Scientific Abstract Presentations: Reconstructive Session 2 Thursday, October 9 Thu, Oct 9 5:00-6:00 p.m. CDT

Background In the evolving field of vascularized composite allotransplantation (VCA), face transplantation has become a transformative option for patients with severe facial disfigurement. However, graft rejection remains a substantial challenge, particularly within the first post-transplant year. In solid organ transplantation, new induction therapies such as rituximab, a B-cell depleting agent, have demonstrated efficacy in reducing acute rejection episodes. However, its use in face transplantation has not been studied. This is the first study to report rituximab induction in face transplantation, evaluating its effectiveness in reducing facial allograft rejection.

Methods
This retrospective review was conducted of four face transplant patients who underwent induction therapy with rituximab and thymoglobulin, followed by triple maintenance immunosuppression, between 2015 and 2023 at our institution. Acute rejection was assessed using a comprehensive approach of clinical appearance, histopathology, and blood sampling, including donor-specific antibody (DSA) levels. These recipient-derived antibodies target donor antigens expressed on the allograft, potentially causing graft injury or rejection. Data analyzed included the time to first rejection, subsequent episodes, and DSA levels. A linear mixed-effects model assessed the relationship between DSA levels and rejection. A linear mixed-effects model was applied to examine the relationship between DSA levels and rejection while accounting for inter-patient variability and timing differences.

Results
In our cohort, the median time to first rejection was 536 days. Patient 1 remained rejection-free for over four years until postoperative day (POD) 1465, at which time DSA was detected. Patient 2 experienced their first rejection on POD 536 with DSA detection. Patient 3's first rejection episode occurred on POD 279, but no DSA was identified at that time, and they have remained DSA-negative since their transplant 4.5 years ago. Finally, Patient 4 has neither experienced rejection nor shown evidence of DSA, currently remaining rejection-free at 1.5 years post-transplant. The linear mixed-effects model did not reveal a significant association between DSA levels and rejection, even after adjusting for patient variability, duration of postoperative follow-up, and differences in timing of rejection episodes.

Conclusions This is the first study to report the outcomes of rituximab-based induction in face transplantation. Our findings show that rituximab can effectively extend rejection-free survival beyond one year. Although some patients developed DSA during episodes of rejection, no significant association between elevated DSA levels and rejection was observed. This may suggest that DSA may not be a reliable predictor of rejection in this induction therapy regimen. Further research is needed to identify more accurate biomarkers for monitoring rejection in these patients.

References 1. Chauhan K, Mehta AA. Rituximab in kidney disease and transplant. Animal Model Exp Med. 2019;2(2):76-82. Published 2019 Mar 26. doi:10.1002/ame2.12064

Background: Soft tissue sarcomas often require reconstruction using either free or pedicled flaps. Lymphedema is a debilitating complication that can develop in this population postoperatively, leading to infections and significant morbidity (1). While prior studies have explored systemic risk factors such as neoadjuvant radiation, surgical risk factors for lymphedema remain poorly defined. Wu et al. (2023) found no difference in lymphedema rates between free and pedicled flaps in thigh sarcomas, but broader extremity analyses are lacking (2). This study evaluates lymphedema incidence following free versus pedicled flap reconstruction for upper and lower extremity sarcomas.

Methods: A single-center retrospective review was performed of adult patients who underwent extremity sarcoma reconstruction between 2015 and 2024. Patients were grouped into two cohorts based on reconstruction type: free or pedicled flap. Demographic and clinical variables (age, sex, operative time, time from resection to reconstruction, hypertension, peripheral artery disease, smoking status, functional status, lymph node dissection, preoperative radiation therapy/chemotherapy, and length of follow up) were compared between cohorts using chi-square and t-tests. A Firth penalized-likelihood logistic regression model was employed to assess the association between reconstruction type and lymphedema development, while including covariates such as age, sex, and neoadjuvant radiation.

