Scientific Abstract Presentations: Reconstructive 2 Thursday, October 26 Thu, Oct 26 3:00-4:30 p.m. CDT

INTRODUCTION In the setting of non-traumatic lower extremity amputations (LEA), there is a high risk of postoperative complications due to the complex comorbidities of patients undergoing this invasive procedure. Incisional negative-pressure wound therapy (iNPWT) is a device that could potentially mitigate adverse effects post-LEA in the setting of wound healing of closed surgical incisions. Currently, there are no trials utilizing iNPWT of closed wounds after LEA. This is a pilot study that compares incisional negative pressure wound therapy and standard dressings in patients.

METHODS Patients indicated for non-traumatic LEA presenting to a high-volume wound center were randomized to receive either an iNPWT (3M-Prevena, Ireland) or a standard dry dressing over their incision at the conclusion of LEA. Demographics and comorbidities were obtained through chart review: diabetes mellitus type 1 (DM1) diabetes mellitus type 2 (DM2), HbAlc, peripheral arterial disease (PAD), chronic kidney disease (CKD), end stage renal disease (ESRD). Incidence of hematoma, seroma, wound dehiscence, and maceration was assessed at 5, 30, and 90-day time points post-procedure. Medical Outcomes Study 12 Short Form Health Survey (SF-12) was given before surgery (entry) and at a 90-day follow-up appointment (exit); change in SF-12 was measured by subtracting scores of entry from exit. Data analysis was performed using STATA (StataCorp, College Station, TX) version 17.0 with statistical significance set at values of p<0.05. Results were reported as (Dry dressing vs. iNPWT).

RESULTS A total of 108 patients were chosen for participation and evenly randomized (n=54 per group); eight patients were lost to follow-up and removed from the study. Demographics between dry dressing and iNPWT groups were similar in age (58.92 ± 13.88 vs. 57.10 ± 12.89 years, p=0.49), BMI ( 28.12 ± 7.11 vs. 30.04 ±7.80 kg/m2, p =0.20), and gender (25/51, 29.41% vs. 18/49, 36.73% females). Prevalence of DM1/DM2 (11.76% vs. 10.20%/74.51% vs. 67.35% p=0.52), CKD (9/51, 17.60% vs. 6/49, 12.24%, p=0.42), ESRD (18/51, 35.29% vs. 10/49, 20.41%, p=0.092) did not differ. The dry dressing group had a higher portion of patients with PAD (30/51, 58.82% vs. 15/49, 30.61%, p=0.005). Hospital length of stay was similar (12.65± 9.54 vs. 13.27± 8.06 days, p=0.74), however, the dry dressing group waited significantly longer to successfully use a prosthetic (93.2±100.6 vs. 82.09±179.2 days, p=0.031). There were no differences in rates of hematoma, seroma, or maceration between both groups at all three time points. No differences were recorded in rates of failure to heal (4/51, 7.84% vs. 6/49, 12.25%, p=0.44) or fall requiring hospitalizations (3/51, 5.88 % vs. 7/49, 14.29%, p=0.16) at the 90-day follow-up. Patients in both groups reported comparable decreased quality of life after LEA (-13.83±10.35 vs. -14.02±11.09 SF-12 score, p=0.46).

CONCLUSION There was no difference in complications between the control and iNPWT groups, even as the control had a higher proportion of patients with PAD. Patients receiving iNPWT waited less time to use a prosthesis, however, still had the same degree of decrease in SF-12, indicating lower quality of life, post-amputation as the control group. We welcome other institutions to explore whether iNPWT can be a promising tool to improve patient care following LEA.

Purpose: Anatomic and functional descriptions of trunk and breast lymphedema following breast cancer treatment are emerging as indicators of lymphatic dysfunction, better elucidating the disease process. ICG-lymphangiography has been instrumental in characterizing this dysfunction in extremity lymphedema and can be used to assess other regions. Previous work has established a validated Trunk Lymphedema Staging System (TLSS) to characterize such affected areas. This study aims to identify risk and protective factors for the development of truncal and upper extremity lymphedema using alternative lymphatic flow, providing implications for medical and surgical treatment.

