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

Purpose: Chordomas are rare, malignant bone tumors of the axial skeleton requiring surgical removal. Soft tissue reconstruction is often needed post-extirpation to reduce the risk of peritoneal content herniation into the sacral defect. Reconstruction can be challenging secondary to tumor size and large resection margins. Several studies have explored use of various muscle flaps such as gluteus maximus (GM), paraspinous muscle (PSM), and vertical rectus abdominis muscle (VRAM); however, little data exist to inform reconstructive approaches based on anatomical considerations. The purpose of this study is to describe pre-surgical factors associated with post-chordoma resection reconstruction and evaluate patients' post-operative outcomes. Methods: We retrospectively reviewed charts of patients who underwent surgical resection for chordoma and reconstruction by plastic and reconstructive surgery at a single institution between 2013-2023. We abstracted patient demographics, tumor characteristics, surgical details, and post-operative complications. Wilcoxon rank sum, Chi-squared test, Fisher's exact test, and Kruskal-Wallis with post-hoc pairwise analyses were used to compare outcomes based on reconstruction method. Results: Among patients presenting with chordomas, 68 met inclusion criteria having chordomas derived from the lower lumbar (L4-L5) or sacral regions; 67 underwent sacrectomy. A majority of patients received GM flaps (n=36, 53%); VRAM and PSM flaps were the second most-commonly used [n=12 (18%) each]. The remaining 8 (12%) patients underwent reconstruction without incorporation of muscle (e.g., Fascio cutaneous flaps). GM and VRAM flaps were primarily used to reconstruct defects at the level of the sacrum (n=47, 98%) while 7 (58%) and 5 (42%) PSM flaps were used for lumbar and sacral reconstruction, respectively. Non-muscle reconstruction was most often used for sacral chordomas (n=6, 75%). The median (interquartile range [IQR]) tumor volume among patients with GM flaps was 92cm3 (12-246) and 468cm3 (271-1592) for VRAM flaps. Median (IQR) tumor volume for PSM flaps was 77cm3 (34-239) and 25cm3 (16-86) for non-muscle reconstruction. Tumor volume in patients who underwent VRAM flap reconstruction was significantly greater than those who underwent GM flaps (p=0.0022) or non-muscle reconstruction (p=0.015). Median (IQR) defect diameter managed by VRAM flaps was significantly longer compared with GM flaps [33(30-46) cm vs. 22(15-30) cm, p=0.001]. Mesh was used to reinforce the defect site in 42 patients; no differences in mesh use frequency between reconstructive options were noted. Median (IQR) follow-up was 34 (13-73) months. Post-operatively 27 (68%) patients developed surgical complications, 12 (44%) of whom experienced more than one. Overall, dehiscence occurred in 16 (24%) patients. Other complications included infection (n=9, 13%), seroma (n=5, 7%), and partial flap necrosis (n=2, 3%). Reconstruction type was not associated with incidence of post-operative complications. Chordoma recurred in 12 (17%) patients. Conclusion: We found that surgical reconstruction following chordoma resection varied depending on chordoma spinal level, tumor volume, and defect diameter. GM and VRAM flaps were more often used following removal of sacral chordomas, with VRAM flaps generally used for larger defects; complication rates were similar among the included reconstructive options. Future studies should further characterize presurgical factors to guide decision making for reconstructive surgeons to optimize soft tissue coverage after chordoma resection.

Purpose: Advancements in genomic analysis have led to the discovery of casual genes underlying many vascular anomalies (VAs), providing the basis for targeted gene therapy. The umbrella term PROS, PIK3CA-Related Overgrowth Spectrum, unifies a group of overgrowth disorders linked by somatic pathogenic variants in PI3K, a regulator of mTOR. Given that patients with PROS have a known, or likely, gene mutation in the PI3K/AKT/mTOR pathway, this study aimed to compare their response to treatment with sirolimus, an mTOR inhibitor, to patients with non-PROS VAs.

Methods: A retrospective single institution review was conducted of patients with VAs initiated on sirolimus therapy from 2019 to 2023. Records were reviewed for patient demographics, VA type, associated symptoms, measurements, and duration of treatment on sirolimus. A positive response to treatment was defined by patient/parent report of improvement in symptoms, quality of life, and/or reduction in size of the lesion via imaging or clinical assessment.

Results: Of the 30 patients initiated on oral sirolimus, 21 (66.7%) met the criteria for a diagnosis of PROS. The median age at the start of treatment was 1.3 years (IQR: 0.0-6.3) and 60% of the patients were female. The median duration of treatment was 396 days (IQR: 231-536). Swelling or overgrowth was the most common symptom in the PROS group (85.7%), followed by an elevated d-dimer (52.4%), and functional impairment (28.6%). In the non-PROS group, the d-dimer level was elevated in 88.9% of patients, 44.4% complained of swelling/overgrowth, and 33.3% reported bleeding of their VA. The median time to positive treatment response was 52 days (IQR: 44-98) in the non-PROS group compared to 36 days (IQR:29-52) in the PROS group (p=0.06).

