other causes.

In comparison to the LS cohort, patients in the AMP cohort had significantly higher CCI (4 vs. 5, p=0.0375), Longer length of stay (25 vs. 34.5 days, p=0.0001), and longer postoperative length of stay (14 vs. 17 days, p=0.0055). The pre-operative vascular status revealed no significant differences in vessel runoffs between the AMP and LS cohorts and rates of pre-LE FTT vascular interventions were comparable (AMP = 23.7% vs. LS=17.9%, p=0.396). Patients in the AMP cohort had significantly higher rates of wounds in the hindfoot (36.8% vs. 19.5%, p=0.015) and plantar foot (34.2% vs. 17.2%, p=0.013). Postoperative complications were markedly higher for the AMP group (57.9% vs. 24.1%, p=0.000), including delayed complications like dehiscence (OR: 2.560, p=0.019), infection (OR: 4.875, p=0.000), and recurrence of osteomyelitis (OR: 8.600, p=0.000) prior to amputation.

On univariate analysis, risk factors for amputation included diabetes (OR: 3.582, CI:1.582-8.106), neuropathy (OR: 3.649, CI:1.728-7.703), CKD (OR: 1.867, CI:1.276-2.731), higher CCI (OR: 1.157, CI: 1.003-1.334), ESRD (OR: 5.271, CI:1.761-15.779), hindfoot defects (OR: 2.413, CI:1.167 - 4.991), plantar foot defects (OR: 2.507, CI: 1.193-5.272), history of Charcot arthropathy (OR: 4.207, CI: 1.731-10.223), and elevated a1c levels (OR: 1.203, CI:1.061-1.365). On multivariate logistic regression, history of Charcot arthropathy remained a significant risk predictor of amputation (OR:3.2, CI:1.2-8.3).

Conclusion: Multiple risk factors for amputation following LE FTT patients with non-traumatic chronic wounds were identified. This study informs optimal treatment strategies, potentially enhancing overall management in complex limb salvage decisions.

References: 1. Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-7. 2. Black CK, Ormiston LD, Fan KL, Kotha VS, Attinger C, Evans KK. Amputations versus Salvage: Reconciling the Differences. J Reconstr Microsurg. 2021;37(1):32-41. doi:10.1055/s-0039-1696733. 3. Chang C-H, Huang C-C, Hsu H, Lin C-M, Huang S-M. Editor's Choice – Diabetic Limb Salvage With Endovascular Revascularisation and Free Tissue Transfer: Long-Term Follow up, European Journal of Vascular and Endovascular Surgery. 2019;57(4):527-536. doi:10.1016/j.ejvs.2018.11.010.

This study was conducted by the ASSERT Group

Purpose: The clinical practice of prescribing postoperative prophylactic antibiotics following postmastectomy breast reconstruction with tissue expanders ranges widely from none to 7 days of postoperative antibiotics, to antibiotics until the drains are removed. The Centers for Disease Control and Prevention (CDC) recommends a single preoperative antibiotic dose for clean and clean-contaminated procedures, even in the presence of a drain1. Definitive studies to determine an optimal therapeutic strategy to prevent surgical site infection (SSI) in implant-based plastic surgical procedures are lacking. The goal of this multi-institutional, prospective, randomized control trial is to determine whether the CDC recommended single preoperative dose (SPD) of antibiotics is not inferior to one week of postoperative (WPO) prophylactic antibiotics in preventing SSI in Tissue Expander based Immediate Breast Reconstruction (TE-IBR) following mastectomy.

Methods: 499 women, 18 years old or older, undergoing TE-IBR were screened and 235 were enrolled across five participating centers after central IRB approval. Following enrollment, subjects were randomized to SPD or WPO groups using permuted block randomization stratified by site to ensure balance on treatment allocation within each site. The WPO group received a single preoperative dose of IV antibiotic with additional intraoperative doses as recommended based on operative time, plus seven days of postoperative antibiotics. SPD Group received a single preoperative dose of IV antibiotic only (CDC recommendation), with any intraoperative doses based on operative time. The other operative details proceeded according to the surgeon's standard procedure. Data was collected using a standard case report form into a central study database set up by The Plastic Surgery Foundation. The patients were followed until TE removal either for infection or exchange or until study end. The primary outcome of interest was SSI by CDC guidelines within 30 days of surgery. The study used non-inferiority trial design to examine whether the test product (SPD) is not worse than the comparator (WPO) by more than a non-inferiority margin of 6% set for this study.

Results: Data from 102 patients randomized to SPD arm and 112 to the WPO arm were used for analysis. 21 patients were withdrawn (18 had change in surgery and no TE placement, 2 withdrew consent, 1 withdrawn by provider). The SSI rate in SPD arm was 17% as compared to 11% for the WPO arm, which is within the non-inferiority margin set for this study but not significant (p=0.496). The rate of TE removal for infection within 30 days of surgery was 6% in SPD arm as compared to 2% in WPO arm. Hospitalization rate (9% in SPD vs 6% in WPO) and Return to OR rate (11% in SPD vs 10% in WPO arm) within 30 days of surgery were also comparable within the two groups.

Conclusions: The two groups have comparable hospital readmission and premature expander removal rates due to SSI. The SSI rate within 30 days of surgery did not differ by more than the non-inferiority margin of 6%. While the findings from this multi-institutional randomized control trial did not demonstrate that a single preoperative dose of antibiotics is not inferior to a 7-day postoperative antibiotic regimen in preventing SSI in TE-IBR, there was also no evidence to support the 7-day regimen was significantly better.

