Scientific Abstract Presentations: Resident Only Aesthetic & Reconstructive Abstracts Session 2 Friday, October 10 Fri, Oct 10 8:00-9:30 a.m. CDT

Purpose: Rhytidectomy, commonly known as a facelift, involves the repositioning and tightening of facial skin and underlying tissues to address visible signs of aging. While numerous techniques have been developed, two approaches are predominantly used today. The first is Superficial Musculoaponeurotic System (SMAS) plication, in which the SMAS layer is elevated and the lateral portion folded onto itself or partially excised to tighten and re-drape the facial tissue(1). In contrast, the deep plane facelift involves dissection beneath the SMAS, separating it from the deeper layers while releasing midfacial retaining ligaments. Although both techniques have demonstrated favorable aesthetic outcomes, ongoing debate persists regarding whether one yields superior results. This study evaluates a large cohort of patients operated on by a single surgeon to determine whether aesthetic outcomes differ in the midface and jowls between patients undergoing SMAS plication versus deep plane facelift. Methods: A retrospective review was conducted of patients operated on by board-certified plastic surgeon and senior author A.L. between 2017 and 2023. The Of 324 cases reviewed, 197 met inclusion criteria. SMAS plication was exclusively performed prior to January 2020, after which almost all patients had deep plane facelifts. Preoperative and postoperative photographs (frontal, 45-degree, and 90-degree left and right profiles) were evaluated by three board-certified plastic surgeons blinded to the technique. A five-point validated scale was employed to rate the final aesthetic outcome of the midface and the preoperative and postoperative appearance of the jowls. Postoperative midface and jowl scores were compared between facelift techniques for each individual reviewer. For the jowls, the mean difference between preoperative and postoperative scores was calculated and compared using a two-tailed t-test. Chi-squared or Fisher's exact tests were used to assess statistical significance for ordinal variables (α = 0.050). Inter-rater reliability was assessed using Cohen's Kappa. Results: Among the 197 patients, 104 (53%) underwent SMAS plication and 93 (47%) underwent a deep plane facelift. The average patient age was 62 years, with a mean follow-up of 20 weeks. No statistically significant differences were found in final postoperative midface scores between techniques, either by individual reviewer (p=0.425, p=0.194, p=0.575) or in the combined analysis (p=0.208). Similarly, there were no significant differences in final postoperative jowl scores between techniques when analyzed individually (p=0.578, p=0.8125, p=0.6041) or when reviewer scores were combined (p=0.970). Notably, the mean difference between preoperative and postoperative jowl scores did not significantly differ according to technique for reviewers one and two. However, reviewer three (p=0.023) and the combined reviewer analysis (p=0.008) demonstrated a significantly greater mean improvement in jowl scores among patients who underwent a deep plane facelift. Conclusion: SMAS plication and deep plane facelift techniques produced comparable aesthetic outcomes in the midface and jowls. However, combined reviewer scores indicated a significantly greater improvement in jowls following deep plane facelift. Limitations of this study include subjective assessment methods; however, it represents one of the largest single-surgeon comparisons of these two techniques to date. 1. Barrett DM, Casanueva FJ, Wang TD. Evolution of the rhytidectomy. World J Otorhinolaryngol Head Neck Surg. 2016;2(1):38-44.

Purpose: Minimally invasive aesthetic treatments (MITs)-including fillers, laser resurfacing, and energy-based therapies-have become increasingly popular non-surgical avenues for facial rejuvenation. However, their long-term efficacy remains unclear, and level IV evidence suggests these treatments may complicate future rhytidectomy and platysmaplasty procedures. Despite this, the true incidence of MIT use among surgical consultation patients remains poorly characterized, particularly given the multitude of available treatment modalities. This preliminary study evaluates trends in MIT use and satisfaction among surgical consultation patients.

Methods: Patients presenting for rhytidectomy or platysmaplasty consultation at our institution between January 2020 and 2025 were identified via retrospective chart review, with additional prospective recruitment of current/new patients. Participants completed an anonymous online (Qualtrics) or in-person survey eliciting demographic information, history, frequency of and satisfaction with MITs, use of topical skin-care products, and history of surgical facial procedures. Data were analyzed for trends in MIT modality, frequency, and satisfaction. Chi-square tests evaluated sex and MIT distribution; multinomial tests assessed treatment category distribution; Fisher's exact tests examined willingness to repeat treatments across categories and associations between MIT history and (1) skin-care product use, and (2) prior facial surgery; Kruskal-Wallis tests compared treatment number per patient, satisfaction, and improvement across MIT categories (p<0.05 considered significant).