Conclusion: In this study, patients with PROS experienced a positive response to treatment with sirolimus faster than those with non-PROS VAs. While sirolimus is an established treatment modality for VAs, its effect on PROS patients is often rapid and profound. As alternative candidates become available for the treatment of VAs, studies should continue to evaluate the relationship between genetic status and time to treatment response.

Background: The 1978 Alma-Ata Declaration became a landmark document that significantly shaped the global health agenda and in turn global surgery. It placed an emphasis and priority on low-cost primary healthcare, while inadvertently portraying surgical care as resource intensive thereby overshadowing essential surgery. Recently, there has been a growing recognition of surgery as a fundamental aspect of healthcare and its contributions to the global burden of disease has seen a shift along with advocacy. This review underscores the impact of the 1978 Alma-Ata Declaration by summarizing the body of literature pertaining to its influence on surgery as a whole with an emphasis on plastic surgery by identifying themes and offering a new perspective for its role on the global stage.

Methods: A PRISMA-adherent review encompassing articles on the Alma-Ata Declaration and global plastic surgery was undertaken using PubMed and Google Scholar in January 2024. All articles that were relevant to the 1978 Declaration and mentioned its impact on surgery were included. Data were extracted regarding the characterization of surgery's role on the global stage, influence on global burden of disease, and concluding remarks from the author with respect to primary care and/or essential surgery.

Results: A total of 12 articles were included in the final review that discussed Alma-Ata in the context of surgery and primary care. There were 5 (42%) studies focusing on essential surgery, with 2 (17%) also focusing on anesthesia delivery in combination with surgical access. Roadblocks to global surgery were highlighted to be that it was not viewed as cost-effective and was portrayed as resource intensive. Despite the goal of achieving "Health for All," the Alma-Ata Declaration supported primary care initiatives while erroneously overlooking surgical need. Plastic surgery related procedures were identified in only 2/12 (17%) of articles. Regarding actionable items, 2 (17%) focused on eye health with the remaining focusing on basic surgery. Both publications before 2000 identify the steep challenges that lay ahead in order to achieve "health" for all, while all 10 of the post 2000 papers acknowledged the failure to meet the goal, providing us with a sobering reality check on our ambitious goal towards equitable healthcare.

Conclusion: Despite the intentions of the Alma-Ata Declaration to achieve primary healthcare for all, global surgery and particularly global plastic surgery did not pan out as planned. The declaration failed to recognize the importance of surgical services as part of comprehensive health care, not to mention the numerous challenges low-or-middle-income-countries (LMIC) face. As a result, access to safe and timely surgical care remains limited in many LMICS, contributing to a significant burden of surgically treatable conditions and preventable deaths. To address these challenges and truly bring surgery to everyone, barriers and gaps in delivering surgical care must be closed. There is a need to overhaul how we approach global surgery, moving away from a one-size-fits-all approach and towards a more tailored and sustainable model. This requires collaboration between governments, international organizations, and local stakeholders to develop and implement context-specific strategies that prioritize equity, accessibility, and quality in surgical care.

Purpose: Breast reconstruction among patients with inflammatory breast cancer (IBC) poses unique challenges due to the need for intensive trimodal therapy and the need to balance risk of recurrence or disease progression with the optimal timing of reconstruction. Due to oncologic treatment, patients are traditionally advised to undergo delayed reconstruction at least 12 months following adjuvant radiotherapy. The National Cancer Database does not distinguish between those who undergo delayed versus immediate reconstruction, so research on optimal timing of reconstruction is limited. Further study on clinical and patient-reported outcomes, especially regarding reconstruction timing, is necessary to optimize treatment planning and quality improvement in this unique patient population.

Methods:
A single-center retrospective study was conducted on patients with IBC who underwent breast reconstruction at our institution. Using our institutional IBC program database, we identified patients who were diagnosed with IBC between 1996 and 2023 and underwent immediate or delayed breast reconstruction. Patients without reconstruction-related clinical or operative documentation in their electronic health record were excluded from complete chart review. Clinical staging, timing of reconstruction, and type of reconstructive procedure were recorded. Detailed retrospective review of operative and follow-up documentation was conducted to analyze reconstruction-specific outcomes. Complications captured in review included infection, skin necrosis, dehiscence, seroma, and hematoma at the donor and recipient sites. Flap complications included skin flap necrosis, partial flap/fat necrosis, and total flap loss. Aesthetic outcomes included breast asymmetry. Multivariable analysis was precluded by limited sample size.

