Scientific Abstract Presentations: Reconstructive 1 Thursday, October 26 Thu, Oct 26 1:30-2:30 p.m. CDT

Purpose: Lower extremity (LE) wounds are costly and common sequelae of diabetes and vascular disease. These patients may require multiple operative interventions to achieve healing, but some progress to amputation. The 5-year mortality after major amputation in the diabetic foot ulcer population ranges from 40% to 80%. The current management paradigm for diabetic patients with non-healing wounds emphasizes preservation of limb length with necessary salvage procedures rather than pursuing early amputation.1 However, critical assessment of cost effectiveness, care access disparities, impacts on quality of life, and functional outcomes for patients have raised challenges to this paradigm.2,3 This study aims to assess if undergoing multiple LE salvage procedures (LESP) has effects on amputation rates, time to amputation, and time to healing of chronic diabetic wounds.

Methods: A retrospective cohort study of patients with chronic LE wounds treated at a large tertiary care center from 2015-2022 was conducted. Diabetic patients with at least 1 non-traumatic LE wound were included. Cohorts were initially grouped by having had a salvage procedure or not; those that had not undergone a salvage procedure were excluded from the analysis. Cohorts were further stratified by number of salvage procedures into having only had one (1) procedure or multiple (2+). Further stratification was made by number of wounds (single vs. multiple), amputation status (yes/no), and healing status (healed vs. non-healed). Cox proportional hazards regression was conducted to assess effects of multiple LESPs on time to limb amputation and time to healing among patients with diabetic wounds. Other confounding variables (race, gender, glycemic control, nutrition status, smoking status, comorbidities, social vulnerability index) were accounted for in the analysis.

Results: When adjusted for race, comorbidities, SES, and smoking status, there was no significant difference in amputation rate between multiple LESP and single LESP cohorts (73.5% vs. 61.3%, p=0.097). Patients with poor glycemic control (HbA1c >7%) had delayed time to healing when compared to patients with more optimal control (HR=1.36, CI 1.136-1.514, p=0.04). Time to amputation was not significantly different between multiple LESP and single LESP cohorts (HR: 0.93, 95% CI 0.608-1.418, p=0.7).

Conclusions: Multiple surgical interventions to attempt limb salvage may not be warranted in diabetic patients with lower extremity wounds. Based on these data, patients who undergo one salvage attempt versus multiple had no difference in amputation-free survival. In the era of value-based care, this suggests that one operative limb salvage attempt may be warranted, but multiple attempts may incur unnecessary costs and ultimately delay rehabilitation and recovery.

References: 1. Black CK, Ormiston LD, Fan KL, Kotha VS, Attinger C, Evans KK.Amputations versus Salvage: Reconciling the Differences.J Reconstr Microsurg.2021 Jan;37(1):32-41.doi: 0.1055/s-0039-1696733.Epub 2019 Sep 9.PMID: 31499559. 2. Labovitz JM, Day D.The Biomechanics of Diabetes Mellitus and Limb Preservation. Clin Podiatr Med Surg.2020 Jan;37(1):151-169.doi: 10.1016/j.cpm.2019.08.011.Epub 2019 Oct 21.PMID: 31735265. 3. Driver VR, Fabbi M, Lavery LA, Gibbons G.The costs of diabetic foot: the economic case for the limb salvage team.J Vasc Surg. 2010 Sep;52(3 Suppl):17S-22S.doi: 10.1016/j.jvs.2010.06.003. Erratum in: J Vasc Surg.2010 Dec;52(6):1751.PMID: 20804928.

Background: As management of complicated wounds secondary to diabetes mellitus (DM) and other chronic comorbidities become more laborious in presenting patients, biologically engineered tissue products have shown great promise in augmenting healing and faster return-to-normal function in soft tissue reinforcement and regenerative soft tissue repair."1" While adjunctive use of biologics have proven to provide considerable benefits in reconstruction, there are significant associated product costs.

Purpose: To compare outcomes of chronic diabetic wounds adjunctively treated with a biologic product with goals to develop effective treatment algorithms and policies for using biologics to provide the most benefit to patients while promoting hospital resource efficiency.