1. Berríos-Torres et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection. JAMA Surg. 2017;152(8):784–791.

The ASSERT trial was supported by The Plastic Surgery Foundation.

Introduction Repairing nasoseptal asymmetry and deviation in rhinoplasty involves implanting autologous nasal septal cartilage grafts. Patients with severe septal deformations may present challenges of limited septal cartilage available for repair. Utilizing 3D printed L-strut implants to replace septal cartilage may enhance current surgical approaches, but their mechanical strength is understudied. Silk-Fibroin Gelatin (SFG) has known biocompatibility and mechanical behavior that mimics cartilage tissue. Using Finite Element Analysis (FEA) models, we compared the mechanical behavior of 3D printed SFG to septal cartilage under two loading conditions to evaluate its potential for septal cartilage replacement.

Methods The FEA model applied a 0.1 N loading force at the nasal tip (given the septum's role in tip projection and a region subject to forces exerted during physical exams) or the "keystone" region (an area critical for dorsum support). Analyses included deformation, stress, and strain energy (energy required to restore the original shape when load is removed).

Results All models had a maximum deformation located at the nasal tip and maximum stress at bony-chondral junctions. SFG exhibited lower deformation and strain energy than septal cartilage. All stress magnitudes were lower than individual material yield stresses indicating they likely undergo reversible deformation.

Conclusion Our results suggest that 3D printed SFG implants potentially exhibit similar mechanical response to septal cartilage while undergoing loads at the "keystone" and nasal tip. These results are promising and drive future work using FEA to further evaluate 3D printed septal implant structure and suitability for use as septal cartilage replacement in complex septoplasty.

Introduction:

Hidradenitis Suppurativa (HS) is a chronic, debilitating inflammatory skin disorder that primarily affects the apocrine gland bearing areas of the body (1). It is characterized by recurrent painful nodules, abscesses, sinus tracts and scarring that negatively impacts a patient's physical health and impairs their quality of life (QoL) (2). Surgical intervention is warranted for complicated and advanced stage disease when medical treatments have failed. We hypothesize that completely excising HS lesions with primary closure of defects that are amenable to closure would significantly improve patient's QoL and overall function, even in the setting of high risk for dehiscence.

Methods:

We conducted a retrospective cohort study of 84 patients diagnosed with HS undergoing surgical excision of axillary disease at a single institution. The study evaluated healing outcomes, physical limitations and QoL improvements. Patients completed pre- and post-surgery Disabilities of the arm, shoulder and hand (DASH) and Short Form-36 Health Survey (SF-36) assessments. Shoulder range of motion (ROM) measurements (flexion/abduction) were recorded pre-surgery, at 3 months and 1-year post-surgery by a physical therapist. Weeks to heal (WTH), wound dehiscence and return-to-work (RTW) status were collected.

Results:

84 patients in total with 147 axillary excisional sites. Of the 147 sites, 122 were closed primarily of which 73 (60%) remained closed (closed/closed) and 49 (40%) experienced wound dehiscence (closed/dehisced). None of the closed\dehisced patients were offered further surgery. All were instructed to allow the wounds to heal in with local wound care. 25 sites were left open to heal by secondary intention (open). The patients within the closed/closed cohort showed statistically significant differences in all parameters, WTH (4.4 vs 16.3, p<0.001), RTW (6.3 vs 18.7, p<0.001), DASH (25.8 vs 38.4, p<0.001), SF-36 (27 vs 35.2, p=0.046), abduction (114.1º vs 100.2º p=0.001) and flexion (131.7º vs 113.5º, p<0.001) when compared to open. Patients within the closed/dehisced cohort also showed statistically significant differences in RTW (7.4 vs 18.7, p<0.001) and abduction (111.4º vs 100.2º, p=0.008) when compared to the open cohort. When comparing closed/dehisced to closed/closed there was no statistically significant difference in abduction (111.4º vs 114.1º p=0.713), RTW (7.4 vs 6.2, p=0.711) or SF-36 (27.3 vs 27, p=1.0).

Conclusion:

Surgical excision is integral in the management of recalcitrant HS. In the axilla, these incisions can have a high dehiscence rate (40%) due to risk of infection, tension, moisture, intertrigo. Despite the dehiscence, many patients treated with excision and surgical repair experienced improved QoL, ROM, healing and expedited RTW. In most cases, dehiscence represents partial or subtotal opening of the wound, so the openings are smaller than surgical sites left open to heal in secondarily. With the disease foci eliminated, patients are able to resume more normal activities in a timelier manner when compared to wounds left open to heal secondarily.

References: 1.Besma BD, Boussema F, Aydi Z, et al. Hidradenitis suppurativa (Verneuil's disease). J Saudi Soc Dermatol Dermatol Surg. 2013;17:1–5. 2. Schneider-Burrus S, Jost A, Peters EMJ, et al. Association of hidradenitis suppurativa with body image. JAMA Dermatol. 2018;154:447–451.

