Scientific Abstract Presentations: Resident Abstracts On-Demand Thursday, September 19 Thu, Sep 19 8:00-10:00 a.m. PDT

Introduction: Management of distal upper extremity trauma with extensive soft tissue, nerve, and arterial involvement presents a challenge for reconstruction. The most common options for soft tissue reconstruction include the reverse radial forearm, posterior interosseous, groin, or free flaps. We present the case of an 11-year-old male following an ATV collision with a resulting grade 3 open distal radius and ulna fracture, 5x13 cm volar soft tissue defect with exposed flexor tendon, radial artery occlusion, and median nerve injury which was reconstructed with an ulnar-based transposition flap (UBTF) and sural nerve cable graft.

Methods: The patient underwent several debridements until a clean wound bed was achieved. Integra was used for initial wound closure, and an UBTF and cable graft were employed for definitive management. Median neurolysis and debridement demonstrated a 6 cm nerve gap, which was repaired using a 26 cm sural nerve autograft in a cable fashion. Soft tissue reconstruction with a UBTF was achieved by making a curvilinear incision on the volar surface of the forearm, transposing the flap to the most distal and radial aspect to cover the defect. Split-thickness skin grafts were placed on the antecubital fossa and the distal aspects of the wrist to decrease tension on flap inset.

Results: The patient reported full flexion and extension at digital joints with excellent opposition to the thumb and progressive paresthesia of the thumb, index, and long fingers in the first month of intervention. After five weeks, the patient received physical therapy. After eight weeks, there was an improvement in wrist flexion from 60 to 65 degrees and in wrist extension from 25 to 35 degrees. The patient has regained sensation in the thumb, index, and long fingers, and has returned to all activities of daily living with good grip strength at the five-month follow-up.

Conclusion: Reconstructing nerves in the distal upper extremity can be a significant challenge, especially when the distal radial artery is blocked due to injury. Achieving functional nerve restoration and soft tissue coverage is crucial in such cases. The UBTF reduces donor site morbidity and can be an alternative choice for reconstruction in cases of compromised radial arteries. We utilize a unique flap for soft tissue coverage in situations where conventional flaps cannot be used, while decreasing the donor site morbidity.

Background: Anastomotic couplers are commonly used in microsurgical venous anastomosis. Advantages of coupler use over suturing in microsurgical venous anastomosis may include time savings associated with reduced flap ischemia and operating room time, lack of intraluminal foreign material that could increase risk of thrombus, and stenting of the anastomosis to maintain patency. While issues with vessel couplers may be encountered, these issues may be under reported and are not well characterized.

Methods: The Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was queried to describe malfunctions of anastomotic coupler use reported to the FDA from February 2014 to February 2024. The product class "Device, Anastomotic, Microvascular" was used to identify applicable reports. Malfunction reports were included in the analysis if they described the relevant device and patient problems. Reports were excluded for insufficient or duplicate information, or if they referred to a publication without individualized report of the used devices.

Results: There were 225 malfunctions associated with the use of microvascular anastomotic couplers reported to the FDA from 2014 to 2024 according to the inclusion and exclusion criteria. Malfunctions were attributed to early dislodgment of rings prior to deployment from the instrument (61; 27%), bent pins (44; 19.6%), inability to fully attach coupler (40; 17.7%), misaligned rings (25; 11.1%), opening of coupler after deployment (14; 6.2%), flow coupler specific issues (14; 6.2%), lack of coupler disengagement from the instrument after deployment (11; 4.9%), vessel injury (7; 3.1%), handling damage prior to patient use (5; 2.2%), and leaking after deployment (3; 1.3%). The majority of these malfunctions occurred with coupler diameter size 2 to 3 mm (178; 79.1%). Of the reported malfunctions, 65 reports (28.9%) were verified by examination of the returned device. Following these malfunctions, the most common intervention was opening and using a new coupler device (191; 84.9%) followed by hand-sewn suture anastomosis (17; 7.6%).

Conclusions: It is important to be aware of and avoid possible malfunctions associated with couplers during their use, particularly when learning how to perform microsurgery. The majority of malfunction reports were not verified, highlighting the likelihood of malfunctions associated with technical error. Handsewn venous anastomosis should still be an important skill to develop as an alternative to coupler anastomosis.

Background: Over 95% of the approximately 32 million Americans with a reported penicillin allergy may be penicillin tolerant upon confirmatory allergy testing. However, most will not undergo testing and instead be given β-lactam alternative antibiotics for surgical prophylaxis or treatment of infections leading to an increased risk of antibiotic-related complications such as Clostridium difficile infection, antimicrobial resistance, treatment failure, and decreased efficacy when used as surgical prophylaxis. The goal of this study is to better understand plastic surgeons' current practices for perioperative antibiotic management of patients with non-anaphylactic penicillin allergies and their attitudes toward confirmatory penicillin allergy testing.

Methods: A survey instrument was designed and pretested to optimize content validity, face validity, and utility, and administered electronically to all active and candidate members of The Aesthetic Society. Surgeons were queried about their perioperative antibiotic management and allergy testing practices. All responses were anonymous.

Results: The survey was completed by 272 respondents (14.5% response rate). For patients with a reported non-anaphylactic penicillin allergy undergoing a "clean" (CDC Class I) surgical procedure, 33% of respondents intraoperatively administer β-lactam alternative antibiotics including clindamycin, vancomycin, or other alternative antibiotics. Among respondents who opted to administer an alternative, 28.4% reported being more likely to change to a first-generation cephalosporin after being presented with a recent JAMA article reporting only 2% cross-reactivity between penicillin and cephalosporins. Regarding antibiotic duration, thirty-nine percent of respondents continue prophylactic antibiotics for 4 days if a breast prosthesis is placed. If a surgical drain is placed, 49% of respondents continue antibiotics for 4 days or until all drains are removed. Finally, ninety-two percent of respondents never recommend penicillin allergy testing, of whom 40% reported being more likely to recommend testing after learning about it.

Conclusions: For patients with a reported penicillin allergy undergoing elective procedures, plastic surgeons are well-positioned to recommend allergy testing in the preoperative setting and optimize perioperative antibiotic administration.

Purpose

Strides in artificial intelligence technologies have led to the development of Large Language Models (LLMs) like Generative Pre-Trained Transformers (ChatGPT). These technologies rely on training and refining neural networks using large datasets to provide personalized and contextualized content (1). They are available to the public and have gained populatity among both patients and physcians. The accessibility of these chatbots has made thema valuable source of health information, especially by providing education through interactive and tailored conversations. However, the quality of health information and advice provided by ChatGPT remains to be assessed as it can influence patients' health behavior (2). This study aimed to evaluate the accuracy of ChatGPT responses in addressing common concerns and questions about rhinoplasty.

Methods and Materials

Ten questions, based on data from the American Society of Plastic Surgeons, were chosen to represent the necessary information for rhinoplasty informed consent (2,3). These questions were reviewed and approved by experienced and board-certified plastic surgeons. Each question was input as a single prompt into ChatGPT-4 and the first response to each prompt was recorded. The responses were collated and presented to board-certified plastic surgeons for assessment using SurveyMonkey® in December 2023. Responses were rated on a four-item Likert scale. Respondents were asked to rank responses as "Completely correct", "Correct but insufficient", "Misleading information as well as correct information", and "Completely incorrect".

Results

ChatGPT generated ten complete responses to the prompts. The median length of response was 403 words, with a range of 336 to 480 words. Five board-certified plastic surgeons participated in the survey. None of the responses were rated as "Completely correct" by all assessor, but all were rated either "Completely correct" or "Correct but insufficient". While the responses did not reference or provide specific resources, nine out of the ten responses included a safety recommendation advising users to discuss their queries and concerns with their surgeon. No obvious AI-genereated errors, known as hallucinations, were noted in this study.

Conclusions

The popularity of ChatGPT among patients introduces new opportunities for self-education and understanding surgical conditions and procedures. ChatGPT provided generally accurate and high-quality responses to address the most commonly asked questions about rhinoplasty. While all patients undergoing procedures should be educated by their surgeons to obtain informed consent, they can still benefit from the additional information provided by LLMs like ChatGPT. It should be noted that ChatGPT was not designed nor specifically trained for medical use and may potentially produce inaccurate or factually incorrect information. As LLMs continue to evolve, their role in surgery could also expand.

References 1. OpenAI. GPT-4 [Internet]. [cited 2024 Apr 7]. Available from: https://openai.com/gpt-4 2. Xie Y, Seth I, Hunter-Smith DJ, Rozen WM, Ross R, Lee M. Aesthetic Surgery Advice and Counseling from Artificial Intelligence: A Rhinoplasty Consultation with ChatGPT. Aesthetic Plast Surg [Internet]. 2023 Oct 1 [cited 2024 Mar 30];47(5):1985. Available from: /pmc/articles/PMC10581928/ 3. American Society of Plastic Surgeons. Rhinoplasty Questions | American Society of Plastic Surgeons [Internet]. [cited 2024 Mar 30]. Available from: https://www.plasticsurgery.org/cosmetic-procedures/rhinoplasty/questions

Introduction: Traumatic brain injury (TBI) is a known and severely underreported complication of facial fractures. Screening for TBI in the facial fracture population is often excluded from the initial trauma evaluation despite well documented benefits of early TBI diagnosis. Objective indicators of TBI risk may be of clinical utility for prompting screening efforts. Our aim is to investigate the predictive power of radiographic fracture severity for TBI symptom burden.
Methods: A retrospective cohort analysis of all patients with orbital floor fractures presenting from February 2022 – February 2023 was performed. Patient charts were reviewed for age, sex, mechanism of injury, fracture pattern, Glasgow Coma Score (GCS) at presentation, requirement of admission, need for operative fixation of fractures, and concomitant injuries. Radiographic analysis of patient fractures included orbital floor fracture area, orbital index parameters (fracture area, inferior rectus morphologic changes, and fracture location), and comprehensive facial injury score. Patients were then surveyed using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) for evaluation of ongoing TBI symptoms. The RPQ is a well validated assessment of 16 key TBI symptoms with the ability to provide TBI phenotype information. Tests of significance between groups were two-tailed t-tests and chi-square analysis. Statistical significance was accepted when p<0.05. Binary logistic regression and receiver operating characteristic (ROC) curves were used for prediction of persistent TBI. Results: 28/76 (36.8%) patients sustained an orbital floor fracture and completed the RPQ. Mean age of this cohort was 56.1 years-old, and 67.9% of patients were female. Mean follow up time was 12.3 months from facial fracture to date of survey (range, 6-21 months). 21.4% of patients had TBI symptoms at the time of RPQ follow-up. Orbital floor fracture area was greater in the TBI group compared to control (3.81cm^2 vs 1.80cm^2, p=0.002). 40% of patients with orbital index ≥4 had TBI symptoms compared to 0% of patients with orbital index <4 (p=0.008). Patients with fractures requiring operative intervention were more likely to have TBI symptoms compared to nonoperative fractures (50.0% vs 5.6%, p=0.005). Comprehensive facial injury score did not differ in patients with TBI symptoms compared to other patients (4.33 vs 3.43, p>0.05). On binary logistic regression, fracture area, orbital index score, and operative intervention were not significant predictors of TBI symptoms. AUC values based on ROC curves for fracture area, orbital index score, operative intervention, and a combined model of these three variables were 0.871, 0.758, 0.803, and 0.909, respectively. The combined model had a significantly improved AUC for prediction of TBI symptoms compared to operative intervention alone (0.909 vs 0.803, p=0.010). Conclusion: Facial trauma has a significant risk of long-term TBI symptom burden. The radiographic severity of orbital floor fractures alone does not predict TBI symptoms. Operative intervention may play an additive role in potentiating TBI symptom burden.