Methods: Patients undergoing revisional breast surgery with suspicion of upper extremity lymphedema between 12/2014 and 3/2020 were offered lymphangiography. The breast and lateral/anterior trunks were visualized and blindly evaluated for collateral axillary and inguinal lymphatic flow. Summary statistics were computed, and a linear-weighted Cohen's Kappa statistic was calculated comparing alternative drainage evaluation. Binomial regression was used to compute relative risks (RR). Significance was assessed at alpha=0.05.

Results: 86 sides (46 patients) were included. 12 sides underwent no treatment and were considered controls. 88% of the non-controls had alternative lymphatic flow. This was seen in ipsilateral axillae (64%), ipsilateral groins (57%), contralateral axillae (20.3%), and contralateral groins (9.3%). Cohen's Kappa for alternative drainage was 0.631 ± 0.043. Ipsilateral axillary and contralateral inguinal drainage was associated with a reduced risk of developing truncal lymphedema (RR 0.78, CI 0.63-0.97, p=0.04; RR 0.32, CI 0.13-0.79, p=0.01, respectively). Radiation therapy increased the risk of truncal and upper extremity lymphedema (RR 3.69, CI 0.96-14.15, p=0.02; RR 1.92, CI 1.09-3.39, p=0.03, respectively). Contralateral axillary drainage and axillary lymph node dissection increased the risk of upper extremity lymphedema (RR 4.25, CI 1.09-16.61, p=0.01; RR 2.83, CI 1.23-6.52, p=0.01, respectively).

Conclusions: Building upon previous work on truncal lymphedema, this study shows risk and protective factors for the development of truncal and upper extremity lymphedema. Most prevalent alternative channels drain to the ipsilateral axilla and groin. Ipsilateral axillary and contralateral inguinal drainage are protective against truncal lymphedema. Patients with radiation, axillary lymph node dissection, and contralateral axillary drainage have the highest risk of upper extremity lymphedema. This study amplifies existing data on collateralization in post-operative breast cancer patients while expanding its implications in trunk and breast lymphedema. These findings have important clinical implications for post-operative manual lymphatic drainage and for determining eligibility for lymphovenous bypass surgery.

Background: An unanswered question with open tibial fractures is whether the type of flap used affects hardware retention. In many instances, flap survival does not necessarily equate hardware retention, or even eventual limb salvage. Nevertheless, hardware failure or infection would at the very least necessitate multiple repeat surgeries and long-term intravenous antibiotics with a decreased chance of limb salvage. In this study, we performed a 10-year single-institution review and analysis of all patients who had placement of hardware for open tibial fractures followed by flap coverage.

Aims: The primary aim of the study was to investigate if there was a relationship between flap type (pedicled vs free and muscle vs fasciocutaneous flaps) and primary and secondary outcome measures. A secondary aim of the study was to determine if there was any difference in primary and secondary outcome measures when comparing the period of time from 2012 to 2016 (where there was not a formal orthoplastic collaboration) and from 2017 to 2021, where our institution had a formal orthoplastic team.

Methods: Inclusion criteria consisted of patients who underwent pedicled or free flap coverage of Gustilo IIIB or IIIC tibial fractures requiring ORIF. An initial cohort of 100 unique patients was retrieved based on EMR analysis by CPT codes. After individualized chart review, a cohort of 58 patients had sufficient data for inclusion in the study. Of these 31 had pedicled flap reconstruction, while 27 had free flap reconstruction. In addition, in this cohort, 36 had reconstruction with muscle flaps, while 22 had reconstruction with fasciocutaneous flaps. Within the pedicled flap cohort, there were 14 fasciocutaneous and 17 muscle flaps. Within the free flap cohort, there were 8 fasciocutaneous and 19 muscle flaps. Outcomes and complications were statistically analyzed based on flap type. Flap type was stratified into free vs pedicled flaps and muscle vs fasciocutaneous flaps. Primary outcome measures included hardware failure and infection requiring hardware removal. Secondary outcome measures included limb salvage, flap success, and fracture union.

Results: Overall primary outcome measures were better for pedicled flaps (n=31), with lower rates of hardware failure and infection (25.8%; 9.7%) compared to free flaps (n=27) (51.9%; 37.0%). Limb salvage and flap success were not different comparing pedicled and free flaps. There was no significant difference in outcomes between muscle and fasciocutaneous flaps. Multivariable analysis showed that patients who had free vs pedicled flaps or muscle vs fasciocutaneous flaps had a higher chance of hardware failure. A formal orthoplastic team was established in the second 5 years, after which flap numbers were higher and hardware failure less for pedicled and fasciocutaneous flaps.