Results: Survey response rate was 19% (115 patients contacted electronically, 13 surveyed in-person; 24 total respondents). Most respondents (M:3, F:21, mean age 61.9 ± 10.0, range: 36-83) were female (p<0.001) and endorsed prior MIT (n=19, mean age 62.0 ± 10.4) (p<0.01). Reported MITs included fillers (n=13), laser (n=10), energy-based treatments (n=9), chemical peel (n=8), microneedling (n=5), and Kybella or cool-sculpting (n=1), with significant variation in treatment type distribution (p=0.02). 68% of MIT patients (n=13) reported receiving more than one category of MIT. Skin-care product use (retinol=6, tretinoin=7, niacinamide=1) was higher among MIT-reporting patients (53%) compared to non-MIT patients (0%). Prior facial or neck surgery was more common among MIT patients (92%) than non-MIT patients (20%), trending toward significance (p=0.05). Percentages of patients reporting satisfaction, appearance improvement, and willingness to repeat treatments were lower for energy-based therapy (22% satisfied, 44% improved, 44% willing to repeat) compared to fillers (69%, 85%, 69%) and peels/laser treatments (75%, 75%, 67%). Mean number of treatments per person was also lower for energy-based therapies (1.5) compared to fillers (2.1) and peels/laser treatments (2.0). Popular target regions included jowls/jawline, neck, cheeks, and submental regions for energy-based treatments, and marionette lines, lips, and nasolabial folds for fillers.

Conclusion: Patients seeking rhytidectomy or platysmaplasty are significantly more likely to have undergone MITs, with female patients particularly likely to report prior treatments. Variability in the likelihood of intervention choice suggests certain modalities are more popular. Fillers and peel/laser treatments were associated with higher satisfaction and improvement compared to energy-based therapies, which had lower repeat rates. The strong association between MIT and surgical history suggests that MITs may precede or complement surgical rejuvenation. Understanding these evolving patterns may enhance patient counseling, surgical planning, and outcomes.

Purpose Many ethnic patients seeking rhinoplasty often present with insufficient dorsal projection, necessitating augmentation rhinoplasty. The debate over the optimal material for nasal augmentation continues, particularly between autologous tissue (bone, cartilage), allograft (cadaveric cartilage), and alloplastic implants (Gortex, silicone). We propose that when performed correctly alloplastic augmentation may offer improved, consistent aesthetic outcomes with reduced operative time, lower morbidity, and a favorable complication risk profile.

Methods A retrospective review of patients who underwent silicone implant augmentation rhinoplasty by the senior surgeon from January 1995 to October 2024 was conducted. In brief, the senior surgeon creates a precise dorsal pocket, extending from the radix to the tip of the nose for the placement of a custom-carved silicone implant. In addition to demographic data, surgical details such as form of anesthesia administered, type of graft employed, etc. and post-operative outcomes were recorded. Case details were also collected for any subsequent revision procedures.

Results Over the span of the study, 1019 patients underwent augmentation rhinoplasty with silicone implant by the senior surgeon. A majority of the patients were ethnic, predominately East Asian females (90%), aged 14 to 75 years, and underwent closed primary rhinoplasty. Average operative time was 45 minutes. A tip graft was used in 764 cases (75%). The average follow-up period was 1 year (range between 1 month to 25 years). The secondary revision rate was about 10% (n=103), primarily due to unsatisfactory dorsal height (n=43, 4%) necessitating exchanges for different implants thicknesses. Malposition was noted in 4% (n=37) of cases, requiring either a new implant or reinsertion of the existing one. Infection occurred in 3 cases, which required removal of the implant. Extrusion rates were less than 1% (n = 9), most linked to secondary rhinoplasties. In cases of extrusion among our I-shaped implant cohort, some were salvaged through removal and immediate reinsertion, while most were managed with removal under local anesthesia followed by secondary implantation three months later. 10 patients (1%) opted for explantation, primarily due to their desire to no longer have an implant, although most reported no significant issues. A majority of patients achieved satisfactory aesthetic results.

Conclusion Nasal augmentation is often necessary for patients seeking ethnic rhinoplasty. Silicone implants represent an ideal solution, particularly for patients lacking nasal dorsum and tip projection. When conducted by an experienced surgeon, the complication profile of implant rhinoplasty is comparable to that of other aesthetic facial implant procedures. Silicone implants for nasal augmentation carry a low, acceptable risk profile, are cost-effective, and offer predictable, satisfactory aesthetic outcomes.

Introduction Surgical stress elicits a complex systemic inflammatory response, often reflected in routine laboratory markers such as the Neutrophil-to-Lymphocyte Ratio (NLR). This hematologic ratio has been recognized as a predictor of outcomes in various surgical fields, yet its role in plastic surgery remains underexplored. The perioperative change in NLR (Delta NLR), calculated as the difference between postoperative and preoperative values, may capture the magnitude of the innate immune response following surgical trauma. A diminished increase in this marker could reflect either a blunted inflammatory response or an impaired immunologic adaptation (1). This study aims to evaluate the association between Delta NLR and the occurrence of minor postoperative complications in patients undergoing body contouring surgery

Methods A retrospective review was conducted of patients who underwent body contouring surgery. Demographic data, preoperative and postoperative NLR values, and the incidence of minor postoperative complications were recorded (Seromas, fibrosis, dehiscence). The Delta NLR was computed as the difference between postoperative and preoperative values. Statistical analysis included descriptive statistics, the Mann–Whitney U test for group comparisons. A p-value <0.05 was considered statistically significant.

