Late Breaker Break Session #2: Plastic Surgery Topics (Non-CME) Thursday, September 26 Thu, Sep 26 4:00-5:00 p.m. PDT

Introduction: The gold standard of microsurgical breast reconstruction is the deep inferior epigastric perforator (DIEP) free flap (1-3). As techniques have evolved, DIEP flaps have significantly reduced the morbidity previously caused by transverse rectus abdominis muscle (TRAM) and muscle-sparing TRAM (msTRAM) flaps. However, abdominal wall complications continue to persist after DIEP flap surgery, with bulge rates reported as high as 33% (4,5).

Methods: The first 25 patients undergoing DIEP flap surgery with the use of Duramesh (MSI, Chicago, IL) by the senior author were identified. A retrospective chart review of patient and surgical details was performed. Charts were reviewed for outcomes including incisional hernia (IH) formation, bulge, surgical site infections (SSI), and/or surgical site events (SSE). Standard descriptive summary statistics were used for patient characteristics, surgical details, and primary and secondary outcomes.

Results: 25 patients were reviewed. Average age was 51.0±10.7 years. Average body mass index (BMI) was 28.3±3.8 kg/m2. 84% (N=21) had a breast cancer history. Of those, 57% (N=12) had chemotherapy and 38% (N=8) had breast radiation. 72% (N=18) of patients had a history of prior abdominal and/or abdominal wall surgery. Average follow-up duration was 216±39 days. One patient developed a bulge, no patients developed an incisional hernia.

Conclusions: Duramesh mesh suture provides a promising opportunity for DIEP surgeons to minimize abdominal wall morbidity as well as mesh-related complications. Mesh suture can be used in a similar fashion as other sutures to perform primary closure of the anterior rectus sheath while also providing force-distribution benefits typically unique to planar mesh. This pilot study suggests that Duramesh is a safe, simple alternative to existing techniques in DIEP flap surgery and can be considered by microsurgeons to reduce fascial dehiscence, bulge, and/or hernia formation in postoperative patients.

1. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59(6):571-9. doi:10.1016/j.bjps.2006.01.004
2. Lee BT, Agarwal JP, Ascherman JA, et al. Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps. Plast Reconstr Surg. Nov 2017;140(5):651e-664e. doi:10.1097/PRS.0000000000003768
3. Masoomi H, Hanson SE, Clemens MW, Mericli AF. Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database. Ann Plast Surg. Sep 1 2021;87(3):242-247. doi:10.1097/SAP.0000000000002664
4. Parmeshwar N, Lem M, Dugan CL, Piper M. Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. Microsurgery. Nov 2023;43(8):855-864. doi:10.1002/micr.31107
5. Lindenblatt N, Gruenherz L, Farhadi J. A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction. Gland Surg. Aug 2019;8(4):389-398. doi:10.21037/gs.2019.06.05

Background: Ventral hernia repair (VHR) poses a significant challenge due to high recurrence rates, with reported incidences of nearly 30% following repairs with mesh.(1) Hernia recurrence following mesh repair can occur due to a multitude of reasons including excessive tension, suture failure, or "cheese-wiring" of fixation sutures through tissue. To address this, efforts have focused on enhancing mesh reinforcement. The T-Line Hernia Mesh is a novel synthetic, polypropylene mesh specifically designed to prevent anchor point failure by evenly distributing tension through mesh suture reinforcement thus reducing the rate of hernia repair failures.(2) While the T-Line Hernia Mesh has proven to be safe and effective in the early postoperative period, limited literature exists on long-term outcomes.(3) Therefore, the aim of this study is to illustrate the long-term outcomes of VHR following T-Line Hernia Mesh use.

Methods. We conducted a single institution retrospective cohort study of patients who underwent VHR with the T-Line Hernia Mesh. Data collected included patient demographics, medical comorbidities, operative details, complications, and hernia recurrence. Additionally, postoperative patient reported outcomes (PROs) were collected using the Hernia-Related Quality-of-Life (HerQLes) survey. Descriptive statistics were used to analyze this patient population.

Results: A total of 19 patients (9 males and 10 females) underwent VHR with T-Line Hernia Mesh fixation during the study period. The median age was 60 years (range 53-64) with a median BMI of 30.26 kg/m2 (range 28.2-34.08). The prevailing medical comorbidities included hypertension in eight patients (82.11%), followed by tobacco use and diabetes in two patients (10.53%). Additionally, three patients (15.79%) had previously undergone hernia repairs, all of which were open repairs with mesh fixation.

