Scientific Abstract Presentations: Research & Technology Session 5 Friday, September 27 Fri, Sep 27 2:00-3:30 p.m. PDT

Introduction:

The standard of care (SOC) for deep partial thickness or full thickness burns is autologous grafting, which is being challenged by new technologies. The RECELL® Autologous Cell Harvesting Device prepares a non-cultured autologous skin cell suspension for application to burn wounds. Epidermal autografting with RECELL® provides comparable results to SOC while reducing donor graft size and morbidity, making it ideal for patients with large total body surface area (TBSA) burns. It has been shown use of RECELL® is cost saving or cost neutral compared to SOC for overall hospital resource use per unit cost. This study aims to compare the size of burn wound coverage per operative minute for RECELL® autografting versus standard split thickness autografting (STSG). The authors hypothesize that utilizing RECELL® decreases the operative time for definitive coverage of large burn wounds thereby offsetting unit cost.

Methods:

This is a case-control study of all adult surgical encounters for RECELL® epidermal autografting versus matched SOC STSG encounters performed by a single burn surgeon at a single ABA-verified burn center between April 2016 and January 2021. Patient demographics, burn characteristics, and surgical details were collected from electronic medical records (EMR). RECELL® patients were matched with STSG controls, prioritizing treated surface area and anatomic location, followed by burn etiology, patient age, and sex.

Results:

Twenty RECELL® surgeries were performed on sixteen patients. These encounters were matched to twenty STSG surgeries performed in eighteen patients. The RECELL® and STSG groups were not significantly different regarding age, BMI, co-morbidities present, sex, and diversity of race. Between the two groups, most burns resulted from flame injury, and subjective analysis of graft adherence was comparable. Time to re-keratinization of the burn wound (20.4 vs 19.0 post-operative days; RECELL®, STSG) was similar.

Treated burn wounds were located on the lower extremity (81.3% vs 100%), upper extremity (68.8% vs 76.5%), and trunk (50.0% vs 64.7%) in RECELL® and STSG encounters, respectively. The average graft thickness harvested was similar between RECELL® encounters and matched controls (0.0063″ vs 0.0056″). The average burn wound size and operative duration was 2824.4 cm2 in 112.78 minutes for RECELL® and 2318.65 cm2 in 104.6 minutes for STSG. As a result, RECELL® covered 25.0 cm2 in comparison to SOC STSG coverage of 22.2 cm2 per operative minute.

Conclusions:

Patient demographics were comparable between the matched groups as well as surgical complications, time to definitive wound closure, and overall graft adherence.

Our data trends toward demonstrating that RECELL® autografting treats a larger wound size per operative minute compared to matched STSG controls. These results are likely restricted to large, as opposed to small, treatment areas. This increased operative productivity with RECELL® assists in offsetting the unit cost. This benefit is in addition to the previously published benefits of using RECELL® in large burns including decreased donor site size and morbidity. In conclusion, selective use of RECELL® can offset the unit cost through increased operative efficiency, lessen donor site morbidity, and produce similar results as SOC STSG.

Purpose Although employment is a commonly evaluated outcome in burn populations, it is under-evaluated for other indications for plastic and reconstructive surgery. Many patients undergoing reconstructive surgery will require extensive physical or occupational therapy, and revisions or multi-stage procedures. Lower income individuals, who are more likely to work in manual labor settings,(1) may be especially vulnerable to the loss of wages associated with prolonged recoveries. Furthermore, with recent inflation, downstream effects of loss of wages may culminate in detrimental health effects, such as food insecurity.(2) Here we evaluated the employment status of patients who underwent plastic, reconstructive, or burn surgery within the past year to determine for potential risk factors and sequelae of unemployment after surgery.

Materials & Methods Patients attending post-op follow-up appointments at the outpatient plastic and reconstructive surgery and burn surgery clinics at a level one trauma center and regional burn center completed a survey including their current employment status (employed, unemployed, student, homemaker, retired) as well as the Household Food Security Survey Module (3) and whether they use food assistance resources (i.e. regional food bank, Supplemental Nutritional Assistance Program) between June 2023 and February 2024. Medical records were queried to collect demographics, surgery type, and number of operating room trips. Association of unemployment with demographic and clinical characteristics were assessed via Chi-square test, or Fisher's Exact, or Mann-Whitney U test as appropriate.