Conclusions: Pedicled flaps were associated with lower rates of hardware failure and infection requiring hardware removal. A formal orthoplastic team improves hardware-related outcomes.

Background: Spinal degenerative deformities have a prevalence of over 27% in US adults.1 $34 billion is spent annually on spinal instrumentation and fusion to address these deformities.2 Wound closure after fusion using paraspinal muscle flaps has been associated with reduced rates of complications, including infection and reoperation.3 However, no study has addressed the cost effectiveness of this added intervention. The high prevalence of degenerative deformities and subsequent healthcare expenditures highlights the need for resource utilization studies to inform decision-makers on best operative practices.

Methods: A retrospective review was performed on adult patients at our institution who underwent posterior spinal fusion due to degenerative deformity between 2019 and 2022. Patients with infection, spinal tumor, or connective tissue disease were excluded. Patients were stratified by the prophylactic use of muscle flap closure following fusion, and outcomes were compared between groups using chi-square tests and odds ratios (OR) with an alpha of 0.05. Costs were applied to operative, inpatient, and outpatient resources, and univariate and multivariate regression were performed to measure the impact of muscle flaps on costs.

Results: 520 patients were included in this study. Diagnoses included 319 patients (61%) with spondylosis, 142 (27%) with scoliosis, 47 (9%) with discopathy, and 12 (2%) with other musculoskeletal pathologies. 240 patients received muscle flap closure and 280 underwent primary closure. These cohorts were similar in terms of sex, race, ethnicity, BMI, and length of fusion. The flap group was statistically younger (mean age 57.7 vs 61.4 years) and more likely to have had prior spine surgery (63% vs 54%). Flap closure patients had significantly fewer readmissions (10% vs. 17%, OR 0.56), reoperations (8% vs 14%, OR 0.56), and hardware failures (0.4% vs. 4%, OR 0.10), and more seromas (10% vs. 2%, OR 6.11) than the control group. There were no differences in infection, hematoma, or wound dehiscence rates. Operative time, hospital length of stay, and subacute rehabilitation use did not vary between groups. In the multivariate regression, when controlling for independently significant factors like age, diagnosis, comorbidities, and length of fusion, muscle flap closure remained a significant predictor of costs, and was associated with a $7,376 reduction in overall costs per patient.

Conclusions: This resource utilization study shows that muscle flap closures correlate with improved outcomes by reducing complication rates, while also leading to decreased costs per patient. These findings support the use of prophylactic muscle flap closures following posterior spinal fusion from patient safety and health economics perspectives.

1. Parenteau CS, Lau EC, Campbell IC, Courtney A. Prevalence of spine degeneration diagnosis by type, age, gender, and obesity using Medicare data. Sci Rep. 2021;11(1):5389. doi:10.1038/S41598-021-84724-6
2. Rajaee S, Bae H, Kanim L, Delamarter R. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012;37(1):67-76. doi:10.1097/BRS.0B013E31820CCCFB
3. Wright MA, Weinstein AL, Bernstein JL, et al. Muscle flap closure following complex spine surgery: A decade of experience. Plast Reconstr Surg. Published online 2020:642E-650E. doi:10.1097/PRS.0000000000007274

Background: Surgical treatments for breast cancer related lymphedema (BCRL) include vascularized lymph node transplant (VLNT) and debulking lipectomy. Clinical outcomes are assessed using subjective patient questionnaires (LYMPH-Q), bioimpedance scores (L-dex), and relative volume change in the limb of interest, which often do not correlate with each other. However, there are potential quantitative imaging biomarkers that have yet to be explored in depth that could be used to assess clinical outcomes. Our clinical experience suggests that dermal thickness, measurable on MRI, may correlate with BCRL severity. This may also may negatively correlate with improvement of the disease process after surgical intervention. Therefore, the aim of this study is to investigate whether dermal thickness could be utilized as an objective indicator of postoperative changes following VLNT and debulking.