Results:
Of 51 patients diagnosed with IBC (46 Stage 3, 1 Stage 4, 4 unknown) who underwent reconstruction, 82% received reconstruction in the delayed setting. The majority of patients were of white race (86%) and non-Hispanic (63%) with a mean age of 48 years (range 22-86 years). The mean times between reconstruction and initial mastectomy, chemotherapy, and radiation were 557 (SD 619) days, 616 (SD 388) days, and 471 (SD 267) days, respectively. Of the 51 patients, chart review was conducted for 23 patients (20 autologous, 2 two-stage implant-based with latissimus dorsi, 1 single-stage implant-based). Among autologous reconstruction (19 DIEP, 1 TRAM) and two-stage implant-based and latissimus dorsi reconstruction patients, there were 2 or fewer instances of donor and recipient site complications. Additionally, there were no instances of total flap loss, but 2 instances of mastectomy skin flap necrosis and 4 instances of partial flap loss/fat necrosis were identified. All 23 patients had documentation of breast asymmetry following reconstruction.

Conclusions: There is a lack of consensus on appropriate timing of breast reconstruction in patients with IBC given their typical treatment course as compared to non-IBC patients. This study suggests that patients with IBC who elect for reconstruction do so on average more than 12 months status-post mastectomy, chemotherapy, and radiation. Comparison of complication rates to reconstructed non-IBC patients is limited by the sample size of this study. Larger, prospective studies are greatly needed to further characterize oncologic and surgical characteristics that may influence outcomes among the reconstructed IBC population.

INTRODUCTION Vascularized fibular bone grafts (VFBG) have gained popularity in limb preservation surgery, for reconstruction of long bone defect1. Large bone defects are created by wide excision of sarcomas, and this traditionally have been reconstructed with avascular allografts with local tissue flaps. However, reconstruction with allografts is associated with significant morbidity as they have a high rate of infection and nonunion2. The long bones of the lower extremities transmit a great amount of force, and reconstruction of these bones can be challenging. VFBGs are well suited for this role as they have long cylindrical shape, great mechanical strength, predictable vascular pedicle, and limited donor-site morbidity3. Further, they hypertrophy over time, according to the transmitted stress, and can fill a large defect3,4. Outcomes after lower extremity reconstruction are still lacking in the literature. Our study aims to congregate the available evidence on outcomes of VFBGs for lower extremity salvage procedures. METHODS We conducted an extensive literature search using the major databases including PUBMED, EMBASE, Web of Science and Scopus. Articles were screened following the PRISMA guidelines by two independent authors. Only articles written in English Language with complete data were included. Meta-analysis of proportion was used to report the outcomes and complications. RESULTS Of the 1150 retrieved articles, 21 qualified for inclusion, reporting on 285 patients who had bony defect after sarcoma resection. Mean age was 16.7yrs [mean range: 9.8-30yrs], and mean defect size was 14.7cm. 175 patients had adjuvant chemotherapy, and 17 patients received adjuvant radiotherapy. Bone graft survival rate was 91.9% [95% CI: 19.48 - 70.42 P=0.0037], Graft union rate was 83.5% [95% CI: 29.22 - 73.31, P=0.008], and mean time to union was 11.3months. Mean MSTS score was 26 and mean follow up time was 40.6months. Graft fracture rate was 21.8% [95% CI: 0.00 - 56.75, P=0.48], and Limb Length discrepancy rate was 17.5% [95% CI: 24.47 - 83.43 P=0.0061]. Local recurrence rate was 2% [95% CI: 0.00 - 72.54, P=0.161]. CONCLUSION VFBG are a suitable choice for lower extremity salvage surgeries and are associated with high rate of graft survival and union. The time to union is also fast, and patients mostly return to their pre-morbid activity level. REFERENCES 1. Liu S, Tao S, Tan J, Hu X, Liu H, Li Z. Long-term follow-up of fibular graft for the reconstruction of bone defects. Medicine (Baltimore). 2018 Oct;97(40):e12605. doi: 10.1097/MD.0000000000012605. PMID: 30290632; PMCID: PMC6200552. 2. Ng VY, Louie P, Punt S, Conrad EU. Allograft Reconstruction for Sarcomas of the Tibia. Open Orthop J. 2017 Mar 22;11:189-194. doi: 10.2174/1874325001711010189. PMID: 28458731; PMCID: PMC5388789. 3. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN. Vascularized fibula transfer for lower limb reconstruction. Microsurgery. 2011 Mar;31(3):205-11. doi: 10.1002/micr.20841. Epub 2011 Feb 25. PMID: 21360586. 4. Shi LL, Garg R, Jawa A, Wang Q, Chai Y, Zeng B, Jupiter JB. Bony Hypertrophy in Vascularized Fibular Grafts. Hand (N Y). 2022 Jan;17(1):106-113. doi: 10.1177/1558944719895784. Epub 2020 Jan 27. PMID: 31984803; PMCID: PMC8721809

Background: The indication for lower extremity (LE) limb salvage using free tissue transfer (FTT) has continued to expand to patients who have historically needed primary amputations. However, the prevalence of peripheral vascular disease (PVD) and other comorbidities in this patient population remain as risk factors for chronic limb ischemia and amputation despite efforts towards limb salvage. The aim of this study was to determine the risk factors for limb loss in patients with PVD receiving LE FTT.