Results The final cohort of 86 participants was predominantly Hispanic or Latino (74%), and had Medicaid insurance (81%). More than half of post-op patients were unemployed at the time of survey (52%). Unemployment was more common in male patients (64% unemployed vs 39%, p=0.03) and surgical management of trauma or burn injuries compared to oncologic or other indications (68% vs 41% vs 35%, p=0.02). Unemployed patients also had more operating room trips (p<0.001). Food insecurity was more common among unemployed patients compared to all other employment statuses (53% food insecure vs 22%, p=0.02), and less than half (48%) of unemployed patients experiencing food insecurity were using any resources for food assistance.

Conclusion Unemployment was highly prevalent among post-op patients, especially among traumatic and burn reconstruction patients. Undergoing multiple surgeries may be an additional risk factor for unemployment, and potential impacts on productivity should be considered during surgical planning. Vocational evaluation should be utilized to maximize return to work, and screening for potential sequelae of unemployment, such as food insecurity, may prevent development of negative health outcomes associated with loss of wages.

References 1- Overview of Occupational Employment and Wage Statistics. US Bureau of Labor Statistics, May 2022. [Available from: https://www.bls.gov/oes/current/overview_2022.htm] Accessed 25 Feb 2024. 2- Food Prices: Information on Trends, Factors, and Federal Roles. US Government Accountability Office, 2023. Report No. GAO-23-105846. 3- US Household Food Security Survey Module. Economic Research Service, US Department of Agriculture [Available from: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/survey-tools/#household]. Accessed 05 Jun 2023.

Objectives: Monitoring inflammatory cytokines is crucial for assessing healing process and photobiomodulation (PBM) enhances wound healing. Meanwhile, cAMP response element-binding protein (CREB) is a regulator of cellular metabolism and proliferation. This study explored potential links between inflammatory cytokines and the activity of CREB in PBM-treated wounds.

Methods: A total of 48 seven-week-old male SD rats were divided into four groups (wound location, skin or oral; treatment method, natural healing or PBM treatment). 6-mm-diameter round shape wounds were treated with 808 nm laser every other day for 5 times (total 60 J). The wound area was measured with a caliper and calculated using the elliptical formula. Histological analysis assessed epidermal regeneration and collagen expression of skin and oral tissue with H&E and Masson's trichrome staining. Pro-inflammatory (TNF-α) and anti-inflammatory (TGF-β) cytokines were quantified by RT-PCR. The ratio of phosphorylated CREB (p-CREB) and unphosphorylated CREB was identified through Western blot.

Results: PBM treatment significantly reduced the size of the wounds on day 3 and day 7, particularly in the skin wound group (p < 0.05 on day 3, p < 0.001 on day 7). Collagen expression exhibited significantly higher density in the PBM treatment group (in skin wound, p < 0.05 on day 3, p < 0.001 on day 7, and p < 0.05 on day 14; in oral wound, p < 0.01 on day 7). The TGF-β/TNF-α ratio and the p-CREB/CREB ratio showed parallel trend during wound healing.

Conclusions: Our findings suggested that the CREB has potential as a meaningful marker to track wound healing process.

Background: Most plastic surgeons are in training during the time of known fertility decline. The literature shows that among plastic surgeons, infertility is 7x higher and there are more than double the obstetric complications compared to the general population. In the general population, complications increase with standing >3 hours/day while working, as well as with physical effort and occupational fatigue. Here, we present pilot data highlighting general trends and complications related to working hours spent standing while pregnant. Our ultimate aim is to describe differences between the experiences of surgeons and non-surgeons.

Methods: An 11-item anonymous, IRB-exempt, pilot tested survey addressing experiences with pregnancy, obstetric outcomes and complications, and knowledge of and experiences around fertility and assisted reproductive technology (ART) was developed with a content and survey design expert. Our survey was based on similar surveys described in the plastic and general surgery literature. A series of four email invitations containing the survey link were distributed to all trainees and attendings. Data were analyzed using descriptive statistical methods and risk analysis on Microsoft Excel and SPSS.

