Scientific Abstract Presentations: Reconstructive Session 6 Friday, September 27 Fri, Sep 27 5:00-6:00 p.m. PDT

Purpose: Lymphedema presents a challenge to patients and healthcare providers, with surgical interventions typically reserved for severe cases. A comprehensive approach that combines surgical options with various nonsurgical modalities (such as manual lymphatic drainage (MLD) and compression therapy) is essential for effective patient care. This umbrella literature review aims to fill this knowledge gap by analyzing the effectiveness and safety of various non-surgical lymphedema treatments to promote evidence-based approaches in lymphedema management, thereby improving patients' quality of life.

Methods: A systematic search strategy was developed following PRISMA guidelines. We searched PubMed and Embase databases up to December 2019 for studies on surgical and non-surgical lymphedema management. A total of 448 articles were retrieved and screened against inclusion criteria focusing on systematic reviews and/or meta-analyses that addressed clinical outcomes yielding a total of 19 studies. Two independent reviewers conducted screening and data extraction, with conflicts resolved by a third reviewer. The methodological quality of non-surgical articles was critically appraised using a checklist developed by an umbrella review methodology working group (Aromataris et al., 2015). Data from each study, including interventions, patient demographics, and clinical outcomes, were methodically cataloged.

Results: Results from the umbrella review showed that non-surgical interventions, particularly manual lymphatic drainage (MLD) applied in over twenty sessions, significantly reduced extremity volume, although its efficacy in conjunction with complete decongestive therapy (CDT) or compression therapy remains indeterminate. Other conservative treatments were associated with improvements in lymphatic flow and limb size reduction without complications, while compression therapy enhanced range of motion. However, kinesio taping and exercise therapy showed no statistically significant volume reduction. Acupuncture and low-level laser therapy exhibited promising trends and considerable volume reduction, respectively, meriting further investigation. The methodological quality assessment of the reviewed articles overall suggests a rigorous adherence to review protocols and critical appraisal.

Conclusion: The management of lymphedema remains a challenge due to the chronic nature of the condition and its impact on patients. This review highlights the importance of a multifaceted approach that encompasses non-surgical treatments, tailored to the individual's condition. The effectiveness of manual lymphatic drainage (MLD) and other conservative measures, particularly when applied consistently and intensively, underscores their importance in a comprehensive treatment regimen. However, the limited effectiveness of kinesio taping and exercise therapy in reducing limb volume calls for further research to refine these treatments. Additionally, emerging therapies like acupuncture and low-level laser therapy show potential, warranting further exploration and validation in larger trials.

These findings can guide clinicians in evidence-based decision-making, encouraging an integrative approach to lymphedema management. Future research should focus on long-term outcomes and optimization of individual treatment components that consider patient preferences and comorbidities. The ultimate objective is to improve the quality of life for individuals with lymphedema, underscoring the need for continued innovation and investigation in the field of lymphedema management.

References 1. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc. 2015;13(3):132-140. doi:10.1097/XEB.0000000000000055.

Purpose: Gun-related violence and safety has garnered national attention in the U.S. Gunshot wound (GSW) injuries pose the healthcare system an economic burden as high as $126 billion per year. Previous investigations at the national level have implicated the largest surgical burden to fall onto orthopedic and plastic surgeons costing nearly $77 billion worth in reconstructive care. Orthopedic and plastic surgery intervention was required in 99.7% of surgically treated GSW injuries and associated with 9% of these surgically treated mortalities. In the context of increased variation among state-based approaches to gun safety laws, we sought to understand the tricorollary relationship between state-specific gun laws, incidence of various GSW etiologies and their subsequent burden on reconstructive surgery.

Methods: Twelve states were selected based on available data under the Healthcare Cost and Utilization Project - State Inpatient Database (HCUP-SID) and stratified by their gun law grade ranking validated by the Giffords Law Center to Present Gun Violence. HCUP-SID was then queried for GSW type and injuries and subsequent surgical interventions indexed under the ICD-10 coding system for the following specialties: neurosurgery, head and neck surgery, thoracic surgery, cardiac surgery, vascular surgery, gastrointestinal surgery, genitourinary surgery, and reconstructive (orthopedic and plastic) surgery. These numbers were then normalized to the respective populations of each state. Cochran-Armitage statistical modeling was then employed to determine correlations between gun law grade, incidence of GSW events, and number of subsequent surgical proceedings.