Background: The management of non-traumatic lower extremity (LE) limb salvage patients undergoing free tissue transfer (FTT) is complex and necessitates a multidisciplinary approach. The duration of hospitalization may reflect the surgical complexity, complications, and patient care burden, potentially influencing their recovery. However, its impact on patient-reported outcome measures (PROMs)-key to evaluating functionality, satisfaction, and quality-of-life (QoL)-remains understudied. This study aims to investigate the influence of length of stay (LOS) on PROMs in limb salvage patients undergoing FTT procedures.

Methods: A single-center cross-sectional study was conducted, including patients who underwent FTT, with a postoperative visit between June 2022 and January 2024. Length of stay (LOS) was categorized as hospital (i.e., difference between admission and discharge dates) and postoperative (i.e., difference between date of surgery and discharge dates). The 12-Item Short Survey (SF-12; QoL), PROM Information System Pain Intensity (PROMIS-3a; pain), and Lower Extremity Functional Scale (LEFS; ambulatory function) were completed at multiple times points: 1-month, 3-months, 6-months, 1-year, 3-years, and 5-years postoperatively. Patient demographics, comorbidities, preoperative characteristics, and amputation details were collected.

Results: A total of 41 patients underwent FTT, totaling 86 survey sets. Median postoperative duration of survey completion was 6.4 (interquartile range [IQR]: 2.4-25.5) months. The majority were male (n=33, 74%). Mean age and body mass index were 60.2±14.0 years and 29.9.9±5.7 kg/m2, respectively. Mean Charlson Comorbidity Index (CCI) was 4.1±2.7. Comorbidities included diabetes mellitus (n=23, 56.1%), peripheral vascular disease (n=21, 41%), and chronic kidney disease (n=6, 14.6%). Mean hospital and postoperative LOS were 28.5±12.2 and 14.6±7.2 days, respectively. Patients with a longer postoperative LOS showed reduced ambulatory function (r=-0.247; p=0.048), although this was not observed with hospital LOS (r=0.1566, p=0.609). Both hospital and postoperative LOS were associated with increased pain postoperatively (r=-0.390, p=0.002 and r=-0.332, p=0.007, respectively). QoL did not show significant differences based on either hospital LOS (r=0.1566, p=0.609) or postoperative LOS (r=-0.075; p=0.808).

Conclusion: This study demonstrates that LOS following FTT procedures significantly influences PROMs, including ambulatory function and pain intensity, which may be multifactorial. Collecting PROMs over time with larger sample sizes is critical for enhancing our understanding of patient experiences in the face of limb loss.

Background Approximately 400,000 ventral hernia repairs (VHR) are performed annually in the US and complex abdominal wall reconstruction is often required for advanced repair (1). Experienced plastic surgeons may perform components separation technique, which is reserved for large and complex hernias. Associated costs of VHR approach 3.4 billion, with emergency repairs and other postoperative complications comprising a considerable proportion of costs (2). As hernia reoccurrence rate has been shown to increase with each subsequent reoperation and been associated with postoperative complications (3,4), it is crucial to perform effective preoperative risk assessment.  Frailty measures have demonstrated increased predictive capability for various surgical complications as compared to historical surgical risk proxies including age, BMI, and other single comorbidities (5). The 5-factor modified Frailty Index (mFI-5) is a patient-specific measure based on existence of diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension requiring medications, and functional health status. The purpose of this study was to examine the association between the mFI-5 and various postoperative complications following ventral hernia repair in patients who received component separation technique as reported in the National Surgical Quality Improvement Program (NSQIP) database.    

Methods
A retrospective review of the NSQIP database from 2015 to 2020 was performed for patients who underwent VHR with components separation technique. Descriptive analyses of demographics, comorbidities, ASA Class, mFI-5 score, complications, and incisional/ventral hernia repair were performed. Frailty scores were calculated for each patient, a score of 1 was considered mild frailty and ≥ 2 was considered severe frailty. Multivariable regression was performed for frailty, age, BMI, smoking status, chronic steroid use, sex, ASA class, and hernia characteristics to determine relationship to all-cause 30-day complications, surgical site complications, length of stay, readmission and reoperation. All statistical analyses were performed using R software, and P < 0.05 was considered statistically significant.    Results
A total of 14,575 patients were identified. Mild frailty was a significant predictor of all-cause complications (OR 1.22, 95% CI 1.11–1.34), readmission (OR 1.20, 95% CI 1.06 – 1.37) and length of stay (OR 1.04, 95% CI 1.01–1.07) (p<0.05). Severe frailty was a significant predictor of a significant predictor of all-cause complications (OR 1.50, 95% CI 1.34–1.68), readmission (OR 1.37, 95% CI 1.17–1.59) length of stay (OR 1.14, 95% CI 1.10–1.19) and reoperation (OR 1.24, 95% CI 1.01–1.52). Age was only a positive predictor for length of stay (OR 1.27, 95% CI 1.18 – 1.36) (p<0.05). Smoking status and ASA class of 4 were predictive of all outcomes. Of hernia characteristics, mesh use was found to be protective for all outcomes. Elevated BMI was predictive of surgical site complications and reoperation. Chronic steroid use was predictive of length of stay.

Conclusion
Frailty, as measured by the mFI-5 index, has predictive capacity for many postoperative complications for VHR with component separation technique. Given the high comorbidity prevalence and complication rate in patients receiving components separation for ventral hernia repairs, there is a role for preoperative frailty assessment in risk stratification and optimizing safe patient outcomes.