Results: We had a 15.9% (106 women, 36 men/902) response rate; average age was 39 years and 74.6% were female. 55.1% were trainees. Of female respondents, 54.7% reported having ever been pregnant. Most respondents (42.1%) had their first child during training. Of the women who reported live births, 50% reported pregnancy or obstetric complications. There was a total of 160 pregnancies: 63.8% resulted in live births, 27.5% resulted in loss prior to 20 weeks, and 6.9% resulted in elective termination. Results were stratified by average weekly hours spent working on feet across pregnancies (>40 and <40). 48.5% vs. 50% reported complications and 42.9% vs. 20% of pregnancies resulted in loss prior to 20 weeks (OR 3.0, 95% CI [1.447, 6.219]) in the >40 vs. <40 groups, respectively. Of the 59% who reported having tried to conceive, 29.3% reported difficulty; of those, 58.3% reported utilizing ART. 68.8% of respondents reported no prior knowledge of or education about fertility or ART.

Conclusions: Our pilot data demonstrates high prevalence of pregnancy and obstetric complications as well as pregnancy loss, greater in those who stood >40 hours/week while working while pregnant. This may be a surrogate for surgeons, particularly plastic surgeons, who spend significant time standing. Next steps include expanded data collection, as well as exploration of free responses around experiences with fertility and fertility education, which will inform a structured didactic curriculum for plastic surgery residents to include information about specialty-specific data, insurance coverage, and cryopreservation. Female surgeons may be associated with better outcomes, and recruitment/retention of quality female plastic surgeons is critical to the advancement of the specialty. As more women continue to apply to plastic surgery residency, and as the age of trainees continues to rise, it is imperative that we offer formal education around these topics early in training. This may lead to greater physical and mental health among plastic surgeons, and thus higher satisfaction in the workplace and ultimately better patient care.

Background: Telemedicine services experienced unprecedented growth during the COVID-19 pandemic, offering patients the convenience of seeking care remotely while reducing time and travel commitments. Our institution, home to one of the country's largest pediatric plastic surgery divisions, serves a prominent urban area and vast rural community. Given the adaptability of many encounters to telemedicine, this study aims to compare patient satisfaction in pediatric plastic surgery between telemedicine and in-person settings.

Methods: A retrospective analysis was conducted on Press Ganey surveys routinely collected at our institution from March 2020 to December 2022. Surveys were completed by parents or guardians of pediatric plastic surgery patients (aged 0-17 years) after in-person or telemedicine clinic encounters with a single surgeon. Thirteen of the 25 survey questions were relevant to both in-person and telemedicine encounters and were included for analysis. Top Box scores (indicating the percentage of most favorable responses) were recorded as frequencies with percentages and compared using Fisher's exact test.

Results: Verified surveys were available for both telemedicine and in-person encounters between June 2020 and November 2022. During this period, 738 encounters were conducted via telemedicine; 301 were new visits and 437 were return visits. Of the 223 surveys meeting inclusion criteria, 159 were from in-person encounters, and 64 were from telemedicine encounters. Telemedicine visits consistently had Top Box scores equal to or greater than in-person visits across all 13 survey questions. Statistically significant differences were observed for 2 questions: ease of contacting the practice (p = 0.002) and ease of scheduling appointments (p < 0.0001).

Conclusions: This study demonstrates comparable patient satisfaction in pediatric plastic surgery between telemedicine and in-person encounters with a single surgeon at our institution. These findings provide valuable objective data about the patient experience, highlighting the potential of telemedicine to optimize practice models and improve access to care in pediatric plastic surgery.

Background/Purpose: Craniofacial and pediatric plastic surgeons offer unique services that contribute value to their respective institutions. The goal of this study was to evaluate billing, collection, and compensation patterns in pediatric plastic surgery and to use machine learning models trained on data collected from our national survey to provide calibrated salary predictions and wRVU benchmarks.

Methods: A survey was distributed to 36 U.S. pediatric plastic surgery divisions/departments. Requested information included faculty salaries, relative value units, and distribution of clinical volume and non-surgical professional responsibilities. Data was collected over a six-month period and subsequently analyzed using R Studio (Version 1.3.1093). An interactive calculator was created in R Shiny to allow individual surgeons to predict their estimated compensation and wRVU targets.