Results: Increased gun law grade was negatively correlated with overall GSW events as well as those stemming from self-harm, unintentional, assault-related deaths (p<0.005). Similar trends were revealed between gun law grade and mortalities caused by GSWs (p<0.005). Regarding the surgical burden of GSW treatment, there was a significant association between gun law grade and interventions within head/neck, thoracic, cardiac, vascular, GI, as well as orthoplastic reconstructive surgery. Orthoplastic surgeries accounted for the largest surgical burden in the treatment of GSWs in ten of twelve included states.

Conclusions: Our study is the first to characterize the interrelated correlation between state-based differences in gun law legislation, GSW etiological incidence, and their respective surgical burden. The implications of our data suggest that states with a lower gun law grade (ie. weaker gun safety measures) experience higher overall GSW injuries (particularly stemming from assault, self-harm, and accidental categories) as well as mortality. Such states are also saddled with a higher burden in surgical treatment of GSW events, which in most states (similar to national trends) often falls onto reconstructive surgeons. Our work will contribute to the ongoing policy debate on how to best address the GSW epidemic and the rising costs associated with its surgical treatment - a topic that is clearly relevant to the practice of reconstructive surgeons.

Background: Over the past decade, immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection(ALND) has emerged as the standard of care for prevention of breast cancer related lymphedema (BCRL). More recently, neoadjuvant chemotherapy (NC) has been increasingly utilized to reduce locoregional and distance disease with favorable results.(1,2) Nodal pathologic complete response (pCR) is defined as the absence of axillary disease following NC and ALND.(2,3) Our study aims to evaluate the impact of nodal pCR on success of ILR.

Methods: A retrospectively maintained, IRB approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between 2018 and 2023. Patients who presented for at least one follow up in our multidisciplinary lymphedema clinic met criteria for inclusion. Patient demographics, oncologic therapy, intraoperative factors and surgical outcomes were evaluated. Pathologic response to NC and outcomes following ILR were further explored. Nodal pCR was defined as 0 positive lymph nodes after ALND.

Results: 392 patients underwent ILR at our institution from 2018 to 2023. Neoadjuvant chemotherapy was completed by 367 patients (94%). Average patient age was 51 +/- 12 years with a BMI of 28.4 +/- 6.7 kg/m2. Thirty-one (8.4%) of these patients developed BCRL. Of patients who underwent NC, 146 (40%) had a nodal pCR and 221 (60%) did not. The average number of lymphatic vessels identified for ILR were similar between groups (3.00 ± 1.41 v. 3.23 ± 1.42, p = 0.09). In comparison of pathologic response and development of lymphedema, 14 (45.2%) patients with nodal pCR developed BCRL vs. 17 (54.8%) with an incomplete response, p=0.52. Patients without nodal pCR were not significantly more likely to develop lymphedema compared to those with complete response (OR: 0.80 (0.38-1.68), p=0.55).

Conclusion: This data comment upon our institutions outcomes following ILR, with a focus on the impact of nodal pCR on available lymphatics at time of ILR and development of BCRL. Consideration of this data is critical as NC remains an increasingly popular early breast cancer treatment. Nodal pathologic response does not appear to impact the number of available lymphatics or success of ILR in our population, and as a result patients should be considered candidates regardless of final axillary pathology. As ALND become less common with advances in NC, further comparative studies between patients with nodal pCR who do and do not undergo ALND + ILR will help further guide lymphatic intervention.