References 1. Poulose BK, Beck WC, Phillips SE, Sharp KW, Nealon WH, Holzman MD. The chosen few: disproportionate resource use in ventral hernia repair. Am Surg. Aug 2013;79(8):815-8.

2. Beadles CA, Meagher AD, Charles AG. Trends in emergent hernia repair in the United States. JAMA Surg. Mar 1 2015;150(3):194-200. doi:10.1001/jamasurg.2014.1242

3. Holihan JL, Alawadi Z, Martindale RG, et al. Adverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications. J Am Coll Surg. Aug 2015;221(2):478-85. doi:10.1016/j.jamcollsurg.2015.04.026

4. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg. Jan 2003;237(1):129-35. doi:10.1097/00000658-200301000-00018

5. Akhavan AA, Liu H, Alerte E, et al. "Frailty Indices Outperform Historic Risk Proxies as Predictors of Post-Abdominoplasty Complications: An Analysis of a National Database". Plast Reconstr Surg. May 9 2023

INTRODUCTION Burns injuries represent a leading cause of mortality and morbidity in the United States (1). Serious injuries are surgically managed by burn surgeons trained in plastic or general surgery. However, due to the Accreditation Council for Graduate Medical Education (ACGME)'s recent elimination of the burn surgery requirement for general surgery training, the role of plastic surgery in burn surgery care has become increasingly important (2). This study aims to quantitively investigate the current role of plastic surgery in burn care at a single academic institution with an affiliated ABA-verified Burn Center and capture the exposure medical students receive on burn training.

METHODS A retrospective cohort study was performed of burn patients admitted to UPMC Mercy, the only comprehensive ABA-verified Burn Center and Level I Trauma Center in Western PA, from January 2012 to December 2022. Data from all patients admitted for burn injuries was obtained from a prospectively maintained internal database.

A survey was also distributed to over 200 AAMC medical student representatives. Participants were asked about their education related to burns, including the timing and settings of burn education, topics covered, and perceived level of preparedness for managing burn injuries. Data was collected anonymously and analyzed using descriptive statistics.

RESULTS 3843 patients were admitted for burn injuries, with 39.3% (n=1509) requiring surgery. Plastic surgeons were consulted for 17.5% (n=264) of these patients, performing a total of 658 procedures. Burn patients operated on by plastic surgeons received an average of 2.49±2.02 procedures. Most of the procedures performed by plastic surgeons involved severe and deep burns or anatomically challenging areas, such as the hand (n=362; 55.0%) and head/neck (n=165; 25.1%). These procedures involved acute coverage of complex burn injuries or delayed reconstruction of postburn deficits, such as scar contracture.

Survey results demonstrated that 63% of respondents received education on burns during their medical school tenure. The primary mode of instruction was through lectures (60%), followed by interest groups (40%). Topics on burn depth and total body surface area were universally covered. However, only 38% of students reported feeling satisfied regarding preparedness for managing burn injuries, and 20% learned about referral guidelines.

CONCLUSIONS Plastic surgeons play a crucial role in the acute and reconstructive care of burn patients, often performing multiple procedures with injuries to anatomically complex areas. Since burn training is no longer required for general surgery residency, plastic surgeons are uniquely positioned to fill the ongoing shortage of burn specialists. Otherwise, we anticipate a significant decrease in access to quality burn care.

The survey results demonstrate that plastic surgery emerged as the predominant specialty associated with burn education. Previous studies underscore the significance of mentorship and educational exposure in shaping students' career preferences (3, 4), emphasizing its importance in cultivating the future generation of surgeons committed to the field of burn surgery.

This study aims to encourage burn education within training curricula. Increasing plastic surgery representation in burn surgery would leverage their highly specialized skillset in wound healing and reconstructive surgery, ultimately improving burn patient outcomes.

REFERENCES 1. Burn Incidence Fact Sheet. American Burn Association. May 8, 2017. Accessed August 03, 2023. https://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/. 2. ACGME program requirements for graduate medical education in general ... www.acgme.org. June 12, 2022. Accessed August 04, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/440generalsurgery2023.pdf. 3. Shahrokhi S, Jindal K, Jeschke MG. Three components of education in burn care: surgical education, inter-professional education, and mentorship. Burns. 2012 Sep;38(6):783-9. doi: 10.1016/j.burns.2012.01.012. Epub 2012 Feb 22. PMID: 22360958; PMCID: PMC3384758. 4. Johnson LS, Travis TE, Shupp JW. What is the value of a burn surgery rotation in surgical residency? The American Surgeon. 2019;85(12):1314-1317. doi:10.1177/000313481908501222

Background: Patients undergoing abdominal wall reconstruction (AWR) have an increased risk of respiratory compromise. Studies have evaluated the impact of AWR on pulmonary function tests (PFTs); however, the prognostic utility of intraoperative PFTs for predicting complications following AWR remains uncertain (1-3). This study aims to investigate the association between intraoperative PFT values, particularly peak inspiratory pressure (PIP), and postoperative pulmonary complications in patients undergoing AWR.

Methods: An IRB approved single-institution retrospective review was performed of patients undergoing AWR for ventral hernia repair between January 2017 to September 2022. Demographics, including age, gender, smoking history, and history of COPD or emphysema were noted. Clinical characteristics, intraoperative PFTs including PIP and tidal volume (TV), and postoperative respiratory complications were recorded. Major complications were defined as requiring mechanical ventilation or BiPAP. Minor complications were defined either as the use of antibiotics, supplemental oxygen, nebulizer, anti-tussitives, or a complication that resolved without requiring treatment. Univariate and multivariate analyses were used to predict postoperative pulmonary complications.