Results A total of 109 patients were included. The overall median Delta NLR was 4. When stratified by the presence of minor complications, patients without complications had a higher median Delta NLR (4.27) compared to those with minor complications (2.43). This difference reached statistical significance (U = 839.0, p = 0.045). Quartile analysis revealed a consistent trend: patients within the lowest Delta NLR quartile exhibited the highest complication rates. This suggests that a limited rise in NLR following surgery may be associated with increased susceptibility to minor postoperative events, potentially due to an inadequate inflammatory response necessary for optimal tissue healing and infection control.

Discussion Our findings indicate that Delta NLR may serve as a meaningful perioperative biomarker in body contouring surgery. Unlike static pre- or postoperative values, the dynamic change in NLR appears more reflective of the patient's immediate immunologic response to surgery. A lower Delta NLR might reflect either an attenuated inflammatory surge or an exhausted immune profile, thereby increasing vulnerability to minor complications such as seroma formation, wound dehiscence, or superficial infections. These results highlight an opportunity for preventive intervention. Preoperative optimization of immune function through vitamin supplementation (including vitamin C, D, and zinc) and pharmacologic immunomodulators could enhance the innate immune response, increase Delta NLR values, and potentially reduce minor postoperative complications.

Conclusion A lower Delta NLR is significantly associated with an increased incidence of minor postoperative complications in patients undergoing body contouring procedures. These findings advocate for the incorporation of Delta NLR into perioperative protocols, both as a predictive biomarker and a guide for implementing preventive nutritional and pharmacologic strategies to enhance immune resilience and surgical outcomes.

1. Verdonk F, Einhaus J, Tsai AS, Hedou J, Choisy B, Gaudilliere D, Kin C, Aghaeepour N, Angst MS, Gaudilliere B. Measuring the human immune response to surgery: multiomics for the prediction of postoperative outcomes. Curr Opin Crit Care. 2021;27(6):717–725. doi:10.1097/MCC.0000000000000883

Purpose: Chin augmentation (genioplasty) is one of the most common facial cosmetic procedures, playing a key role in enhancing facial aesthetics through modification of the jawline shape, contour, and position. Techniques range from invasive orthognathic surgeries to less-invasive procedures such as alloplastic implants. Injectable fillers are increasingly popular for their ability to replicate orthognathic surgery outcomes through a minimally invasive approach. The spatial effects and volumetric changes of an FDA-approved hyaluronic acid (HA) filler for chin augmentation, are not well characterized. This study analyzed volumetric changes and patient-reported outcomes (PROs) following HA filler injections for chin augmentation over a 90-day period.

Methods: Patients aged 22-55 years seeking chin augmentation and suitable for filler injections were prospectively enrolled. Individuals with filler injections within the year prior were excluded. Up to 3mL of Volux (JUVÉDERM, Allergan Aesthetics, an AbbVie Company, Irvine, CA) were injected into the periosteal, submuscular plane of the anterior jawline/chin by a single experienced aesthetic plastic surgeon. Volumetric measurements via 3-dimensional photogrammetry (VECTRA-H2, Canfield Scientific, Inc., Fairfield, NJ) and PROs (FACE-Q) were collected immediately post-injection and at 14, 30, and 90 days. The Tissue Displacement Factor (TDF) was calculated by measuring the change in tissue volume from pre- to immediately post-injection and dividing it by the actual injected HA volume to assess the volumetric tissue response. Volumetric changes at 30 and 90 days were compared to the effective volume observed at 14 days. Friedman test analyses were performed.

Results: Ten patients participated, with 90% retention at 90 days. The mean immediate TDF was 1.4 (SD 0.22). The average volume maintenance of the HA filler at 30- and 90-days was 117% (IQR 94.8 - 119%) and 82.4% (IQR 76 – 94.2%), respectively. FACE-Q responses significantly improved post-injection from pre-injection, reflecting increased patient satisfaction with chin, lower face, and overall facial appearance (all p > 0.05). There was no correlation between volume maintenance and PROs.

Conclusion: JUVÉDERM Volux HA filler injections provide effective and sustained chin augmentation, with measurable volumetric enhancement and high patient satisfaction over a 90-day period. The observed TDF of 1.4 indicates a strong immediate volumetric response, and although volume maintenance slightly decreased over time, PROs remained significantly improved across all follow-up points. These findings support the use of HA filler as a minimally invasive, aesthetically impactful option for anterior jawline contouring.