Resources:

1. Kaytaz Tekyol K, Gurleyik G, Aktaş A, Aker F, Tanrikulu E, Tekyol D. Pathological Complete Response to Neoadjuvant Chemotherapy in Patients With Breast Cancer: The Relationship Between Inflammatory Biomarkers and Molecular Subtypes. Cureus. 2021;13(4):e14774.
2. Sasanpour P, Sandoughdaran S, Mosavi-Jarrahi A, Malekzadeh M. Predictors of Pathological Complete Response to Neoadjuvant Chemotherapy in Iranian Breast Cancer Patients. Asian Pac J Cancer Prev. 2018;19(9):2423-2427.
3. Von Minckwitz G, Untch M, Blohmer J et al. Definition and Impact of Pathologic Complete Response on Prognosis After Neoadjuvant Chemotherapy in Various Intrinsic Breast Cancer Subtypes. Journal of Clinical Oncology. 2012;30:1796-1804.

Introduction Pectus excavatum (PE) is a common congenital chest wall deformity characterized by a depression of the sternum and deformation of the adjacent costal cartilages. Correction is frequently achieved utilizing the Ravitch procedure which includes cartilage resection and sternal osteotomy followed by manual reduction and internal fixation with locking reconstruction plates. Recent modifications to the treatment protocol at our institution include mechanical reduction of the sternum utilizing a Rultract ratcheting crane retractor avoiding the need for a right thoracotomy and subsequent chest tube. Additional changes include intercostal nerve blocks with liposomal bupivacaine and utilization of Enhanced Recovery After Surgery (ERAS) pain management. This study examines the impact of these changes on postoperative recovery following surgical correction of pectus excavatum.

Methods A retrospective review of the Electronic Health Record over the past 10 years was conducted to identify patients who underwent PE correction using a standard Ravitch procedure verses the enhanced Ravitch protocol (ERP) utilizing the Rultract, intercostal blockade and ERAS pain management protocol. Data pertaining to postoperative pain scores (determined by Visual Analog Scale (VAS), length of stay (LOS), and postoperative outcomes were collected and analyzed using descriptive statistics.

Results Of 22 patients who underwent chest wall reconstruction and met inclusion criteria, 8 patients received a standard Ravitch procedure, and 14 patients were managed with the ERP. Patients receiving ERP demonstrated a significant decrease in LOS compared to those undergoing the traditional repair, with an average LOS reduction from 5 days to 1.9 days (p < 0.00005). Additionally, patients receiving ERP experienced a significant decrease in postoperative pain, with pain scores on postoperative day 1 (POD1) decreasing from an average of 5.38 to 3.9 (p < 0.024). Similarly, average pain scores at discharge decreased from 5 to 2.7 (p < 0.006). No patients in the ERP group developed a pneumothorax or required a chest tube in contrast to the standard treatment group where this was encountered in all patients.

Discussion
The ERP including utilization of the Rultract retractor, allows for improved visualization and access to deformity intraoperatively, which facilitates a more precise correction while minimizing trauma to the surrounding tissue and structures. Additionally, we believe the liposomal bupivacaine nerve blocks and ERAS pain management protocol utilization show improved postoperative patient comfort and satisfaction demonstrated as lower postoperative pain scores decrease in LOS and early mobilization.

Conclusion Implementation of the enhanced Ravitch protocol including utilization of the Rultract retractor, liposomal bupivacaine nerve blocks and ERAS pain management is associated with a statistically significant reduction in patient length of stay and postoperative pain while negating need for chest tubes.