Results: Of the 36 pediatric plastic surgery divisions surveyed, 27 programs responded with complete data. Complete responses were almost evenly distributed across most AAMC regions (27.3% each from the West Coast and South, 31.8% from the Midwest, and 13.6% from the Northeast). Most responding institutions were academic teaching hospitals (86.3%), representing a total of 91 pediatric (or partially pediatric) plastic surgeons. Over the past five years, five institutions (22.7%) had received funding from their associated medical schools, 15 (68.2%) had received financial support from their associated health system, and 14 (63.6%) reported having endowment funding. All institutions (100%) reported accepting some mixture of private and public insurance as well as uninsured and/or self-paying patients.

The average starting salary for a fellowship-trained pediatric plastic surgeon was $385,476 (SD: $74,915, Range: $175,000-$500,000). Across institutions, the average estimated starting wRVU benchmark for a full-time (1.0 FTE) clinical faculty member was 5,551 (SD: 1707, Range: 2,250-8,272).

Two variables were found to be highly statistically significant predictors of salary, namely the portion of practice comprised of craniofacial surgery (p-value = 0.005), a positive predictor, and the portion of practice in the outpatient clinic (p-value <0.001), a negative predictor. These and other stepwise-selected covariates were used to create an interactive salary and wRVU predictive calculator (Figure 1)

Conclusions: Our study provides baseline measures and standards for compensation and wRVUs in pediatric plastic surgery. Using the largest ever survey of pediatric plastic surgeons, we were able to construct robust predictive models for compensation based on clinical and administrative responsibilities as well as a centralized user interface to predict pediatric plastic surgeon starting compensation based on fellowship training, years of clinical experience, proposed distribution of clinical responsibilities, and region of practice.

Introduction Plastic surgery training has continued to evolve over the past decade with a greater emphasis on the integrated model (1,2). As a result, it is crucial to reexamine the function and purpose of all general surgery rotations to ensure well-rounded training in plastic surgery. Guidelines for rotations are set forth by the American Board of Plastic Surgery (ABPS) (3). However, different programs continue to adopt unique curricula (4). A study by Rifkin et al in 2019 reported an average of 12.8 ± 4.7 months of general surgery rotations (5). We hypothesize that there has been a gradual trend towards fewer general surgery months as the total number of integrated programs continues to increase.

Methods Match data from 2012-2023 was obtained from the National Resident Matching Program website. The most current list of integrated plastic surgery programs was obtained from the American Council of Educators in Plastic Surgery (ACEPS) website. Rotation schedules for postgraduate years 1 through 6 were obtained through official program websites where available between January and February 2024. The numbers and types of general surgery months were recorded and compared between programs of various types and sizes. General surgery rotations included intensive care unit, surgical oncology, breast surgery, colorectal surgery, cardiothoracic surgery, acute care surgery, minimally invasive surgery, trauma surgery, vascular surgery, pediatric surgery, and transplant surgery.

Results There are more integrated programs becoming available each year while independent programs continue to downtrend. Rotation schedules were obtained for 66/89 (74.2%) programs. The average number of general surgery months was 10.3 ± 3.0 months across all programs. Programs within departments have significantly fewer general surgery rotations than those within divisions (8.9 ± 4.3 months versus 10.6 ±; 9.5 months; P = 0.03;). However, association with both independent and integrated residencies versus integrated residency only (10.5 ± 9.0 months versus 9.3 ± 7.2 months; P = 0.09) and 1-2 residents per incoming class year versus 3-5 residents per incoming class per year demonstrated no significant differences (10.0 ± 6.2 months versus 10.4 ± 10.8; P = 0.40).

Conclusions The number of integrated plastic surgery programs has increased by 68% over the decade while the number of independent programs has decreased by 33% over the same timeframe. Programs continue to change their rotation schedules, and over the 5 years, there has been a 20% decrease in the total number of months spent on general surgery rotations. As of 2024, plastic surgery programs associated with departments have fewer general surgery rotations than those associated with divisions which can be explained by greater autonomy. However, there was no significant differences in months of general surgery rotations when programs were stratified by size and association with an independent track. Despite this apparent overall decrease, the inter-program curricula largely vary. The ABPS and ACEPS must continue to re-evaluate required general surgery rotation exposure to ensure resident exposure to plastic surgery and clinical competency is optimized.