Results: There were 75 patients identified: 33 free flaps and 42 pedicled flaps. Free flaps included anterolateral thigh (51.5%), latissimus (15.2%), and superficial circumflex iliac artery perforator flap (12.1%) while pedicled flaps included gastrocnemius (16.7%), vertical rectus (14.3%) and latissimus flaps (11.9%). The majority of patients underwent lower extremity reconstruction (53/75, 70.7%), while the remainder underwent upper extremity reconstruction (22/75, 29.4%). Demographics were comparable between the free and pedicled flap cohorts, with no significant differences in sex, incidence of hypertension, active smoking (21.2% vs 33.3%, p = 0.25), age (61.7 vs 56.5 years, p = 0.18), or follow-up duration. Pedicled flaps demonstrated significantly shorter operative times than free flaps (5.4 vs 8.2 hours, p < 0.001). Sentinel lymph node dissection was performed in 7 cases (9.3%). There were 10 patients who developed lymphedema post-operatively, none of whom underwent lymph node dissection. Notably, lymphedema was observed exclusively in the pedicled flap cohort (10/42 vs 0/33, p = 0.003). Multivariable Firth regression identified pedicled flap reconstruction as an independent predictor of lymphedema (coefficient 3.66, 95% CI 0.58–6.76, p = 0.020) compared to free flap reconstruction. In contrast, age (p = 0.320) and history of preoperative radiation (p = 0.320) were not statistically significant predictors of lymphedema.

Conclusion: Pedicled flap reconstruction was associated with the development of lymphedema in extremity sarcoma patients, while free flap patients had no observed cases. These findings suggest free tissue transfer may potentially reduce lymphatic disruption, particularly in the setting of oncologic extirpation. Future studies in larger cohorts are needed to validate these findings and to explore the role of intraoperative lymphatic preservation techniques in mitigating risk.

References: (1) Friedmann D, Wunder JS, Ferguson P, et al. Incidence and Severity of Lymphoedema following Limb Salvage of Extremity Soft Tissue Sarcoma. Sarcoma. 2011;2011:289673. doi:10.1155/2011/289673 (2) Wu P, Elswick SM, Akhavan AA, et al. Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction. Plast Reconstr Surg Glob Open. 2020;8(7):e2912. doi:10.1097/GOX.0000000000002912

Introduction: Effective pain management is crucial in perioperative care, particularly in open abdominal wall reconstruction (OAWR). Epidural analgesia has been the gold standard for abdominal surgeries (1), but continuous peripheral nerve blocks such as ON-Q have gained popularity due to their potential advantages, including postoperative outcomes and cost benefits (2). This study compares the perioperative outcomes and costs associated with epidural analgesia versus ON-Q pain control in OAWR.

Methods: A retrospective review of a prospectively maintained single-surgeon database from 2012to 2019 identified OAWR patients receiving either epidural analgesia or ON-Q pain control. Primary outcomes included hospital length of stay (LOS) and complication rates (infection, wound dehiscence). A cost analysis was conducted to estimate comparative costs of each modality using contemporary institutional pricing. Statistical significance was set at p<0.05.

Results: Among 401 OAWR patients, 226 received epidural analgesia, and 175 received ON-Q. Mean LOS was significantly shorter in the ON-Q group (7.8 vs. 9.7 days, p<0.001). Complication rates, including infection and wound dehiscence, were similar between groups (p>0.05). Cost analysis estimated a total 3-day postoperative cost of $1,400–$3,300 for epidural analgesia versus $1,200–$2,400 for ON-Q. The shorter LOS in the ON-Q group suggests potential cost savings by reducing hospitalization days.

Conclusion: ON-Q pain control is associated with a significantly shorter hospital stay and comparable complication rates compared to epidural analgesia in OAWR. Cost analysis suggests potential financial benefits. Further prospective studies are needed to validate these findings and assess long-term outcomes.

(1) Melland-Smith M, Zheng X, Messer N, Beffa L, Petro C, Prabhu A, Krpata D, Rosen M, Miller B. Epidural analgesia and post-operative ileus after incisional hernia repair with transversus abdominis release: Results of a 5-year quality improvement initiative. Am J Surg. 2024 Apr;230:30-34. doi: 10.1016/j.amjsurg.2023.11.009. Epub 2023 Nov 11. PMID: 38000938.

(2) Gebhardt R, Mehran RJ, Soliz J, Cata JP, Smallwood AK, Feeley TW. Epidural versus ON-Q local anesthetic-infiltrating catheter for post-thoracotomy pain control. J Cardiothorac Vasc Anesth. 2013 Jun;27(3):423-6. doi: 10.1053/j.jvca.2013.02.017. PMID: 23672860.