Methods: LE FTTs performed by a single surgeon from July 2011 to January 2023 were reviewed. Patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, and postoperative complication data was collected. Preoperative angiograms were reviewed for evidence of arterial abnormalities. Patients with PVD were those who had any evidence of diseased vessels on angiogram in the anterior tibial, posterior tibial, peroneal, or dorsalis pedis vessels. Univariate analyses were performed to determine significant covariates to the primary outcome, which was progression to ipsilateral amputation.

Results: Among 300 patients who received LE FTT, there were 130 patients with evidence of diseased vasculature (PVD) on preoperative angiogram. Angiogram abnormalities in the PVD group showed that 60.0% had a 2-vessel run-off (VRO), 30.0% had a 1-VRO, and 10.0% had 0-VRO. The PVD group was significantly older (60 vs. 55, p=0.000) and had a higher Charlson Comorbidity Index (5 vs. 3, p=0.000). They also had significantly higher rates of comorbidities including diabetes (66.2% vs 45.9%, p=0.000), neuropathy (52.3% vs. 36.1%, p=0.005), chronic kidney disease (CKD) (22.3% vs. 10.6%, p=0.007), and congestive heart failure (8.5% vs. 2.9%, p=0.035). On postoperative complications, the PVD cohort had significantly higher rates of dehiscence (20.8% vs. 11.8%, p=0.033) and infection (19.2% vs. 10.0%, p=0.022). The overall amputation rate was not significant between two groups (PVD:15.4% vs. No PVD: 10.6% , p=0.216).

On multivariate analysis, risk factors that remained independent for eventual amputation included history of cerebrovascular accident (OR:16.9, CI: 1.74-165.0), end-stage renal disease (ESRD) (OR:16.3, CI: 2.0-132.9), albumin level (OR: 5.6, CI: 1.4-23.1), intraoperative transfusion (OR: 4.9, CI: 1.1-20.9), and post-FTT infection (OR:7.1, CI: 1.8-27.9).

Conclusion: Patients with a history of ESRD, CVA, lower preoperative albumin level, intraoperative transfusion or a post-FTT infection appeared to be at a much higher risk for eventual amputation. Close multidisciplinary follow-up in these patients focused on medical management, vascular optimization, and infection control are needed to achieve long-term limb salvage.

PURPOSE: Acellular Dermal Matrix (ADM) products are pivotal in reconstructing full-thickness skin defects, significantly reducing donor site requirements and time to closure (1). Traditionally, these products necessitate a two-stage surgical process, wherein skin grafting follows the vascularization and integration of the ADM (2). This study introduces an innovative approach by co-applying scaffolds with cells, specifically utilizing autologous skin cell suspension (ASCS) technology. This method enables the delivery of a heterogeneous mix of autologous, freshly disaggregated skin cells directly to the patient's wound. Employing a nude mouse model, our research investigates the feasibility of combining collagen/fibrin scaffolds with freshly disaggregated human skin cell suspensions (hSCS). METHODS: Tissue-engineered skin constructs were created by seeding collagen/fibrin scaffolds (3.3 mg/mL) with human Keratinocytes, Fibroblasts, Dental Pulp Stem cells (DPSCs), and Human Umbilical Vein Endothelial cells (HUVECs). After 21-days, cells had self-assembled into epidermal/dermal layers with a histological appearance of native human skin. The constructs were then disaggregated using ASCS technology into hSCS (0.8 million cells/mL). Full-thickness circular dorsal wounds (d=8 mm) on athymic male mice (10-11 weeks, n=2) were created and treated with tissue-engineered skin constructs (control) or acellular collagen/fibrin scaffolds co-applied with hSCS on the under/top surface scaffolds (design 1) or top of the scaffolds only (design 2). On day 7, wounds were assessed and prepared for H&E staining and Image J analysis. RESULTS: Our findings reveal pronounced differences at both macroscopic and microscopic levels across all three experimental groups. The co-application of scaffolds with hSCS notably diminished both wound bed length and perimeter compared to treatments utilizing cellular tissue-engineered skin constructs. This suggests that the disaggregation process may expedite wound closure by fostering quicker healing. Specifically, in design 1, the rapid formation of a scab and significant reduction in scaffold depth underscored an accelerated and hypercellular healing response. Conversely, design 2 exhibited a more uniform cellular distribution, apparent vascularization, and preservation of scaffold depth up to day 7. These observations imply a slower matrix turnover and a more substantial role of the scaffold in maintaining wound structural integrity. CONCLUSION: Collagen/fibrin scaffolds, when co-applied with freshly disaggregated human skin cell suspensions (hSCS), have shown potential in accelerating the healing of full-thickness wounds in mice. Our findings indicate that scaffolds yield the best outcomes when exclusively paired with disaggregated hSCS on the scaffold surface. Looking ahead, our research will explore varying hSCS concentrations, introduce additional time points for analysis, and employ further staining techniques. These steps aim to determine the most effective co-application methods and understand how changes in technique influence vascularization and the scaffold's role in wound remodeling. REFERENCES: 1. He C, Yang Z, Jin Y, Qi X, Chu J, Deng X. ADM Scaffolds Generate a Pro-regenerative Microenvironment During Full-Thickness Cutaneous Wound Healing Through M2 Macrophage Polarization via Lamtor1. Frontiers in physiology. 2018;9:657. 2. Gardien KLM, Pijpe A, Brouwer KM, et al. Short- and Long-term Outcomes of an Acellular Dermal Substitute versus Standard of Care in Burns and Reconstructions: A Phase I/II Intrapatient Randomized Controlled Trial. 2023;36(10):540-548.

