Scientific Abstract Presentations: Reconstructive 6 Friday, October 27 Fri, Oct 27 5:00-6:00 p.m. CDT

Introduction: Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. Our aim was to present our 12-year experience utilizing Integra® bilayer wound matrix for nasal reconstruction. Primary endpoints included success of Integra integration, followed by time to complete healing, complication rate, recurrence, and aesthetic intervention.

Methods: A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with Integra between 2012-2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow up were included.

Results: Fifty-one patients (28 males, 23 females) met inclusion criteria with a median age of 77 years of age. Non-Hispanic Caucasians made up the majority of the study (98%), with 43% having a history of tobacco use. Basal cell carcinoma (BCC) was the most common cutaneous malignancy diagnosed (61.5%), followed by squamous cell carcinoma (SCC) (13.5%), and melanoma in-situ (13.5%). A total of 53 lesions were treated, with each acquired defect repaired and reconstructed separately with Integra. The most common lesion location involved the nasal sidewall (50%), followed by the nasal tip (44.4%). The mean pre-operative lesion size was 3.3 cm2, with a mean post-Mohs surgery defect size of 10.8 cm2. 30.8% (n=16) of defect sites underwent same-day Integra reconstruction, with 69.2% (n=36) proceeding to undergo two-stage reconstruction. Integra successfully reconstructed the acquired Mohs defect in 94.2% of this population. Average time to completed healing was 145.35 + 86.0 days. No instances of disease recurrence were recorded. The total complication rate was 9.62% (n=5). The average size for successful healing without complication is 10.8 cm2. The average defect size for complications or failure of skin graft was 14.7 cm2. Only seven sites (13.46%) underwent procedures for aesthetic improvement, with all revisions occurring after two stage reconstruction.

Conclusion: When used in single or two staged reconstruction, Integra bilayer wound matrix is an adequate reconstructive option for the nose with low complication and revision rates.

Background: Neuropsychiatric disorders (ND) have higher prevalence in patients with Hidradenitis Suppurativa (HS). Bipolar spectrum disorders are over twice as likely in patients with HS compared to age- and behavior-matched controls. Additionally, psychological sequelae associated with lower quality-of-life metrics in patients with HS may contribute to higher prevalence of anxiety and mood disorders. Concomitant ND in the setting of a debilitating and chronic inflammatory disorder may impact how patients interact with their surgeons and interface with the healthcare system at large. This study aims to investigate how ND may impact utilization of plastic surgery care in patients presenting to plastic surgery clinic for HS treatment.

Methods: A retrospective chart review was conducted for patients who were seen in clinic for Hidradenitis Suppurativa by plastic surgery from 2018 to 2022. Data collection included insurance type, number of clinic visits and billed procedures, and history of neuropsychiatric disorders (ND). Patients without at least one procedure in the studied period were assumed ineligible for operative intervention. Otherwise, clinic visit to billed procedure ratio was calculated for patients with at least one procedure. Comparisons of continuous variables used Welch's t-tests and categorical comparisons utilized Odds Ratios and Pearson Chi-Squared analysis.

Results: 218 patients were seen for HS from 2018-2022, for a total of 639 clinic visits and 323 billed procedural codes. 107 (49%) patients had a history of ND with 175 total psychiatric diagnoses, including depression, anxiety, psychotic disorders, and bipolar spectrum disorders. Patients with concomitant HS and ND were 2.32 times as likely to have public insurance compared to HS patients without ND (p=0.0046). The average number of clinic visits for patients with ND (3.28 ± 3.30) compared to patients without ND (2.65 ± 2.27) were found to have no difference (p=0.10). Of those who had at least one procedure (86), the average number of billed procedures for patients with ND was 3.24 and 4.43 for patients without ND (p=0.227). Clinic Visit to Billed Procedure ratios (CV:BP) were calculated for patients who underwent at least one procedure, with an overall average of 1.95:1. For patients with ND, the average CV:BP was 2.23:1 while patients without ND were shown to have a significantly lower CV:BP at 1.57:1 (p=0.044). Of ND diagnoses, the highest CV:BP ratios were found in patients with depression and bipolar spectrum disorders, both found to have average CV:BP ratios of 2.34:1.