Introduction: Vascular complications in fibula free flap (FFF) surgery can arise from atherosclerotic and arteriosclerotic disease in the peroneal artery. (1) Computed Tomography Angiography (CTA) has become the standard for preoperative risk assessment. (2) However, current evaluations rely on qualitative assessments to determine surgical eligibility. Therefore, using two quantitative scoring systems that assess different components of vascular health, we aim to improve preoperative vascular assessment and patient risk stratification in FFF surgery. The first is the bollinger score, a validated system that provides a graded measurement of atherosclerotic burden from the contrast phase of CTA scans. (3) The second is the Lower Limb Arterial Calcification (LLAC) score, which measures the amount of calcium buildup using the Agatston method on the non-contrast phase of CTA scans. (4) By combining both scoring systems, our goal is to comprehensively assess vascular health in the peroneal artery and establish a more objective framework for preoperative risk stratification in FFF surgery.

Methods: A retrospective review was conducted on all head and neck microvascular FFF procedures performed at a university-affiliated, tertiary care center between August 2021 and March 2023. Data collected included patient demographics, medical history, operative details, and postoperative complications within 90 days. Peroneal artery bollinger and crural segment LLAC scores from the donor lower extremity were calculated from preoperative CTAs.

Results: A total of 117 patients were included. In our unadjusted analysis, higher bollinger scores showed a significantly increased risk for flap failure. After adjusting for potential confounders, increasing bollinger scores remained significantly associated with an increased risk of major complications, minor complications, and longer hospital stays. Increasing LLAC scores showed a trend toward increased fistula formation. Combining both scores improved risk stratification, as patients who exceeded both receiver operating characteristic cut points experienced an 8.36-fold higher risk of major complications.

Conclusions: Preoperative vascular assessment of donor vessels is critical for optimizing free flap survival and minimizing postoperative complications. This study is the first to explore the utility of quantitative preoperative risk assessment in FFF surgery. Our findings suggest that preoperative vascular scoring systems can stratify patient risk and enhance surgical planning, and that integrating multiple scoring systems to assess different aspects of vascular health may improve risk prediction. However, multi-institutional studies with larger patient cohorts and extended follow-up periods are necessary to validate these findings and establish standardized preoperative risk models.

1. Karanas YL, Antony A, Rubin G, Chang J. Preoperative CT angiography for free fibula transfer. Microsurgery. 2004;24(2):125-127. doi:https://doi.org/10.1002/micr.20009
2. Abou-Foul AK, Fasanmade A, Prabhu S, Borumandi F. Anatomy of the vasculature of the lower leg and harvest of a fibular flap: a systematic review. Br J Oral Maxillofac Surg. Nov 2017;55(9):904-910. doi:10.1016/j.bjoms.2017.08.363
3. Bollinger A, Breddin K, Hess H, et al. Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images. Atherosclerosis. Feb-Mar 1981;38(3-4):339-46. doi:10.1016/0021-9150(81)90050-2
4. Chowdhury MM, Makris GC, Tarkin JM, et al. Lower limb arterial calcification (LLAC) scores in patients with symptomatic peripheral arterial disease are associated with increased cardiac mortality and morbidity. PLoS One. 2017/9/8 2017;12(9):e0182952. doi:10.1371/journal.pone.0182952

Background: Breast cancer–related lymphedema (BCRL) significantly affects quality-of-life after axillary lymph node dissection (ALND). Although immediate lymphatic reconstruction (ILR) may reduce BCRL incidence, long-term outcomes and predictors remain unclear. We report long-term BCRL prevalence in patients undergoing ILR and delineate factors associated with BCRL after ILR.

Study Design: We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 at our institution. Primary outcome was BCRL prevalence, defined as ≥2cm limb difference at two contiguous points. Secondary outcomes included BCRL predictors, postoperative complications, and compression garment use.

Results: We identified 172 patients with a mean age 50.9±11.6 years, body mass index of 29.5±6.9 kg/m², and follow-up time of 23.1±15.2 months. Most patients (57.7%) underwent mastectomy, ALND with breast reconstruction. Median number of lymph nodes removed during ALND was 15 (IQR, 10.0-21.0), and median number of positive lymph nodes was 2.0 (IQR, 0.0-4.0). Cumulative BCRL incidence was 7.0% (n=12 patients). Compared to pooled estimates from 10,774 patients undergoing ALND alone, ILR cohort had significantly lower BCRL rates: 2.5% vs. 16.5% (<12 months), 3.7% vs. 24.6% (12–24 months), and 7.0% vs. 23.6% (>24 months) (p < 0.001). Black/African American patients had significantly higher lymphedema rates than White patients (18.8% vs. 4.5%, p=0.005). In adjusted analyses, Black/African American race was an independent predictor (OR, 6.38; p<0.006) of BCRL.