Introduction: Robotic-assisted reconstructive surgery is emerging as an invaluable tool for plastic surgeons, offering benefits such as enhanced visualization, reduced donor site morbidity and easier patient recovery. While robotic-assisted harvest of a free omental flap has been documented for a few applications such as lymph node transfer,[1,2] its use in scalp reconstruction has yet to be well described.

Case description: We present the case of a 64-year-old female who suffered a severe dog attack resulting in a substantial bilateral frontoparietal scalp defect with both partial- and full-thickness loss. Following initial wound management, she opted for definitive reconstruction with free tissue transfer of the omentum. The omentum was harvested using the da Vinci Xi surgical system and was extracted from the abdomen through a Pfannenstiel incision. The omentum measured 25.5 x 35 cm ex vivo. The tissue was then transferred to cover the scalp defect. Both superficial temporal vessels were exposed, but due to the zone of injury, these were found to be inadequate. Therefore, a novel anastomosis was performed. The superficial temporal vessels were dissection more proximal into the substance of the parotid until a deep branch was identified. These middle temporal vessels were found to be more robust and suitable for microsurgical anastomosis. Bipedicle anastomosis of the free omental flap was performed to the bilateral middle temporal vessels. The flap provided stable coverage for the scalp wound, facilitating delayed split-thickness skin grafting upon development of a healthy bed of granulation tissue.

Discussion: This case represents the largest robotically-harvested free omental flap reported (892.5 cm2). It highlights the utility of this technique for coverage of large defects and outlines an alternative to the conventional scalp reconstruction with a free latissimus dorsi flap. While laparoscopic omental flap harvests have been previously described,[3] robotic assistance offers additional advantages as a minimally-invasive technique such as improved surgeon ergonomics and finer dexterity similar to microsurgical techniques. Additionally, alternative recipient vessel sites are described. The middle temporal vessels, proximal branches off the superficial temporal vessels, run deep to temporal fascia with branches to the muscle and fascia. With dissection into the substance of the parotid, they can be identified and usually are of adequate caliber for micro anastomosis. These vessels can provide a great alternative to avoiding potentially-problematic interposition vein grafts required to reach the facial vessels outside the zone of injury.

Conclusion: Robotic-assisted free omental flap is a good option for scalp reconstruction, providing robust tissue that can readily accept autografts and easily be sculpted. Its use warrants consideration in other cases requiring free tissue transfer given the advantages of a robotic harvest coupled with the predictability of its blood supply. Additionally, in cases where the superficial temporal vessels are unsuitable, the middle temporal vessels present a promising alternative for anastomosis.

References: [1] Frey JD, Yu JW, Cohen SM, Zhao LC, Choi M, Levine JP. Robotically Assisted Omentum Flap Harvest: A Novel, Minimally Invasive Approach for Vascularized Lymph Node Transfer. Plast Reconstr Surg - Glob Open 2020;8. doi:10.1097/GOX.0000000000002505. [2] Teven CM, Yi J, Hammond JB, Aime VL, Pallace NM, Pearson DG, et al. Expanding the Horizon: Single-port Robotic Vascularized Omentum Lymphatic Transplant. Plast Reconstr Surg - Glob Open 2021;9:E3414. doi:10.1097/GOX.0000000000003414. [3] McIntyre BC, Lobb D, Navarro F, Nottingham J. Laparoscopic Free Omental Flap for Craniofacial Reconstruction: A Video Article Demonstrating Operative Technique and Surgical Applications. J Craniofac Surg 2017;28:311–3. doi:10.1097/SCS.0000000000003343.