Methods: A retrospective review identified patients with BCRL treated with VLNT and/or debulking. Patients were included if they had both pre- and post-operative MRIs. Dermal thickness was measured at 4 points (medial/ulnar, lateral/radial, posterior/dorsal and anterior/ventral) in 2 different locations in the upper arm and 2 different locations in the forearm, for a total of 16 sites per arm. For each patient, the unaffected arm was set as the control for the affected arm. Maximum dermal thickness was determined at the anatomical location that had the highest dermal thickness measurement. Data was analyzed stratified by treatment groups: VLNT, debulking, or VLNT + debulking. Wilcoxon rank sum test was used to compare changes to the affected arm with the unaffected (control) arm. Univariate linear regression was used to assess the relationship between dermal thickness reduction with changes to LYMPH-Q scores, L-dex scores, and relative volume change.

Results: 89 patients were identified, of which 24 met the inclusion criteria. Ten patients underwent debulking, 6 underwent VLNT, and 8 underwent sequential debulking and VLNT. Overall, there was a significant reduction in relative volume change, in the pre and post operative measurement (p < 0.001). Maximal dermal thicknesses significantly decreased in all treatment groups, apart from the VLNT cohort (p =0.5). There was a median dermal thickness change of 0 mm across all regions in the control arm, while there was a significant reduction in 12/16 limb compartments in the affected arm. Change to dermal thicknesses significantly correlated with changes to LYMPH-Q, L-dex, and relative volume change in 4/16 limb compartments.

Conclusion: Dermal thickness may potentially be used to track post-operative outcomes in BCRL after debulking, but further understanding of variations due to anatomical location and the selection of the optimal imaging technique require further exploration.

Background: Despite the common administration of blood product transfusions for traumatic lower extremity (LE) injuries, their effect on LE free flap outcomes is uncertain. There is evidence that blood transfusions are associated with infection and other surgical complications; however, these studies are not specific to LE reconstruction. We evaluated the effect of perioperative blood transfusions on LE free flap outcomes in trauma patients. Methods: A retrospective chart review was performed on patients undergoing free flap reconstruction following acute LE injuries from 2016 through 2021. The perioperative period for blood product transfusions was defined as ±3 days from the procedure. Parameters included patient demographics, perioperative characteristics, and outcomes. Major complications were used as a composite variable and defined as complications requiring reoperation (hematoma, flap thrombosis, flap necrosis >10%, infection requiring reoperation). Univariate analysis between the transfusion and non-transfusion group was performed using Student's t test and Chi-square analysis. Multivariable analyses were performed using generalized linear models and negative binomial regression to adjust for additional factors that might influence outcome. All statistical tests were performed with significance p< 0.05. Results: Of the 205 patients, 48% received packed red blood cells (PRBC) perioperatively. The rate of major complications was higher in the transfusion group (19% vs. 10%, p=0.09). Units of PRBCs transfused were independently associated with major complications (OR=1.34 per unit PRBC, CI:1.06-1.70, p=0.015). While wound size (314 cm2 vs 168 cm2), injury severity score (17 vs. 13), and intraoperative estimated blood loss (134 mL vs. 76 mL) were greater in the transfusion group (p<0.01), they were not significantly associated with major complications on multivariate analysis. Conclusion: The number of units of PRBCs given perioperatively was the only variable independently associated with major complications. This association suggests the usage of restrictive transfusion protocols in patients requiring LE reconstruction. In centers already transfusing restrictively, supplemental treatment modalities such as tranexamic acid should be further studied to decrease blood loss and transfusion needs in LE microvascular reconstruction.

Background: Current Procedural Terminology (CPT) codes provide a uniform language for reporting and billing surgical procedures. Reconstructive techniques have been available for over 15 years to treat lymphedema, a debilitating and progressive disease, yet specific CPT codes have not been assigned to these procedures. We hypothesized that great heterogeneity would exist in coding practices, and that inadequate codes may ultimately limit the treatments offered.

Methods and Materials: A 22-item questionnaire was offered to members of the American Society of Reconstructive Microsurgeons. The Qualtrics survey assessed the type and volume of lymphatic reconstruction procedures performed, the CPT codes used for each procedure and their combinations, as well as the challenges related to coding and patient access to care.