Conclusions: Prevalence of ND is high in patients with HS. While there was no significant difference in overall clinic visits or billed procedures between HS patients with and without ND, there was a significantly higher ratio of clinic visits per billed procedure in patients with ND. Surgeons with HS practices may find it beneficial to streamline utilization of plastic surgery resources while remaining sensitive to individual patient needs. Further investigation will include assessment of revision rates, disease severity, and medical therapy optimization in association with ND in the HS population.

Introduction: To date, little is known about the relationship between donor-HLA-specific antibodies (DSAs) and C4d deposition in target tissues of facial vascularized composite allografts (fVCA). Knowledge about the relationship would help better define the potential role of these classic surrogate parameters of antibody mediated rejection (AMR) for the characterization of VCA rejection.
Materials & Methods: We retrospectively studied the relationship between DSAs and C4d target tissue deposition in a cohort of nine fVCA patients who received a total of ten fVCAs, performed at Brigham and Women´s Hospital (Harvard Medical School, Boston, USA) between 2009 and 2020; currently being followed at Yale New Haven Hospital (Yale School of Medicine, CT, USA). DSA cutoff for positivity was at 1,000 mean fluorescence intensity units and C4d positivity was assessed through dermatopathology via immunostaining. Phi coefficient for DSA and C4d result (binary variables) correlation, point-biserial test for DSA and C4d result correlation with rejection grade and post-operative month, and Spearman correlation between rejection grade and postoperative month, were computed using Python SciPy v1.10.0 library. Results: Four patients showed de novo DSA formation following facial transplantation. Suspecting AMR in fVCA recipients led to C4d testing in four members of this cohort, yielding positive results at various points post-transplant. In the time-points with simultaneous measurements of DSA and C4d, 19.4% of time-points had positive DSA and C4d measurements, 50% had only one positive value and 30.6% showed negative results for both DSA and C4d. The average rejection grade was highest (mean=2.0, SD=0.75) in the time points with two positive values, compared to points with one positive value (mean=1.66, SD=1.20) and two negative values (mean=1.16, SD=1.11). DSA and C4d did not show correlation (φ=0.0, p=0.12). In instances of concurrent skin and mucosa rejection grade measurements, 32% showed different results in mucosa and skin according to the Banff Classification, however, difference of rejection grade between skin and mucosa was not statistically significant. Conclusion: While a trend was observed with higher grade of rejection and simultaneously positive DSA and C4d results, no notable correlation was discerned between DSA and C4d deposition in target tissues. It is noteworthy that only skin samples were immuno-stained for C4d, and with preceding evidence suggesting higher immunogenicity of mucosa compared to skin, there is a possibility of a more robust antibody-mediated response in mucosa which could have been overlooked in this study. This limitation warrants further investigation of AMR in mucosa samples, as deep tissue rejection may not be accurately reflected in the skin; skin samples rarely showed classic signs of AMR such as evidence of vasculitis, neutrophilic margination, thrombi in DSA+/C4d+ samples. Further studies are necessary to elucidate the exact role of AMR for VCAs.

Purpose: Standard dressings for the treatment of pediatric partial thickness burns require frequent dressing changes that are both painful and anxiety-inducing for patients. Our institution adapted a traditional skin graft donor site dressing into a 'stickdown' burn dressing. This consists of a one-time application of bacitracin and 3% bismuth tribromophenate/vaseline impregnated gauze (Xeroform™) that adheres to the wound bed and peels off as new epithelialized skin forms. The goal was to minimize patient/caregiver discomfort, narcotic usage, and hospitalization rates. This study aimed to compare clinical outcomes of the stickdown dressing to traditional dressings.

Methods and materials: A retrospective cohort study of pediatric patients (age < 18 yrs) with partial thickness burns treated at a Level I pediatric trauma center over four years was conducted. Patients who received a standard dressing regimen (N = 74 "NSD") were matched to patients treated with a Xeroform™ stickdown protocol (N = 37 "SD"). Propensity score matching based on age, burn depth (superficial vs deep partial thickness), mechanism of injury, and total body surface area (TBSA) was performed. Univariate analyses utilized Wilcoxon Rank Sum and Fisher's Exact tests.