Results: The cohort included 168 patients (118 women, 50 men) with a mean age of 55 years and mean BMI of 33. The mean TV was 415mL and the mean PIP was 19.44cmH2O. 52 patients (30.95%) experienced respiratory complications postoperatively with 10 patients (5.95%) experiencing major complications. The two most common major complications noted were acute respiratory distress syndrome and severe dyspnea. The average amount of time from the day of surgery to complications overall to present was 3.45 days. Increasing TV was not found to be significantly associated with major or minor postoperative respiratory complications. Increasing PIP was significantly associated with both major and minor postoperative respiratory complications after adjusting for age, smoking, and history of COPD or emphysema (p<0.001). In those who developed postoperative respiratory complications, the mean PIP was 21.65cmH2O versus a mean of 18.55cmH2O in those who did not develop complications (p <0.001).

Conclusion: Intraoperative elevations in PIP are associated with increased susceptibility to major and minor pulmonary complications following AWR independent of relevant patient risk factors. These findings hold potential significance in guiding postoperative care strategies for patients undergoing AWR.

References:

1. Sood, R. F., Lipira, A. B., Neligan, P. C., Louie, O., Wright, A. S., & Gibran, N. S. (2019). Respiratory Failure following Abdominal Wall Reconstruction: An Analysis of the Nationwide Inpatient Sample. Plastic and reconstructive surgery, 143(1), 165e–171e. https://doi.org/10.1097/PRS.0000000000005115

2. Blatnik, J. A., Krpata, D. M., Pesa, N. L., Will, P., Harth, K. C., Novitsky, Y. W., Rowbottom, J. R., & Rosen, M. J. (2012). Predicting severe postoperative respiratory complications following abdominal wall reconstruction. Plastic and reconstructive surgery, 130(4), 836–841. https://doi.org/10.1097/PRS.0b013e318262f160

3. Petro, C. C., Raigani, S., Fayezizadeh, M., Rowbottom, J. R., Klick, J. C., Prabhu, A. S., Novitsky, Y. W., & Rosen, M. J. (2015). Permissible Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction. Plastic and reconstructive surgery, 136(4), 868–881. https://doi.org/10.1097/PRS.0000000000001621

Introduction: Ventral Hernia (VH) repair poses many challenges. Consensus holds that minimally invasive techniques reduce the incidence of infection from open VH repair. Additionally, strong evidence suggests that placing the reinforcing mesh in the retrorectus (i.e., sublay) plane optimizes outcomes. However, both dissection of the retrorectus plane and the consolidation of the posterior rectus fascia can be technically challenging. To reach ideal repair, we describe a novel, minimally-invasive technique for VH repair, the staple single incision retrorectus surgery (sSIRRS).

Methods: Between September 2018 and May 2021, a retrospective review identified 30 patients with VH that underwent repair by sSIRRS. Data about patient demographics, comorbidities, hernia characteristics, operative details, and postoperative outcomes were recorded.

Surgical Technique: A small, 3-4cm incision is created directly over the hernia. Dissection exposes the defect and the anterior rectus fascia. The hernia is reduced. The retrorectus space is then entered in a cephalad direction on either side of the linea alba. Dissection is continued to create enough space on either side of the linea alba to insert a laparoscopic articulating powered stapler. Caudad dissection can also be undertaken to provide complete dissection from sternum to pubis. The tissues are compressed, and the stapler is fired. This creates an anterior and posterior staple line while plicating any diastasis recti and expanding the retrorectus space. A small amount of manual dissection is required beyond the staple line to allow placement of the jaws. With completion of the retrorectus space dissection, a reinforced biologic tissue matrix or synthetic mesh can be placed. Prior to placing the mesh reinforcement in the retrorectus space, the posterior fascial defect is closed with a running 2-0 PDS suture. The space is measured, and the mesh is cut to size. To anchor the mesh, 18" 0 barbed suture is placed at the apex of the cephalad and caudad staple line. The mesh is then cabled into position.

Results: Of the 30 patients, the average age was 57.5 years. Two patients had diabetes, fourteen had hypertension, and four were smokers. Average BMI was 31.3 kg/m2. Hernia recurrence was the primary indication for surgery for twenty patients. 63% of patients were discharged upon completion of the operation. One patient on anticoagulation, which was held perioperatively, had a postoperative hematoma, resolving without any intervention. No other complications were observed during the 90-day postoperative period. No patients had hernia recurrences with a follow-up time of 45.9 months (range: 23.3-55.5).

Conclusions: The sSIRRS technique allows minimally invasive repair of VHs. VHs repaired with this approach have had no recurrences and minimal complications at long-term follow up. Compared to other approaches (e.g. MILOS, eTEP), the sSIRRS technique had a reduced length of stay. This technique approaches ideal repair in a time of increasing ventral hernia burdens in an aging population.