Intraoperatively, the median defect area was 90.00 cm2 (range 144-194) and median T-Line Hernia Mesh area was 260 cm2 (range 163.25-300). Mesh placement was onlay in 17 patients (89.47%) and sublay in two patients (10.53%). Furthermore, three patients (15.79%) underwent a concomitant procedure with panniculectomy during hernia repair. The median operative time was 158 minutes (range 119.5-197), with a median estimated blood loss (EBL) of 50 mL (range 30-100).

Postoperatively, one patient experienced a complication, a seroma necessitating hospitalization within 30 days of the hernia operation. Additionally, no hernia recurrences were observed during a median follow-up time of 371 days (range 185-535). Regarding PRO data, nine patients (47.37%) responded to the survey with a median time to survey response from operation of 618 days (range 522.5-813). Among the respondents, majority of patients denied having any pain or symptoms related to their abdominal wall and reported that their abdominal wall had a significant impact on their life (55.56%, n=5). Notably, only one patient reported a perceived recurrence of their hernia; however, this has not been confirmed through clinical examination.

Conclusions:

In this study, VHR with T-Line Hernia Mesh proved to be effective and safe in preventing long-term hernia recurrence.

References:

1. J. W. Burger et al., Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240, 578-583; discussion 583-575 (2004).
2. D. L. Lima et al., A Novel Polypropylene Mesh (T-Line(R)) for Abdominal Wall Repair: Early Experience at Three Centers in the United States. Surg Technol Int 42, (2023).
3. A. W. Hollins, H. Levinson, Report of novel application of T-line hernia mesh in ventral hernia repair. Int J Surg Case Rep 92, 106834 (2022).

Background Today's wound dressings include adhesive paper strips, cyanoacrylate and polyester mesh systems, transparent films, foams, and hydrogel/hydrocolloid dressings. Many of these dressings are made from synthetic compounds which can cause complications known as Medical Adhesive Related Skin Injuries (MARSI) (1). The prevalence of MARSI in the United States has been on the rise with up to 1.5 million patients annually having serious complications to surgical adhesives (2). Silk fibroin is an emerging biomaterial with enhanced properties of cellular regeneration, growth and proliferation (3). The use of a biocompatible silk fibroin wound dressing has the potential to decrease the incidence of wound healing complications and improve patient outcomes compared to synthetic dressing alternatives (4).

Methods A prospective, randomized, single-blinded clinical trial was conducted from August 2022 to June 2023 on 50 patients who were dressed with a silk fibroin wound dressing on one side of their body and on the contralateral side with 3M Steri-Strips® (semisynthetic nonwoven rayon) after undergoing abdominoplasty, reduction mammaplasty, mastopexy or brachioplasty procedures (n=100). Data was collected over 5 postoperative visits using photographs and an investigator administered questionnaire to track erythema, blistering, discomfort, surgical site infection, pharmaceutical intervention, wound dehiscence and early detachment.

Results 20.8% (10/48) of patients were assessed by surgeons as having skin erythema surrounding the incision on the Steri-Strip® control side and 0% (0/48) on the silk bioprotein dressing side (p=0.002). The frequency of breast triple point separation in 43 cases was 30.2% (13/43) on the Steri-Strip® side and 9.3% (4/43) on the silk side (p=0.012). 75% (36/48) of patients had partial or total detachment of Steri-Strips® while 0% (0/48) had total detachment of the silk dressing and 18.8% (9/48) had partial detachment of the silk dressing within the first two weeks (p<0.001). Given the high rate of premature detachment of Steri-Strips®, the exposed incisional site was more prone to delayed wound healing.

Conclusion The beneficial properties of a woven silk fibroin wound dressing include high biocompatibility, non-allergenicity, ease of application and removal, oxygen permeability across the healing surgical site, wound exudate egress, flexibility, mechanical strength, the promotion of skin edge de-tensioning and the minimization of shear forces at the level of the dermis. This study presents an innovative alternative for surgical site wound dressings through the modern reinvention of one of the oldest biomaterials known to humanity, silk (5).