Methods and Materials: A single-institutional retrospective chart review from 2016 to 2021 evaluated 155 diabetic patients adjunctively treated with a biologic product during reconstruction. Biologics include porcine urinary bladder matrix (pUBM), bovine collagen (BC), amniotic membrane/tissue (AM/T), acellular dermal matrix (ADM), and porcine dermis (PD). Patients were classified by having an open lower extremity wound(s) with or without DM. Patient demographics and medical history were collected. Evaluated outcomes included lower extremity amputation, osteomyelitis, and mortality stratified by specific biologic product implemented in patient care. Categorical variables were analyzed using Pearson chi-square and Fisher exact test. Binomial logistic regression and Akaike Information Criterion analysis (AIC) assessed potential impacts biologics may have on patient outcomes in addition to determining the regression model with the best fit for the quality of data.

Results: Mean follow-up was 3.5 years. Sixty-two percent were male and 38% were female. Seventy-nine percent were Caucasian, 19% African-American, 1% Native American/Alaska Native, and <1% Native Hawaiian or Pacific Islander. Mean age was 60.1 years. Thirty-four percent of patients had chronic history of DM. Forty-three percent of patients experienced ulcer recurrence. Sixty-two percent of patients received pUBM. The remaining 37% were treated with higher-costing biologics."2" Thirty-eight percent of patients had history of osteomyelitis with 17% recurrence rate. Twenty-three percent of patients suffered amputation. Of amputees, 51% were diabetic. Thirty percent of patients were assessed per Wagner's classification. Charlson Comorbidity Indexes were 11% low-risk, 21% mild-risk, 25% moderate-risk, and 44% severe-risk. Overall mortality was 15%, with 23% and 12% being with and without DM, respectively. In the cohort that received treatment with pUBM, patients with DM experienced higher amputation rates compared to patients without DM (p = .0035). There were no significant differences found in outcomes for both groups overall in mortality and osteomyelitis with use of any specific biologic product.

Conclusion: To our knowledge, there is no published evidence to-date reporting associated outcomes of low/high-cost biologics in managing lower extremity DM wounds. Further investigation is warranted to better delineate and understand cost-benefit ratios of outcomes in this specific patient population.

References 1. Johnson RM, Harrison LM, Anderson SR. The Adjunctive Use of Biologically Engineered Products in Plastic Surgery Practice. J Am Coll Clin Wound Spec. 2018;8(1-3):4-9. Published 2018 Jan 31. doi:10.1016/j.jccw.2018.01.002 2. Martinson M, Martinson N. A comparative analysis of skin substitutes used in the management of diabetic foot ulcers. J Wound Care. 2016;25(Sup10):S8-S17. doi:10.12968/jowc.2016.25.Sup10.S8

Background: The use of osseointegration (OI), a process in which there is a direct structural and functional connection between living bone and the surface of a load-bearing artificial implant, has long been used in dental reconstruction. The notion of expanding this process to extremity reconstruction has been explored within the past three decades. OI implants have become broadly utilized in the European sector using the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) protocol system. This system was recently adopted in the United States, with 20 medical centers nationwide offering OI implant treatments for amputees. In this study, we examine surgical and patient-reported outcomes of transfemoral osseointegration compared to socket-based prosthetics.

Methods: A retrospective review of patients who underwent OPRA stage I and II lower limb reconstruction between September 2021 to December 2022 at our institution was performed. Exclusion criteria included any patients outside the age range of 21-89. Patient demographics, operative details, surgical outcomes, and patient-reported outcomes were collected for analysis. Surgical outcomes included infectious complications, skin graft dehiscence, neuropathic pain, and redundant tissue surrounding the abutment. Patient-reported outcomes included skin irritation, drainage surrounding the abutment, the fit of the prosthesis, ease of prosthesis function, frequency of prosthetic use, and pain associated with weight bearing on the implant.

Results: Six patients were treated. The mean age at the time of Stage I and Stage II reconstruction was 47.83 ± 12.93 and 48.33 ± 12.94, respectively. The mean body index (BMI) was 26.63 ± 3.37 kg/m3. Comorbidities of patients included tobacco use (16%), marijuana use (83.33%), hypertension (50%), and hyperlipidemia (50%). Of the six transfemoral osseointegrated implants, three patients experienced superficial wound dehiscence surrounding the abutment (50%), two patients experienced hematoma development (20%), three patients returned to the OR for redundant tissue debulking (50%), and one patient returned to the OR for skin dehiscence (16%). Of the patient-reported outcomes, one patient reported skin irritation (16%), three patients reported serous drainage (3%), one patient reported difficulty of fit (16%), and all of the patients (100%) reported weight bearing without pain.