Results: The two cohorts had similar demographics and burn characteristics including mechanism of injury (NSD: 79.7% scald, 17.6% contact/friction, 2.7% flame vs SD: 86.5% scald, 13.5% contact/friction, P=0.55), and median TBSA (2.5% NSD vs 3% SD, P=0.70). A similar number of patients were admitted to the hospital (31.1% NSD vs 32.4% SD, P=1.0), most commonly for pain control (54.5% NSD vs 58.3% SD, P=0.80). Hospital stay duration was longer in standard dressing group but the difference was not statistically significant (median 2.0 days NSD vs 1.0 days SD, P=0.23). Stickdown patients utilized a similar amount of narcotics during their hospitalization (7.7+/-12.1 average daily morphine milli-equivalents vs 5.1+/-9.5, P=0.91). There were no differences in outcomes such as time to burn re-epithelialization (median 13.0 NSD vs 12.0 SD days, P=0.20) or any wound healing complications. The only significant difference was median number of dressing changes needed (12.0 NSD vs 0.5 SD, P<0.0001).

Conclusions: The Xeroform™ stickdown dressing requires significantly fewer dressing changes and has equivalent clinical outcomes to standard dressings for the treatment of pediatric partial thickness burns. Decreasing dressing change frequency has the potential to decrease both anxiety during burn recovery and subsequent psychological effects, such as anxiety or PTSD, which are common following pediatric burns.¹

1. Woolard A, Hill NTM, McQueen M, et al. The psychological impact of paediatric burn injuries: a systematic review. BMC Public Health. 2021;21(1):2281. Published 2021 Dec 14. doi:10.1186/s12889-021-12296-1

Background: Access to surgical care in low-to-middle-income countries (LMIC) especially in war-torn and refugee-densely populated areas such as Palestine is increasingly recognized as a global health priority. Plastic surgical capacity in Palestine has not been evaluated before in the current published literature. The aim of this study was to conduct the first systematic, comprehensive, and nationwide evaluation of plastic surgical capacity in Palestine.

Methods: This is a cross-sectional study conducted between December 2022 and February 2023 and included all healthcare facilities that provide plastic surgery services in Palestine except private centers run by non-surgeons. A modified version of the validated 5-domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool was administered in each facility through a face-to-face interview. Hospitals' PIPES indices were computed; data were aggregated and analyzed for geographic and private/public disparities.

Results: A total of 9 facilities were included in the study; 5 (55.6%) were in the West Bank and 4 (44.4%) in Gaza. The majority were governmental hospitals (n=5, 55.6%). The mean PIPES index was (Personnel = 4.1, Infrastructure = 18.6, Procedures = 10.2, Equipment = 19.7, and Supplies = 22.4). The number of hospital beds, functioning operating rooms, and plastic surgeons (regardless of board-certification status), per 100,000 people were 41.3, 0.9 and 0.4, respectively. There were only 4 board-certified plastic surgeons; only one in Gaza. None of the facilities surveyed had a plastic surgery residency training program. Deficiencies in PIPES were significant as follows: 77.8% of facilities do not perform free flaps (none in Gaza), 55.6% do not perform any microsurgical procedures (none in Gaza), 55.6% lack a system to identify complications, and 55.6% of facilities do not offer regular plastic surgery CME courses to their plastic surgeons. The average hours of electricity per day in Gaza vs West Bank was 8.0 vs 24.0, p=0.02.

Conclusions: Evaluating plastic surgical capacity in Palestine reveals significant deficiencies across all five domains of the modified PIPES tool, most pronounced in Gaza. We hope these results would inform stakeholders about the status of plastic surgery in Palestine to help eliminate surgical care disparities, to build plastic surgical training programs, and to improve access to safe plastic surgical care in the country.

Background En-bloc excision of sacral tumor results in extensive bone and soft tissue defects as well as vital organ exposure"1". Soft tissue reconstruction is essential for dead space obliteration and wound healing"2". Diverse reconstruction options using locoregional flaps have been utilized, but were limited by postoperative morbidity as high as 50%"3". An optimal reconstruction method that offers acceptable complication rates has yet been sought for. Here, we aimed to evaluate the effectiveness of free latissimus dorsi (LD) flap for post-sacrectomy defect reconstruction by comparing its outcomes with that of a local gluteus maximus (GM) flap.