Purpose: Aortic graft exposure and infection are risk factors for graft failure and mortality. Muscle flaps are an important part of the reconstructive armamentarium to provide prophylactic graft coverage and salvage should abdominal contamination occur. This case describes the unique use of the vastus lateralis-fascia lata composite myofascial flap to cover and salvage an aortic graft when local flaps were unavailable.

Methods: The authors present the case of a pedicled vastus lateralis and tensor fascia lata flap used to provide vascularized tissue coverage of an aortic Dacron interposition graft during graft salvage in the setting of a contaminated abdomen. A literature review was performed for articles relating to the use of rectus femoris or vastus lateralis flaps for aortic graft coverage.

Results: A 70-year-old man presented with fevers and vomiting. He had a recent history of retroperitoneal liposarcoma treated with neoadjuvant radiation and radical resection 2 months prior including aortic interposition grafting and omental flap complicated by bowel leak, recurrent retroperitoneal abscesses and enterocutaneous fistulae with previous percutaneous drainage and conservative management. Exploration revealed a necrotic omental flap and exposure of the interposition graft to the contaminated abdomen. Following debridement and extensive irrigation with rifampin the reconstructive service was consulted for graft coverage. Local retroperitoneal flaps were in the radiated field and unable to be used. An omental flap had already been utilized and failed, and a rectus flap was not possible due a previous nephrectomy compromising its blood supply, and a rectus femoris flap was deemed too small. Given the size of the defect a combined vastus lateralis and tensor fascia lata graft was chosen to provide tension free vascularized coverage of the aortic graft.

A literature review revealed two case reports. A case from 2019 detailed the prophylactic use of a pedicled rectus femoris flap for coverage of an aortic graft in a contaminated abdomen following a gunshot wound injury (1). Another case from 2019 details the use of a free chimeric anterolateral thigh and vastus lateralis flap for reconstruction of an ischemic thoracic wall defect with exposed aortic graft and pleura following a thoracoabdominal aortic aneurysm repair, although this reconstruction was delayed for weeks until the wound was clear of infection (2).

Conclusions: The vastus lateralis and tensor fascia lata myofascial flap is a useful salvage flap for aorta coverage following abdominal contamination if local options are unavailable. The vastus lateralis is a long, bulky muscle with a large arc of rotation and reliable blood supply from the lateral circumflex branch of the femoral artery that can provide coverage of large defects.

1. Patete CL, Gishen K, Nugent A, et al. "Primary selection of a pedicled rectus femoris flap for protection of aortic graft." J Vasc Surg Cases Innov Tech. 2019 Nov 18;5(4):512-517.
2. Smith K, Rossi P, Rokkas C, et al. "Thoracic wall ischemia after repair of thoracoabdominal aortic aneurysm requiring large microvascular soft tissue reconstruction." J Vasc Surg Cases Innov Tech. 2019 Jun 25;5(3):255-258

Introduction: Burns affecting the cervicofacial region are prevalent, impacting patients' quality of life (1,2). Despite its frequency, lack of research exist on predictive factors for healing outcomes specifically in this area. Therefore, we aim to investigate the influence of the burn depth on Manchester scale scores (3,4,5). Materials and methods: This is an IRB approved prospective observational cohort study enrolled patients who experienced their first cervicofacial burn episode and received treatment at a tertiary-level burn unit from July 2022 to July 2023. The Manchester scale, designed to assess aesthetic characteristics of a scar, including color, shininess, contour, texture and distortion was administered six months following the injury. A Wilcoxon test was conducted to evaluate among burn depth subgroups while a multivariate linear regression analysis was conducted to evaluate the impact of burn depth on the Manchester score. Results: A total of 112 patients consented to participate in the study consisting of 58.1% males and 48.2% females. The median age of the population was 22 years old (IQR: 5, 37). Flames were the most common causative agent at 38.4% of the population, followed by hot liquids at 25% and oil at 17%. In terms of burn depth, 85.71% of patients suffered second-degree burns, while 14.28% had third-degree burns. The median Manchester Scale score was 8 (IQR 7,9) points, with patients with second-degree burns scoring significantly lower compared to those with third-degree burns (medians 8.0 vs. 9.5, p=0.027). When evaluating subdomains, contour and texture were found to be significantly lower in the second-degree burns compared with the third-degree burn (medians 1.0 vs. 2.0, p= 0.008) and (medians 1.0 vs. 2.0, p= 0.006) respectively. Undergoing a surgical intervention was associated with an increase in the total Manchester Scale score by 2.43 points (95% CI 1.54-3.32, p<0.001), while friction burns are linked to a decrease in the scale by 2.58 points (95% CI -4.35, -0.80, p=0.004). Conclusion: Our finds suggest that burn depth, causative agents, and treatment interventions play a role in determining the aesthetic outcomes of cervicofacial burns. Specifically, surgical interventions demonstrate a positive impact on Manchester scale scores. Further research should focus on objective instruments of burns and scar healing evaluation to optimize patient outcomes. References: 1. Gaviria Castellanos JL, Santamaría N, Velandia Patiño CA y col. Georreferenciación de las quemaduras en Bogotá, Colombia. Rev Col cirugía estética y reconstructiva. 2019; 25(2) 61 – 71. 2. Manrique Martínez I, Angelats Romero CM. Abordaje de las quemaduras en Atención Primaria. Pediatr Integral. 2019; XXIII (2) 81 – 89. 3. Milena, L. P., Lisandra, V. C., & Daniela, G. V. Cicatrización patológica asociada a la distribución corporal de lesiones por quemadura térmica en niños. In Primera Jornada Virtual de CirPlast Sancti Spíritus. 2020. 4. Jiménez Serrano, Rocío, & García Fernández, Francisco Pedro. Manejo de las quemaduras de primer y segundo grado en atención primaria. Gerokomos. 2018; 29(1), 45-51. 5. Isabel Cristina, R. G., & Elmer David, P. V. Repercusión de las quemaduras en infantes. In Primera Jornada Virtual de CirPlast Sancti Spíritus. 2020.

Purpose: Fluoroscopy, and other procedures using radiation exposure, can induce acute and chronic skin damage. Fluoroscopy-induced chronic radiation dermatitis(FICRD) is a complication of fluoroscopy-guided interventions. With increasing numbers of percutaneous coronary intervention (PCI) and complex cardiac procedures, higher accumulated radiation dose in patients has been observed.

Materials and Methods: We conducted this study by reviewing cases records of all patients who had received PCI with radiation dermatitis during 2013 to 2023, only patients whose clinical photos were available for reviewing, would be included for further evaluation. Patients were grouped as conservative treatment group (Group I) and surgical treatment group (Group II).

Results: From August, 2013 to December, 2023, there were 34 patients with radiation dermatitis after fluoroscopy intervention, 4 patients loss follow up, finally 30 patients were included in our study. 10 patients received conservative treatment, while 20 patient underwent surgical treatment. The wound size(square centimeter, cm2) was significantly higher in Group II (85.96±44.7 vs. 179.64±128.29, p=0.010) but the healing time(months) was significantly lower (8.6±7.56 vs. 1.28±1.24, P=0.014).

Conclusion: In the management of fluoroscopy-induced chronic radiation dermatitis, one-stage radical excision with immediate wound reconstruction showed the best result in our study.

Objectives: Zygomaticomaxillary Complex (ZMC) fractures, constituting 10-30% of facial fractures, are commonly managed surgically. However, comminuted fractures present a persistent challenge to surgeons. The conventional fixation method via Keen's approach faces difficulties due to difficulty in handling surgical tools arising from limited surgical space. While accurate reduction is pivotal in ZMC fracture management, achieving stable fixation without compromising reduction is equally crucial. Despite the advantages of Patient-Specific Implants (PSIs), such as customization and reduced surgery time, their cost, production time, and limited adaptability present significant hurdles. Consequently, we present a case utilizing moldable putty as a practical solution for effectively managing well-reduced ZMC fractures during miniplate intraoperative design. Materials and Methods: A 47-year-old male presented with comminuted, displaced ZMC fractures following a motorcycle accident. Surgical management involved Keen's approach, with displaced bone reduced using bone hook and Dingman elevator. To ensure precise shaping of plates without disturbing the fragments, a putty template was meticulously crafted. The dimensions of the fracture site were gauged, and heavy-body putty, comprising of silicone polymer base and catalyst, was mixed in a 1:1 ratio into a sterile polyvinyl glove. This putty was delicately applied to the fracture site, adhering to its contours without disrupting the reduction, solidifying within 3-minutes. The solidified putty served as a template for bending titanium miniplate outside the surgical field, enabling its accurate application along the reduced buttress curvature without necessitating further modification. Results: Fixation was successfully achieved along the curvature of the buttress using 6mm screws. By fabricating and applying the plate immediately outside the surgical setting, without the need for repeated adjustments, the fixation process proceeded seamlessly. A thorough six-month follow-up evaluation, including X-ray and facial computed tomography (CT), revealed a well-maintained state of reduction, indicative of precise anatomical reconstruction and improved facial appearance. Notably, there were no occurrences of postoperative complications such as facial asymmetry, trismus, hypoesthesia, or implant-related infections. The patient expressed satisfaction with the outcome during the six-month postoperative follow-up period. Conclusion: The utilization of Computer-Aided Surgery (CAS), Computer-Aided Design (CAD), and PSIs for managing ZMC fractures is increasingly recognized for its potential to enhance precision and minimize surgical trauma. However, the consideration of patient-specific factors and resource availability remains paramount. Given the financial and temporal constraints associated with PSIs, the emergence of moldable putty as a viable alternative is noteworthy. The application of putty enables the creation of precise templates, thereby mitigating the trial-and-error inherent in conventional methods and offering a straightforward, accessible, and time-efficient approach to intraoperative miniplate bending. This approach not only facilitates enhanced precision and reduced surgical duration but also contributes to improved patient outcomes. Further studies are necessary to validate its efficacy in optimizing time management in clinical settings.

Purpose: Gynecomastia is the most common cause of breast-related signs or symptoms in men. Most males experience some degree of gynecomastia during their lives, with up to 65% of adolescent males being affected.1 Atypical ductal hyperplasia (ADH) is known to significantly increase the risk for breast cancer in women. However, little is known about the implication of ADH in adolescent males with gynecomastia. We present a rare case series of three male adolescent patients with gynecomastia and concomitant ADH discovered on pathology.

Methods: A chart review of pediatric patients who underwent reduction mammoplasty for gynecomastia with resultant ADH on pathologic analysis were identified at our institution. Patient demographics, clinical, pathologic, operative and follow-up details were collected.

Results: Three adolescent male patients were diagnosed with ADH from December 2017 to December 2024. Power assisted liposuction with subglandular tissue excision was performed for all patients. Median patient age at ADH diagnosis was 16 years old (range 16 to 17 years old). All three patients had bilateral ADH on final pathology. There was no patient reported family history of breast cancer. No preoperative or post-operative imaging was performed on patients. No patient took adjuvant therapy. At a median follow-up of 30 months (range 5 to 72 months), no patient developed known breast cancer.

Conclusion: Male breast cancer is very uncommon and represents less than 1% of all breast cancer. ADH, a known finding related to higher the risk of developing breast neoplasia in women, is an even rarer incident in patients with gynecomastia. Literature concerning recommendations for male patients diagnosed with ADH following incidental finding during gynecomastia excision is sparce, and those concerned with the pediatric population are even fewer. It seems that there may not be an increased risk of breast cancer in adolescents with gynecomastia and ADH 2 however, there is currently no consensus about indication of therapy or surveillance after diagnosis. As plastic and reconstructive surgeons, it is important to be aware of this possible diagnosis- which may lead to improved preoperative discussions, counseling and management expectations in our pediatric population.

References 1) Lapid, O., Jlink, F., & Meijer, S. L. (2015). Pathological Findings in Gynecomastia: analysis of 5113 Breasts . Annals of Plastic Surgery, 163-166. 2) Coopey, S. B., Kartal, K., Li, C., Yala , A., Barzilay, R., Faulkner, H. R., . . . Hugh, K. S. (2019). Atypical ductal hyperplasia in men with gynecomastia: what is their breast cancer risk? Breast Cancer Research and Treatment, 1-4.