Conclusion: Based on our data, transfemoral osseointegration in patients with previous above the knee amputation may be an effective alternative to socket-based prosthetics in lower limb reconstruction. Further studies on the applications of osseointegrated implants for extremity reconstruction in plastic surgery and patient-reported outcomes may determine this treatment modality to have benefits not seen in socket-based prosthetics when considering method of extremity reconstruction.

Purpose The pedicled anterolateral thigh (ALT) flap is a well-known flap that can be used in lower trunk soft tissue reconstruction through standard ALT dissection.1 This flap may also be dissected in a reverse pedicled fashion for knee region defects.2 Literature is limited in detailed descriptions of the surgical technique for the elevation, rotation, and submuscular tunneling of the pedicled ALT. Furthermore, literature is limited in a standardization that expresses reliability. Through cadaver dissections and clinical outcomes, we will standardize this technique, making it reproducible and safe for clinical application in patients undergoing complex pelvi-perineal and knee region reconstructions.

Methods and Materials Anatomic studies of 40 ALTs were harvested in 20 cadavers. Freestyle technique with perforator preserving incision was performed to identify perforators and isolate flap components. The lateral femoral cutaneous nerve (LFCN) was identified in all flaps. From May 2010 to May 2016, 42 patients, ages 28 to 60 were treated with freestyle perforator preserving technique for the pedicled ALT. Vessels to the rectus femoris muscle were ligated for elongation of the main pedicle as necessary. Inguinal and perineal defects required submuscular tunneling under the sartorius and rectus femoris muscles. Contralateral defects necessitated additional suprapubic, subcutaneous tunneling. For the reverse type, superdraining was performed. Dissection and preservation of the LFCN maintained flaps as sensate.

Experience Forty-two patients were treated with pedicled ALT flaps. Eight months mean follow-up.

Results Twenty-two fasciocutaneous and 20 myocutaneous flaps were harvested, 60% including the LFCN. Six functional vaginal reconstructions, 3 functional penile reconstructions, and various hip, perineal and abdominal defects were successfully treated. The reverse ALT required superdraining to the greater saphenous vein in all cases. Sensate flaps regained two-point discrimination comparable to the contralateral thigh within 6 months average. The donor area was grafted in 8 (19%) patients and no major complications or flap losses were observed. Five minor wound dehiscences were treated conservatively.

Conclusions The freestyle sensate perforator preserving pedicled ALT flap is a flexible workhorse flap, suitable for a wide variety of lower trunk reconstructions. Our described method is optimal for preservation of blood flow, as well as pedicle and nerve reach, especially when tunneled submuscularly beneath the rectus femoris and sartorius muscles. With the preservation of the LFCN, the flap can gain sensation similar to the contralateral thigh in a two-point discrimination test within a reasonable amount of time. Moreover, preservation of the LFCN allows for coaptation to locoregional nerves. Superdraining the reverse ALT is suggested to prevent flap congestion. We report our results with the ALT flap as a safe, versatile, and reproducible means of pelvi-perineal and knee region reconstruction.

Citations 1.Ng RW, Chan JY, Mok V, Li GK. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg. 2008;61(2):158-164. doi:10.1016/j.bjps.2007.10.028 2.Demirseren ME, Efendioglu K, Demiralp CO, Kilicarslan K, Akkaya H. Clinical experience with a reverse-flow anterolateral thigh perforator flap for the reconstruction of soft-tissue defects of the knee and proximal lower leg. J Plast Reconstr Aesthet Surg. 2011;64(12):1613-1620. doi:10.1016/j.bjps.2011.06.047

Background: Reconstructing defects in the distal third of the leg presents challenges given a relative lack of pliable and robust local-regional flap options. While free flap transfers may be used for defects in this region, greater understanding of perforator anatomy has invigorated the use of local fasciocutaneous flaps as a viable alternative. Here, we describe terminal peroneal perforator anatomy in cadaveric leg dissections and propose four novel modifications to the reverse sural artery flap (RSAF) that allow for greater coverage of the medial and distal forefoot.

Methods: Peroneal perforators were studied in 38 fresh cadaver leg dissections. Details regarding fibular length and number, position, diameter, and length of perforators were obtained. A surgical case series was performed utilizing four modifications to the RSAF flap: perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, and proximal peroneal artery ligation.

Results: Anatomic dissection: 38 cadaveric legs were dissected, 14 left and 24 right. A total of 138 perforators were identified for an average of 3.63 ± 1.04 perforators per leg. On average, terminal perforators were 10.96 ± 3.67cm from the lateral malleolus, with arterial caliber 0.83 ± 0.34cm and length 4.10 ± 3.42cm. 71% of the terminal perforators were between the 60-80% portion of the fibula, which corresponds to a distance of 6.76-13.52cm from the lateral malleolus. 10.6% of terminal perforators were localized distally and 18.4% were localized more proximally. There was a significant negative correlation between total number of perforators and distance from the lateral malleolus (r = -0.343, p = 0.035).