Purpose: A total of 50 face transplants have been reported since 2005, from 18 centers in 11 countries. The long-term overall outcomes of patient and graft survival and their complication rates (rejection, malignancies, graft loss) along with maintenance immunosuppressive therapy have not yet been assessed in a global multi-center approach.
Materials & Methods: Data was collected at home institutions of participating centers retrospectively until October 2023. The survival of the transplants was assessed with Kaplan-Meier analysis and the correlation between therapy regimen and rejection episodes was explored with Spearman correlation analysis. Results: 14 (77.7%) out of 18 (100%) centers worldwide participated and provided data for 46 (92%) out of 50 (100%) face transplants. The median follow-up time was 8.9 years (range 0.2 to 16.7 years). The 5- and 10-year survival of the transplants was 85 ± 5% and 74 ± 7%, respectively. The median number of acute rejection episodes per year was 1.2 (range 0 to 5.3) for the transplants that were lost and 0.7 (range 0 to 4.6) for the transplants that survived. Graft loss due to chronic rejection was reported in four (8%) patients, of which two (4%) patients were successfully retransplanted. Ten patients (20%) died during follow-up. Two (4%) patients were diagnosed with newly developed malignancy (Leber cell carcinoma at 10 years posttransplant; small cell lung cancer at 10 years posttransplant). A triple therapy of Tacrolimus, Mycophenolate Mofetil and Prednisone was the most common maintenance therapy, used in 34 patients (68%). Four patients (8%) were treated with only Tacrolimus and Prednisone while three patients (6%) were treated with a combination of Belatacept and triple therapy. In three patients (6%) Tacrolimus was exchanged with Sirolimus. No correlation between episodes of acute rejection and maintenance therapy regimen was seen. Conclusion: The overall survival of the face transplants over the past 18 years is encouraging. These data suggest that the acceptable long-term survival of face transplants makes them a safe reconstructive option for extensive facial defects.

PURPOSE: Patients who undergo deep inferior epigastric perforator (DIEP) breast reconstruction have either closed incision negative pressure therapy (ciNPT) or standard dressings applied to the closed abdominal donor site. As there remains clinical equipoise regarding the ability of ciNPT to reduce abdominal wound dehiscence, research in the form of a parallel, two-arm RCT is warranted. This pilot study aims to determine whether an adequately powered randomized control trial (RCT) evaluating the superiority of ciNPT is feasible at our institution.

METHODS: This is a parallel, between-group, RCT pilot study. This study was single-blinded and allocation concealment was maintained by a study statistician. A convenience sample of consecutive patients who consented to DIEP reconstruction were approached for enrollment. Participants were included if they were ≥18 years old and consented to elective immediate or delayed breast reconstruction. Participants were randomly assigned intra-operatively following abdominal incision closure to receive either ciNPT versus standard dressing in a 1:1 ratio using randomly permuted block sizes of 4 or 6. The primary outcome(s) was patient study eligibility, recruitment, and retention. Descriptive statistics were used to analyze clinical and feasibility data.

RESULTS: A sample size rule of thumb of 12 participants per arm (n=24) was used. The pilot achieved an eligibility rate of 87.5%, a recruitment rate of 89.3%, and a post-randomization retention rate of 100%. With respect to the primary clinical outcome of abdominal wound dehiscence, we identified a 16.6% and 41.6% incidence of abdominal wound dehiscence in the ciNPT and control group, respectively.

CONCLUSION: As per the defined feasibility criteria, the authors have chosen to continue the protocol without modifications for the main study. Given study event rates, a fully powered RCT would require a total sample size of n=114 participants.

Purpose: Secondary lymphedema often arises in the setting of surgery, malignancy, and/or radiation.(1) In patients with lymphedema failing conservative therapy, surgical intervention may be warranted.(2) Two microsurgical techniques frequently used in the treatment of lymphedema include lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT),(3,4) but long-term outcomes data for these modalities are lacking. The purpose of this systematic review is to compile existing data surrounding LVA and VLNT in patients followed for greater than two years post-operatively, assessing their efficacy on relevant outcomes such as cellulitis and limb circumference.

Materials & Methods: This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The PubMed, Scopus, and Cochrane databases were searched from inception until October 2023, and inclusion criteria required that patients were adults >18 years of age who were treated for secondary lymphedema with LVA or VLNT and followed for at least 24 months. Primary outcomes (cellulitis events per year, limb circumference) were stratified by upper and lower extremity, and meta-analysis was performed using R 4.3.1. Pooled effect sizes were estimated by the random-effect models, and other analyses included subgroup analysis (by upper/lower extremity) and sensitivity analysis.