Background: Pediatric chest wall defects are reconstructive challenges as rib resections must be reconstituted to stabilize the chest wall in a way conducive for future growth. Currently employed techniques involve reconstruction using rigid or non-rigid fixation to reestablish the function and contour of the chest wall. We describe a novel technique utilizing cadaveric rib graft wrapped in vascularized muscle as an effective alternative due to its allogeneic properties and potential for revascularization.

Methods: The purpose of this study is to describe bony chest wall reconstruction in pediatric patients who underwent oncologic extirpative surgery or congenital reconstruction involving the removal or absence of ≥ 1 rib, with a focus on reconstruction using cadaveric rib graft. Pediatric patients who underwent reconstructive surgery at our institution from January 2020 to December 2023 were included for retrospective analysis. Data collected included age at surgery, etiology, defect size and location, reconstructive materials, complications, and functional status.

Results: Five patients met inclusion criteria with an average age of 6.2 years at the time of chest wall reconstruction. Diagnoses included Ewing sarcoma (n=2), sarcoma (n=2), and osteoblastoma (n=1). Defect size averaged 8.3 cm (range 5-12 cm). Three out of 6 patients had 3 ribs removed (range 1-3 ribs). Three patients underwent pleural reconstruction with either Strattice Tissue matrix™ or Gore-Tex mesh®. Four patients had bony reconstruction using a split cadaveric rib graft that was secured with resorbable plates (n=2), steel wiring (n=2), or polypropylene suture (n=1). All patients had soft tissue coverage using unilateral pedicled muscle flaps which included the latissimus dorsi, serratus anterior, rectus abdominis, trapezius, and/or rhomboid. Complications included wound dehiscence (n=2) and delayed wound healing (n=1). There were no complications requiring reoperation. All 5 patients had full range of motion of the shoulder girdle and upper extremities and exhibited appropriate chest wall contour at postoperative follow-up (average 10.8 months).

Conclusions: This is the first case series describing the use of cadaveric rib wrapped with vascularized muscle in combination with resorbable plating and other fixation techniques to reconstruct the pediatric chest wall when greater than 1 rib is resected. Preliminary follow up demonstrates adequate functional and aesthetic outcomes with a low incidence of complication. Longer term follow-up will be needed to ascertain the effects of cadaveric rib based reconstruction on growth outcomes.

Purpose: Successful separation and reconstruction of conjoined twins requires a qualified multidisciplinary surgical team, often requiring several staged procedures. The classification system for conjoined twins provides an anatomic description of the most prominent site of union (suffix 'pagus') with modifications based on the number of shared external structures (prefixes di-, tri-, tetra-) (1). However, this system is less effective for analyzing the surgical complexity and determining specialist needs for successful separation and reconstruction. We present the Texas Children's Hospital (TCH) classification system for conjoined twins, with the approach, techniques, and outcomes of separation and reconstruction in 4 sets of conjoined twins at a tertiary pediatric hospital.

Methods: A retrospective review was conducted for 4 sets of conjoined twins (8 patients) cared for at Texas Children's Hospital from 2014-2023. Data collected included the size and experience of surgical teams, surgical techniques used, complications, and length of stay. Each twin was then each classified using the proposed TCH classification system, includes all shared structures denoted with a letter; Cranium (C), Thorax (T), Abdomen (A), Pelvis (P), and the degree of fusion in each region ranging from 1 to 4, with 1 point given for each involved structure including soft tissue (skin, muscle, fascia), bone, viscera, and major neurovascular structures.

Results: The types of conjoined twins included thoraco-omphalopagus (T3A3, n = 1), thoraco-omphalo-ischiopagus (T3A2P4, n = 1), ischiopagus (P4, n=1), and omphalopagus (A2, n=1). Preoperative tissue expansion was required in 75% of twins, while 1 required embolization of shared hepatic vessels. After separation, reconstruction including the use of sternal plates and wires (n=3), acellular dermal matrix (n=3), fasciocutaneous flaps (n=4), component separation (n=2), and complex closure (n=4) was completed by plastic surgeons, in concert with other surgical teams. The three patients who underwent sternal reconstruction required additional staged procedures including cadaveric rib grafts (2), pectoralis or omental flaps, and hardware removal. Surgical complications included TE extrusion/failure requiring reoperation (66%), sternal hardware failure (66%), surgical site infection (38%), seroma (13%), and hydronephrosis (13%). Half of the patients required at least 1 unplanned reoperation, and 62.5% of patients required long-term tracheostomy or gastrostomy tube for more than one year. The average length of PRS follow-up was 25 months. The average hospital length of stay was 65 days from separation to discharge. All patients survived.