Background High-definition body sculpting procedures have seen a surge in demand, with abdominal etching emerging as a prominent surgical technique aimed at sculpting a chiseled "six-pack" appearance. While this surgical approach is gaining popularity, limited data exist on the variations in techniques and their efficacy, safety, longevity, and patient satisfaction. This systematic review evaluates various "six-pack surgery" techniques in cisgender males and females to provide insights into outcomes and safety.

Methods A systematic and comprehensive literature review was conducted using PubMed, Cochrane, and Embase Library databases, following PRISMA guidelines to identify studies on surgical abdominal etching techniques. Search terms included "abdominal etching," "six-pack surgery," and "high-definition liposculpture." Two independent reviewers screened and assessed articles for inclusion, with discrepancies resolved by a third reviewer. Inclusion criteria focused on studies in the English language within the last 20 years that examined surgical techniques for abdominal etching or liposculpture aimed at achieving a "six-pack" aesthetic, particularly regarding long-term efficacy and reported complications. Exclusion criteria included studies focused solely on noninvasive or nonsurgical methods, procedures not specifically aimed at creating defined abdominal muscular contouring (e.g., standard body contouring fat reduction), and case reports or studies with fewer than five patients.

Results/Complications A total of 20 studies met the inclusion criteria, comprising clinical studies and retrospective case series published from 2007 to 2024. Across all studies, a total of 9,288 patients underwent abdominal etching, with a mean age of 38.8 years; approximately 76% were female and 24% were male. Commonly utilized techniques included Vibration Amplification of Sound Energy at Resonance (VASER) and power-assisted liposuction (PAL), along with rectus abdominis fat transfer (RAFT), suction-assisted liposuction (SAL), and ultrasound-guided intramuscular fat grafting (1, 2, 3). Studies differed in their approach to abdominal wall sculpting, with some focusing on enhanced definition of the rectus abdominis, while others emphasized contouring of the external oblique. The reported mean follow-up across studies was 18 months. The overall reported complication rate was approximately 9.00%, with contour irregularities and seroma being the most frequently reported complications at 4.30% and 9.60%, respectively. Mean reported rates of skin necrosis and infection were 0.01% and 0.41%, respectively, with no thromboembolic events and virtually no hematomas reported (4). Revision rates ranged from 0.50% to 30%. Patient satisfaction was variably reported, with satisfaction rates ranging from approximately 84% to 98% across studies (5).

Conclusion Abdominal etching is a relatively safe option for the trained plastic surgeon to achieve a sculpted abdomen, with most complications being minor and manageable. The described techniques demonstrate high reported patient satisfaction and stable long-term results. Techniques such as VASER and PAL show consistent efficacy in achieving enhanced muscular definition, while the RAFT method uniquely provides sustained rectus muscle enlargement. Despite variability in methods and follow-up, the overall safety profile and aesthetic outcomes support abdominal etching as a valuable option for patients seeking a "six-pack" surgery. Future studies are needed to optimize tailored techniques for different body types and to standardize safety protocols.

1. Hoyos AE, Millard JA. VASER-assisted high-definition liposculpture: 360-degree results. Aesthetic Surg J. 2007;27(6):594-604.
2. Danilla S, Levy A, Saad A, et al. Advanced in high-definition liposculpture techniques: a multicenter review. Plast Reconstr Surg. 2019;143(5):1154-1166.
3. Saldanha O, Dziabas D, Gonzalez F, et al. Rectus abdominis fat transfer: safety and outcomes in abdominal etching. Aesthetic Plast Surg. 2020;44(3):350-359.
4. Shridharani SM, Stein MJ, Niddam J, et al. Complications in abdominal etching: a systematic review. Plast Reconstr Surg Glob Open. 2022;10(1):e4091.
5. Husain TM; Saad A, Viaro MS. Patient satisfaction and longevity in six-pack surgery: long-term outcomes. Aesthetic Surg J. 2023;47(2):301-308.

OBJETIVE The objective of this study is to combine two current rib surgery techniques: rib remodeling and rib extraction, to achieve a refined waistline and avoid protrusions or the "bulking" effect.

INTRODUCTION Body contouring surgery has always been a challenge in the pursuit of optimal results. For this reason, we have always treated the different components: initially, fat, skin, and then muscle, with various abdominoplasty techniques using wide plications. And the bone component, where brilliant ideas such as those of Dr. Juan Pedro Verdugo with his rib extraction technique and Dr. Raúl Manzaneda with his Ribsxcar technique opened up a different horizon for plastic surgery: achieving a smaller and narrower waist. Thus, motivated by this constant search for improvement, we have seen good results with the aforementioned techniques. We also noticed that a number of patients presented a "bulge" at the level of rib 10, which we call "bulking." Therefore, we propose performing rib remodeling at this level to reduce this effect.