Purpose: Slow-flow vascular malformations, including lymphatic (LMs) and venous (VMs) malformations often require lifelong, interdisciplinary care and access to quaternary care centers with highly specialized teams. We previously showed that patients at our institution who identify as Hispanic/Latino or as non-white are more likely to have Medicaid instead of private insurance and more likely to live within 10 miles of our hospital. This suggests that private insurance patients, more often white, can afford to travel for access. The healthcare utilization of LM/VM patients at our institution was compared based on insurance status and race, and we hypothesize that health disparities for LM/VM patients exist based on insurance status and race.

Methods: A retrospective, longitudinal study was performed of all LM/VM patients seen at one institution between 1/1/2019-12/31/2020. In addition to demographic and insurance data, the patients' healthcare utilizations ("parameters") were collected and normalized to per year utilization: office visits, number of specialists involved, imaging studies, procedures or hospitalizations, and approximate healthcare costs. Patients were stratified based on insurance type (Medicaid and Managed Medicaid vs. private insurance) and race (white vs. non-white) for comparison. LMs/VMs were further divided into "simple" vs. "complex" lesions. Involvement of the airway and/or more than one anatomical area was defined as "complex." Statistical analysis was performed with Welch's t-test for continuous variables and Fisher's exact test for categorical variables using Prism 10. p<0.05 was considered statistically significant.

Results: A total of 125 patients (56 LMs, 69 VMs) were included. Insurance status was available for 124 patients (56 LMs, 68 VMs). Race data was available for 100 patients (49 LMs, 51 VMs). Of these, 76 patients (25 LMs, 51 VMs) had "simple" diseases and 49 patients (31 LMs, 18 VMs) had "complex" diseases. The distribution of simple vs complex LMs/VMs was noted to be equivalent between insurance status and race (p>0.05). Patients with simple diseases had no differences in measured parameters based on insurance status or race. Healthcare utilization parameters were not different between white and non-white patients with complex disease. However, complex patients who had Medicaid was significantly more likely to have received more imaging studies (7.6 vs 3.7 studies/year, p=0.047) and trended towards incurring higher costs ($29,006/year vs $15,106/year, p=0.07). All other parameters were not significant in this group.

Conclusion: At our center, LM/VM patients with private insurance and who are white can more easily travel to quaternary care centers, revealing access inequalities. However, our results demonstrate that once they become patients, LM/VM patients, regardless of insurance or race status receive equivalent healthcare. The one exception is that complex LM/VM Medicaid patients receive more imaging studies. It is unclear what this discrepancy represents. Multi-center studies can shed more insight into how socioeconomic status may affect healthcare equality

Introduction Chin reduction remains a challenging procedure. The U-shaped osteotomy uses a curved osteotomy line designed to improve facial proportions but requires extensive soft tissue degloving1. The novel drawer genioplasty approach involves subapical and mandibular contouring osteotomies while preserving the majority of the floor-of-mouth musculature2. The study aims to compare the efficacy of these two chin reduction techniques and their impacts on the occurrence of submental soft tissue ptosis.

Methods This retrospective study included patients who underwent chin reduction in our department from May 2018 to May 2023, using either drawer genioplasty (n=25) or U-shaped osteotomy (n=21), with a follow-up period of at least six months. Outcomes were evaluated using medical records, computed tomography (CT) images and photographs. The authors compared differences in patient demographics, soft and hard tissue parameters, and scores on the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) between the two groups. Propensity Score Matching (PSM) was used to control for balance in age, Body Mass Index (BMI) change, and the change in hard tissue menton between the groups.

Results The drawer genioplasty and U-shaped osteotomy groups had similar distributions in age, gender, and BMI changes. Both techniques effectively improved facial proportions (p>0.050 for intergroup comparisons), and drawer genioplasty led to a greater reduction in chin length (mean change in hard tissue menton of 5.09 mm versus 4.08 mm), though not statistically significant (p = 0.074). Drawer genioplasty was more flexible, able to be combined with orthognathic surgery while U-shaped osteotomy could not. As for soft tissue, there is a statistically but not clinically significant increase in soft tissue thickness at the menton post-surgery among patients undergoing drawer genioplasty (5.91mm to 6.35mm, p = 0.005), while in U-shaped osteotomy group saw a statistically and clinically significant increase from 6.24mm to 8.26mm (p<0.001). The drawer genioplasty group had less deviation in the expected position of the soft tissue menton compared to the U-shaped osteotomy group (0.44mm versus 2.02mm, p=0.002), suggesting a lower degree of ptosis. Additionally, drawer genioplasty proved superior in patients demonstrating smaller increases in the cervicomental angle (CA) (0.30° versus 6.18°, p<0.001) and the maximal cross-sectional area (CSA) of the anterior belly of the digastric muscle (ABDM) (0.07mm2 versus 17.74mm2, p<0.001), both of which are factors contributing to submental soft tissue ptosis. In the CR-SMFRS, drawer genioplasty also outperformed U-shaped osteotomy(p<0.050). After PSM, the results from 12 matched cases in each group were consistent with the unadjusted findings.

Conclusion Drawer-genioplasty is a more effective and flexible chin reduction procedure that results in decreased soft tissue ptosis compared to U-shaped osteotomy.

References 1. Lai C, Jin X, Zong X, Song G. En-Bloc U-Shaped Osteotomy of the Mandible and Chin for the Correction of a Prominent Mandibular Angle With Long Chin. J Craniofac Surg. Jul 2019;30(5):1359-1363. doi:10.1097/SCS.0000000000005126 2. Wang Y, Guo X, Zhang D, Jin X. A novel chin-reductive drawer-genioplasty using subapical and mandibular contouring ostectomy. Plast Reconstr Surg. Oct 13 2023;doi:10.1097/PRS.0000000000011131

Background: Pediatric chest wall defects are reconstructive challenges as rib resections must be reconstituted to stabilize the chest wall in a way conducible 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 abdominus, 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.

Background Aplasia Cutis Congenita (ACC) is a rare congenital condition characterized by localized or diffuse, partial or complete absence of the epidermis, dermis, and occasionally subcutaneous tissue. Although the exact incidence is unknown, it is estimated that occurs in 1 to 3 in 10.000 births. Clinically, the lesions appear as well-defined, translucent, ulcerated membranes that allow visibility of the underlying structures. The scalp is the most affected site, particularly the vertex, seen in approximately 86% of cases. ACC is believed to be a multifactorial disease. There are two hypothesized pathways for its development: 1) disruption or failure of development of the skin layers and 2) in utero destruction of skin that was previously normally developed. As this condition can be associated with other physical abnormalities or syndromes, it is important to distinguish between the different clinical subtypes. In 1986, a classification grouping ACC into nine different subgroups was suggested by Frieden based on the locations and patterns of skin absence, accompanying abnormalities, and inheritance patterns (1). Nevertheless, as variations of this condition continue to appear, this classification is revealed not to be comprehensive. Treatment of ACC depends on the lesion size and location. Although conservative management is preferred, large defects often require surgical closure.

Case Presentation We present a case of ACC born at our hospital via cesarean section. She was born at a gestational age of 39 weeks with a birthweight of 3.150 kg, an Apgar score of 9-9-9, no placental abnormalities, and no birth complications. The mother was 27 years old at the time of delivery, gravida 3 para 3, with no medical history, no medication history, no family history, no chronic medical illness, or negative consanguinity. Iron and calcium supplements were regularly taken during pregnancy, with poor adherence to folic acid. She reported no history of radiation exposure. Postnatally, a large skin defect over the extensor surface of both legs and arms was noticed and consultation with the pediatric and plastic surgery team was done, who established a diagnosis of ACC. The defect in the legs extended over both knees and ended near the ankle (≃11x5cm). The defect in the arms was localized to the dorsal aspect of both elbows (≃1x2cm). Full neonatal screening was done and a chest radiograph revealed dextrocardia. The patient was managed conservatively with moist gauze dressing and a topical cream containing hyaluronic acid sodium salt and silver sulfadiazine (HYALO4® Control). One month later, complete healing was obtained with the re-epithelialization of the last defect (both knees). No further medical or surgical intervention was required. Due to the presence of dextrocardia and isolated limb defects, our case could not fit in any of the subgroups proposed by Frieden's classification. 

Conclusion Aplasia Cutis Congenita is a rare congenital condition characterized by localized or diffuse, partial or complete absence of the epidermis, dermis, and occasionally subcutaneous tissue. The underlying etiology is still largely unknown with a multifactorial etiology being suggested. In this report, we present a case of aplasia cutis congenita of the limbs associated with dextrocardia. The case was managed conservatively and full healing could be achieved one month after birth. Due to the association of ACC of the limbs with dextrocardia, our case could not be classified under any of the ACC types proposed by Frieden in his classification. Hence, there is a pressing need for a new ACC classification.

References 1. Frieden IJ. Aplasia cutis congenita: A clinical review and proposal for classification. J Am Acad Dermatol [Internet]. 1986 Apr;14(4):646–60. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0190962286700820

Free flap pedicle and perforator injuries are some of the most dreaded complications of any free tissue reconstructive procedure. Even if an injury to the pedicle or perforator is salvageable, the flap is higher risk of further complication due to multiple anastomotic sites and/or vascular grafts along the pedicle required to repair the injury (1).

An immediate bilateral autologous breast reconstruction utilising DIEP free flap was performed following a skin sparing mastectomy on an otherwise healthy 47-year-old female. The DIEP flap harvest and primary end-to-end anastomosis to the internal mammary artery and vein was uncomplicated. While de-epithelializing the flap for inset to the left breast pocket, it was noted to not be bleeding and some blood pooling in the pocket. The pedicle was checked, the primary anastomosis intact, but the pedicle was noted to be transected at the level of the perforator.

Three prior attempts at direct anastomosis was performed to re-vascularise the DIEP flap that was injury and had failed. One final attempt of the perforator repair was performed. This technique utilised vein grafts from one VC and couplers on all anastomoses. The new approach was taken to repair the end of the pedicle to the perforator, instead of a perforator-to-perforator repair at the site of injury.

The anastomotic site was changed to the end of the pedicle directly into the flap. This provided good quality vessels for one last attempt to repair the injured perforator. A consequence of altering the anastomotic site means a significant size mismatch needed to be addressed for the end-to-end arterial anastomosis as this anastomosis was now a pedicle-to-perforator anastomosis. A vein graft was taken from one of the VCs, reversed to overcome any valves that may be present, and 2 x 2 mm couplers were used to interpose the vein graft in the arterial anastomosis. The flap side perforator artery required an arteriotomy between a side branching artery and the perforator main artery to double its calibre at the site of anastomosis for the coupler application. A single VC was anastomosed with a 2mm coupler in standard fashion.

The key steps to this technique's success are: - Altering the anastomosis site along the pedicle out of zone of injury - Introducing a new, healthy vessel segment - Overcoming significant vessel mismatch - Minimising surgeon error

The vein graft and use of couplers in an arterial anastomosis addressed three of the four key points that allow this technique to be successful.

This salvage technique is useful for surgeons who do not have access to super-microsurgical training, techniques and/or instruments as described by Hong, J.P. and Koshima, I. (2,3) and utilised by Velazquez-Mujica et al. (1) in their perforator-perforator anastomosis salvage series.