References:

1. Rohrich RJ, Johns DF, Beran SJ. Graduate medical education in plastic surgery: a time for revolution. Plast Reconstr Surg. 1997;100(5):1333-1335. doi:10.1097/00006534-199710000-00042
2. Pace E, Mast B, Pierson JM, Leavitt A, Reintgen C. Evolving Perceptions of the Plastic Surgery Integrated Residency Training Program. J Surg Educ. 2016;73(5):799-806. doi:10.1016/j.jsurg.2016.03.014
3. Wanzel KR, Fish JS. Residency training in plastic surgery: a survey of educational goals. Plast Reconstr Surg. 2003;112(3):723-729; discussion 730. doi:10.1097/01.PRS.0000069705.52702.80
4. Schneider LF, Barr J, Saadeh PB. A nationwide curriculum analysis of integrated plastic surgery training: is training standardized? Plast Reconstr Surg. 2013;132(6):1054e-1062e. doi:10.1097/PRS.0b013e3182a8089c
5. Rifkin WJ, Cammarata MJ, Kantar RS, et al. From "Coordinated" to "Integrated" Residency Training: Evaluating Changes and the Current State of Plastic Surgery Programs. Plast Reconstr Surg. 2019;143(3):644e-654e. doi:10.1097/PRS.0000000000005325

Purpose

To determine the efficacy of metformin to prevent Breast Cancer Related Lymphedema in patients with Diabetes Mellitus undergoing Axillary Lymph Node Dissection.

Introduction

Breast Cancer Related Lymphedema (BCRL) impacts patients physical health, psychosocial wellbeing, and quality of life (1). Patients undergoing Axillary Lymph Node Dissection (ALND) are more than four times more likely to develop BCRL when compared with Sentinel Lymph Node Biopsy (SLNB) alone (2). Diabetes Mellitus (DM) has a profound impact on endothelial dysfunction, which, in turn, is associated with the pathogenesis of lymphedema. Metformin is a safe, widely used first line agent for the treatment of DM that has anti-inflammatory properties (3). A recent preclinical study showed that treatment with metformin was protective against the development of secondary lymphedema (4). We reviewed metformin use and lymphedema outcomes among patients with DM who underwent ALND at our center for the treatment of breast cancer over an 18-year period.

Methods

Patients who underwent ALND for breast cancer treatment and had a diagnosis of DM at the time of surgery between 2004 and 2022 were identified using our medical records. A detailed chart review was then performed to identify treatment regimens including metformin at the time of ALND. We used Kaplan-Meier plots with the log-rank test as well as Univariable and Multivariable Cox Regression Models to evaluate the association between metformin use and lymphedema development.

Results

A total of 414 patients with a diagnosis of DM at the time of ALND for breast cancer treatment were identified during the study period. Kaplan-Meier analyses and estimated cumulative incidences of lymphedema were lower in the metformin group across the entire follow-up period (24-month cumulative incidence 14% (95% CI, 10%, 19%) in the metformin group vs. 22% (95% CI, 16%, 29%) in the no metformin group), which was statistically significant (log-rank p = 0.026). Univariable (HR = 0.67, p =0.027) and Multivariable (HR = 0.66, p=0.027) Cox Regression Models showed significantly decreased risk of lymphedema development in patients who were taking metformin at the time of ALND.

Conclusions

Metformin may be protective against the development of lymphedema in individuals with DM. Further research is needed to understand the molecular mechanisms and possible utility of metformin in patients without DM.

References 1. Kalemikerakis I, Evaggelakou A, Kavga A, Vastardi M, Konstantinidis T, Govina O. Diagnosis, treatment and quality of life in patients with cancer-related lymphedema. J BUON. 2021 Sep-Oct;26(5):1735-1741. PMID: 34761576. 2. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11:927–933. 3. Kristófi R, Eriksson JW. Metformin as an anti-inflammatory agent: a short review. J Endocrinol. 2021 Sep 28;251(2):R11-R22. doi: 10.1530/JOE-21-0194. PMID: 34463292. 4. Wei M, Wang L, Liu X, Deng Y, Yang S, Pan W, Zhang X, Xu G, Xiao S, Deng C. Metformin alleviates inflammation and fibrosis in lymphoedema by activating AMPK signaling

BACKGROUND: While studies have suggested that plasticity exists between dermal fibroblast and adipocytes, it remains unknown whether fat contributes to fibrosis. We hypothesized that mature adipocytes directly participate in wound repair via conversion into fibroblasts, and that adipocyte-derived fibroblasts (ADFs) contribute to skin scarring.