CLINICAL CASE

This study is quantitative, retrospective, and descriptive. It was performed in Buenos Aires, Argentina, this year. The patient who underwent the procedure had no significant medical history; she was 29 years old and female. Preoperative examinations were normal. A 3D chest CT scan was requested, which was optimal. Initially, rib extraction of ribs 11 and 12 was performed using the technique of Dr. Juan Pedro Verdugo, followed by rib remodeling of rib 10 using the technique of Dr. Raúl Manzaneda.

RESULTS

The results obtained were confirmed by photographs and subjectively through a patient survey. The patient reported satisfaction with the outcome. No minor or major complications occurred. The postoperative period was satisfactory.

We noted a better waist transition, significantly improving the "bulking" effect in the patients.

CONCLUSION

Combined rib treatment, such as rib extraction and rib remodeling, allows us to better optimize waist results, achieving waist refinement and avoiding the bulking effect.

BIBLIOGRAPHY

1. Manzaneda Cipriani, Raúl , Duran Vega, Héctor ; Cala Uribe, Laura :Waist Remodeling without Incision, with Ultrasound-guided Monocortical Fracture, Plastic and Reconstructive Surgery-Global Open 11(12):p e5499, December 2023.

Background: While labiaplasty has become an increasingly popular procedure, current classification systems and surgical guidelines often overlook the superior anterior labial fold, despite its aesthetic and anatomical significance. This study aims to evaluate the prevalence of superior folds and their impact on surgical planning and postoperative outcomes. Methods: A retrospective review was conducted on 30 patients who underwent bilateral labiaplasty using an extended wedge technique between August 2023 and November 2024. Bilateral labiaplasty with extension to the superior fold was performed, incorporating a Burrow's triangle excision for contour refinement.(Figure1) Patient demographics, anatomical features (including the presence of a superior fold and labial asymmetry), and postoperative outcomes were analyzed. The average total VSS score was 1.2 ± 0.6, indicating favorable wound healing with minimal hypertrophy or pigmentation. Surgeon satisfaction was assessed using a 5-point Likert scale based on standardized photographs. Follow-up ranged from 1 week to 2 months, with an average of 1 month. Results: The mean age of patients was 29.0 years. A visible superior fold was observed in 90% of cases and was surgically addressed in 85% of these. Labial asymmetry was present in 70% of patients. All patients underwent bilateral procedures. No complications such as dehiscence, swelling, or contour irregularity were noted, and no revisions were required. The mean surgeon satisfaction score was 4.73 ± 0.45. Conclusions: The superior labial fold is a highly prevalent anatomical feature that warrants routine consideration during labiaplasty planning. Its inclusion in surgical design contributes to high satisfaction and low complication rates. Future classification systems may benefit from incorporating this structure to better guide individualized surgical approaches.

1. Alter GJ. Labia Minora Reduction Using Central Wedge Technique: Central Wedge Technique. Clin Plast Surg 2022;49:447-453.
2. Motakef S, Rodriguez-Feliz J, Chung MT, Ingargiola MJ, Wong VW, Patel A. Vaginal labiaplasty: current practices and a simplified classification system for labial protrusion. Plast Reconstr Surg 2015;135:774-788.
3. Cao YJ, Li FY, Li SK, et al. A modified method of labia minora reduction: the de-epithelialised reduction of the central and posterior labia minora. J Plast Reconstr Aesthet Surg 2012;65:1096-1102.
4. Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol 2000;182:35-40.
5. Goodman MP. Female genital cosmetic and plastic surgery: a review. J Sex Med 2011;8:1813-1825.