Surgical case series: 5 pediatric and 7 adult patients underwent lower limb reconstruction with RSAF. On average, the terminal perforator supplying the RSAF was at 71.0% of the total fibular length, or 9.31 ± 1.80cm, from the lateral malleolus in adults and 70.6%, or 7.14 ± 1.69cm, in children. The final pivot-points were invariably lower than the perforator location, on average 2.64cm and 3.20cm lower than the perforator position in adults and children, respectively. All patients underwent perforator skeletonization and Achilles tendon release. 4 patients also underwent tunneling under the Achilles tendon for coverage of medial foot defects and one patient underwent proximal ligation of the peroneal artery for further reach. Post-operatively, two cases had distal tip necrosis less than 10% and one case resulted in 50% superficial epidermolysis which healed with local wound care. No cases required re-operation or experienced flap failure.

Conclusion: Perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, and proximal peroneal artery ligation are effective modifications to the RSAF that provide enhanced coverage of defects along the medial and distal forefoot. Anatomic dissection demonstrates that the terminal peroneal perforator may lie significantly higher than the recommended 5cm pivot-point above the lateral malleolus, making these modifications crucial in select cases. With careful technique, these modifications can improve the versatility of the RSAF as a local reconstructive option for distal lower limb defects.

Introduction: Lymphedema is a chronic, progressive, condition that significantly reduces quality of life and impacts up to 200 million individuals worldwide.[1] An understudied cause of secondary lymphedema is post traumatic lymphedema (PTL), a known complication of traumatic injury affecting up to 20% of patients who undergo surgical treatment for a traumatic injury. Untreated PTL leads to complications including poor wound healing, recurrent infection, skin fibrosis, and functional impairment. Physiologic lymphatic reconstruction (i.e. LVA or VLNT) has been well characterized in the setting of lymphedema secondary to malignancy treatment. However, diagnosis and treatment of PTL using physiologic lymphatic reconstruction is not well documented in the literature. The authors performed a systematic review of physiologic lymphatic surgical reconstruction in patients with PTL.

Methods: A search was conducted of PubMed, MEDLINE, Embase, and Web of Science, to identify reports of PTL treated with microsurgical lymphatic reconstruction. Inclusion criteria were 1) must describe lymphedema occurring secondary to traumatic injury; 2) must describe microsurgical method of lymphedema treatment. Exclusion criteria were 1) conservative treatment; 2) debulking or lymphatic ligation only; 3) primary lymphedema or malignancy.

Results: A total of 18 reports, representing 112 patients, were found. This included 60 cases of lymph flow restoration via lymph axiality and interpositional flap transfer (LIFT), 39 vascularized lymph node transfers (VLNTs), 11 lymphatic vessel free flaps (LVFFs), 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers (ALVTs). Average patient age was 40.2 years old. The most frequent mechanisms of injury were traffic injuries and crush injuries. The most common site of lymphedema was in the lower extremity. All studies reported clinical improvement of symptoms. No study reported specific diagnostic criteria for PTL outside of clinical diagnosis. Length of time from traumatic injury and mechanism were both not consistently reported, with 52.4% reported as unspecified traumatic injury. Quantitative outcome measures varied, and the most frequently used was lymph flow reduction (LFR) in 45% of cases, followed by reduction of excess volume (REV) in 26%, Lymphedema Severity Index (LIS) in 22%, Lymphedema Life Impact Scale (LLIS) in 13%, and 19% of patients had no quantitative outcomes reported.

Discussion: Our results demonstrated that PTL remains a poorly studied condition with unclear diagnostic criteria. Quantitative outcome measures of lymphedema are not consistently used or reported in this population, making comparisons between surgical techniques and patient cohorts difficult. However, based on our preliminary findings PTL has a favorable clinical prognosis with treated with physiologic lymphatic reconstruction. There are several promising techniques for prophylactic treatment of PTL in the setting of soft tissue reconstruction that should be considered for high-risk patients, especially preventative LIFT or LVFF for simultaneous soft tissue and lymphatic reconstruction. Traditional LVA and VLNT can be reserved for patients who already have PTL. Increasing awareness of PTL and establishing standardized outcome measures will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine the true prevalence of PTL and optimal treatment strategies.