References 1 - Velazquez-Mujica J, Losco L, Aksoyler D, Chen HC. Perforator-to-perforator anastomosis as a salvage procedure during harvest of a perforator flap. Arch Plast Surg. 2021;48(4):467-469. doi:10.5999/aps.2020.02194

2 – Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg. 2010;64(3):291-293. doi:10.1097/SAP.0b013e3181ac4263

Purpose There currently lacks a gold standard in surgical management for Pierre Robin sequence (PRS). Although the literature considers both mandibular distraction osteogenesis (MDO) and tongue-lip adhesion (TLA) as effective surgical options, surgeons have performed MDO more frequently in the past decade. Of late, clinicians have begun routinely employing polysomnography (PSG) data as a diagnostic tool and therapeutic marker for airway obstruction resolution. Given the scarcity of literature comparing outcomes of MDO and TLA-alongside recent new trends in analyzing airway resolution, this review aims to comprehensively evaluate the most recent data regarding airway and feeding outcomes for PRS infants undergoing either MDO or TLA. As such, this review is intended to aid surgeons in the decision-making process when surgically managing PRS patients. Methods A literature review was performed on April 2023 across PubMed and Embase. Articles written in English analyzing the efficacy of MDO and/or TLA for PRS infants published since 2018 were included. Exclusionary criteria include studies with 1) groups of less than 10 subjects, 2) patients undergoing a non-primary MDO or TLA procedure, 3) less than 1 year of follow-up, and 4) data irrelevant to outcomes of interest. Primary outcomes were PSG data (O2 nadir, AHI or apnea/hypopnea index), and growth/weight assessments. Secondary outcomes include tracheostomy avoidance, reoperations, achievement of full oral feeds, gastrostomy avoidance, and complications. Results 22 studies (either randomized clinical trials or retrospective cohort studies) investigating MDO, TLA, or MDO-TLA comparisons were analyzed. All MDO cohorts demonstrated statistically significant improvement when investigating pre and postoperative AHI and O2 nadir data, while none of the TLA cohorts exhibited significant differences between preoperative and postoperative PSG data. Both MDO and TLA patients showed improvement in growth/weight assessments comparable to controls or the WHO standard within the first years of life. There were no differences between MDO and TLA patients in weight percentile differences or weight-for-age z-scores at 1 or 2 years, respectively. 95.7% (446/466) of MDO patients and 96% (121/126) of TLA patients avoided tracheostomy. 1.5% (7/466) of MDO patients required reoperation(s), whereas 11.1% (14/126) of TLA patients required reoperation(s). Multiple MDO studies showed 100% (44/44) achievement of oral feeds within 1 month of surgery, while the largest and most recent TLA cohort study noted 42.5% (31/73) achievement at 9 months. 78.6% (55/70) of MDO patients and 44.7% (42/94) of TLA patients had avoided gastrostomy tube placement at latest follow-up. Conclusion In this review of the latest literature analyzing the efficacy of MDO and TLA in managing PRS infants, our data reveal a more nuanced distinction regarding airway resolution favoring MDO. Now with routinely documented PSG data, MDO has consistently exhibited superior resolution of upper airway obstruction compared to TLA; moreover, the markedly lower rate of reoperations suggests that the airway resolution provided by MDO is more stably maintained. Although noting similarities in growth/weight assessments between MDO and TLA, our data reinforces previous notions suggesting MDO superiority in the achievement of full oral feeds as well as in gastrostomy-tube avoidance.

Abstract Background Facial paralysis is a debilitating condition, with physical, psychological and social sequelae. Facial reanimation surgery (FRS) aims to restore form and function, employing a range of dynamic and static procedures. We performed a bibliometric analysis focused on the 100 most-cited FRS articles to understand emerging trends, identify gaps and assess methodological quality of the highest impact studies.

Methods The 100 most-cited articles in FRS were identified on Web of Science, across all available journal years (from 1976 to 2024). Study details, including the citation count, main subject, and outcome measures were extracted from each article. Oxford Centre for Evidence Based Medicine (OCEBM) Levels of Evidence (LOE) of each study were assessed.

Results The 100 most-cited articles in facial reanimation surgery were cited by a total of 6841 articles and including a total of 5570 patients. Citation per article ranged significantly from 31 to 535 (mean 68.41). Overall, most of the top-cited articles were LOE 3 (n = 43), representing the large number of cohort studies. The remaining number of articles for LOE 5, 4, 2 and 1 were 25, 15, 3 and 3, respectively. Most articles focussed on 'surgical technique' (n = 64), followed by 'outcomes' (n = 22). Patient reported outcome measures (PROMs) were used in 8 articles, and 52 articles reported cosmetic outcome measures.

Conclusion This analysis highlights the need for improved study designs in FRS research, with a profound lack of high-quality studies. Improved research methodologies and adoption of validated PROMs would promote high-quality evidence-based patient care in FRS to optimise clinical decision making and informed consent.

Purpose: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are well-described techniques utilized to combat neuroma and phantom limb pain and to provide greater control of a myoelectric prosthetic.1 TMR at time of below knee amputation (BKA) has been described via a "through-the-wound" approach (TTWA).2 An alternative strategy is to perform nerve management via a "posterior approach" (PA) through the popliteal fossa. In this study, we compare nerve management techniques via PA and TTWA.

Materials and Methods: Institutional review board approval was obtained for this retrospective review performed between January 2020 to April 2023. Patients who underwent nerve management utilizing TMR and RPNI strategies during BKA via PA or TTWA were identified. Patients who underwent delayed nerve management were not included. Patient demographic data, medical history, operative notes, and rehabilitation notes were reviewed. Descriptive and statistical analyses were performed via independent samples t-tests and chi-square tests utilizing Microsoft Excel and IBM SPSS.

Results: In total, 16 patients underwent PA and 20 underwent TTWA nerve management. The TTWA cohort had 7 males and 13 females, and the PA cohort had 13 males and 3 females (p=0.008). There was no different in mean age at surgery (TTWA mean 48 years old, PA mean 47 years old (p=0.9). There were no differences in medical comorbidities, including rates of obesity, between groups.

PA was found to take significantly longer than TTWA, 309 minutes (range; 204 minutes – 309 minutes, SD ± 30 minutes) compared to 208 minutes (114 minutes – 370 minutes, SD ± 71 minutes), respectively (p=0.03). All patients in both TTWA and PA cohorts underwent TMR, however in the TTWA cohort 19 also underwent RPNI compared to 9 in the PA group (p=0.01). There was no difference between time to prosthetic clearance between groups (PA mean 3.6 months and TTWA mean 4.4 months (p=0.54). Those who underwent TTWA were more likely to suffer dehiscence postoperatively (TTWA: 8 subjects, PA 4 subjects, p=0.01). There was no difference in infection rates between groups.

Conclusion: Nerve management via TTWA takes less time than PA. There was no difference in time to prosthetic clearance. PA may have fewer complications compared to TTWA. Additionally, PA may provide more direct access to recipient motor nerves, as evidenced by a lower utilization of RPNI nerve management in this cohort. These findings should be considered by surgeons who perform active nerve management at time of BKA.

References: 1. Mauch JT, Kao DS, Friedly JL, Liu Y. Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review. Pm r. Nov 2023;15(11):1457-1465. doi:10.1002/pmrj.12972 2. Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted Muscle Reinnervation Technique in Below-Knee Amputation. Plast Reconstr Surg. Jan 2019;143(1):309-312. doi:10.1097/prs.0000000000005133

Purpose: The increasing environmental impact of today's one-use items has increased our carbon footprint, and operating rooms are undoubtedly a significant contributor. It is estimated that 30% of the waste produced in the hospital is from operating rooms. This scoping review aims to increase recycling opportunities in the operating room by looking at general themes of waste reduction in the operating room and identify barriers throughout the literature.

Methods: A scoping review was performed on Embase, Medline, CINAHL, and Web of Science. A review of articles published in a 24-year period from 2001-2024 as recycling practices have evolved and improved over the last 20+ years. Inclusion criteria were articles surrounding recycling, reducing waste, and energy consumption in the operating rooms. Biologic waste, anesthetic equipment, and pharmaceuticals were excluded. 93 articles were identified within the inclusion criteria by two separate reviewers and a third reviewer was used for any disagreements.

Results: Articles were organized into key themes perioperatively and intraoperatively. Themes included proper waste segregation, reducing disposable items and packaging, and decreasing unnecessary items.

Conclusion: With this information, education surrounding recycling, decreasing waste, and consumption can be tailored to meet the different needs of operating rooms in an effort to decrease not only our carbon footprint but also balancing costs. After reviewing our practices, multiple barriers and actionable changes were also identified at our institution.

Teaching Objectives: Review up-to-date recycling practices and draw awareness to institutional and self-practices surrounding waste production and recycling opportunities.

Background: Free tissue transfer represents the most technically advanced form of breast reconstruction plastic surgeons can offer. The need for reoperation within days after free flap reconstruction typically represents a major complication and significantly impacts the patient's outcome and healthcare costs. The objective of the study was to identify risk factors associated with return to the operating room within one week of free flap breast reconstruction.

Methods: This is a retrospective cohort study including patients undergoing free tissue transfer for postmastectomy breast reconstruction from 2005 to 2020 in the province of Ontario, Canada (population 14 million). The outcome of interest was return to the operating room within one week of free tissue transfer for breast reconstruction. Reoperations to the breast or donor site used for reconstruction were identified using Ontario Health Insurance Plan billing codes. Multivariable logistic regression models were used to identify independent risk factors associated with emergency free flap reoperation.

Results: We evaluated 2,290 patients who underwent autologous breast reconstruction with free tissue transfer. There were 167 patients (7.29%) who underwent emergency surgery within seven days, and the majority (86%) of reoperations occurred within three days. The odds of reoperation were higher for patients in lower income quintiles (quintile 5 v. quintile 1: adjusted odds ratio [aOR] 2.12, 95% confidence interval [CI] 1.26–3.58, p = 0.005) and in a non-teaching hospital (aOR 1.73, 95% CI 1.09-2.72, p = 0.019). Patients who had radiation preoperatively had reduced odds of emergency reoperation (aOR 0.52, 95% CI 0.33-0.90, p = 0.017). Age, Charlson Comorbidity Index, diabetes, immediate reconstruction, geographical location, and rurality were not associated with free flap takeback.

Conclusion: In a universal health care system, lower-income patients and patients who receive their reconstruction at non-teaching hospitals were at increased odds of reoperation. Nonetheless, these complications are still uncommon. Socioeconomic status should not prohibit reconstruction; instead, increased efforts should be made to mitigate disparities and improve outcomes across all demographics.

Background: Flap loss due to inflow or outflow occlusion, though rare, can be a devastating outcome in women undergoing autologous free flap breast reconstruction. Mechanical compression, kinking and malposition are commonly cited as major contributing factors. To address these issues, the senior author introduced in his practice a novel technique using fibrin sealant to stabilize the pedicle in three dimensions while achieving immediate hemostasis in the surrounding area after completing microvascular anastomoses. We sought to evaluate the safety of this technique by comparing rates of flap loss before and after its implementation.

Methods: Women undergoing free flap reconstruction by the senior author at our institution from 2022 and 2023 were identified. Only those who had surgery within a 10-month period before and after the technique's implementation were included to allow for at least a 6-month follow-up. Demographic, clinical and operative data were extracted from the medical records. The exposure was the use of fibrin sealant as described above. The primary outcome was complete flap loss, with secondary outcomes including intraoperative thrombosis, wound complications (e.g., hematoma, seroma, infection, delayed wound healing, partial flap necrosis), reoperations and early revisions (within 6 months of surgery). Chi-squared and Fischer's exact tests were used to assess differences in clinical-mix and compare outcomes at the patient-level.

Results: The study included 104 patients, with 54 (52%) in the non-fibrin-sealant group and 50 (48%) in the fibrin-sealant group. The median age was 50 years (IQR: 41-56) and the median BMI was 31 Kg/m2 (IQR: 26-34); the majority were White (66%). Demographics and other clinical characteristics were similar between groups (P>0.05). Most patients underwent bilateral reconstruction (53%), as a delayed procedure (88%), using muscle-sparing TRAM (51%) or DIEP (48%) free flaps, and were discharged home on postoperative day 2 (median, IQR 2-3). One flap loss (2%) occurred in the non-fibrin-sealant group due to pedicle kinking, while no flap losses were observed in the fibrin-sealant group (P<0.33). Intraoperative thrombosis rates were 7% and 4% in the non-fibrin-sealant and fibrin-sealant groups, respectively (p=0.45). There were no significant differences in early revisions and all wound-related complications assessed (P>0.05). Reoperations were more common in the non-fibrin-sealant group (11% vs. 0%, P=0.01) but this trend did not persist in stratified analyses to account for flap type differences (P>0.05).