Results: 66 board-eligible/board-certified plastic surgeons completed the survey in full. 83.3% had microsurgical fellowship training, and 56.1% were practicing for >5yrs. All indicated that lymphatic surgery is integral to cancer care, and 86.4% indicated that immediate lymphatic reconstruction should be offered following lymphadenectomy. Most respondents performed lymphovenous anastomosis (LVA; 81.8%), immediate lymphatic reconstruction (ILR; 77.3%), liposuction (80.3%), and vascularized lymph node transfer (VLNT; 80.3%). Respondents who performed LVA (92.6%), ILR (92%), liposuction (62.5%), and VLNT (70.6%) reported that the available CPT codes did not accurately reflect the work done for these procedures. Consequently, 32% of the respondents reduced or stopped offering some procedures, and 69.7% had to forgo operations due to their patients' inability to pay. The study found that insurance coverage and current CPT codes posed significant barriers to patient care, with 98.5% and 95.5% of respondents, respectively, indicating them as challenges. Respondents used a median of 3 CPTs for LVA, 3 for ILR, 3 for liposuction, 1 for indocyanine green imaging, and 1 for VLNT. Across all respondents, 8 different codes were employed for LVA, 9 for ILR, 8 for liposuction, 9 for ICG, and 6 for VLNT. Significant variation was observed in the different CPT code combinations reported by respondents for each procedure: 28 for LVA, 24 for ILR, 12 for liposuction, 20 for ICG, and 14 for VLNT.

Conclusion: Respondents agreed that lymphatic reconstruction is essential to cancer care. A large and heterogeneous set of CPTs is currently employed for billing. Most believe available CPTs are inadequate and limit access to care. Our results suggest that the creation of appropriate codes is necessary to expand access to care and ultimately improve outcomes for lymphedema patients.

Introduction: Peripheral nerve reinnervation following nerve injury is often a slow and incomplete process, resulting in significant morbidity and permanent loss of function of the injured extremity in many patients. Prior studies have shown the efficacy of electrical stimulation to accelerate the recovery of both motor and sensory neurons in peripheral nerve injury models. Moreover, separate investigations have also shown the use of closed-loop cranial nerve stimulation to improve the neuroplasticity of the motor cortex, improving functional outcomes. However, no study has investigated the synergistic effects of both intraoperative electrical stimulation and cranial nerve stimulation for functional improvement within a peripheral nerve injury model. This investigation quantifies the efficacy of both intraoperative electrical stimulation and trigeminal nerve stimulation on motor and sensory functional recovery in a rat peripheral nerve injury model. Methods: Twelve Lewis rats were trained in a reach-to-grasp task for a food reward using their right forelimb in the MotoTrak training system. Baseline sensory data was also retrieved using a Von Frey monofilament test. All rats underwent surgical transection of the median and ulnar nerve of their right forelimb, followed by one hour of intraoperative electrical stimulation. Adjuvant trigeminal nerve stimulation was completed via supraorbital headcap electrodes. Force and sensory data were compared to cohorts of sham surgery (no nerve transection), brief intraoperative electrical stimulation, adjuvant trigeminal nerve stimulation, and a no-stimulation group. Results: The combined cohort of rodents were able to recover to their pre-injury motor function by the third week of rehabilitation, faster than either of the singular electrical stimulation cohorts assessed previously. Moreover, the combined stimulation cohort's functional sensory data demonstrated no change compared to their pre-injury baseline, indicating a full functional recovery prior to the first data timepoint. Conclusions: Peripheral nerve electrical stimulation and adjuvant trigeminal nerve stimulation are two separately acting mechanisms of therapy that employ electric waveforms to improve the functional recovery of injured peripheral nerves. The former acts within the periphery to accelerate axonal growth and regeneration of the nerve, while the latter acts centrally as a way for cortical remapping, improving the task-specific function of newly regenerated nerves. When used simultaneously in a rodent peripheral nerve injury model, these modalities have shown to build upon each other to deliver a faster motor and sensory functional recovery.

Purpose: Pressure injuries (PI) are a major burden on the American healthcare system with an annual incidence of 1 to 3 million and estimated to cost up to $26.8 billion annually.(1,2) While stage 3 and 4 PIs are ideally treated with surgical reconstruction, complex medical and social comorbidities often make members of the affected patient population poor candidates for surgery.(3) Current guidelines for the non-surgical management of chronic PIs recommend serial debridement in an attempt to disrupt the "senescence" of the wound bed and promote an acute wound state.(4) This study examines the assumption that serial surgical debridement accelerates wound healing of pelvic girdle and trochanteric PIs and likely predictive factors related to ulcer resolution.