1. Sleigh BC MB. Lymphedema. StatPears: StatPearls Publishing; Updated 2022.

Purpose: Implant based reconstruction (IBR) can include prepectoral or sub-pectoral reconstruction.[1] While up to 50% of plastic surgeons perform prepectoral IBR, implant rippling secondary to poor superior pole coverage is a common postoperative complaint from patients.[2] Silicone implants that are used in these procedures vary in cohesivity. In the prepectoral plane, it is suspected that highly cohesive implants reduce rippling rates; however, this has not yet been demonstrated.

Methods & Materials: A retrospective cohort analysis of two-stage IBR in the pre-pectoral plane was conducted. Patients who had undergone unilateral or bilateral, skin or nipple-sparing mastectomy and two-stage IBR from January 2020 to June 2022 were identified in our institution's database. Patient demographic data, procedure characteristics (e.g., implant size and cohesivity, concurrent autologous fat grafting), and complications were captured. Patients who were less than 6 months after IBR were excluded. Univariate logistic regression analysis was conducted to identify relationships between implant cohesivity and the likelihood of patients requiring revision procedures and developing post-operative complications.

Experience & Results: 129 patients met the inclusion criteria for this study. The mean follow-up time was 235 (+/- 190) days. Mean age was 48.5 (+/- 10.5) years old. All patients received Allergan Naturelle Silicone Gel Implants. Seventy-two (56%) patients received fat grafting at the time of tissue expander removal and implant placement. A total of 52 patients received the least cohesive implants, 24 patients received moderately cohesive implants, and 53 patients received the most cohesive implants. Fourteen patients (11%) received revision fat grafting after the original implant placement. Thirty-six patients (28%) experienced rippling after the original implant placement. Univariable regression modeling indicated that the patients who received the most cohesive implants were less likely to require additional sessions of fat grafting after the implant placement when compared to the patients who received the two other implant options (OR 0.07, p < 0.05). Furthermore, the patients who received the moderately cohesive (OR 0.30, p < 0.05) and the most cohesive (OR 0.39, p < 0.05) implants were less likely to experience rippling after the implant placement compared to the patients who received the least cohesive implant. In a subgroup analysis, patients with the most cohesive implants who did not receive fat grafting at implant placement did not require additional fat grafting at a later instance (0%). However, 11 (31%) patients who received the least cohesive implant without fat grafting at time of IBR ultimately required additional sessions of fat grafting.

Conclusions: Rippling after prepectoral IBR is a common complication and can be mitigated with fat grafting. The use of highly cohesive implants in prepectoral IBR correlates with significantly fewer rippling complications and revision fat grafting procedures. Study of the cost implications of these findings may further support the advantages of using highly cohesive implants in prepectoral IBR procedures.

[1] Kappos EA, Schulz A, Regan MM, et alPrepectoral versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02/ PREPEC): a pragmatic, multicentre, randomised, superiority trialBMJ Open 2021;11:e045239. doi: 10.1136/bmjopen-2020-045239. [2] Marks, J. M., Farmer, R. L., & Afifi, A. M. (2020, August 19). Current Trends in Prepectoral Breast Reconstruction: A Survey of American Society of Plastic Surgeons Members. Plastic and reconstructive surgery. Global open. Retrieved May 25, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489685/.

Introduction: Secondary lymphedema is one of the biggest complications of lymph node dissection and causes serious morbidity to the affected patients. As such, focuses have shifted towards the prevention of lymphedema. While immediate lymphatic reconstruction for breast cancer patients has been widely studied,1 studies of reconstruction for melanoma patients are lacking. We sought to review the safety and efficacy of immediate lymphatic reconstruction for preventing lymphedema in patients with melanoma.

Methods: A systematic review of studies reporting lymphedema outcomes in patients with melanoma who underwent immediate lymphatic reconstruction was performed in accordance with the PRISMA guidelines using the following databases: PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). A total of 37 titles and abstracts were screened, and six articles were extracted for analysis.

Results: The six studies included 298 patients who underwent either axillary or groin lymphatic dissection for melanoma treatment. Immediate lymphatic reconstruction via lymphovenous anastomosis (intervention group) was done in 115 patients (38.6%), and 183 patients had no lymphatic reconstruction (control group). Follow-up length ranged from 6 to 67 months. Melanoma recurred in 40.7% of the intervention group versus 52.1% in the control group (p=0.067). 5.2% developed lymphedema in the intervention group versus 28.9% in the control group (p<0.0001). Reported complications in the intervention group include wound infections (1.7%), seromas (1.7%), and transient lymphedema (0.9%), while 10 (5.5%) in the control group developed wound infections. There were no significant differences in mortality.