Conclusion: The use of fibrin sealant in breast free flap reconstruction appears safe and is not associated with increased rates of flap loss, microvascular thrombosis, or other wound-related complications. These findings support the continued use of fibrin sealant at the site of arterial and venous microvascular anastomoses and along the pedicle to achieve desired vessel orientation while preventing complications related to kinking and mechanical compression. Further research is encouraged to validate these results and to explore how fibrin sealant can further enhance the quality and safety of free flap reconstructive procedures.

Purpose: Facial gender-affirming surgery (FGAS) is crucial to the gender affirmation process for many transfeminine patients. Malar augmentation, customarily achieved with implants and/or fat grafting, can be instrumental in creating a feminine contour of the midface. This paper presents an alternative technique, zygomatic osteotomy malarplasty (ZOM), which leverages the patient's native bony anatomy. A prior study on ZOM demonstrated statistically significant improvement in patient femininity scores (1). Our study aims to show that ZOM, when compared to alloplastic malar augmentation, is efficacious and reproducible with unique benefits and lower complication rates. The ZOM technique is described in this paper, and a video demonstration of the critical steps is included.

Methods: A single-center retrospective review of 44 patients undergoing ZOM was conducted. Data for minor complications (infection, dehiscence, wound healing issues, asymmetry, and transient numbness) and major complications (nerve injury and need for revision surgery) were collected. Additionally, systematic review and meta-analysis of the literature on alloplastic malar augmentation for FGAS was completed. Electronic databases, including Ovid MEDLINE, Ovid EMBASE, Cochrane, and Web of Science, were searched for qualifying articles. Studies reporting surgical technique, aesthetic outcomes, and complications were included. Studies without adequate detail or follow-up were excluded. Statistical analysis was performed using the Mann-Whitney U Test, and p-values < 0.05 were considered significant.

Results: Forty-four patients with adequate follow-up (average 12.64 months) underwent ZOM at a single institution. Procedures were bilateral, and 88 ZOMs were analyzed. Minor complications were noted in 2/88 (0.023%) instances - both were conservatively managed dehiscence; no major complications were noted. Meta-analysis of alloplastic malar augmentation revealed six studies which included 117 patients with adequate follow-up (average 11.54 months), and 234 alloplastic implant placements. Minor complications included dehiscence 2/234 (0.009%), infection 3/234 (0.013%), and asymmetry 1/234 (0.004%); major complications included return to operating room 2/234 (0.009%). ZOM had lower rates of dehiscence, infection, asymmetry, and return to operating room respectively (p < 0.001). Data on other complications were insufficient for comparison.

Conclusion: The ZOM technique requires a controlled greenstick fracture at the zygomatic and temporal bone junction. The maxillozygion, an anthropometric landmark at this junction, is the most prominent point of the malar eminence and undergoes targeted augmentation by ZOM (2). The fracture is distracted, and bone allograft or autograft is fixated into the gap with miniplates to hold the augmentation. ZOM is safe and effective. While alloplastic implant placement is faster and less invasive, ZOM modifies the patient's own anatomy resulting in customized augmentation with lower rates of complications. With appropriate training, it can be incorporated into the armamentarium of FGAS surgeons.

References 1. Kotha VS, et al. Simultaneous Zygomatic Osteotomies with Reduction Mandibuloplasty – An Approach to Mid- and Lower-Facial Feminization in the Transfeminine Patient. Journal of Craniofacial Surgery. 2022;33(5):1569-1573. 2. Nechala P, et al. Maxillozygional anthropometric landmark: a new morphometric orientation point in the upper face. Annals of plastic surgery. 1998;41(4):402–409.

Hypothesis: Sonography is an effective tool for diagnosing cubital tunnel syndrome. Space occupying visualization, cross sectional area analyzation, and edema can all be assessed in the ulnar nerve. Sonography is utilized currently for minimally invasive approaches to carpal tunnel syndrome and thus is of interest for application in minimally invasive cubital tunnel decompressions. This study explores an in-office alternative to an open surgical procedure through employing the Sonex UltraGuideCTR™ carpal tunnel release system bidirectionally at a single incision site at the level of the cubital tunnel.

Methods: We postulate an alternative approach for cubital tunnel decompression via a minimally invasive surgical intervention. Utilizing the Sonex UltraGuideCTR™ as the incising instrument, dissections were performed on three cadaveric arms under live ultrasonographics. The Sonex UltraGuideCTR™ was specifically chosen due to its inherent ability to avoid unintentional soft tissue damage and iatrogenic nerve injury via a retractable blade and inflatable balloons respectively. The cadaveric operations rigidly simulated a surgical operation in regards to time, technique, and care of dissection. Confirmation of fascial release was achieved post-operatively via an open dissection.

Results: Use of real-time sonography offered the surgeon a unique vantage point to establish proper alignment of the device and to provide confidence throughout the release. In all three specimens, complete release of the deep and superficial fascia of the flexor carpi ulnaris was observed. Fascial split was associated with longitudinal split of the muscle fibers on either side of the release. There was no identified injury to any motor branches supplying the flexor carpi ulnaris muscle. Proximally, the nerve was noted to be completely decompressed in its course as well. There was no identifiable subluxation of the nerve with ranging of the elbow. The first release was completed in 14 minutes; the second release in 10 minutes; and the final release was completed in 7 minutes.

Conclusion: Access to operating theaters is increasingly limited, and the ensuing exigencies of the patient population for in-office procedures has become a driver for novel interventions. Modeled from currently accepted minimally invasive management of carpal tunnel syndrome, the Sonex UltraGuideCTR™ device was utilized in similar fashion at the level of the cubital tunnel to successfully decompress the ulnar nerve. In response to meeting the rising need for patient access to surgical intervention outside of the operating room, such novel approaches are becoming increasingly necessary and embolden surgeons and device developers alike to expand their horizons.

INTRODUCTION: Abdominoplasty is a surgical procedure that structurally reconstructs the function and aesthetics of the abdominal wall. The objective of this work is to show the clinical experience and evolution of a series of cases of patients undergoing Pitanguy abdominoplasty Abdominoplasty using the Pitanguy technique was described in 1967, providing as a contribution to the techniques described up to that time the plication of the rectus abdominis muscles without opening their aponeurosis and the plication of these muscles from the xiphoid process to the pubis for the correction of abdominal diastasis. Another contribution of the technique is the low location of the incision at the level of the pubic hairs with extension to the sides accompanying the style of underwear worn by the patient, taking into account the current variations of each era, suffering slight alterations in the lateral extension. of the incision, moving up or down to leave the scar hidden in underwear. (1,2,3) MATERIAL AND METODS: Retrospective study on 135 consecutive cases operated on between June 2021 and June 2023 in females. Patients belong to group III and IV of the Pitanguy classification (4) The inclusion criteria were female patients between 18 and 70 years old with supra- and infra-umbilical skin sagging, with sagging of the musculo-aponeurotic system. Satisfied parity, BMI less than 30. The exclusion criteria were patients with BMI greater than or equal to 30, uncompensated comorbidities, men. Table 1 shows the characteristics of the evaluated population. RESULTS: The average age was 35 years. The average surgical time was 130 minutes. (range 90 to 230 minutes). The length of the 24-hour hospital stay. Drains were maintained for an average of 72 hours. Thromboprophylaxis with early ambulation and elastic and pneumatic stockings was performed in all patients, thromboprophylaxis with low molecular weight heparin in 80% of patients. The incidence of complications associated with the procedure was: scar alteration (6.7%), seroma (8.9%), hematoma (2.2%), dehiscence (3.7%), deep vein thrombosis (2.2% ). There were no serious complications, such as pulmonary embolism, shock, infection or necrosis. The satisfaction index was very satisfactory 24%, satisfactory 65%, unsatisfactory 9%, not at all satisfactory 2%. CONCLUSION: Results similar to other studies of the same nature found in the literature were evident. The versatility of the classic Pitanguy technique in abdominoplasties allows the treatment of most cases of lipodystrophy and its reproducibility makes it a simple and feasible technique to be performed with safety in a medical residency program. It continues to be a safe approach with good aesthetic and functional results. REFERENCES: 1. Elbaz JS, Flaguel G. Chirurgie plastique de l'abdomen. Paris. Masson, 1977 2. Pitanguy I., Aesthetic Plastic Surgery of Head and Body. Springer 1982. 3. Jaimovich CA, Mazzarone F, Parra JFN, Pitanguy I. Semiologia da parede abdominal: seu valor no planejamento das abdominoplastias. Rev Soc Bras Cir Plást. 1999;14(3):21- 4. Pitanguy I., et al. Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg. 2000;105(4):1499-516.

This study reports the experience of the Plastic aSurgery Department at the Hospital Universitario "Jose Eleuterio Gonzalez," detailing the use of a handmade external fixation device as a last-resort measure for severe hand injuries. Existing literature outlines initial treatment protocols for such injuries, which typically involve irrigation, debridement, fracture stabilization,¹ and, if necessary, the use of a fixator made with syringe-Kirschner wire.² In our setting, immediate access to plates, screws, and other surgical materials necessary for managing these injuries is often hindered, leading to delays during the critical initial period of injury management. This delay results in prolonged hospital stays, increased pain, and a poorer prognosis for our patients due to suboptimal management.³
Materials and Methods: We present and analyze the cases of five patients diagnosed with severe hand trauma evaluated between December 2023 and April 2024, all requiring Syringe External Fixator due to their clinical presentations. Later, these patients underwent the placement of plates once they had financial resources. Presentation of Cases: Case 1: A 36 years old male sustained a gunshot wound to the left hand, resulting in soft tissue avulsion in the dorsal region and a comminuted fracture of the base of the 2nd and 3rd metacarpals. Case 2: A 30 years old male suffered a gunshot wound to the proximal phalanx of the 3rd finger of the left hand, leading to a comminuted and intraarticular fracture. Case 3: A 48 years old male, with a wound from a grinder on the right thenar eminence, presenting tissue avulsion and comminuted fracture of the first metacarpal. Case 4: A 32 years old male with a gunshot wound to the left hand, resulting in an exposed comminuted fracture of the base of the second to third metacarpal, the proximal phalanx of the 4th finger, and a comminuted fracture of the trapezoid bone. Case 5: A 23 years old female sustained a gunshot wound to the right hand, resulting in soft tissue avulsion in the first finger hand and a comminuted fracture of the 1st metacarpal with loss of bone fragment.

Results: Our findings suggest a positive impact, with reduced pain and hospital stays, making our approach an appealing, effective, and cost-efficient alternative for managing these injuries.

Conclusion: This inexpensive method offers several advantages over traditional treatments, including simplicity of assembly, lightweight design, cost-effectiveness, and suitability for urgent and minimally invasive surgeries.

References: 1. Christodoulou N, Asimakopoulos D, Kapetanos K, Seah M, Khan W. Principles of management of hand fractures. J Perioper Pract. 2023 Nov;33(11):342-349. 2. Fleury CM, Yousaf IS, Miles MR, Yousaf OS, Giladi AM, Katz RD. The Syringe External Fixator: Short- and Medium-Term Functional Outcomes From This Inexpensive and Customizable Treatment for Comminuted Intra-Articular Fractures of the Hand. J Hand Surg Am. 2022 Oct;47(10):1013.e1-1013.e12. 3. Rosas S, Gwam CU, Araiza ET, Roche MW, Emory CL, Carroll EA, Halvorson JJ, Plate JF. Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis. Ann Transl Med. 2021 Feb;9(3):210.