Conclusions: ILR following ALND demonstrated significantly lower BCRL rates compared with ALND alone, although Black or African American patients remain at disproportionately higher risk, warranting targeted interventions and further investigation.

Background: TXA is an antifibrinolytic drug that stabilizes fibrin clots and is widely used by surgeons for its hemostatic properties but importantly has not been shown to increase the risk of thromboembolic events. However, there are little to no data regarding the effect of TXA at the microvascular level, particularly how it affects skin flap perfusion. This knowledge gap is of particular concern for surgeons who perform procedures that include elevation of random flaps, for both reconstructive and aesthetic applications, where thin skin flaps rely on random pattern blood flow. To address this question, we utilized a pre-clinical model of random flap elevation to assess the effect of TXA treatment on microvascular perfusion. Methods: A dorsal McFarlane flap model (3 cm x 9 cm) with a cranial pedicle was performed in 250-300g Sprague Dawley rats receiving either 1) intravenous TXA at a therapeutic in vivo dose (10 mg/kg) N=6, 2) intravenous PBS of equal volume N=5, 3) subcutaneous (injected into the flap) TXA at therapeutic in vivo dose (10 mg/kg) N=6, or 4) subcutaneous (injected into the flap) PBS injections of equal volume N=5. The TXA or PBS was injected intravenously via tail vein as a 1 mL bolus or subcutaneously into the flap in 20, 100 microliter injections distributed evenly across and within a 1 cm perimeter around the entire flap, 5 minutes prior to incision. Area percent gross necrosis of the flap was measured using ImageJ image analysis software at days 7 and 14. In vivo fluorescent imaging following intraperitoneal fluorescein injection was also performed at each timepoint to assess flap perfusion and congruence with gross imaging. Two-tailed t-tests were performed to assess differences in area percent gross necrosis between groups. Histological analysis to assess vascularity, wound healing, and microscopic necrosis is ongoing. Results: Groups receiving TXA perioperatively had significantly lower area percent gross necrosis compared to control at day 7 (32.94 vs. 15.17, p=0.0448) and day 14 (34.83 vs. 14.03, p=0.0120). There was no difference in effect between subcutaneous and intravenous routes of administration for both PBS at day 7 (36.69 vs 30.70, p=0.7108) or day 14 (31.33 vs. 37.45, p=0.7159) or TXA at day 7 (13.14 vs. 17.19, p=0.6930) or day 14 (15.96 vs. 12.10, p=6033). This was supported by fluorescent imaging findings. Conclusions: Peri-operative administration of TXA does not negatively impact thin random flap perfusion and may even decrease rates of necrosis with no difference between subcutaneous and intravenous administration. These data provide further evidence regarding the safety for use of TXA as a hemostatic agent in procedures that involve elevation of random flaps.

Background: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is associated with significant postoperative pain and resource utilization. Although transversus abdominis plane (TAP) blocks are gaining momentum in Enhanced Recovery After Surgery (ERAS) protocols, data on their cost-effectiveness-particularly the differential impact on unilateral versus bilateral procedures-remain limited.

Methods: A retrospective cohort study was conducted analyzing data from 129 patients (TAP group: n=65; No-TAP group: n=64) who underwent DIEP flap breast reconstruction at a single institution between 2012-2023. Primary outcomes included initial pain scores (0-10 scale), hospital stay, and total opioid consumption (converted to intravenous morphine equivalents). Propensity score matching and multivariate regression analyses controlled for potential confounders including BMI, procedure laterality, and timing. Economic analysis within an ERAS framework incorporated estimates of inpatient care costs, TAP block placement and infusion with standard bupivacaine/ropivacaine, analgesic medications, PCA usage, and epidural usage.

Results: After propensity score matching, patients who received TAP blocks demonstrated significantly shorter hospital stays compared to those without TAP blocks (4.58 vs. 5.45 days, p=0.0004). Initial pain scores were lower in the TAP group but did not reach statistical significance (3.63 vs. 4.50, p=0.25). Total opioid consumption was similar between groups (46.98 vs. 50.43 mg IV morphine equivalents, p=0.78), though previous studies have demonstrated opioid-sparing effects (1). The data demonstrated a clear shift in pain management strategy, with TAP blocks effectively replacing traditional modalities as evidenced by substantially reduced utilization of PCA pumps (4.6% vs. 59.4%) and epidurals (1.5% vs. 18.8%), while maintaining comparable pain control. Economic analysis revealed significantly lower total healthcare costs in the TAP group ($17,540 vs. $20,350, p=0.003), representing a $2,810 (13.8%) cost reduction per patient. Importantly, cost savings were more pronounced for unilateral procedures (23.6% reduction) compared to bilateral procedures (6.6% reduction), primarily driven by greater hospital stay reduction in unilateral cases (27.2% vs. 11.7%).