Results:
In total, 21 studies provided data on patients treated for secondary lymphedema via LVA (n = 216) or VLNT (n = 432). The cohort possessed a mean age of 56.4 +/- 3.7 years with corresponding mean BMI of 26.7 +/- 3.7. All patients were followed for at least 24 months post-operatively. For patients treated for upper extremity lymphedema, LVA significantly reduced the mean cellulitis rate from 1.25 events/yr to 0.20 events/yr (p<0.0001), and VLNT reduced the cellulitis rate from 2.53 events/yr to 1.47 events/yr (p<0.0001). Similarly, in patients treated for lower extremity lymphedema, LVA decreased cellulitis rates from 1.48 to 0.07 events/yr (p<0.0001), while VLNT reduced cellulitis from 5.59 to 0.50 events/yr (p<0.0001). Limb circumferences were noted to be improved for both upper and lower extremity limbs treated by VLNT.

Conclusion: LVA and VLNT are microsurgical therapies that produce durable improvements in cellulitis rates at two years post-operatively. VLNT was also shown to reduce limb circumference. Cellulitis and limb circumference are relevant outcomes which greatly impact patient quality of life in the lymphedema patient population, and VLNT and LVA should continue to be explored as options in the treatment algorithm for secondary lymphedema.

References: 1. Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol. 2017 Dec;77(6):1009-1020. 2. The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. Lymphology. 2016 Dec;49(4):170-84. 3. Schaverien MV, Coroneos CJ. Surgical Treatment of Lymphedema. Plastic & Reconstructive Surgery. 2019;144(3):738-758. 4. Chang DW, Dayan J, Greene AK, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plastic and Reconstructive Surgery. 2021;147(4):975.

Introduction The deep inferior epigastric perforator (DIEP) flap is a dependable microvascular technique for breast reconstruction with low revision rates. Previous literature has identified risk factors associated with reoperation among patients undergoing DIEPs. The goal of this study is to delve into the repercussions of reoperation on patient outcomes, providing a comprehensive understanding of its impact.

Methods This is a retrospective cohort study using the Nationwide Readmission Database. The Nationwide Readmission Database is the largest all-payer publicly available readmission database in the US. Patients were included if they had an ICD 10-PR code for DIEP flap reconstruction from January to June in 2016-2020. Reoperations within the index admission for DIEP reconstruction were identified using ICD 10-PR codes. The primary outcome was 180-day readmission rates. Secondary outcomes included deep venous thrombosis/pulmonary embolism rates, most common reasons for readmission, in-hospital and 180-day mortality, and resource utilization, characterized by total hospitalization charges and costs and length of stay. Confounders were adjusted for using multivariate regression analysis. Total hospitalization charges and costs were adjusted for inflation over time using the consumer price index. Statistical analyses were conducted using STATA MP, 14.0.

Results A total of 19,208 patients underwent DIEP reconstruction and were included in the study, 2.4% (469) of whom had a reoperation during the index admission. The mean age was 51 years for both groups (reoperation and no-reoperation). The all-cause 6-month readmission rate was 10.5%. Patients who underwent a reoperation during their index admission were 77% more likely to get readmitted than patients who only had their DIEP reconstruction (adjusted odds ratio (aOR):1.77, 95% confidence interval(CI):1.23-2.57, p<0.01). In addition, patients with a reoperation during their index admission were almost 9 times more likely to form a deep venous thrombosis with or without a pulmonary embolus in the hospital (aOR:8.93, CI:6.10-13.09, p<0.01) and 3 times more likely to do so in the next 6 months (aOR:2.84, CI:1.26-6.40, p=0.01). The most common reasons for readmission were infection, followed by secondary reconstructions for deformities/disproportions of the reconstructed breast, then sepsis, and finally, pulmonary embolisms. In-hospital and 6-month mortality rates were less than 1% for both groups. Reoperation increased the adjusted mean length of stay by 1.6 days (adjusted mean difference (aMD):1.6, CI:1.12-2.00), p<0.01). Consequently, the adjusted mean difference in the total hospitalization charges (aMD):$68,651, CI:$49,916-$87,386), p<0.01) and total hospitalization costs (aMD:$15,261, CI:$11,138-$19,383, p<0.01) were increased among patients who underwent a reoperation during their index hospitalization compared to patients who did not.

Conclusion Reoperation after DIEP flap reconstruction is associated with increased 6-month readmission rate, DVT/PE rates both during the index admission and within the subsequent 6 months, and healthcare resource utilization. Reoperation during the index admission increases the long-term morbidity associated with DIEP reconstruction.