Purpose As an urban, public, safety-net hospital, Los Angeles General Medical Center provides care to many disadvantaged patients who are low-income and uninsured. Restricted by the limited resources afforded by the county health system, our plastic surgery clinic observed multiple operational inefficiencies that increased appointment wait times and workplace stress and decreased access to care, resulting in reduced quality of care and an increased risk of burnout in the clinic's staff and surgical residents. We sought to identify operational friction points in attempt to improve cycle time, access to care, and overall satisfaction of patients, residents and staff.

Materials & Methods Data were collected between January to November 2023 through the Lean Healthcare Systems Engineering process consisting of Gemba walks, literature reviews, stakeholder interviews, surveys, and data analysis. Over 20 interviews were conducted with stakeholders of different positions and seniority levels to assess themes regarding clinic inefficiencies. Patient cycle times were calculated from 6 clinic visits over 2 months (April–May 2023) evaluating 137 patients and from county cycle time data from 5 months (Oct '22, Nov '22, Jan '23, April'23, and May '23) evaluating 1063 patients. Patient Satisfaction Surveys were administered to 46 patients (August–September 2023) leaving the clinic to determine patient satisfaction ratings. The Safety Culture Attitudes Questionnaire was administered to 8 nurses and 10 residents to determine staff satisfaction and clinic safety ratings.

Results Patient cycle times were over 2 hours on Tuesday's clinic (n=670) and 1.5 hours on Thursday's clinic (n=384). Patients (n=46) rated the clinic a 9.22/10 on overall experience with 82% definitely finding their referral to appointment wait time acceptable and 80% definitely finding the waiting room time acceptable. Both nurses and residents (n=46) were nearly neutral when assessing whether clinic morale was high (3.33/5), staffing levels were sufficient (3.11/5), and if new personnel training was adequate (3.4/5). Twelve specific proposed changes resulted from these findings, including shaping demand through enforcing referral requirements (e.g., BMI, HbA1c cutoffs), revising scheduling templates, initiating multidisciplinary clinic huddles, improving continuity through a resident orientation handbook, providing additional materials for patient education (e.g., breast reconstruction video in English and Spanish), and standardizing a photo storage system.

Conclusion Lean Healthcare Systems Engineering serves as a beneficial methodology to identify and eliminate clinical waste while maximizing the output of existing resources through a low-cost and sustainable process. This is part of an ongoing quality improvement initiative in an urban safety-net plastic surgery clinic that aims to 1) allow residents and support staff to focus on caring for patients while lessening waste and the burden of burnout, 2) facilitate communication among staff to lower frustrations, and 3) improve patient access to quality care and satisfaction. Through this initiative, we have identified problem areas, involving scheduling, team work, clinic screening, materials/supplies, and clinic practices. For each identified area, we have created pratical recommendations on how to mitigate these. Our recommendations from this project are being implemented in our clinic operations at this time.

Aims This study aims to present a novel and scalable approach to monitoring patient peri-operative recovery by leveraging physical activity (PA) data from patient smartphones in the context of breast reconstruction.

Methodology Smartphone activity data was gathered from 32 patients who underwent autologous breast reconstruction between 2022-2023. Patients were contacted via telephone, and data was gathered using an application developed for the study, "StepHome Trial" (Jack Graham). Hourly "Walking and Running Distance" was recorded from 28 days before the operation date up to the present day, from patients with iPhones via Apple Health (Apple Inc.).

Results The analysis revealed that breast reconstruction patients had a median recovery time of 34.5 days (IQR 31.8), as measured by the return to pre-operative physical activity levels. Notably, median recovery times were shorter for patients with autologous reconstruction (43.5 days, IQR 29.8) compared to those with concomitant sentinel lymph node biopsy (46.0 days, IQR 18.0) and axillary surgery (51.0 days, IQR 34.0).

Conclusions Mobile health technologies offer the potential to harness passively collected patient data, providing new insights into post-operative recovery. Future applications of this methodology can inform shared decision-making processes in evaluating treatment options and offer real-time feedback to patients during their recovery journey.

Purpose: Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report EDX findings in a cohort of patients undergoing surgery for nTOS and also analyze patient related and intraoperative factors associated with positive EDX findings supportive of a diagnosis of NTOS.

Methods: Baseline characteristics of patients including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison.

Results: A total of 30 consecutive patients were included in this study comprising 11 (36.7%) male and 19 (63.3%) female patients, with a mean age of 44.6 ± 17.6 years. When classified by type of nTOS, 22 (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and one (3.3%) patient with type 2 nTOS. In terms of the pattern of nTOS, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P<0.05) were significantly associated with positive EDX findings.

Conclusions: EDX assessment, at this point in time, may not be the best modality for diagnosis of nTOS. Inter-individual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX.

Purpose: This study provides an updated epidemiological analysis of hand and forearm fractures in the United States. In addition, the study also aims to characterize differences in the frequency of hand and forearm fractures in the United States before and during the COVID-19 pandemic.

Methods and Materials: We identified all Emergency Department (ED) encounters with a primary diagnosis of hand and forearm fractures (ICD-10-CM diagnostic codes of S52.0 to S52.9 and S62.0 to S62.9) in the United States from 2018 to 2021 using the National Hospital Ambulatory Medical Care Survey database. Descriptive statistics were performed to assess the distribution of fractures by anatomic site, age, sex, race, payer status, hospital location. Chi-square tests of independence were used to evaluate differences in these distributions before and during COVID-19. Alpha level was set a priori at 0.05. Cramer's V was calculated to determine the strength of each association.

Results: During COVID-19 (2020-2021), EDs across the United States experienced 2,748,087 presentations for hand and forearm fractures, which constituted 1.01% of all ED visits during this period. This was equivalent to the pre-COVID-19 period (2018-2019) with 2,660,174 encounters for hand and forearm fractures, which made up 0.95% of all ED presentations. Radius and/or ulna fractures composed the largest portion of all hand and forearm fractures (46% during 2018-2019 and 51% during 2020-2021). The age group of 5-14 years was most affected, accounting for 27% of all hand and forearm fractures during each period. Most patients paid for the encounters with private insurance (30% during 2018-2019 and 31% during 2020-2021) or Medicaid/state-based programs (31% during 2018-2019 and 33% during 2020-2021). Hospitals in the South contributed the highest fraction of hand and forearm fractures nationally (42% during 2018-2019 and 36% during 2020-2021). Distributions of age, sex, race, anatomic location of fracture, payer status, and hospital location were statistically significantly different between the pre-COVID-19 and COVID-19 periods (p < 0.001); however, the effect sizes were all negligible to small (VCramer < 0.20).

Conclusions: COVID-19 was associated with negligible changes in ED presentations for hand and forearm fractures in the United States. These findings suggested that despite a global pandemic and mandated social distancing which arguably disrupted many aspects of our daily lives, the risk factors and propensity for hand and forearm fractures surprisingly did not seem significantly altered. Further studies are needed to characterize the major determinants of the epidemiology of hand and forearm fractures in the United States in order to mitigate the national burden of these injuries.

Introduction: Pedicled latissimus dorsi (LD) flaps are a common technique in autologous breast reconstruction given the proximity to the breast and reliable blood supply. LD flaps can be raised with or without denervation of the thoracodorsal nerve. Although leaving the nerve may offer better long-term muscle bulk, it may also contribute to painful muscle twitching, retraction, animation deformities, and arm movement limitations (1). Various treatments for these sequelae have been described ranging from complete excision of the LD flap to delayed denervation through axillary incisions (2). We present a case of delayed transection of the neurovascular pedicle to bilateral myocutaneous LD flaps for breast reconstruction to address symptomatic spasticity.

Case Report: A 41-year-old woman with BRCA1 presented with chest pain and muscle spasms following bilateral mastectomy with reconstruction by latissimus dorsi flaps performed 3 years prior. The LD muscle along with its neurovascular pedicle was divided and excised from the lateral chest leaving a medial cuff of muscle along the skin paddle. Preserved collateral vascular flow was confirmed with the SPY Elite fluorescence imaging system (SPY) [Stryker, Kalamazoo, MI USA]. Breast reconstruction was completed with subsequent bilateral silicone implant placement.

Discussion: With delayed open transection of the muscle and neurovascular bundle in the axilla, the patient's symptoms were relieved while maintaining adequate soft tissue coverage for implant-based reconstruction. Less invasive measures, such as transection of the thoracodorsal nerve alone would result in ongoing motion restriction, lateral bulk, and retraction of the intact denervated LD muscle. Alternatively, complete resection of the myocutaneous LD flap would necessitate tissue expansion and additional surgery surgical procedures to achieve the final reconstructive results. It is a common technique in plastic surgery to divide the flap pedicle once neovascularization has occurred. However, assessing whether collateral inflow will be adequate in a large myocutaneous flap can be challenging. Transection could risk distal ischemia, tissue necrosis, and later exposure of the implant. The use of SPY intraoperative fluorescence angiography proved a valuable tool to assess and ensure viability of the flap after transection.

1. Schroegendorfer KF, Hacker S, Nickl S, Vierhapper M, Nedomansky J, Haslik W. Latissimus dorsi breast reconstruction: how much nerve resection is necessary to prevent postoperative muscle twitching? Plast Reconstr Surg. 2014 Dec;134(6):1125-1129. doi: 10.1097/PRS.0000000000000739. PMID: 25415082.
2. Halperin TJ, Fox SE, Caterson SA, Slavin SA, Morris DJ. Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction. Ann Plast Surg. 2007 Jul;59(1):23-5. doi: 10.1097/01.sap.0000258975.55090.20. PMID: 17589254.

Background Diabetes often lead to poor healing ulcers and lower leg amputation throughout the world. Free tissue transfer is a powerful reconstructive method for patients with substantial diabetic foot ulcers. This study aimed to analyse the outcome of diabetes foot resurfacing using TDAP flap by investigating age and gender of the patients, skin defect site , complications, and outcomes associated with TDAP flap transfer in diabetic foot ulcers.

Materials and Methods Between 2014 and 2023, we analyzed 20 cases (7 female and 13 male) who underwent free flap reconstruction from TDAP flap at the Department of Plastic Surgery, Kaohsiung Veteran Hospital. Additionally, we collected data from 15 cases of diabetic foot reconstruction using the ALT flap as a comparison group. Our aim was to investigate potential differences between the ALT flap (the most commonly used free flap in our hospital) and the TDAP flap in diabetic foot reconstruction. We collected and analyzed basic data from both groups, including age, gender, wound size, and operation time. We compared patient characteristics, complications, and success rates with those of the ALT flap group. Furthermore, we combined the two groups to identify any potential risk factors that may increase adverse events in free flap diabetic foot reconstruction.

Results Included in this study were a total of 35 patients, with 20 in the TDAP group and the remaining 15 in the ALT group. There were no statistically significant differences observed in most variables, including age, gender, HbA1c level, comorbidity, Wegener, flap size, and follow-up duration. However, in terms of vein anastomosis, more cases in the TDAP group only received one vein anastomosis, whereas in the ALT group, most cases received two vein anastomoses (p=0.0321). We also observed a shorter operation duration in the TDAP group (TDAP group: 6 hours and 26 minutes vs. ALT group: 7 hours and 27 minutes), although there were no statistically significant differences observed. There were 2 cases of total flap necrosis in the TDAP group and no cases of total necrosis in the ALT group (p=0.1625). Both groups experienced several cases of other complications, including infection (TDAP: 20%; ALT: 20%), seroma (TDAP: 0%; ALT: 13%), and dehiscence (TDAP: 10%; ALT: 6%).Furthermore, in our risk factor analysis, we found that HbA1c levels may be a risk factor in free flap diabetic foot reconstruction (p=0.492).