Conclusion: In patients with melanoma who undergo lymph node dissection, immediate lymphatic reconstruction is effective for the prevention of secondary lymphedema. No differences were found between the groups in recurrence of melanoma or mortality, but further studies should be conducted to concretely validate these findings.

References: 1. Hill WKF, Deban M, Platt A, Rojas-Garcia P, Jost E, Temple-Oberle C. Immediate Lymphatic Reconstruction during Axillary Node Dissection for Breast Cancer: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open. 2022;10(5):e4291. Published 2022 May 9. doi:10.1097/GOX.0000000000004291

Purpose: Plastic surgery involvement in complex locoregional closure of back wounds following spine surgery has increased significantly within recent decades. Muscle flap closure, as opposed to traditional layer-by-layer approximation, has been shown to decrease rates of wound complications such as seroma, infection, and dehiscence. However, the impact of the use of barbed suture on operative time, surgical cost, and patient outcome for complex back closure remains unknown.

Methods: A retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure between January 2016 and July 2021. Patients were divided into barbed suture and conventional suture cohorts (Figure 1). Operative characteristics, including duration of surgery, were extracted from the medical record. Postoperative complications such as seroma, infection, dehiscence, and need for reoperation were collected. An estimated cost savings was calculated using figures reported in the literature.

Results: Of 110 patients, 67.3% (74/110) underwent muscle flap-based reconstruction with barbed suture. Rates of seroma (p = 1.0), infection (p = 0.21), dehiscence (p = 0.66), and other complications were statistically similar between groups. After adjusting for the length of surgical closure, the mean time per centimeter was 3.1 min/cm versus 4.6 min/cm for barbed and conventional suture cohorts, respectively, resulting in a time savings of 1.5 min/cm (p < 0.001) (Table 1). The calculated time savings for muscle flap closure of average incision length was 34.5 min (18.6 – 50.4 min), and the overall financial savings was calculated to be $1094.10 ($513.75 – $1674.45) per case.

Conclusion: The use of knotless barbed suture in complex closure of back wounds results in decreased operative time and hospital cost, while conferring similar rates of complication to conventional suture.

Introduction In patients with peripheral arterial disease (PAD), there is a high prevalence of Major Depressive Disorder (MDD). PAD patients with MDD have an increased risk of lower extremity amputation (LEA) compared to PAD patients without MDD. In the general population, it is established that LEA preserves physical health but decreases quality of life and may increase symptoms of MDD. It is unclear which direction LEA influences mental health in complex plastic reconstructive surgery patients, and thus, this study aims to assess MDD symptomology in PAD patients after LEA.

Methods A retrospective chart review of patients from a single institution wound center with PAD, a diagnosis verified by multiple chart documentation, who received LEA from a senior author (C.E.A.) were reviewed from January 2018 to July 2022 was conducted. All patients with a Patient Health Questionnaire (PHQ) or Hamilton Depression Rating Scale (HAM-D) were included. A PHQ score ≥ 4 and subsequent HAM-D ≥ 8 prior to the date of amputation were included in the MDD cohort. HAM-D scores within 3 months before and after LEA date were collected. Paired t-tests were used for analysis through STATA VSN 7.0 with a significance level set at 0.05.

Results Out of 305 patients with PAD who underwent LEA, 92 (30.6%) were diagnosed with MDD prior to amputation. These patients had an average age of 58.81 +10.81 years and BMI of 30.64 + 7.68 kg/m2; 31 (33.69%) were females; 42 (45.65%) had a history of smoking; 56 (60.86%) were diagnosed with type II diabetes; and 39 (42.41%) with peripheral neuropathy. These patients had an average of 2.23 + 2.39 invasive vascular interventions (stent placement, balloon angioplasty, or open bypass) prior to LEA. Of the patients with MDD, HAM-D scores significantly decreased after LEA three-fold (12.88 + 4.19 vs. 4.12 + 5.76, p=0.0001).

Conclusions Psychiatric well-being in reconstructive surgery patients is not well-researched but its understanding is important in improving patient care, as our study found a high prevalence of MDD amongst PAD patients. Our cohort of MDD patients reported decreased depressive symptoms after LEA. Future studies will explore whether a history of MDD influences post-LEA coping and resilience in vulnerable plastic reconstructive surgery patients.