Introduction: The management of Hidradenitis Suppurativa (HS) in patients who have undergone massive weight loss represents a unique surgical opportunity, allowing not only the removal of excess skin but the repurposing of this tissue for the strategic treatment of HS. This case series presents an integrative approach that leverages body contouring techniques alongside vascularized flap reconstructions derived from redundant tissues, aiming to address both conditions simultaneously. This strategy underscores a unique alternative surgical approach compared to conventional methods that treat these issues in isolation.

Methods: We retrospectively reviewed a series of 15 patients who underwent surgical treatment for HS and excess skin following massive weight loss. The interventions included localized HS excisions combined with reconstructive surgeries for excess skin removal, employing panniculectomy, brachioplasty, thighplasty, mastopexy, and monsplasty with co-localized regional flaps for optimal aesthetic and functional results. Patient selection criteria, surgical techniques, and post-operative care protocols are described. 2 patients from the series are highlighted below.

Results: Case 1: A 47-year-old female, post-laparoscopic gastric bypass, presenting with a significant weight loss of 110 pounds. The patient suffered from recurrent skin rashes, infections, and exacerbation of her abdominal and axillary hidradenitis. This patient was offered a panniculectomy in which redundant soft tissue was removed in addition to the active abdominal hidradenitis allowing for re-draping of unaffected abdominal skin into the defect thus resolving both issues. After the patient had adequately healed, she underwent excision of her right axillary hidradenitis with utilization of a posterior arm flap for pedicled coverage of the defect. This allowed for a brachioplasty type excision of the excess arm tissue while also providing vascular tissue to the defect. Case 2: A 27-year-old female, post-gastric sleeve, presented with an 85-pound weight loss and complaints of excess skin and hidradenitis in the inguinal region and mons. The patient underwent excision of HS with the utilization of redundant medial thigh tissue for coverage. Thus, the patient benefited from contouring of her medial thigh with an anteromedial thigh flap while providing healthy, unaffected tissue into the area of previous HS.

Conclusion: This study is the first to describe a combined surgical approach leveraging body contouring and reconstructive techniques in the surgical management of HS and excess skin in patients following massive weight loss. This strategy not only optimizes aesthetic and functional outcomes but also offers a holistic solution to the complex challenges these patients face. These patients benefited from a marked improvement in the physical manifestations of both HS and excess skin. Our findings suggest that this approach is safe and effective in the management of HS and excess skin removal after massive weight loss. Further research and new applications of these techniques may encourage a shift in current clinical practice.

Background: Mobile surgical units (MSUs) have been utilized for many years to facilitate surgical care at the frontlines. However, their current role in plastic and reconstructive surgery particularly in austere environments and low-to-middle-income countries (LMICs) is unclear.

Methods: A search strategy was developed to include studies evaluating MSUs in general with sub-analysis of plastic surgery uses. A PRISMA-compliant literature search was conducted using PubMed, Cochrane, Embase, Scopus, and Web of Science from inception to April 2023. Title and abstract, and then full-text screening against eligibility criteria was performed independently by two reviewers and consensus was achieved by a third reviewer.

Results: Reviewers identified 460 studies, of which 6 were included in the analysis. Model types included tent (n=2), truck/bus (n=2), train (n=1) and lastly a portable bubble that serves as a sterile operative field (Figure 1). The main use was in orthoplastic surgery particularly in limb amputation and reconstruction (n=3) with two models used in burn and hand surgery. Three of these models were used by the US military in combat zones. The main benefits reported for MSUs were improving access and time to intervention therefore preventing delays in care. Limitations reported were limited space in case of mass causalities, scarce resources, lack of operating room sterility for later cases therefore potential increased risk of surgical site infection. The overall quality of studies included was poor with most of the studies being case series (level 4) on the Oxford Center for Evidence-Based Medicine scale (n=5, 83.3%).

Conclusions: The study results show that MSUs can be good alternatives for providing plastic surgical care in austere environments and LMICs, however further improvement of MSUs is required to improve their portability, safety and reduce perioperative morbidity.