Methods: This retrospective study identified a random sample of 800 inpatient and outpatient diagnoses with ICD-10 codes associated with pressure injuries located over the bony pelvis and greater trochanters seen at the Yale-New Haven Health system from 2013-2020. PIs with <6-months follow-up were excluded. Patient demographics, presence of diabetes, smoking status, count of surgical/sharp debridements, Braden score, ulcer stage, and volume of tissue loss at presentation were collected as likely predictive factors. Primary outcomes included ulcer resolution, surgical closure, recurrence, and mortality. Data were manually cross-referenced with patient charts to ensure accuracy. Chi square tests were used to compare ulcer resolution between experimental groups and multivariate logistic regression was used to determine factors associated with ulcer resolution. Significance was defined as p < 0.05.

Results: Out of 325 wounds, 37.2% (n=121) had documented resolution with 20.9% (n=68) receiving reconstructive surgical closure. Overall mortality rate was 16.6% (n=33) and one-year recurrence was 8.6% (n=28). Of the 148 ulcers labeled Stage 3 or 4 treated with conservative management alone, 23.0% (n=34) achieved resolution. No significant increase in resolution was observed in ulcers receiving >1 debridement (p=0.08) . Of the likely predictive factors analyzed, none were found to correlate with PI resolution (p>0.05).

Conclusion: Given the inconvenience, discomfort, and cost associated with serial surgical debridement, we recommend more judicial and selective application of sharp debridement rather than a frequent weekly use of sharp debridement for all patients with chronic wounds. Future research on pelvic and trochanteric PIs must recognize the limits of the senescence model and seek new ways of thinking about wound healing.

1. Padula WV, Delarmente BA. The national cost of hospital-acquired pressure injuries in the United States. Int Wound J. 2019;16(3). doi:https://doi.org/10.1111/iwj.13071
2. Mervis JS, Phillips TJ. Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. J Am Acad Dermatol. 2019;81(4):881-890. doi:https://doi.org/10.1016/j.jaad.2018.12.069
3. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:https://doi.org/10.1097/won.0000000000000281
4. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: A retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306-311. doi:https://doi.org/10.1111/j.1524-475x.2009.00485.x

Purpose: The DIEP flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal donor site morbidity still occurs. Traditional rectus diastasis (RD), bulge, and hernia repair with open techniques and onlay mesh have high complication rates. We present a case series of delayed robotic repair of symptomatic RD and bulge following abdominally based breast reconstruction.

Methods: A single-center, retrospective review was conducted of patients who underwent DIEP flap breast reconstruction and subsequent robotic-assisted repair of RD and bulge. Pre-operative demographics and post-operative clinical and patient-reported outcomes were reviewed. RD up to 5 cm and any ventral/umbilical hernias were repaired by a single general surgeon via plication with running suture and reinforcement with macroporous mesh.

Results: Ten patients with an average age of 49 years (range 41-63) and BMI of 31 kg/m2 (range 26-44) were included in the study. The average DIEP flap size was 664.95 g (range 315-1197), the average number of perforators harvested was 2.5 (range 1-4). RD and hernia sizes were 2.9 cm (1.5-4.2) and 5.8 cm2 (<1-15), respectively. One patient (10%) experienced post-operative surgical site complications including seroma and wound infection. Two patients (20%) reported a post-operative bulge but CT scan showed no evidence of hernia recurrence. Five patients completed a post-op survey which demonstrated that in general, one's abdominal wall affects their health and mental well-being. At 30 days post-op, most patients felt that their abdominal wall does not interfere with activities of daily living.

Conclusions: In a small percentage of patients, abdominal free flap-based breast reconstruction is associated with symptomatic rectus diastasis and abdominal bulge. Minimally invasive robotic repair of rectus diastasis up to 5 cm can be performed with mesh reinforcement. This technique is effective with low complication rates and improvement in quality of life.