Conclusions In conclusion, our study investigated the outcomes of diabetic foot resurfacing using TDAP flap reconstruction. We analyzed 35 patients, with 20 undergoing TDAP flap reconstruction and 15 undergoing ALT flap reconstruction. Our findings indicate that TDAP flap reconstruction is comparable to ALT flap reconstruction, making it a viable option for diabetic foot reconstruction with a shorter surgery duration (almost an hour less) and a similar complication rate. Both methods can be utilized in lower limbs with significant tissue loss. Additionally, our analysis underscores the importance of monitoring HbA1c levels as a potential risk factor in diabetic foot reconstruction.

Introduction Carpal tunnel syndrome (CTS) is the most common compression neuropathy associated with rheumatoid arthritis (RA) and can occur in up to 30% of patients, yet studies investigating CTS often exclude patients with RA. The goal of this systematic review is to present the current literature on treatment outcomes for CTS in the RA population. Methods A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-adherent systematic review and meta-analysis was performed. Interventional studies in patients with CTS and RA were retrieved from Ovid (Medline), CINAHL, Cochrane Trials, and Scopus. Operative or nonoperative treatment modalities were included for review. Case reports, case series with <10 patients, synthetic or animal models were excluded. Treatment modality, follow-up period, symptomatic improvement, and complications were assessed. Results Seven studies including 205 patients and 267 hands met screening criteria for evaluating interventions in managing CTS in the setting of RA. The identified interventions fell into three categories: corticosteroid injection (CSI); surgical release via endoscopic (ECTR) or open (OCTR), and low-level laser therapy (LLLT). Two studies (29%) utilized CSI, three studies (43%) involved surgery, one (14%) evaluated LLLT, and one (14%) used a combination of CSI and surgery. The mean age was 56 years (range: 27-88 years), 81% were female, mean RA duration was 6 years (5-7 years), and mean follow-up was 4 years. Patients with RA had significantly decreased odds of needing repeat injection. The ECTR study reported 100% of patients with symptomatic relief with 0% complication, whereas the remaining two OCTR studies had a success rate of 90%. Complications were reported in three surgical intervention studies (43%) and the pooled rate was 11% (range: 0-14%), with 14% of OCTR having a complication. The most common complication was marginal skin necrosis followed by superficial infection. Almost all patients (n=5/6, 83%) experienced symptomatic improvement after CSI and ECTR (n=34/36, 94%). Conclusions The treatment of CTS in the RA population is interventional, as compared to an initial trial of splinting in the general population. RA patients appear to respond well to CSI, potentially due to the underlying known inflammatory process. The success rate following surgery is high, although the OCTR studies had a higher complication rate compared to ECTR. Novel noninvasive interventions, such as LLLT show promise in improving functionality; however, further research is warranted to establish its efficacy and role in the treatment for CTS in patients with RA. Limited quality evidence is available to delineate the optimal treatment patterns for RA patients with CTS. Further prospective trials and RCT for this patient population.

References Kaya Subaşı P, Güler T, Yurdakul FG, Ataman Ş, Bodur H. Carpal tunnel syndrome in patients with rheumatoid arthritis and psoriatic arthritis: an electrophysiological and ultrasonographic study. Rheumatol Int. 2021;41(2):361-368. doi:10.1007/s00296-020-04745-8 Manente G, Torrieri F, Di Blasio F, Staniscia T, Romano F, Uncini A. An innovative hand brace for carpal tunnel syndrome: A randomized controlled trial. Muscle & Nerve. 2001;24(8):1020-1025. doi:10.1002/mus.1105

Purpose: Over the last several years there has been an increasing focus on diversity and trend in increasing number of female and underrepresented minority in plastic surgery trainees.(1,2) The purpose of this study was to analyze the diversity of current US plastic surgery and identify relationship between race and/or gender of respective program directors (PD) and chairs.

Methods: Data on the gender and race was collected on a total of 99 independent and integrated plastic surgery residencies in the US. Student's T-test was performed to compare the association between the race and gender of PD's and Chairs to their respective trainees. A Chi-square test was performed to compare the expected number of male and female residents as well as resident race to the observed residents' demographics. A mixed-effects logistic regression model was performed to examine the effects of resident's demographics on having white or male PD/Chair. A Chi-square test was performed to examine the relation between residents' race and chair or PD race.

Results: Of PDs, only 22.22% were female (77.78% male) and even fewer women chair roles at 14.14% (85.86% male). Of plastic surgery trainees, 52.03% were male, 47.97% female; 71.67% were White, 21.81% Asian, 3.75% Black or African American, and 2.83% other. There was a significantly higher number of white residents than expected when compared to the 2023 US census data (p<0.05). A significantly higher number of male residents was noted when compared to the 2023 US Census data (p<0.05). A significant relationship between white PDs and white residents was noted on correlation analysis (p<0.05). Residents in urban locations (population density >10,000) were less likely to have a white or male PD (P<0.05), while there was no statistical difference in race. Additionally, programs with white program directors had a significantly higher percentage of white residents compared to Asian or African American program directors (p<0.05). Trainees in residency programs located in the West region were more likely to have a female PD compared to residencies in other regions (South, Midwest, Northeast, West) (p<0.05).

Conclusion: Our study shows an association between PD and trainee race, as well as location and PD gender, possibly indicating a remaining bias within the field. Program leadership remains predominately male, and the racial demographics of plastic surgery trainees remains predominantly white. While the field of plastic surgery has made efforts to expand the diversity of plastic surgery trainees, much work remains to establish an environment more accommodating to a diverse patient population.

1. Hernandez JA, Kloer CI, Porras Fimbres D, Phillips BT, Cendales LC. Plastic Surgery Diversity through the Decade: Where We Stand and How We Can Improve. Plast Reconstr Surg Glob Open. 2022 Feb 22;10(2):e4134. doi: 10.1097/GOX.0000000000004134. PMID: 35223343; PMCID: PMC8865516.

2. Tolson HC, Raikar DH, Morris BE, Ferguson EMN, Shahriary E. Ethnic and Sex Diversity in Academic Plastic Surgery: A Cross-sectional Study. Plast Reconstr Surg Glob Open. 2023 Jun 30;11(6):e4991. doi: 10.1097/GOX.0000000000004991. PMID: 37396840; PMCID: PMC10313300.

Introduction: Augmentation mammoplasty represents a widely sought surgical procedure, affording women the opportunity to attain their desired breast aesthetics. The procedure's success hinges upon meticulous patient selection, informed decision-making, and the quality of the patient-surgeon interaction. Comprehensive pre-operative evaluation, precise surgical techniques, and vigilant post-operative care are pivotal in ensuring favorable outcomes.

Materials and Methods: This retrospective study involved 120 patients who underwent augmentation mammoplasty through the inframammary subfascial approach, with seven cases excluded due to simultaneous secondary interventions. The study accentuated the omission of drainage, introducing a postoperative protocol advocating early postoperative arm mobility, with patient consent captured on videotapes, and discouraging overnight stays, thereby enabling a prompt return to normal activities within 24 hours. Complications were categorized as either major, necessitating revision surgery, or minor.

Results: Out of the 113 patients, 8.8% encountered complications, predominantly of a minor nature. Minor complications encompassed reactions to absorbable sutures (4.4%), effectively managed through localized dressings, and a 0.9% infection rate, which responded satisfactorily to oral antibiotics. A solitary seroma (0.9%) was percutaneously drained one month post-surgery without recurrence. Notably, only one patient necessitated revision surgery due to unilateral prosthesis rotation. Hematomas and necrosis were conspicuously absent in the reported cases.

Conclusion: This study underscores the significance of optimizing augmentation mammoplasty techniques to enhance patient recovery and satisfaction. The strategic elimination of drainage, promotion of early postoperative arm mobility, and the discouragement of overnight stays demonstrate their potential to expedite recovery. The predominance of minor complications, effectively managed, and the complete absence of hematomas and necrosis, attest to the safety and efficacy of these innovative techniques. The insights derived from this study offer promise for the improvement of patient recovery and satisfaction in the context of augmentation mammoplasty. Furthermore, they emphasize the continuous refinement of surgical techniques and patient care as integral factors for achieving favorable outcomes and an enriched patient experience.

A separation of the soft tissues from the skeletal structure of the digits without skin disruption is extremely rare, with most of the documented cases in literature being in the toes (1, 2). In the hand, even though being exceptionally unusual, it can have devastating consequences. Our case involves a 29-year-old patient who presented at our emergency department following a work-related injury with a roller press in the right upper limb, resulting in a closed degloving injury of the right thumb. Upon clinical examination, the skeletal structure was not palpated in the thumb pulp and the finger had no capillary refill. Additionally, a metacarpophalangeal joint dislocation was observed. After dorsal fasciotomy of the first interdigital space, soft tissue reduction and joint fixation, the thumb regained perfusion. However, during the postoperative period, the patient presented with inadequate perfusion of the thumb, with necrosis of the soft tissues distal to the metacarpophalangeal joint and bony necrosis of the distal phalanx. Surgical debridement was made, and microsurgical reconstruction of the thumb was needed. A wrap around toe transfer and a reverse flow posterior interosseous flap for the dorsum of the first ray was performed. The postoperative period proceeded uneventfully. At six months postop, the patient regained hand function for daily activities and work with a satisfactory aesthetic result. The "empty thumb," although exceedingly uncommon, presents unique challenges both in the initial assessment of the patient and in determining the appropriate reconstructive options (3). In the worst scenario as seen in our patient with partial finger necrosis, microsurgical reconstruction may be needed in order to preserve hand function.

1. Flaherty JD, Evans DA, Danahy PR. The empty toe phenomenon: a type of closed degloving. Am J Orthop (Belle Mead NJ). 1998 Jul;27(7):524-5. PMID: 9678239.
2. Tang CL, Lee SS, Lin TY, Lin YK, Yeh YS, Lin HL, Lee WC, Chen CW. Empty toe: a unique type of closed degloving injury with dismal outcome. Am J Emerg Med. 2013 Jan;31(1):263.e1-3. doi: 10.1016/j.ajem.2012.03.031. Epub 2012 Jul 12. PMID: 22795410.
3. García-López A, Marco-Martinez F, Lopez-Oliva F,Closed Degloving of the Thumb, The Journal of Hand Surgery, Volume 32, Issue 8, 2007, Pages 1259-1261, ISSN 0363-5023.

Purpose: Addiction to prescription opioids continues to represent a pervasive public health crisis. Surgery is a common precursor to opioid initiation, with surgeons being among the most frequent prescribers of opioids. Within plastic surgery, studies have revealed opioid over-prescription after common surgical procedures such as breast reconstruction. Whether or not opioid prescription patterns differ based on race remains to be defined. This study aims to identify opioid prescriptions after breast reconstruction and determine whether these patterns differ between black and white patients.

Methods: A retrospective chart review was conducted to identify patients who underwent breast reconstruction at a single institution in 2023. Inclusion criteria comprised male and female patients of any age who underwent breast reconstruction and identified as black or white. Exclusion criteria included opioid use or history of opioid use disorder. Demographic and operative variables were collected. Outcome variables included opioid prescription, dose received, number of pills dispensed, and refill requests. 51 patients were excluded from the analysis. Continuous variables were tested using the Wilcoxon Rank-Sum test and categorical variables were compared using Chi-Squared or Fisher's exact test depending on sample size.

Results: 255 patients underwent 390 distinct operations. Age ranged from 17-77 with median and mean age of 51. Two patients identified as transgender female patients while the rest identified as female. BMI ranged from 16.8-40.2 with median 27.2 and mean 27.7. 19.6% (N=50) patients had comorbidities. 68.7% (N=268) of cases were immediate. 27.7% (N=108) cases were inpatient, 61.0% (N=238) ambulatory, and 11.3% (N=44) outpatient.