Introduction: Recovery after significant burn injury is multifactorial and requires assistance from a variety of disciplines for rehabilitation. Key disciplines such as physical therapy (PT) and occupational therapy (OT) play vital roles in helping patients improve physical function, regain independence, and undergo social integration. Rehabilitation continues beyond acute hospitalization into the outpatient phase and can take place in various settings, including burn centers or external facilities. The setting for outpatient rehabilitation is often determined by uncontrollable factors such as insurance and patient geography. Limited data exists on exploring how these various settings impact patient-reported outcomes. The aim of this study is to compare functional outcomes in burn survivors between rehabilitation received in a burn center versus external facilities. Methods: A retrospective analysis was conducted for adult burn survivors over the age of 18 from 2016-2024 using a multicenter longitudinal patient-reported outcome database. Participants were classified as receiving rehabilitation if they endorsed PT/OT usage in the last 6 months. Rehabilitation settings were categorized as either internal or external to a burn center at 6, 12, and 24 months post-hospital discharge; excluding those that changed setting type. Demographics and usage rates were collected at all time points. Both adjusted (demographics, insurance, TBSA) and unadjusted mixed-effect models assessed the impact of internal burn center PT/OT services on functional outcomes (physical function, social roles, community integration) at 6, 12, and 24 months compared to external centers. Lagged models explored how 6-month therapy predicted 12-month outcomes. Results : Of 1,520 participants meeting inclusion criteria, 868 had data at 6 months, 679 at 12 months, and 496 at 24 months. PT/OT use peaked at 6 months (48.5%) and subsequently declined at 12 (28.6%) and 24 months (18.1%). Among these, the proportion receiving burn center care decreased over time (6 months 37.5%, 12 months 31.3%, 24 months 25.9%). In the unadjusted lagged model, burn center care at 6 months was associated with 3.33-points higher social roles at 12 months (p=.044) compared to those treated at external centers. The adjusted lagged model showed a 1.06-point higher community integration at 12 months (p=.011) compared to those treated at external centers. Cross-sectional analysis comparing rehabilitation at a burn center versus an external site showed no discernible effect on physical function, social roles, or community integration at 6 or 12 months. Conclusions: Utilization of physical and occupational therapy, along with burn center participation, declined over time. Patients who received rehabilitation services at a burn center demonstrated improved community integration. Despite the minor benefits of burn center rehabilitation, cross-sectional analysis revealed no significant differences in outcomes, indicating that rehabilitative therapy can be delivered effectively in non-burn center settings. Future studies to determine whether burn severity influences functional outcomes among the various outpatient settings may offer additional insights.

Introduction: Free tissue transfer provides a solution for reconstructing lower extremity soft tissue defects after trauma, severe infection, and oncological resection. These cases are often challenging, as the lack of local tissue laxity and convex surface of the lower extremity can lead to pedicle compression after coverage. Methods exist to lessen this risk of compression, including additional free tissue transfer, and local tissue rearrangement. ¹,²,³ We hypothesize that a cause of venous thrombosis and subsequent flap failure is excessive extrinsic pressure over the flap and vascular pedicle. Veins could potentially collapse from progressive postoperative swelling after closure, causing impaired blood flow dynamics and elevating the risk of flap loss if not recognized and addressed. This study describes the use and safety of skin substitutes to facilitate a tension-free closure over the vascular pedicle and around the flap.

Materials and methods: An IRB-approved retrospective review was conducted of patients undergoing lower limb reconstruction with free tissue transfer and skin substitute. From July 2024 to present, ten patients were included, of which seven were due to trauma, one due to oncological resection, and one due to complications from total knee arthroplasty. Patient demographics, comorbidities, flap characteristics, skin substitute size, and surgical outcomes were analyzed.

Results: There were no intraoperative complications. The mean age was 46.3 ± 17.2 years. Postoperative complications were monitored for at least 21 days. One patient returned to the operating room within the first 24 hours after reconstruction secondary to venous thrombosis. The anastomotic site was readily accessible for thrombectomy and re-anastomosis beneath the skin substitute, which was replaced. The patient progressed without any further complications. There was one post-operative hematoma requiring evacuation without complication. There were no instances of partial or complete flap loss.

Conclusions: The shifting of the concept of the "reconstructive ladder" to "reconstructive elevator" has vastly increased the volume at which reconstructive surgeons are performing free tissue transfers. Here, we demonstrate the safe use of skin substitute to facilitate a tension-free closure over the vascular pedicle and around the flap. This method allows tension-free coverage of the vascular pedicle without any recruitment of local or free flap tissue itself. This technique also simplifies access to the vascular pedicle during takebacks and can be easily replaced. We hypothesize that as microsurgeons become more knowledgeable of this method, use of skin substitutes in this capacity will increase, potentially increasing their success rate while decreasing flap takeback rate.

References: 1. Leclère FM, Desnouveaux E, Choughri H, Casoli V. Acellular dermal matrix: New applications for free flap pedicle coverage - A prospective study in 10 patients. J Cosmet Laser Ther. 2018;20(4):200-204. doi:10.1080/14764172.2016.1248439

2. Han HH, Min KH. Is split-thickness skin graft safe for coverage of the vascular pedicle in free tissue transfer? J Plast Surg Hand Surg. 2019;53(3):193-197. doi:10.1080/2000656X.2019.1580589.

3. Kim D, Lee JH, Park MS, Ahn MR, Jun D, Lee JH. Managing Vascular Pedicle Exposure in Free Tissue Transfer Using a Reprocessed Micronized Dermal Substitute in Lower Extremity Reconstructions. Bioengineering (Basel). 2024;11(3):241. Published 2024 Feb 28. doi:10.3390/bioengineering11030241

Background: Penile Inversion Vaginoplasty (PIV) traditionally relies on full-thickness scrotal skin grafts (SSG) to construct the neovaginal canal but the heterogeneity of a patient's anatomic donor tissue such as penile skin length, pelvic dimensions, or abundance of scrotal skin can limit vaginal depth and restrict elasticity. The tunica vaginalis, conventionally used as a vascularized flap for urethral reconstruction, represents a viable adjunct. This study is the first to compare functional and safety outcomes of neovaginal canal lining using a tunica vaginalis and scrotal skin graft construct versus the traditional scrotal skin graft only in PIV.