Background: Up to 75% of women undergoing breast reconstruction after mastectomy choose implant-based breast reconstruction (IBBR). Surgical site infection (SSI) can lead to reconstruction failure. This may also lead to oncologic treatment delays. Although most literature demonstrates approximately a 10% SSI rate with IBBR, there are reports of rates as high as 30-50%. However, there is scant data on SSI rates in patients receiving postmastectomy radiation therapy (PMRT) who undergo IBBR. Furthermore, there is no consensus on postoperative antibiotic protocols for this population. This study aims to evaluate SSI rate among IBBR patients who receive PMRT as well as evaluate postoperative antibiotic regimens used in this population. Methods: A retrospective, single institution study was performed. All adult female patients who underwent IBBR between June 2020 and July 2023 were included. Patients who received autologous surgery during any part of reconstruction were excluded. Complications, including SSI and reconstruction failure, were collected. Postoperative prophylactic antibiotic regimens used after implant or tissue expander (TE) device placement were analyzed. Results: Our cohort included 301 patients. The median age was 48 years (IQR 41 – 56). Thirty percent of patients included underwent PMRT (N=91). There was no difference in the rate of SSI after TE placement in patients who eventually underwent PMRT and patients who did not undergo PMRT (11% versus 10.9%, p = 0.57). Additionally, PMRT was not associated with a significantly higher rate of SSI (18.5%) following TE to implant exchange versus non-radiated patients (12.9%, p = 0.31). Duration of prophylactic postoperative antibiotic therapy after implant exchange was not associated with an increased risk of SSI or implant loss (p = 0.62 and p = 0.15, respectively). Conclusions: PMRT was not associated with significantly higher risk of SSI after TE to implant exchange in the setting of postoperative antibiotic prophylaxis. Postoperative prophylactic antibiotic duration did not significantly impact the risk of SSI or implant loss in patients. With increased efforts to promote antibiotic stewardship, further studies are needed to evaluate antibiotic use in patients undergoing PMRT and IBBR to improve evidence-based practices.

Introduction: Venous thromboembolism (VTE) is extensively studied in trauma patients, but burn patients require special consideration due to their unique pathophysiology and management strategies. Currently, there are no specific prophylaxis recommendations to help mitigate VTE in burn patients.

Methods: The US National Trauma Data Bank (NTDB) was analyzed to identify patients with burn encounters from 2017-2021 using ICD-10 event codes. Our primary outcome measure was incidence of VTE, which included deep venous thrombosis and pulmonary embolism. Secondary outcome measures included need for blood transfusion and need to return to the operating room due to hemorrhage from skin/soft tissues/extremities. Multivariable regressions were conducted to evaluate the relationship between various VTE chemoprophylaxis types, timing of VTE prophylaxis, and VTE incidence while controlling for age, sex, %TBSA and inhalation injury.

Results: A total of 326,614 patients with burn injuries were identified in the NTDB during the study period, of whom 5,604 (1.7%) had a VTE event during their hospital admission. The majority of patients did not receive VTE chemoprophylaxis (54.1%). Of those that did, the most commonly used VTE chemoprophylaxis drug was low molecular weight heparin (LMWH) (37.9%), followed by unfractionated heparin (UH) (4.1%). Chi-squared analysis found that LMWH was significantly less associated with VTE incidence compared with UH. However, when controlling for age, sex, inhalation injury, and %TBSA, there were no differences among chemoprophylaxis type and incidence of VTE. Longer time to VTE chemoprophylaxis was significantly associated with increased odds of VTE when controlling for the same covariates (OR=1.04 95% CI 1.03=1.07, p<.001). Neither VTE prophylaxis type nor timing of VTE prophylaxis administration was significantly associated with an increased need for blood transfusion. Heparin was the only VTE prophylaxis type significantly associated with increased odds of returning to the OR for a bleeding-related complication (p<.001).

Conclusions: A majority of burn patients in the NTDB did not receive VTE chemoprophylaxis. In patients who did get chemoprophylaxis, unfractionated heparin may be associated with a higher rate of VTE and surgical bleeding complications when compared with LMWH. Delayed initiation of VTE prophylaxis correlates with a higher likelihood of VTE occurrence. Developing specialized VTE prevention guidelines for this population can enhance their care and outcomes.

Purpose The physiologic and psychosocial effects of stimulants use have potential to negatively impact surgical outcomes. Stimulants, such as cocaine and amphetamines, cause endothelial dysfunction and vasospasm, which can predispose these patients to peri- and post-operative complications.(1, 2) In addition, stimulant use can also result in behavioral complications such as loss of follow-up or noncompliance.(3) In this study, we evaluate the effects of stimulant use on surgical complications and ambulatory status following flap-based lower extremity reconstruction.

Materials & Methods Patients undergoing free or local flap to the lower extremity from June 2007 to January 2022 were eligible for inclusion. Stimulant use was defined as positive urine toxicology on admission or self-report of recent regular stimulant use. Stimulant non-use was defined as negative urine toxicology and self-reported lack of stimulant use. Patients with a history of stimulant use with unclear chronicity of use were excluded. The association of stimulant use with 1) flap complications (partial or full flap loss, revision or amputation) and 2) ambulatory status (full vs wheelchair or assistive device) at last follow up were assessed first by Chi-square test, then by multiple logistic regression while adjusting for age, BMI, race/ethnicity, and smoking status.