98.0% (N=382) of patients received opioid prescriptions. 91.1% (N=348) received oxycodone (2.5-15 mg q4-6h), 8% (N=3) received oxycodone and tramadol (5 mg q4-6h, 25-50mg q6h), 2.9% (N=11) received tramadol (25-50 mg q6h), 2.4% (N=9) received hydromorphone (1-2 mg q4-6h), 1.6% (N=6) received hydrocodone-acetaminophen (5-325 q6h), 0.5% (N=2) received morphine (7.5-15 mg q6-12h). 0.3% (N=1) received oxycodone and morphine (5 mg q4h, 15 mg q6h), and 0.3% (N=1) received oxycodone and hydrocodone-acetaminophen (5-325 mg q6h, 5 mg q4h). Number of pills prescribed ranged from 5-60, the most frequent being 15 (N=123), followed by 20 (N=93), 10 (N=64), and 25 (N=31). 10.7% (N=41) of patients requested refills. There were significant differences between black and white patients on BMI, hypertension, diabetes, breast cancer, and whether cases were bilateral, implant or flap-based however no differences in opioid prescriptions.

Conclusion Most patients were prescribed opioids after surgery, with only eight (who identified as white) being discharged without an opioid prescription. Furthermore, less than 11% of patients requested refills. Studies have found that patients receive more opioids than needed post-operatively, and that this excess is associated with drug diversion, long-term use, and opioid use disorder. Studies Interestingly, white patients were more likely to undergo bilateral surgery and implant-based reconstruction and less likely to undergo flap-based reconstruction. However, the higher proportion of white patients represented could have influenced these findings. Additional research is needed to identify differences in opioid prescriptions based on race and mitigate excess opioid prescriptions for all patients.

This case study describes the successful application of the NovoSorb™ Biodegradable Temporizing Matrix (BTM), a synthetic degradable polyurethane foam, for a challenging lower limb pyoderma gangrenosum (PG) wound in a 71-year-old woman with significant comorbidities, including rheumatoid arthritis, type 2 diabetes, hypertension, and hypercholesterolemia. This is noted as the first instance of using a fully synthetic dermal substitute for PG wounds.

Initially diagnosed after a minor trauma led to a painful, ulcerating wound, conventional treatments such as prednisone and adalimumab proved minimally effective. The patient underwent extensive soft-tissue debridement to manage the infection, setting the stage for using BTM to enhance wound closure, as skin grafting was deemed unsuitable due to the exposed tendons and the patient's overall health profile.

The BTM application followed aggressive immunosuppression and antibiotic therapy to manage underlying conditions and prevent further infection. Despite early complications such as subseal exudate collection, which required bedside intervention to drain, the BTM integrated well with a 95% success rate by day 58, even in the presence of infections like P. aeruginosa and S. aureus. This integration continued, leading to successful grafting with a meshed split-thickness skin graft by day 81, achieving 100% graft take.

The management of PG wounds typically avoids direct wound closure techniques like autografting due to the risk of pathergy-worsening of the condition through surgical intervention. However, the use of BTM in this case facilitated effective healing without inducing pathergy, demonstrating its potential as a superior alternative to other dermal matrices which might be contraindicated in infected wounds [1-5].

The case underscores BTM's advantages in managing complex wounds through its infection resistance and ability to foster robust tissue layers suitable for grafting. The patient's severe pain, a primary complaint, was markedly alleviated post BTM application, highlighting another significant benefit of this treatment approach.

In conclusion, this example highlights BTM's utility in treating difficult inflammatory wounds, positioning it as a promising option for similar challenging clinical scenarios, and paving the way for further exploration of synthetic dermal substitutes in complex wound management.

References: 1. Climov M, Bayer LR, Moscoso AV, et al. The role of dermal matrices in treating inflammatory and diabetic wounds. Plast Reconstr Surg 2016;138:148S-157S. 2. Wagstaff MJD, Salna IM, Caplash Y, et al. Biodegradable temporising matrix (BTM) for the reconstruction of defects following serial debridement for necrotizing fasciitis: A case series. Burns Open 2019;3:12-30. 3. Young CA, Semple HK, Kode GM. Complex wound healing in a complex patient. Wound Prac Res 2022;30:169-174. 4. Damkat-Thomas L, Greenwood JE, Wagstaff MJ. A synthetic biodegradable temporising matrix in degloving lower extremity trauma reconstruction: a case report. Plast Reconstr Surg Glob Open 2019; 7:e2110. 5. Cheshire PA, Herson MR, Cleland H, et al. Artificial dermal templates: A comparative study of NovosorbTM biodegradable temporising matrix (BTM) and Integra® dermal regeneration template (DRT). Burns 2016;42:1088-1096.

INTRODUCTION: The fibula free flap was first performed for mandibular reconstruction in the late 1980s. Since then, it has become the main stay for reconstruction of segmental mandibular defects. Over the last two decades, changes in practice have impacted upon the success rate and performance of the operation. The increased use of higher doses of adjuvant radiotherapy and the use of preoperative 3D printed models and cutting guides have impacted the success and performance of the procedure. We retrospectively reviewed our more recent experience of cases to assess these and other factors affecting the procedure results.

MATERIALS & METHODS: 118 fibula mandibular reconstructions were done from 2010 to 2013. There were 83 men and 35 women with a median age of 60 years and range from 14 to 84 years. 75 cases were reconstruction of defects resulting from cancer resection. The majority were for squamous cancer (68, all stage IV). Five were treated for osteosarcoma. Two had salivary origin malignancies. Fourteen patients had osteoradionecrosis requiring segmental resection. Twenty-six patients had benign tumors. Ameloblastoma being the most common. Two patients had trauma-gunshot wounds and one had severe osteomyelitis.

RESULTS: Twenty patients had a history of prior radiotherapy. One of which experienced early flap failure. Six developed late hardware exposure requiring hardware removal (6/19, 32%). Forty patients received postoperative concurrent chemoradiotherapy. Of those, four had late flap failure and 10 had late hardware exposure (14/40, 35%). Of the 58 cases not exposed to radiotherapy, there were seven early flap failures and six cases of late hardware exposure (6/51, 12%). Overall, there were 12 flap failures and 22 cases of late hardware exposure requiring operative hardware removal. Prefabricated 3D models and cutting guides were employed beginning in 2017. Forty-six cases were done using this technology. Compared to the prior 72 cases where this technology was not used, the average operative time was reduced by one hour. Other factors analyzed were the impact of vein graft use, osseoocutaneous vs. osseous grafts, tobacco use, BMI and other comorbid factors.

CONCLUSIONS: Free fibula flaps represent a reliable means for osteocutaneous reconstruction of multiple defects throughout the body. In particular, free fibula flaps offer an ideal option for reconstruction of the mandible. The flap has a high technical success rate (90%) including in patients with radiation exposure. However, late failure with hardware exposure is a significant issue, especially in patients with radiation exposure. The use of cutting guides appears to have substantially reduced the operative duration of fibula flaps. This appears to contribute to the anecdotal and demonstrated importance and usefulness of virtual surgical planning in plastic surgery.

Background: Postoperative pain management following breast procedures in plastic surgery, such as breast reduction and breast tissue expander placement after mastectomy, have typically required the use of narcotic medication. Post-operative opioid dependence and chronic opioid use is well documented and remains an issue in the United States. Multimodal analgesia has emerged as an alternative approach aiming to improve pain control while minimizing opioid consumption and its associated complications. However, comparative studies evaluating patient-reported outcomes in pain control of multimodal analgesia versus traditional narcotic regimens in this context are limited. Methods: A retrospective cohort study was conducted to compare the effectiveness of multimodal analgesia versus a traditional narcotic regimen for postoperative pain control in patients undergoing breast reduction and breast tissue expander placement after mastectomy. Patients were categorized into two groups based on prescribing patterns of plastic surgeons at an academic center: (1) multimodal analgesic group given tramadol and gabapentin post-operatively and (2) narcotic analgesic group given hydrocodone-acetaminophen post-operatively. Pain intensity outcomes were assessed using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity measure survey scores at the first and second week postoperatively. Mixed repeated-measures analysis of variance (ANOVA) was utilized to compare the pain intensity scores between the two groups at different time points. Results: A total of 107 breast reduction patients were included in the study, with 52 patients in the multimodal analgesia group and 55 patients in the traditional narcotic group. Patients reported significantly higher levels of pain at week 1 compared to week 2 for both groups, p<0.001. However, there was no significant difference between the types of pain management at both time points (narcotic overall mean = 57.57, SE = 1.47; multimodal overall mean = 58.34, SE 1.47; p = 0.705). For post-mastectomy tissue expander placement, 52 patients were included in the study, with 19 patients in the multimodal analgesia group and 33 patients in the traditional narcotic group. Patients reported significantly higher levels of pain at week 1 compared to week 2 for both groups, p<0.026. Similarly, there was no significant difference between the types of pain management at both time points (narcotic overall mean = 62.82, SE = 2.11; multimodal overall mean = 58.67, SE 2.78; p = 0.241). The mean difference of PROMIS scores were less than 10, thus indicating no clinically meaningful difference between the two groups of pain management. Conclusion: Our findings demonstrate that there is no significant difference between the use of multimodal analgesia compared to traditional narcotic regimens for post-operative pain control following breast reductions and tissue expander placement. Implementation of multimodal analgesic protocols in this patient population may lead to reduced opioid consumption while having equivocal pain control.

Introduction: Frontonasoencephaloceles affect 1:40,000 livebirths and require complex reconstruction of the cerebral herniation defect, bony and soft tissue defects. In cases where staged reconstruction is required, access for bony and soft tissue defect closure that will minimize scarring is important but not well described. This article aims to describe a technique for closure of the residual bony and soft tissue defect in a non-urgent setting, that limits the need for extensive soft tissue dissection and local tissue rearrangement following removal and reduction of the frontoencephalocele.

Methods: This was a case report of a single surgeon at a single institution. Our patient was a three-month-old male diagnosed with a nasofrontoencephalocele prenatally.

Reconstructive planning: At birth normal skin covering over the encephalocele was found (Figure 1). Day 1 of life MRI (Figure 2) showed nasofrontal encephalocele 27 x 19 mm with midline frontal calvarial defect and neural tissue protruding through the defect. Due to adequate soft tissue coverage the decision was made to delay the reconstruction until three months of age.

Technique description: Surgical planning included two markings: 1) circular intralesional incision in the nasofrontal area overlying the encephalocele for access to reduce the encephalocele, reconstruct the bony defect and excise excess skin (Figure 3); 2) coronal incision was marked in case we needed larger access, but a portion of the incision 3 cm long on the right parietal area was planned to harvest a small bone graft (Figure 3). A 15-blade was used to incise through skin over the encephalocele and dura was identified. We proceeded with blunt dissection through the thin subcutaneous plane between skin and dura circumferentially around the mass and down to the edges of the bony defect. We exposed the bony defect everywhere except at the right supratrochlear area where we maintained periosteum for an inferiorly-based pericranial flap if needed. The dura was entered (Figure 4) and the redundant encephalocele was excised. A defect-sized pericranial flap was harvested to cover the dural closure, ensuring a water-tight closure (Figure 4). A bone graft was harvested from the right parietal bone and secured with the Sonic Resorb X system at nasofrontal junction (Figure 5). The right parietal defect was then packed with the particulate graft and covered with surgicel (Figure 6). The residual circular defect in the skin was closed with deep dermal absorbable sutures in a pursestring technique (Figure 7).

Results: There were no intraoperative complications or acute postoperative complications, with respect to infection, dehiscence, CSF leak. At 3 months, the defect remained reduced and the pursestring scar was becoming flatter.

Discussion:

Our technique describes an algorithm for timing and type of repair, and a surgical approach for bony and soft tissue reconstruction in frontonasoencephalocele that minimizes scarring in a staged reconstruction. Autologous bone graft can be harvested through limited coronal incision and soft tissue can be closed using a pursestring skin closure technique. These techniques will hopefully minimize coronal and pericranial scarring and allow easier access for future delayed procedures.