Methods A retrospective review was conducted of all patients who underwent partial or total sacrectomy and immediate soft tissue reconstruction with free LD flap or local GM flap between January 2013 and December 2022. Postoperative outcomes including complication and patient recovery were compared between the two groups.

Results Nineteen patients were analyzed, including 10 with local GM flap and nine with free LD flap. The two groups showed similar baseline characteristics. Complication developed in nine patients: seven in the GM group (70%) and two in the LD group (20%). In the GM group, seroma (50%) was most common, followed by wound dehiscence (40%), infection (30%), and re-operation (30%). Two donor site seromas (22%) were reported in the LD group, which were resolved with clinic-based aspirations. NO complication developed at the sacrectomy site in the LD group. The LD group showed a significantly shorter drain-indwelling period (8.1 days vs. 13.7 days), smaller drain amount (810 cc vs. 3361 cc), shorter hospital stay (22.9 days vs. 48.8 days), and earlier initiation of ambulation or rehabilitation (8.4 days vs. 30.5 days) than the GM group.

Conclusion Soft tissue reconstruction with free latissimus dorsi myocutaneous flap provides reliable outcomes and enables early recovery in sacrectomy patients. Free LD flap may be considered more effective for post-sacrectomy reconstruction, compared to traditional loco-regional flaps.   References 1. Fourney DR, Rhines LD, Hentschel SJ, et al. En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg Spine. 2005;3(2):111-122. 2. Diaz J, McDonald WS, Armstrong M, Eismont F, Hellinger M, Thaller S. Reconstruction after extirpation of sacral malignancies. Ann Plast Surg. 2003;51(2):126-129. 3. Asaad M, Rajesh A, Wahood W, et al. Flap reconstruction for sacrectomy defects: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(2):255-268.

Background: There is little known about the incidence of postoperative complications among patients with COVID-19 positivity undergoing elective surgical operations. The purpose of this study was to identify differences in post-operative complications following elective abdominal wall reconstruction (AWR) in patients diagnosed with COVID-19 as compared to patients presenting pre-pandemic.

Methods: A single-institution, retrospective chart review was performed of patients who underwent AWR with component separation technique and placement of acellular dermal matrix between January 2017-September 2022. Patients were stratified by date: pre-COVID-19 (1/2017-12/2019) and post-COVID-19 (1/2020-9/2022). All patients with a confirmed positive Covid-19 diagnosis were also identified. Data collected included demographics, clinical characteristics, and complications. Complications were classified as major (requiring readmission or needing surgical intervention) and minor. Univariate and multivariate analyses were performed.

Results: 168 patients were included. The mean age was 54 and mean BMI was 33. There were 75 patients who underwent surgery pre-COVID and 93 patients after. 16/93 (17%) had a positive COVID-19 test prior to surgery or during perioperative period. These two groups were risk matched. COVID-19 patients had no significant increase in postoperative complications. Major complications occurred in 13.3% in the pre-COVID group and 7.5% in the post-COVID. COVID-19 patients were more likely to be younger (48 vs 57, p=0.049); and more likely to have a shorter length of stay in the hospital (3 vs 5.8; p=0.038).

Conclusion: During the pandemic, there was no associated increase in postoperative complications in our case series of patients undergoing AWR with component separation and acellular dermal matrix. This study by is limited by its small sample size. Further investigation should be done on this topic to obtain more statistical power.

Background: Gender disparities in plastic surgery (PS) authorship have been documented in PS literature. The Relative Citation Ratio (RCR) Index is a new metric that normalizes for field and time, which can be utilized to compare authors. This study aims to evaluate differences in gender authorship in reconstructive microsurgery (RM) studies, as well as the impact of gender on the RCR Index.