ABSTRACT Purpose: In the United States, lymphedema often arises as an adverse effect of lymph node dissections and radiation employed to treat a primary malignancy.(1) Following diagnosis and physical therapy, physiologic surgery such as vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB) are effective in preventing and managing the physical and functional morbidity associated with lymphedema.(2,3) However, further characterization of their relative efficacy in upper and lower extremity, primary and secondary lymphedema is warranted. Methods: A retrospective cohort study of adult patients who underwent therapeutic VLNT or LVB of the upper and lower extremity from January 2018 to August 2022 was conducted. Patients were divided into upper and lower extremity cohorts based on the location of the procedure received. Patient demographics, lymphedema characteristics, operative details, postoperative complications, limb measurements, and pre- and postoperative Lymphedema Life Impact Scale (LLIS) scores were compared between cohorts. Results: A total of 85 patients underwent LVB or VLNT within our study period, of which 65 were of the upper extremity, and 20 patients were of the lower extremity. At the median time of follow-up of 20 (IQR: 11,33) months, patients of the lower extremity cohort had significantly lower reductions in differential measurements at >1 year postoperatively (p=0.0372) and at the time of last follow-up (p=0.047) compared to the therapeutic upper extremity cohort. Similarly, the lower extremity cohort had significantly higher LLIS scores at 1- (p=0.001), 3- (p=0.020), and 6 months (p=0.013) and >1 year postoperatively (p=0.005). Conclusions: Lymphedema surgery may be less effective in improving clinical and patient-reported outcomes in the lower extremity than in the upper extremity. These results emphasize the importance of setting proper preoperative expectations, optimal procedure selection, and a multidisciplinary approach in providing individualized patient care.

REFERENCES 1. Lopez M, Roberson ML, Strassle PD, Ogunleye A. Epidemiology of Lymphedema-related admissions in the United States: 2012–2017. Surgical Oncology. 2020;35:249-253. 2. Scaglioni MF, Fontein DB, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. 2017;37(8):947-953. 3. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plastic and reconstructive surgery. 2013;132(5):1305-1314.

Purpose: Osseointegrated prostheses are a novel solution for lower limb amputees that seek to improve mobility, nerve pain, and other issues related to poorly tolerated sockets. Surgical drains are placed during implantation and soft tissue contouring to reduce post-operative fluid accumulation. Postoperative complications of osseointegration include soft tissue infection and osteomyelitis, which may require operative washout, debridement, and even implant removal if not diagnosed and treated early. Little is known about the impact of drain placement or duration on rates of infection. Firsthand information on drain use and infection rates in this population will aid physicians in preventing and managing adverse outcomes in this comorbid population.

Methods: A retrospective analysis was performed on all patients who received a single-stage lower-limb osseointegration at our institution between 2017 and 2022. Demographics, medical history, and postoperative complications were reviewed. Each patient included in the study had at least 3 months post-operative follow up. Pearson's chi-squared test and Student's t-tests were used to assess the association between patient characteristics and infections, using an alpha of 0.05. Multivariable regression was used to determine the impact of drain duration on infection rate after controlling for other significant predictors of infection identified in the univariate analysis.

Results: Our study included 70 patients: 45 males and 25 females with 50 transfemoral and 20 transtibial amputations. Surgical drains were maintained for an average of 4.5 ± 3.7 days after implantation. 67 patients had 1 drain, and 3 patients had 2 drains. Of these 70 patients, 20 developed a soft tissue infection or osteomyelitis within the first 3 months after implantation. Female sex and history of prior amputation before osseointegration were significant predictors of post-operative infection (p<0.01). Drain duration was not a significant predictor of postoperative infection in the univariate analysis (p>0.05). After controlling for patient sex and history of prior amputation, drain duration was still not a significant predictor of infection when controlling for sex and prior amputation (p>0.05). Notably, there were no instances of postoperative seroma or hematoma in this cohort.

Conclusions: As osseointegrated prostheses become more accessible for lower limb amputees, plastic surgeons will become increasingly responsible for managing soft tissue concerns, including postoperative infection. Our study shows that drain duration is not a predictor of these infections, while sex and previous amputations are nonmodifiable predictors. These results aid physicians in anticipating infectious complications in certain patient populations and demonstrate that drain duration should not influence the decision to remove drains.

Introduction: Burn injuries remain a significant source of trauma in the United States. Of approximately two million burns annually, 100,000 warrant hospitalization. Furthermore, burn injuries disproportionately affect racial and ethnic minorities. Adult African American and Hispanic patients experience worse post-burn outcomes in wound healing and community integration compared to White patients. Although disparities are well documented in adult populations, less is known regarding those in pediatric patients' burn care. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge management in minority pediatric burn patients. We hypothesize these patients require more surgery for their burns and undergo more unplanned re-admissions than non-minority patients.