Conclusions: This study highlights a novel aspect of TAP block utilization: greater cost savings in unilateral DIEP flap reconstructions. Overall, TAP blocks were associated with significantly shorter hospital stays and substantial healthcare cost reductions, consistent with prior economic analyses in abdominal surgery (2). By integrating TAP blocks into ERAS protocols, we observed a marked decrease in both PCA and epidural use, indicating a fundamental shift in perioperative pain management that preserves adequate analgesia while reducing resource utilization. The notably larger cost reduction in unilateral procedures versus bilateral procedures offers practical guidance for clinical decision-making and resource allocation in breast reconstruction. These findings reinforce the value of TAP blocks in ERAS pathways for DIEP flap surgery.

References: 1. Zhong T, Ojha M, Bagher S, et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: a double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg. 2014;134(5):870-878. doi:10.1097/PRS.0000000000000613 2. Ayad S, Babazade R, Elsharkawy H, et al. Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia [published correction appears in PLoS One. 2016 Sep 22;11(9):e0163687. doi: 10.1371/journal.pone.0163687.]. PLoS One. 2016;11(4):e0153675. Published 2016 Apr 15. doi:10.1371/journal.pone.0153675

BACKGROUND: Cancer-related lymphedema is an incurable, chronic, debilitating and lifelong condition affecting one in three cancer patients undergoing axillary lymph node dissection. Lymphovenous bypass (LVB) is a promising surgical intervention for the management of cancer-related lymphedema. This condition, resulting from damage to the lymphatic system following cancer treatment, leads to swelling, pain and functional impairment. This significantly impacts patients' quality of life. Despite the increasing use of LVB for lymphedema treatment in recent years, there is a lack of high-level, prospective, long-term data and standardized outcome metrics. The purpose of this study was to analyze the long-term, prospective outcomes of LVB throughout the past two decades using all available outcome measures.

METHODS: We conducted a systematic review on PubMed, Embase, and Web of Science to identify prospective clinical trials investigating LVB for lymphedema treatment in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Outcome data included limb measurements, cellulitis episodes, compression use, and complications. Only prospective clinical trials with a minimum follow-up duration of 12 months were included. For studies involving multiple procedures, only outcomes from LVB cohorts were analyzed.

RESULTS: Eighteen prospective studies (2004-2024) were included, comprising a total of 1334 patients undergoing LVB with a mean follow-up time of 18.7±10.6 months. An average of 3.0±0.7 anastomoses were performed per patient. LVB was associated with significantly reduced limb volumes with 19.72% (95% CI 18.44-21.82; p<0.001), 27.42% (95% CI 26.85-31.05; p<0.001) and 29.55% (95% CI 29.05-32.07; p<0.001) mean reduction one, two and three years after LVB, respectively. Additionally, LVB decreased the total number of cellulitis episodes by 97.0% (95% CI 94.72-98.02; p<0.001) and the number of episodes per year by 91.6% (95% CI 90.02-93.09; p<0.001). A total of 41.4% of patients discontinued compression garment use following LVB.

CONCLUSIONS: This is the largest study to evaluate the long-term safety and efficacy of LVB, summarizing two decades of prospective experience. LVB is a safe and effective treatment option, yielding durable improvement in limb volumes and cellulitis reduction. LVB is a safe and effective treatment option, yielding durable improvements in limb volumes and reductions in cellulitis episodes. Additionally, LVB facilitates a reduced dependency on compression garments, enhancing patients' quality of life.

Purpose We have previously presented our protocol for truncal lymphatic mapping and the destructive effect of breast cancer therapy on common drainage pathways of the trunk. Surgical treatment of breast cancer related truncal lymphedema with lymphovenous anastomosis (LVA) remains poorly described. Here we present our algorithm for analyzing superficial lymphatic patterns within truncal lymphedema patients to identify viable targets for LVAs.

Methods We reviewed breast cancer patients with truncal lymphedema who underwent fluorescent lymphography between December 2014 and January 2024. We assessed the direction of lymphatic drainage and dermal backflow patterns throughout the trunk. Dermal backflow severity in various regions of the trunk were compared using analysis of variance. We performed full case reviews of patients who received LVAs.