Methods: Data was collected on patients aged 18 and older who underwent PIV between January 2019 and February 2025. Primary exposure was defined by use of either a tunica vaginalis and scrotal skin graft construct (TV-SSG) or a full thickness scrotal skin graft (SSG) only for neovaginal canal lining. Primary outcomes included intra-operative complications, wound healing delay, granulation tissue, difficulty with dilation, loss of depth, stenosis, revisions, reoperations, and readmissions. Comparative analysis assessed outcomes between graft type and multivariable logistic regression models were used to predict TV-SSG use and assess its association with surgical outcomes. Statistical significance was set to P < 0.05.

Results: Of 650 PIV patients, 108 patients (16.6%) underwent SSG only and 542 (83.3%) underwent TV-SSG construct for neovaginal canal lining. Across the outcomes examined, patients in the TV-SSG group had fewer intraoperative complications (2.8% vs. 7.4%, p=0.039), less delayed wound healing (10.7% vs 21.3%, p=0.002), less granulation tissue (20.1% vs 31.5%, p=0.009), and less graft failure requiring intervention (0.4% vs 2.8%, p=0.035) compared to the SSG only group. Additionally, loss of depth was observed in 9.6% of the TV-SSG group compared to 16.0% of the SSG only group, a difference that trended towards statistical significance (p = 0.058). Rates of readmission, reoperation, neo-vaginal stenosis, dilation difficulty, and revision surgeries were comparable between groups.

On multivariable logistic regression controlling for statistically significant demographics and comorbidities, characteristics predicting TV-SSG use include concurrent orchiectomy (aOR 5.85; 95%CI [2.88 – 11.92], p < 0.001) and decreased penile length (aOR 0.64; 95%CI [0.47 – 0.89], p = 0.01). No other penile characteristics, such as elasticity or scrotal skin, were significant predictors of TV-SSG use. Similarly, time on hormone therapy and age started on hormone therapy was not significant in predicting TV-SSG use.

Conclusion: The present study supports the use of the tunica vaginalis as a safe adjunct and potentially superior alternative to scrotal skin grafts only for PIV neovaginal canal lining.

BACKGROUND: While free fibula flaps have been widely used for the bony reconstruction of defects in head and neck, spine and extremities, donor-site morbidity is still a concern. Donor site complications have been well-studied in adults, however, the data in the pediatric population remain limited. This study exclusively reports a long-term donor-site morbidity of fibula flap harvests in the pediatric population.

METHODS: A retrospective study evaluating all patients younger than 18 years who underwent fibula flap harvests at a single academic institution from January 1998 to July 2024 were reviewed. Patients with closed physis at time of surgery were excluded . Demographics and clinical characteristics, and donor-site complications were recorded. Radiographic assessments were made. Toronto Extremity Salvage Score (TESS) surveys were sent to patients.

RESULTS: Thirty-eight free fibula flaps were harvested in 36 patients with a mean age of 13 years (standard deviation, SD: 3.5 years). Twenty patients were female and 16 were male. The mean follow-up time after fibula harvest was 4.7 years (SD: 4.2 years). Fibula flaps were used to reconstruct the extremity defects in 23 (63.8%) cases, followed by spine/sacrum defects in 9 (25%) cases, and facial skeleton defects in 4 (11%) cases. Twenty-nine (80%) of the reconstructions were performed for primary malignant neoplasms (sarcoma), 6 (17%) for benign lesions, and 1 (3%) for congenital defects. In 6 (16.7%) cases, fibular heads were included in the harvest, with no observed limb length discrepancies at the donor site. Skin paddle was included in the fibula harvest in 3 (8.3%) cases. In eight cases, syndesmotic screws were utilized. The mean length of utilized bone was 15 cm (SD: 6.4 cm). . Additionally, patients younger than eight years at the time of surgery did not exhibit a higher incidence of donor site complications compared to those aged eight years or older. In the fibular epiphyseal transfer group (n = 6), harvesting the head resulted in a 100% incidence of peroneal nerve palsy; however, all nerve palsies resolved over time (mean, 24 months). Additional complications in this group included one case of varus deformity (16.7%) and one case of FHL weakness (16.7%). In the standard free fibula harvest group (n = 32), complications included four cases of lower extremity neuropathy (12.5%), one peroneal nerve palsy (3.1%), two cases of FHL weakness (6.3%), two varus or valgus deformities (6.3%), one wound dehiscence (3.1%), and one toe IP contracture (3.1%). All fibular donor site incisional wounds healed without any additional intervention. All patients regained ambulation. Eighteen (50%) patients returned to sporting activities such as swimming and biking. The mean TESS for this cohort was 95.5.