METHODS: AdipoqCreERT transgenic driver mice were crossed to R26mTmG reporter mice to generate AdipoqCreERT;ROSA26mTmG mice to perform lineage tracing of mature adipocytes. To achieve local adipocyte ablation AdipoqCre;ROSA26mTmG;R26tm1(HBEGF)Awai mice were generated and wounded, and diphtheria toxin (DT) was injected into the wound base. DT- and vehicle control-treated wounds underwent histologic analysis. Lastly, we performed scRNAseq, Visium gene spatial analysis, and CODEX protein analysis on wounded and unwounded tissue to identify fibrotic ADF subpopulations.

RESULTS: Using our AdipoqCre;ROSA26mTmG adipocyte lineage-tracing model, we identified significantly greater number of adiponectin lineage-positive cells (GFP+) within wounds at post-operative day-14 (POD-14) compared to unwounded skin (P<0.05, n=12) (Fig.1A). Compared to typical subcutaneous adipocytes, the GFP+ cells exhibited upregulation of fibroblast markers and downregulation of adipocyte markers. FACS further confirmed that the GFP+ cells were fibroblasts and increased to 10% at POD-14(Fig.1B). DT-induced ablation of Adipoq lineage-positive cells (Fig.1C) exhibited reduced scar thickness (Fig.1c) and collagen deposition at POD-14 compared to control wounds (P<0.05, n=12) (Fig.1D). Using an in-vitro collagen gel system we establish that mechanics alone is sufficient to drive the adipocyte-to-fibroblast conversion. scRNAseq and spatial gene and protein analysis revealed distinct mechanical sensitive subpopulations of ADFs expressing high levels of Piezo1 and Piezo2 (Fig.1E-F). We further show that Piezo1 or Piezo2 -inhibition yields regenerative healing by preventing adipocytes' activation to fibroblasts, in both mouse-wounds using small molecule Piezo inhibitors and Piezo1/Piezo2 genetic knockouts (Fig.1G-H). In addition, Piezo1 inhibition via P1i overcomes skin scarring in a novel human-xenograft-wound model. Lastly, we show that Piezo1 inhibition can was sufficient to induce near-complete wound regeneration of 1- month, 2.5 month and 4 month established mouse scars with return of hair follicles, including full recovery of unwounded-like extracellular architecture, compared to untreated wounds which remained scar-like on histology (n=30) (Fig.1I).

CONCLUSIONS: Our findings strongly suggest that mature adipocytes in the skin undergo conversion to pro-fibrotic fibroblasts in response to injury. Importantly, Piezo1 -inhibition induced wound regeneration even in pre-existing established scars, a finding that suggests a role for adipocyte-to-fibroblast transition in wound remodeling, the least-understood phase of wound healing.

Background: Fascial bulging or hernias post deep inferior epigastric flap range from 3 to 7%, highlighting the possibility of developing disfiguring bulges in the DIEP population. These can range from full hernias where bowel may be involved to aesthetic bulges. Though a small percentage, such results can yield unaesthetic and negative functional results down the line and require further operative interventions. In this abstract, we offer an operative approach to repairing these post DIEP bulges using a robot-assisted, minimally invasive technique.

Methods: Patients are laid supine on the operating table. Access to the abdominal cavity is created using a Veress or Hassan technique with the placement of a 12mm port for the camera port peri-umbilically. Pneumoperitoneum is established and two other 8mm robot ports are inserted using direct visualization. Trocars are placed about 10cm on either side of the camera port and 10cm from anterior superior iliac spine. 3 instruments are required: hot shears, Cadiere forceps and a large needle driver. Peritoneum is opened intra-abdominally to expose the hernia defect and the hernia sac and contact is carefully dissected out using a combination of sharp dissection and electrocautery. Once hernia sac is removed, fascia is intra-abdominally closed using a running V-lock PDS suture. Progrip mesh is placed to a size that overlies the closed defect, and the peritoneum is closed primarily with a running vicryl stitch. The abdomen is then desufflated and port sites are closed. Patients were reviewed from a single surgeon over one hospital system from 2020 to 2024 at our institution. Patient demographics, surgical characteristics, robot time, and complications were assessed.