Conclusions: Appropriate planning with multidisciplinary care leads to successful conjoined twin separation and reconstruction, with morbidity driven primarily by the extent of shared tissues/organs and the need for staged procedures. Although unavoidable in most cases, pre-separation tissue expansion and sternal reconstruction carry a high risk for complications and reoperation. The TCH classification system is a useful tool in the early assessment of each twin's degree of fusion, which will improve multidisciplinary team building, surgical planning, and expectation management with parents.

Citations: 1. Potter EL, Craig JM. Pathology of the Fetus and the Infant. 3rd ed. Chicago: Year Book Medical; 1975.

Background The management of lower extremity soft-tissue defects (LESTD) with concomitant Gustilo class 3 fractures can be challenging to the reconstructive surgeon, particularly in the pediatric population. While these injuries are rare in children, they can result in long lasting implications. Their complexity is made even more difficult by the limited amount of literature and lack of consensus in the orthoplastic management of these injuries. In this study, we review our own institutional experience with these complex injuries.

Methods A retrospective review was conducted of all patients referred to the plastic and reconstructive surgery service for lower extremity open fracture soft tissue reconstruction at a single Pediatric Level 1 Trauma Center between 2012 and 2022. Only patients with Gustilo class 3 fractures were included in the review. Data including surgical timing, perioperative findings, operative approach, and postoperative outcomes were reviewed and analyzed.

Results Of 67 patients requiring definitive soft tissue coverage secondary to fractures of the lower extremity, 8 patients' had Gustilo 3 fractures and met inclusion criteria. The mean age of the patients was 12.5 years. Six patients had Gustilo 3B (G3B) fractures and two had Gustilo 3A (G3A) fractures. Five patients with G3B underwent reconstruction with free latissimus dorsi flap and one patient with a pedicled flap and adjacent tissue transfer. On the other hand, both patients with G3A underwent reconstruction with local flaps. On average, the first operative intervention occurred within 12 and 24 hours of injury for G3B and G3A, respectively. Mean time for definitive soft tissue reconstruction was 7 and 9 days from injury for G3B and G3A with the mean number of reoperations being 3 and 0.5, respectively. There were 2 cases of primary flap loss and 1 case of postoperative wound infection requiring additional surgical intervention. 2 patients required an Ilizarov frame for bony transportation over an average of 239 days. Functionally, no limb-length discrepancies nor growth restrictions were observed with 5 patients bearing weight as tolerated and 3 fully weight bearing on extensive follow up (mean 318 days).

Conclusion Long bone open fractures associated with LESTD present unique challenges, particularly in the pediatric population. Multidisciplinary collaboration, timely microsurgical reconstruction with judicious surgical exploration and repair allow for uniform healing at an age of exponential skeletal growth. A delicate balance must be kept between soft tissue coverage and bony reconstruction to restore form and function in pediatric patients.

Background Acute intravascular thrombosis is a significant postoperative complication in patients undergoing lower extremity salvage with free tissue transfer. The impact of perioperative anticoagulation on thrombotic events in free flap lower extremity salvage is not well understood. This study aims to characterize the incidence and risk of thrombotic events in patients undergoing lower-extremity limb salvage with free tissue transfer.

Methods A single-institution retrospective chart review was conducted assessing all patients who underwent lower-extremity limb salvage using free flap reconstruction between January 2015 and September 2023. Patient demographics, operative characteristics, anticoagulation/chemoprophylaxis dosage, and outcomes were collected. Bivariate analysis was conducted in R version 4.3.0, with p-values less than 0.05 indicating significance.

Results The 137 patients that were included overall had a median age of 57.1 [IQR: 37,65.8] years and a median BMI of 28.6 [IQR: 25,31.8]. The majority of patients were male (n=77, 56.2%). The indications for flap coverage were postoperative wound complications in 79 (57.7%), acute lower extremity trauma in 50 (36.5%), and oncologic resection in 8 (5.8%). The most commonly utilized reconstructive flap options were the radial forearm (n=53, 38.7%), followed by the anterolateral thigh free flap (n=47, 34.3%).