Methods: A single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, mechanism of burn injury, details of inpatient surgical and non-surgical care, post-discharge follow-up, re-admissions, and post-discharge treatments for scar management were collected. Minority status was determined from patients' self-reported race/ethnicity in the electronic medical record. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized to determine statistical significance in primary outcomes such as burn injury characteristics, readmissions, and follow-up rates between minority and non-minority patients.

Results: A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Average length of stay was 9.3 days (SD: 15.2). Sixty-five (19.6%) patients required burn intensive care unit (ICU) admission, of which average ICU length was 12.7 days (SD: 24.9). Regarding burn treatment, 103 (31.0%) patients underwent surgical management. There were 23 (6.9%) patients who were readmitted, with 314 (94.6%) patients presenting for at least one follow-up visit. Minority (Hispanic, Black, Asian) patients were significantly more likely to experience non-accidental burn injury (p <0.01), inhalational injury (p< 0.01), surgical management (p <0.01), and to require skin graft (p <0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p <0.01) than White patients. Minority patients were not significantly more likely to be readmitted (p =0.82) and have higher TBSA (p = 0.66) than White patients.

Conclusions: Minority pediatric patients often present with worse burn injuries and are significantly more likely to experience non-accidental burns and inhalational injury. These burn injuries require surgical management such as skin graft, which then require longitudinal reconstructive procedures including laser therapy. Further research is necessary to characterize and provide resources and support minority pediatric patients require in their post-burn recovery. Short-term goals should be to better facilitate physical and psychosocial outcomes in this often underserved patient population.

Funding: The contents of this abstract were developed under a grant from the National Institute on Disability, Independent Living, and rehabilitation Research (NIDILRR grant number 90DPBU0007). NIDILRR is a Center within the Administration for Community Living (ACL), Department of health and Human Services (HHS). The contents of this abstract do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.

Background: Obesity rates have dramatically increased over time, with an anticipated 50% of the population to be considered obese or overweight by the year 2030. Correspondingly, the demand for bariatric surgery continues to increase as well. With universal acceptance and significant weight loss following these procedures, the subsequent interest in body contouring increases similarly. Within this unique population of patients who experience massive weight loss, universal BMI cutoffs may inappropriately exclude individuals who may otherwise ultimately be safe surgical candidates who stand to profoundly benefit from the procedure. We aim to systematically review the literature surrounding the role of BMI in the development of post-panniculectomy complications after massive weight loss and establish new BMI cutoff recommendations for preoperative screening. Methods: The authors performed a systematic review and meta-analysis of the literature according to PRISMA guidelines using PubMed, Embase/OVID, and Cochrane databases from inception through June 2022. A meta-regression utilizing a random-effects model was then conducted examining the effect of BMI on all cause post-operative complications with both Cochrane Q and I2 test statistics to assess study heterogeneity. A cohort of patients receiving panniculectomies between 2007-2019 were then identified using NSQIP and used to build a univariate logistic model with respective ROC curves that were internally validated using Python and R. Results: A total of 34 studies were included in the systematic review. A meta-regression model conducted to examine the effect of BMI on all cause post-operative complications utilizing a random-effects model with Cochrane Q and I2 tests demonstrated significant study heterogeneity that precluded meta-analysis. Our NSQIP training cohort univariate logistic regression demonstrates that BMI is significantly associated with all complications (OR 1.05, 95% CI 1.04-1.0). ROC curves developed from this regression demonstrate that BMI significantly predicted all complications and wound complications, with an AUC of 0.64 (95% CI 0.62-0.66) and 0.66 (95% CI 0.63-0.69), respectively. With a testing cohort, we calculated and internally validated a BMI cutoff for all complications to be 33.2 and for wound complications to be 35, that were fit to RSC's which illustrates that after which, we observe only marginal increases in complication incidence with incremental BMI increases. Conclusion: In the setting of rising obesity, the number of patients undergoing bariatric surgery and requesting body contouring procedures after massive weight loss are increasing. Our systematic review and analysis illustrate that the risk of surgical complications rises most dramatically for patients with a BMI over 33.2, which is above several institutions' eligibility cutoffs. By increasing preoperative BMI screening cutoffs, a more nuanced patient-centered conversation regarding risks and benefits of body contouring can be had to ultimately increase access and inclusion for this unique population.