Results: 10 patients were identified who met inclusion criteria for a case series evaluation. Mean time from original DIEP to hernia repair was 2.8 years. Mean age was 56.0 years at time of index case and 58.8 years at time of hernia repair. Mean BMI was 31.8. Defects ranged from 2-10cm, repaired mainly with Progrip Mesh that ranged from 12x8cm to 15x15cm in size. One patient had a Spigelian hernia repaired with a Ventralight ST mesh. Other incidental hernias (umbilical, inguinal, femoral) were found in three patients, which were also repaired at the time of surgery. Mean console time was 63 minutes and required three instruments to perform surgery. Most patients were discharged the same day, while two stayed for one post-operative day (post-operative nausea, 24 hours of IV antibiotics). There was a single recurrence of a DIEP hernia bulge, repaired via the open approach 1.7 years after the prior robotic repair.

Conclusion: We offer robot-assisted hernia repair as a safe, minimally invasive technique and approach for post-operative DIEP hernia bulges. These procedures are less morbid than some of the open techniques with aesthetically appealing results in an ambulatory setting with discharge on the same day.

Background: Utilizing regional oxygenated blood-flow, functional magnetic resonance imaging (fMRI) demonstrates cortical activity in the brain. Activity in the visual processing regions of the brain in response to visual stimulus can be demonstrated via increased activity in the occipital lobe on fMRI. Here, we present evidence of occipital lobe activation on fMRI to visual stimulus of the transplanted eye in the case of the first human whole eye transplant (WET).

Methods: A 46-year-old male underwent partial face and whole eye transplantation with donor-recipient optic nerve (ON) coaptation after high-voltage electrical injury. At post-operative months 3 and 6, the subject underwent fMRI, where various visual stimuli were presented to him and cortical activity was measured. Imaging was captured with both eyes closed, only native eye closed, only transplanted eye closed, and both eyes open. Various stimuli were presented, including complete darkness (no stimulus), flashing white light at 2Hz, at 4Hz, and object storytelling.

Results: The subject reports no vision from transplanted eye. However, during the 2Hz flashing light protocol, fMRI showed activity in the occipital lobe during visual stimulus to the transplanted eye that was comparable to that seen by visual stimulus to native eye. In the object storytelling protocol, less activity was noted with only the native eye covered than with only transplanted eye covered. The fMRI showed no occipital lobe activity with both eyes closed. These results remained consistent over the 3- month interval.

Conclusion: The subject demonstrates occipital lobe activity on fMRI upon exposure to visual stimulus after ON coaptation in the case of the world's first successful WET.

Background: During the COVID-19 pandemic, elective procedures including cleft palate and/or lip repair were halted around the world. Smile Train, the largest cleft organization with partner hospitals across the world, is dedicated to providing discounted quality cleft care for all. This study investigated how barriers to cleft care changed before, during, and after the COVID-19 pandemic.

Methods: We obtained surveys from all Smile Train Hospitals who completed the Barriers to Care Survey from 2018, 2020, and 2022. Responses were categorized by region: North Asia, Asia, Africa, and Americas & Europe. Barriers were categorized into themes including: lack of patient awareness, equipment, funds, operating room access, professionals, staff, supplies, and barriers in patient travel and health. Descriptive and statistical analyses were completed for differences.

Results: 664 survey responses were collected in 2018, 571 in 2020, and 563 in 2022, most often answered by a surgeon. Across all regions, survey responses indicating patient awareness as a barrier to cleft care decreased between 2018 and 2022 (41.42% in 2018, 37.83% in 2020, and 27.71% in 2022, p-value 0.018). In contrast, the proportion of patient health as a barrier increased between 2018 and 2022 (34.94% in 2018, 40.98% in 2020, and 46.36% in 2022). In Africa, patient health was reported as an increased barrier during the time of COVID (37.58% in 2018, 48.74% in 2020) and remained a barrier in 2022 (45.31%). While patient awareness in the Americas & Europe improved (18.02% in 2018, 4.20% in 2022), lack of professionals was reported as more of a barrier since 2018 (9.01% in 2018, 17.65% in 2022). In Asia, the proportion of patient awareness improved (46.72% in 2018, 32.57% in 2022), while the proportion of patient health worsened (44.16% in 2018, 59% in 2022). In North Asia, barriers including patient awareness, lack of equipment, funds (p-value <0.001), staff (p-value 0.042), and supplies decreased from 2018 to 2022.