(1) Dhivya S, Padma VV, Santhini E. Wound dressings - a review. Biomedicine (Taipei). Dec 2015;5(4):22. doi:10.7603/s40681-015-0022-9

(2) Kim J, Shin Y. Medical Adhesive-Related Skin Injury Associated with Surgical Wound Dressing among Spinal Surgery Patients: A Cross-Sectional Study. Int J Environ Res Public Health. Aug 30 2021;18(17)doi:10.3390/ijerph18179150

(3) Fumarola S, Allaway R, Callaghan R, et al. Overlooked and underestimated: medical adhesive-related skin injuries. Journal of Wound Care. 2020;29(Sup3c):S1-S24. doi:10.12968/jowc.2020.29.Sup3c.S1

(4) Jao D, Mou X, Hu X. Tissue Regeneration: A Silk Road. J Funct Biomater. Aug 5 2016;7(3)doi:10.3390/jfb7030022

(5) Patil PP, Reagan MR, Bohara RA. Silk fibroin and silk-based biomaterial derivatives for ideal wound dressings. Int J Biol Macromol. Dec 1 2020;164:4613-4627. doi:10.1016/j.ijbiomac.2020.08.041

Purpose Prepectoral tissue expander (TE) based breast reconstruction is an innovative modality as it may lead to less pain and improved aesthetics than subpectoral TE placement. However, prepectoral TE reconstruction does not have the perfusion benefit of the pectoralis major muscle adjacent to the skin, increasing the risk for mastectomy skin ischemia. Hyperbaric oxygen therapy (HBOT) has been shown to salvage compromised mastectomy skin. We analyzed the reconstructive outcomes of patients undergoing TE placement and HBOT usage at our institution.

Methods We performed a retrospective chart review of patients undergoing immediate TE breast reconstruction from July 2016 through January 2022. Patient demographics, intraoperative data, receipt of HBOT, complications at the 48-hour, 30-day, and 90-day mark, and final breast reconstruction choice were collected. Chi-squared tests determined associations between receipt of HBOT and TE plane (prepectoral vs. subpectoral). Analyses were performed by-patient and by-breast.

Results
We included 357 patients (568 breasts) undergoing immediate TE breast reconstruction. The distribution of TE placement was 83% prepectoral (298 patients, 476 breasts), 13% subpectoral (47 patients, 73 breasts), and 3% unknown (12 patients, 19 breasts). Prepectoral TE placements were associated with larger mean mastectomy weights (650 g vs. 563 g) and TE sizes (479 cc vs. 456 cc) than subpectoral TE placements. More prepectoral (n=19, 33 breasts) compared to subpectoral (n=0) patients received HBOT (p=0.03). For patients who received HBOT, concern for mastectomy skin necrosis was noted on average 7 days after surgery (SD: 4.8 days) and HBOT was started on average 10 days after surgery (SD: 7.7 days). Hyperbaric oxygen therapy significantly salvaged more mastectomy pockets, preventing a return to the operating room for TE explantation in 76% (n=25/33) of breasts, compared to 52% (n=17/33) who had mastectomy skin necrosis but did not receive HBOT (p=0.03). For patients who had successful mastectomy pocket salvage after HBOT, the distribution of reconstructive outcomes was not significantly different than those who did not receive HBOT and did not have TE explantation (p=0.09).

Conclusions
Our study of HBOT in immediate prepectoral TE based breast reconstruction demonstrated that when mastectomy skin necrosis occurs, HBOT is able to significantly salvage more mastectomy pockets. In addition, this data may improve the conversation between patients and surgeons regarding the potential benefits of HBOT for compromised mastectomy skin pockets.

Introduction: The decision to undergo gender affirming surgery is difficult for individuals with gender dysphoria disorder due to cost, recovery time, and possible complications. It is well–established that transgender individuals have higher rates of mental health disorders and substance use than the general population, but the effects of gender affirming surgery and hormone therapy on mitigating these factors are less understood. Our aim is to see if gender-affirming surgery in addition to hormone therapy has a protective role against the development of mental health and substance use disorders, compared with hormone therapy alone.