Methods: A cross-sectional study was performed from 2002 to 2020. A PubMed query was constructed using keywords and controlled vocabulary to extract RM-related studies in the top 1 plastic surgery journal: Plastic and Reconstructive Surgery Journal. A two-stage screening process by two independent reviewers was conducted to select eligible studies. If discordance was present a third reviewer moderated the discussion, and a joint decision was made. Names of first and senior authors were extracted. The likely gender was adjudicated by using NamSor-Software. If the gender probability calibrated was <85% a manual internet search was performed. RCR information was extracted from NIH iCite. Unpaired T-test and Chi-Squared test were used to assess differences between groups.

Results: A total of 424 articles were included in this study, corresponding to 827 authors. A statistically significant difference was found in the rates of gender between first and senior authors (p = 0.021). The first authors were identified as males in 80% of the cases and females in 20%. Significant higher mean weighted RCR were found in male compared to female first authors (52.2 females vs 111.2 males, p < 0.001). For senior authors, males represented 89% and females 11%. No statistically significant differences were found in the mean weighted RCR between senior authors' gender (122.1 females vs 171.6 males, p = 0.1184).

Conclusion: A considerably greater number of males are publishing in RM-related studies compared to females, with significantly more males being senior authors compared to first authors. Males had higher weighted RCR scores compared to females. This study suggests that equity in gender authorship within this field is yet to be achieved and future studies identifying barriers for females to publish in RM are needed to properly propose targeted efforts to decrease this gender disparity.

Purpose: Recent findings have identified pre-transplant coping as an important factor in predicting psychosocial trajectories in recipients of a face transplant. However, little is known about how post-transplant coping strategies impacts psychosocial (long-term) outcomes in fVCA patients. Therefore, with an increasing number of patients receiving face transplantation, it is important to understand the psychosocial effects of this life altering procedure, which is the aim of this study.

Materials & Methods: We assessed post-transplant coping and psychosocial outcome across eight fVCA patients, receiving transplantation at Brigham and Women´s Hospital (Harvard Medical School) between 2009 and 2020 and currently being followed at Yale New Haven Hospital (Yale School of Medicine), using the Brief-COPE questionnaire and the Short-Form-12 questionnaire for self-reported physical and mental health(questionnaires being administered from October 2022 to January 2023). The nine coping mechanism categories studied using Brief-COPE were Acceptance, Positive Reframing, Active Coping and Planning, Emotional and Instrumental Support, Religion, Humor, Behavioral Disengagement, Denial & Self-blame, and Substance Use.

Results: Scores in three coping mechanism categories showed a negative association with mental health: Behavioral Disengagement (r=-0.577, p=0.25), Denial & Self-blame (r=-0.733, p=0.071), and Substance Use (-0.412, p=0.5) and the other six factors showed mild to moderate positive correlation with mental health. Religion showed strong and significant negative correlation with physical health (r=-0.89, p=0.006). Older age of recipient strongly correlated with higher mental health scores (r=0.77, p=0.033) as well as with usage of Emotional and Instrumental Support (r=0.729, p=0.049). Time since transplantation negatively correlated with mental health (r=-0.524, p=0.197). Within coping mechanism categories, Venting and self-distraction correlated significantly with active coping (r=0.788 p=0.025), humor and active coping also showed strong association (r=0.808, p=0.020) and moderate negative correlation was observed between substance use and usage of emotional and instrumental support (r=-0.425, p=0.500); substance use also positively correlated with denial and self-blame (r=0.756, p=0.125).

Conclusion: Patients and their support network should receive education and guidance to reduce harmful coping mechanisms and promote adaptive strategies that have been shown to positively impact physical and mental health, and this guidance should be tailored and specific to the patient. Factors supporting mental health outcomes may differ from those supporting physical recovery, such that separate attention should be given to coping factors specifically associated with positive psychosocial outcomes. Our findings suggest that working towards decreasing Behavioral Disengagement, Denial & Self-blame, and Substance Use may be particularly relevant targets for therapeutic interventions post-transplant, as our analysis suggests diminishing a harmful coping strategy can associate with decreased use of other maladaptive mechanisms and increased usage of adaptive coping mechanisms. Addressing these coping strategies and their correlation with physical and mental health is crucial for improving the long-term psychosocial outcome for face transplant recipients and preventing adverse effects such as non-adherence and chronic rejection, which can lead to graft loss and death.