Conclusions: Patient awareness and health seem to have been most impacted by the pandemic; yet regional disparities exist. Notably, North Asia had the most improvement in reported barriers to care which may demonstrate solution creativity amidst a crisis and/or increased aid provided to this region during the pandemic compared to others.

Purpose: Secondary lymphedema (LE) is a common complication of cancer treatment and is characterized by progressive fibrosis and inflammation. Using immunosequencing of CD4+ T-cells in clinical lymphedema skin biopsies, we have discovered T-cell clones in lymphedematous tissues that recognize insulin (1). Other studies have shown that diabetes is a significant clinical risk factor for lymphedema development and that insulin sensitizing medications improve lymphedema outcomes in preclinical mouse models (2, 3). Taken together, these studies suggest that insulin and insulin receptor (INS-R) signaling may play a role in the pathophysiology of LE. The purpose of this study was therefore to use mouse models of LE to investigate insulin resistance and insulin signaling in LE tissue.
Methods: Secondary lymphedema was induced in mice by tail lymphatic excision and compared with sham-operated animals (n= 8-10/group). Tail fluid was collected at 2 and 6-weeks following tail lymphatic ablation and insulin concentration was quantified using an insulin ELISA. Insulin tolerance test was performed in 4-hr fasted LE and control mice by serial blood glucose measurements following intraperitoneal insulin administration. Insulin signaling was compared between lymphedema and control mouse tail skin biopsy samples and in the gastrocnemius muscle after tissue harvest and ex-vivo stimulation with insulin (10nM). Results: The concentration of insulin in lymph fluid was significantly increased 6 weeks after surgery compared with fluid collected 2 weeks post-op (p<0.05). Fasting blood glucose levels and insulin resistance following an insulin bolus was modestly, though significantly increased in mice with lymphedema compared to sham controls (p<0.05 for both). Insulin receptor expression was decreased in muscle biopsies and increased in tail skin biopsies collected from mice with lymphedema. The expression of insulin receptor adaptor proteins as well as insulin receptor substrates (IRS) 1 and 2 was markedly decreased in tail skin biopsies collected from mice with lymphedema; in contrast we found no differences in these proteins in muscle biopsies suggesting that lymphedema can alter insulin receptor signaling locally.
Conclusion: Our study suggests that lymphatic injury results in increased tissue levels of insulin, insulin resistance, and decreased insulin receptor signaling in lymphedematous tissues. Lymphatic injury also has mild effects on systemic glucose tolerance. Our findings are consistent with and provide a molecular mechanism for previous studies demonstrating a protective role for insulin-sensitizing drugs. Future studies are needed to understand the effects of insulin signaling on lymphatic endothelial dysfunction and inflammatory cell activation.

1. Campbell A-C, Mehrara BJ, Brown S. T Cell Repertoire Diversity in Lymphedema: Investigating the Antigens Driving the T Cell Response. Plastic and Reconstructive Surgery – Global Open. 2022;10(10S):107.
2. Wei MW, Liangliang; Liu, Xin; Deng, Yaping; Yang, Sanhong; Pan, Wenjie; Zhang, Xiaoshan; Xu, Guangchao; Xiao, Shune; Deng Chengliang. Metformin Alleviates Inflammation and Fibrosis in Lymphoedema by Activating AMPK Signalling. Social Science Research Network (SSRN). 2023:35.
3. Chen Z, Ghavimi SAA, Wu M, McNamara J, Barreiro O, Maridas D, et al. PPARγ agonist treatment reduces fibroadipose tissue in secondary lymphedema by exhausting fibroadipogenic PDGFRα+ mesenchymal cells. JCI Insight. 2023;8(24).