Methods: A retrospective analysis was conducted using TriNetX, a multi-institutional de-identified database that operates through Current Procedure Terminology (CPT) and International Classification of Diseases (ICD) codes. Assigned males at birth (AMAB) over 18 years of age with a diagnosis of gender dysphoria disorder within TriNetX from inception to January 2024 were included in the study. The cohort only included individuals on hormone therapy. The cohort was then separated based on undergoing gender affirming surgery. If a patient had a previous substance use disorder or psychological disorder, they were removed from that specific analysis. Risks of developing Opioid Use Disorder (OUD), Cannabis Use Disorder (CUD), Alcohol Use Disorder (AUD), cocaine dependence, nicotine dependence, depression, anxiety, and attempted suicide were determined any time following diagnosis in the non-surgical group, and starting 1 day after surgery in the surgical group. Propensity score matching was used to balance cohorts based on age, race, and ethnicity. A p-value <0.05 was used to determine statistical significance.

Results: After selection criteria were met, 19,984 AMAB were in the non-surgical cohort while 1,341 AMAB were in the surgical cohort. Following propensity score matching 1,341 AMAB remained in both groups. AMAB who did not receive gender affirming surgery had a higher risk of developing OUD (p=0.175), CUD (p=0.006), AUD (p=0.171), cocaine dependence (p=0.986), nicotine dependence (p<0.007), depression (p<0.007), anxiety (p<0.001), and OCD (p=0.839) than individuals who did receive surgery. There was no difference in suicide attempts.

Conclusion: Based on our study, AMAB with gender dysphoria on hormone therapy who did not receive gender affirming surgery had a higher risk of developing OUD, CUD, AUD, nicotine dependence, depression, and anxiety than those who did receive surgery. This data suggests that gender affirming surgery may play a positive role in improving quality of life in AMAB with gender dysphoria disorder, compared with hormone therapy alone.

Introduction: Gender dysphoria describes distress due to a discrepancy between one's assigned gender and gender identity. It is well–established that transgender individuals have higher rates of mental health disorders and substance use than the general population, but the effects of gender affirming surgery and hormone therapy on mitigating these factors are less understood. The recent 2022 U.S. Trans Survey has demonstrated that transgender individuals largely report an improved quality of life after hormone therapy and surgery. Previously, our group researched the role of gender-affirming surgery and the development of substance use and mental health disorders, but we did not assess the use of hormone therapy. Our aim is to see if gender-affirming surgery in addition to hormone therapy has a synergistic, protective effect against the development of mental health and substance use disorders, compared with hormone therapy alone.

Methods: A retrospective analysis was conducted using TriNetX, a multi-institutional de-identified database that operates through Current Procedure Terminology (CPT) and International Classification of Diseases (ICD) codes. Assigned females at birth (AFAB) over 18 years of age with a diagnosis of gender dysphoria disorder within TriNetX from inception to January 2024 were included in the study. The cohort only included individuals on hormone therapy. The cohort was then separated based on undergoing gender affirming surgery. If a patient had a previous substance use disorder or psychological disorder, they were removed from that specific analysis. Risks of developing Opioid Use Disorder (OUD), Cannabis Use Disorder (CUD), Alcohol Use Disorder (AUD), cocaine dependence, nicotine dependence, depression, anxiety, and attempted suicide were determined any time following diagnosis in the non-surgical group, and starting 1 day after surgery in the surgical group. Propensity score matching was used to balance cohorts based on age, race, and ethnicity. A p-value <0.05 was used to determine statistical significance.

Results: After selection criteria were met, 21,016 AFAB were in the non-surgical cohort while 4,039 AFAB were in the surgical cohort. Following propensity score matching 4,039 AFAB remained in both groups. AFAB who did not receive gender affirming surgery had a higher risk of developing OUD (p=0.168), CUD (p=0.006), AUD (p=0.08), cocaine dependence (p=0.034), nicotine dependence (p<0.001), depression (p<0.001), anxiety (p<0.001), OCD (p=0.528), and suicide attempts (p=0.07) than individuals who did receive surgery.

Conclusion: Based on our study, AFAB with gender dysphoria who did not receive gender affirming surgery had a higher risk of developing OUD, CUD, AUD, nicotine dependence, depression, anxiety, and attempted suicide than those who did receive surgery. This data suggests that gender affirming surgery may play a positive role in improving quality of life in AFAB with gender dysphoria disorder, compared with hormone therapy alone. Additional research is required to characterize this effect further, as well as evaluate the impact of surgery on adolescents.