Results Our cohort included 106 hemi-trunks (85 patients). Lymphatic drainage to the ipsilateral axilla was seen in 39%, while 61% had drainage to the ipsilateral groin, and 25% had contralateral drainage. Dermal backflow was significantly worse in the superior trunk, above the IMF (p<0.001). 84% of the mastectomy skin flaps had diffuse or absent superficial lymphatic channels representee sever lymphatic congestion. Two patients underwent microsurgical treatment. The location of each LVA was plotted around regions of most severe lymphedema and based on the direction of lymphatic drainage. Using florescent lymphography to identify patent lymphatic channels and ultrasound to identify nearby veins, two LVAs were performed per patient in the lateral chest, inferior to the IMF. The orientation of each anastomosis supported lymphatic drainage from the severely congested mastectomy flaps to the ipsilateral inguinal lymph nodes. Both patients reported immediate reduction in swelling and symptoms.

Conclusion Building on our previous data, we have gained an improved understanding for patterns of lymphatic drainage after breast cancer treatment. Plotting drainage of the trunk and strategically placing LVAs has been critical to our reconstructive success.

Skin cancer, particularly non-melanoma skin cancer (NMSC), remains a prevalent diagnosis in the United States and poses significant challenges in treatment.1 The National Comprehensive Cancer Network (NCCN) recommends complete excision, emphasizing the importance of preserving function and optimizing aesthetic outcomes.2,3 Mohs Micrographic Surgery (MMS) is considered the gold standard treatment reporting cure rates as high as 99-100%, but it requires specialized training.4,5 In our private plastic surgery center, we use two surgical techniques for NMSC treatment: traditional intraoperative frozen section analysis (IFSA) and our novel technique Frozen Section Mohs (FSM).

We conducted a retrospective chart review comparing the clinical outcomes of the IFSA versus FSM performed by one plastic surgeon. The primary outcome was cancer recurrence and false negative rate, which was obtained by searching the pathology lab's database for IFSA and FSM procedures between January 2016 to July 2023. Secondary outcomes include defect size, number of stages, operative time, and complications. χ2-square and two-sample t tests were conducted for select variables.

There were 1598 IFSA procedures and 1714 FSM procedures included in the final analysis. Baseline characteristics were similar across both groups. The pathology lab identified two recurrences in the IFSA group and zero recurrences in the FSM group (99.9% and 100% cure rates, respectively; p=0.23). The false negative rate was 8/1598 (0.46%) for IFSA and 2/1714 (0.11%) for FSM. The average number of stages to achieve clear margins was 1.15 for IFSA which was similar to FSM at 1.17 stages (p=0.09). The average defect size for IFSA (2.13 cm2) was significantly higher than for FSM (1.83 cm2) (p=0.003). The IFSA complication rate was 3.5%, which was higher than the 2.28% complication rate for MFSM (p=0.03).

Traditional IFSA and our hybrid FSM are equally effective techniques for NMSC removal. Plastic surgeons can use either of these techniques to treat skin cancer with optimal cure rates without requiring Mohs training.

References

1) Guy GP, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. 2015;48(2):183-187. doi:10.1016/j.amepre.2014.08.036 2) Otsuka ACVG, Bertolli E, de Macedo MP, Pinto CAL, Duprat Neto JP. Intraoperative assessment of surgical margins using "en face" frozen sections in the management of cutaneous carcinomas. An Bras Dermatol. 2022;97(5):583-591. doi:10.1016/j.abd.2021.09.013 3) Schmults CD, Blitzblau R, Aasi SZ, et al. Basal Cell Skin Cancer, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2023;21(11):1181-1203. doi:10.6004/jnccn.2023.0056 4) Alsaif A, Hayre A, Karam M, Rahman S, Abdul Z, Matteucci P. Mohs Micrographic Surgery Versus Standard Excision for Basal Cell Carcinoma in the Head and Neck: Systematic Review and Meta-Analysis. Cureus. 2021;13(11):e19981. doi:10.7759/cureus.19981 5) Català A, Garces JR, Alegre M, Gich IJ, Puig L. Mohs micrographic surgery for basal cell carcinomas: results of a Spanish retrospective study and Kaplan–Meier survival analysis of tumour recurrence. J Eur Acad Dermatol Venereol JEADV. 2014;28(10):1363-1369. doi:10.1111/jdv.12293