Results Among 326 patients with flaps to the lower extremity from 2007 to 2023, 111 patients had sufficient data to determine stimulant use status; 49 stimulant users and 62 stimulant non-users were identified. 45 patients underwent free flaps and 66 underwent local flaps, with a trend toward more free flaps in stimulant users (51% vs 32%, p=0.07). Most flaps were performed for trauma for stimulant users and non-users alike (96% vs 91%, p=0.46). Flap complications rates were similar for stimulant users and non-users (20% vs 17%, p=0.91), and there remained no relationship after adjusting for potential confounders (OR 1.03, p=0.96). Duration of follow-up did not differ by stimulant use status (median 3.8 vs 3.2 months, p=0.73), with return to full ambulatory status also not associated with stimulant use (44% vs 41%, p=0.92). After adjusting for potential confounding factors, stimulant use remained unassociated with return to full ambulation (OR 0.73, p=0.47); only age was associated with return to full ambulatory status (OR 0.97, p=0.03).

Conclusions These findings are reassuring that it is safe to perform flap-based lower extremity reconstruction in active stimulant users. With adequate adherence to follow-up, stimulant users can have favorable lower extremity reconstruction outcomes.

References 1- Böttner J, Fischer-Schaepmann T, Werner S, Knauth S, Jahnke HG, Thiele H, Büttner P. Amphetamine increases vascular permeability by modulating endothelial actin cytoskeleton and NO synthase via PAR-1 and VEGF-R. Sci Rep. 2024 Feb 13;14(1):3596. doi: 10.1038/s41598-024-53470-w. PMID: 38351286; PMCID: PMC10864289. 2- Safdari KM, Converse C, Dong F, MacDougall NA, Hyer K, Runyon A, Ahlering H, Comunale ME. Hemodynamic Effects of Methamphetamine and General Anesthesia. Anesthesiol Res Pract. 2022 Feb 17;2022:7542311. doi: 10.1155/2022/7542311. PMID: 35222639; PMCID: PMC8872671. 3- Cornwell DQ, Thompson AR, Ivie RM, Working ZM, Friess DM, Meeker JE. Methamphetamine in Orthopaedics: Considerations of an At-Risk Population. JBJS Rev. 2021 Jun 22;9(6). doi: 10.2106/JBJS.RVW.20.00229. PMID: 34550663.

Introduction As mastectomy rates rise with advances in cancer screening and diagnosis, more patients are pursuing post-mastectomy implant-based reconstruction (IBR), the majority of which are performed in a two-stage manner. IBR traditionally involves implant placement in the subpectoral plane; however, emerging evidence suggesting prepectoral IBR may superior patient outcomes. Following IBR, patients may opt to pursue revision procedures to optimize comfort or cosmesis. Revision procedures increase total costs, resource utilization, and risks of undergoing breast reconstruction and should be considered in patient and provider decision-making. This study aims to compare rates of revision procedures between patients who underwent subpectoral and prepectoral two-stage IBR up to 12 months post-operation.

Methods Patients at a single institution from November 2021 to December 2023 were identified pre-operatively and recruited for enrollment. females who were at least 18 years old undergoing skin or nipple sparing mastectomy with two-stage IBR using acellular dermal matrix were included. Exclusion criteria for analysis was being less than 12 months after index surgery. Additional revision procedures including fat grafting, implant exchange, removal of implants, conversion to autologous reconstruction, capsular revision, and skin excision, were monitored for enrolled patients up to 12 months post-initial operation. Chart review was performed to gather demographic and clinical variables. Statistical analysis including chi-square test, Fisher's exact test, and multivariate regression with covariates of surgical plane, age, race, BMI, diabetes, treatment laterality (unilateral vs. bilateral), chemotherapy, and lymph node procedure (sentinel lymph node biopsy or axillary lymph node dissection) was performed to compare the prepectoral and subpectoral cohorts. Statistical significance was set at 0.05.

Results A total of 48 subpectoral patients (80 breasts) and 91 prepectoral patients (166 breasts) were enrolled. In total, 3 (6.3%) subpectoral and 16 (18%) prepectoral patients underwent at least 1 additional revision procedure (p=0.064), trending toward more revisions for prepectoral patients. Multivariate regression found that neither surgical plane (subpectoral vs. prepectoral OR 0.39, 95 percent CI 0.08, 1.42, p=0.2) nor any other covariates were associated with greater odds of a patient undergoing an additional revision procedure (p>0.05).

At the breast level, 5 (6%) subpectoral and 32 (19%) prepectoral breasts underwent revision surgeries (p=0.007). There was no significant difference in specific types of revision procedures between the subpectoral and prepectoral treatment groups (p>0.05). Additional fat grafting was performed in 5 (6%) subpectoral and 18 (11%) prepectoral breasts (p=0.2). Implant exchange occurred in 1 (1%) subpectoral breast and 9 (5%) prepectoral breasts (p=0.2). Conversion to autologous flap reconstruction was observed for no subpectoral and 4 (2%) prepectoral breasts (p=0.3). Capsular revision was performed for no subpectoral and 6 (4%) prepectoral cases (p=0.2). Skin excision was conducted in no subpectoral breasts and 8 (5%) prepectoral breasts (p=0.06).

Conclusions The findings of this prospective study suggest that there is a greater tendency for patients who undergo prepectoral IBR to pursue additional revision surgeries when compared to patients who undergo subpectoral IBR. Understanding such trends can aid surgeons in appropriate patient selection and counseling. Data acquisition is ongoing, so results may be subject to change.