Flap thrombosis was reported in 19 (13.9%) patients after a median 14.1 [IQR: 3.6,43.6] hours postoperatively. Venous thrombosis (n=16, 84.2%) was more common than arterial thrombosis (n=5, 26.3%), and nearly all events (n=17, 89.4%) were identified in postoperative patients utilizing standard DVT chemoprophylaxis. Preoperatively, dosing of anticoagulation was prophylactic in 63 (46.0%), therapeutic in 3 (2.2%), and deferred in 71 (51.8%). Postoperatively, 124 (90.5%) were on standard chemoprophylaxis, 12 (8.8%) on therapeutic, and 1 (0.7%) received no agent. There was no significant difference between utilization of anticoagulation agent and dosage with flap thrombosis in the preoperative (p=0.999) and postoperative setting (p=0.720). Antiplatelet therapy was infrequently added in the perioperative timeframe, and was used in 32 (23.4%) patients preoperatively and 34 (24.8%) postoperatively. There was no significant difference between utilization of antiplatelet therapy and flap thrombosis in the preoperative (p=0.772) and postoperative setting (p=0.782). Patients who endured thrombotic events were more likely to have total flap loss (p<0.001), infection (p=0.050), and postoperative bleeding (p=0.019). Operative length and dangling protocols were not associated with risk of thrombotic events. Overall flap success rate was 92.7% with a flap salvage rate of 47.4% after thrombotic events.

Conclusion Acute intravascular thrombosis was strongly associated with adverse outcomes, including flap loss and infection. Perioperative chemoprophylaxis regimen varied widely and nearly all thrombotic events after free flap reconstruction were identified in patients with standard postoperative chemoprophylaxis dosage. A standardized, stratified escalation of dosages of VTE chemoprophylaxis may be appropriate to minimize postoperative thrombotic events.

Introduction Immediate lymphatic reconstruction (ILR) has been utilized in the prevention of breast cancer related lymphedema (BCRL) with good success. However, a subset of these patients still developed BCRL. We aimed to evaluate delayed lymphatic reconstruction with lymphaticovenicular bypass (LVB) in the management of BCRL after failed ILR.

Methods Patients who developed BCRL despite ILR between 2018 and 2023 were included in this study. Patients were offered delayed LVB if they had visible lymphatic channels seen on indocyanine green (ICG) lymphangiography. BCRL was assessed based on symptoms, circumferential limb measurements, and bioimpedance spectroscopy.

Results A total of 33 patients out of 394 patients (8.4%) developed BCRL after ILR. Of these 33 failures, 12 patients underwent delayed LVB. The average age was 55 ± 9 years, and average BMI was 32.6 ± 7.1 kg/m^2. The mean number of anastomoses completed was 2.9 ± 1.5 during ILR and 3.8 ± 1.9 during delayed LVB. All patients had adjuvant radiation therapy. Eight patients (24.2%) developed recurrence of their breast cancer. Patients developed BCRL about 13.7 ± 8.6 months after ILR. Of the seven patients with delayed LVB for whom adequate follow up was available, six noted improvements in BCRL.

Discussion Analysis of failed ILR is important in understanding the factors that place patients at higher risk for BCRL. With close follow up, patients that develop BCRL despite ILR can be offered delayed LVB with relatively good success.

Introduction: Dysphagia is a debilitating consequence of head and neck cancer and its treatments, profoundly impacting patients' quality of life and health status. Severe dysphagia is linked to lower survival rates, highlighting the critical need for effective interventions. Recent studies have shown that social support is a significant factor influencing outcomes in this patient population, including survival. Herein, we evaluate the influence of a significant other on the return to oral feeds following head and neck defect reconstruction in cancer patients.

Methods: A pilot analysis was conducted on oral cavity, laryngotracheal, and pharyngoesophageal reconstructions performed at our center between 2019 and 2023. Patients' medical records were reviewed for demographic, oncological, surgical, and postoperative outcome data.

Results: The study cohort comprised 140 patients, with 61.4% (n = 86) being male. The average follow-up duration was 16 months (Standard deviation, 14.4 months). Of the patients, 27.1% (n=38) were single, divorced, or widowed. Return to oral feeds was significantly associated with being in a relationship (88% vs. 77.2% for partnered vs. single patients, p=0.046). Stratification by gender revealed sustained significance in males (87.6% vs. 64.3% for partnered vs. single males, p=0.003) but not in females (88.9% vs. 89.7% for partnered vs. single females, p=1). Multivariate logistic regression, adjusted for sex, confirmed relationship status as a significant predictor of return to oral feeds (Odds ratio, 2.52; p=0.028). Further subgroup analysis of male patients only, incorporating additional clinically-relevant variables such as smoking history and area of resection, reaffirmed being in a relationship as a significant predictor (Odds ratio, 4.16; p =0.023) of return to oral feeds.

Conclusions: Our study underscores the importance of social support in head and neck cancer treatment outcomes. We found that being in a relationship significantly predicts return to oral feeds, particularly in male patients, suggesting a potential role of social support in postoperative recovery. However, these findings were not sustained in female patients, indicating the need for further exploration of gender-specific factors influencing rehabilitation outcomes in head and neck cancer surgery.