INTRODUCTION Peripheral neuropathies (PN) are a broad range of disorders affecting the peripheral nervous system commonly associated with diabetes mellitus (DM). As the disease progresses, patients may experience decreased mobility, altered gait, and ulceration that ultimately lead to loss of function. As a consequence, these patients may undergo non-traumatic lower extremity (LE) amputation. Early identification of gait abnormalities in PN patients may aid in optimizing limb salvage (LS) outcomes, specifically pertaining to postoperative healing and prevention of re-ulceration in the future. This study aims to analyze spatiotemporal gait parameters of DM patients with and without PN.

METHODS
Patients were prospectively enrolled between June 2021 and January 2024 if they were (1) ≥18 years old, (2) able to safely and independently ambulate without pain or assisted devices, (3) had no open lower extremity (LE) wounds, and (4) no LE surgeries within the last three months. Patient demographics, comorbidities, preoperative characteristics, and amputation details were collected. Participants completed a protocol including wearable sensors, a 120-second walk test, and a 30-second Romberg (sway) test. The Motility Lab software (Hamilton Thorne) provided data on cadence, gait speed, elevation midswing, single limb support, double limb support, stride length, and sway. Data analysis used an independent sample t-test (p < 0.05, STATA VSN 18.0). A multivariable logistic regression analysis including chronic kidney disease (CKD) and peripheral vascular disease (PVD) was performed to control for confounding variables.

RESULTS Of the 452 patients completing spatiotemporal gait testing, 185 (69.2%) patients had DM. Of whom, 128 (30.8%) had PN (PN+) and 57 (30.8%) did not have PN (PN-). Mean age was 63.50±10.89 years. Mean body mass index (BMI) was 31.80±8.06 kg/m2. PN+ patients had significantly higher rates of CKD (n=32, 29.1% vs. n=8, 15.1%; p<0.001) and PVD (n=50, 39.1% vs. n=8, 14.0%, p=0.001). There were more males in the PN+ cohort than the PN- cohort (n=89, 69.5% vs. n=28, 49.1%; p=0.008). PN predicted slower gait speed (0.81±0.23 vs. 0.89±0.21; p=0.018) and cadence (97.12±11.64 vs. 100.81±11.33; p=0.027), lower single limb support (35.47±3.13 vs. 36.98±0.33; p=<0.001), increased double limb support (29.30±5.71 vs. 26.12±4.77; p=<0.001), shorter stride length (0.99±0.22 vs. 1.05±0.20; p=0.031), and increased sway (0.21±0.18 vs. 0.16±0.10; p=0.016). Multivariate regression revealed PN decreased single limb support (β=-1.02, p=0.033) and increased double limb support (β=2.53, p=0.005).

CONCLUSION PN significantly impacts gait parameters of patients with DM, indicating a deterioration in their walking patterns. Recognizing the early signs of gait abnormalities can aid in timely interventions to minimize the risk of ulcers and further complications, underscoring the importance of a multidisciplinary approach to patient care.

Background Head and neck defects following Mohs resection pose a reconstructive challenge that requires consideration of aesthetics and function. While the use of biologic agents has expanded greatly beyond their original use in burn management, objective data and analysis concerning biologics in the reconstruction of head and neck defects are still lacking. The purpose of this study was to evaluate the use of biologic agents in reconstructing skin and soft tissue defects of the head and neck while illustrating lessons learned from over a decade's worth of cases performed by a single plastic surgeon (J.F.T.).

Methods We conducted a retrospective review of patients who underwent head and neck reconstruction using biologic agents, such as Integra and ACell, from January 2013 to June 2023 performed by senior author. Patients who underwent some form of head or neck reconstruction using biologics were included. Cases lost to follow-up or lacking sufficient documentation were excluded. Each case was evaluated for key patient characteristics, defect location, defect size, and reconstructive modality. Patient outcomes were analyzed, including time to healing, use of secondary biologics or grafts, and complications.

Results 520 patients underwent head and neck reconstruction by senior author. Defects mostly involved the scalp (36.7%) or the nose (25.6%), with variable sizes. Integra was the most common biologic agent used for reconstruction (63.3%). 50.6% of patients required a split-thickness or full-thickness skin graft following the biologic and 41.5% healed completely with the biologic alone. Patients had a median (IQR) time to healing of 72.5 (45.8-127.5) days as measured through follow-up. We measured complications as patients who required more than one biologic or one skin graft, since this is the customary practice, and found it to be 71 cases (13.7%). The median defect size was significantly larger in patients who experienced complications that required additional biologics or grafts (p < 0.001). There was no significant difference in complications in patients older than 75 years, smokers, or patients taking anticoagulants (p > 0.05).

Conclusions Reconstruction of head and neck defects following Mohs resection poses a significant challenge. While these deformities are commonly reconstructed using primary closures, skin grafts, and local flaps, incorporating biologics provides surgeons with an additional and valuable tool. This study, the most extensive to date, underscores the advantages and effectiveness of biologic agents. Biologics are less invasive than local flaps and offer reliable results that can be applied across a range of defect locations and sizes. In most patients, biologic agents were used in a two-staged procedure with skin grafting for better skin tone matching and cosmesis. However, we also found that a sizable percentage of patients healed completely with the biologic alone, with no need for follow-up skin grafts and additional donor site morbidity. Although reconstruction is safe to perform on elderly patients, smokers, and patients on anticoagulation, a larger defect size is a predictor of complications. The lessons learned from the past decade highlight the growing role of biologics in head and neck reconstruction, given their high success rate and tolerability.