CONCLUSIONS: Fibula flaps have been used for the reconstructions of vertebral, sacral and extremity defects in the pediatric population with a donor site complication occurring in 34.2% of the donor extremities. Despite the high incidence of complications, the majority of children regained activity status similar to their baseline. Appropriate counselling to patients and families in regard to donor site morbidity should be provided.

Introduction Free tissue transfer is an important tool for the reconstruction of lower extremity defects though is prone to unique complications associated with dependency, most notably venous congestion. Nationally, there is significant variance in the post-operative management of lower extremity free flaps, particularly in the initiation and subsequent progression of dependency, often named a 'dangle protocol.' Differences among dangle protocols can lead to significant impacts on patients in terms of duration of bedrest, total cost of hospitalization, return to work, and overall mobility and rehabilitation. The purpose of our study was to understand the current landscape of dangle protocols at high-volume microsurgery centers nationally. To our knowledge, this the first national cross-sectional survey that describes the nuances of post-operative protocols in the USA.

Methods An anonymous REDCap survey was created with questions focusing on patient and flap demographics including practice type, indications for lower extremity free flap reconstruction, post-operative care and restrictions, and specifics about the timing and duration of various elements of a dangle protocol. A list of all microsurgery fellowships was collated from programs listed on the American Council of Educators in Plastic Surgery (ACEPS) website. The websites of all microsurgery fellowships were reviewed. Any fellowships that described exposure to solely breast microsurgery or upper extremity microsurgery were excluded. Fellowship program directors were emailed and asked to identify the surgeon at their institution who performs the most lower extremity free flap reconstruction. The study survey was sent to these identified surgeons.

Results A total of 31 fellowship programs were identified and six responses were collected for a response rate of 19.4%. Among surgeons, half primarily practice at a level 1 trauma center and half primarily at a university-affiliated hospital with a range of 1 to 8 surgeons per institution who perform lower extremity free flap reconstruction. The most common indication for reconstruction was secondary wound breakdown with exposed bone or hardware followed by acute open fracture. Two-thirds routinely order vascular imaging for pre-operative planning. Responses were evenly split between muscle and fasciocutaneous flaps as the most common type of free flap performed, with two reporting that their dangle protocol changed based on flap type. Other factors reported to influence the dangle protocol included recipient site above the knee (67%), number of venous anastomoses (33%), and size of flaps (33%). Almost all (83%) include a period of bedrest (range 0-5 days). All initiated dependency differently (most commonly between post-operative day 3 to 5), and there was considerable variation among the duration, frequency, and progression of dependency periods. Two-thirds do not restrict weight-bearing status for soft-tissue only defects, while one-third limit weight-bearing for two weeks. Average length of stay for a patient with an uncomplicated post-operative course ranged from 2 days to 1.5 weeks.

Discussion There is wide variance in lower extremity free flap protocols among academic institutions nationally including pre-operative evaluation and preparation, dangle protocols, and post-operative restrictions. These may have significant impacts on patient quality of life, total cost of care, and return to work. Understanding the differences in protocols and elucidating any patterns in complications will be interesting to inform care and possibly influence clinical care practices.

Purpose: Ventral hernias are a common and challenging complication following liver transplantation, with standard repair techniques resulting in high recurrence rates. We present the efficacy of a novel TAR-based abdominal wall reconstruction (AWR) approach that uses bilateral rectus muscle flaps and dual mesh reinforcement.

Methods: A retrospective chart review was conducted of patients who underwent incisional hernia AWR from 2019 to 2025. Patient characteristics, procedure-specific variables, and outcomes were collected. Outcomes were analyzed using comparative and multivariate regressions such as Firth's penalized logistic regression and penalized Poisson linear regression analyses, with significance set at p<0.05.

Results: A total of 107 patients were identified. TAR and bilateral rectus flaps were conducted in 81 (76%) and 92 (86%) of cases, respectively, while retrorectus mesh and onlay mesh were placed in 92 (86%) and 70 (65%) of cases, respectively. Overall complication rate was 6.5%, comprising of 2 seromas, 2 hematomas, 3 wound dehiscence, and 3 surgical site infections.

While onlay mesh use was not significantly associated with the presence of overall complications (OR = 0.31, p = 0.09), it was linked to significantly lower odds of wound dehiscence (OR = 0.070, p = 0.007) and a reduced number of complications (β = -1.4, p = 0.031). Closure of the posterior fascia in an interrupted fashion compared to running closure, was associated with higher odds of wound dehiscence (OR 20.64, p=0.007), presence (OR 8.85, p=0.012), and number of complications (β = 1.9, p=0.001). There were no statistically significant findings in bilateral rectus flap and retrorectus mesh use across all surgical outcomes.

Conclusions: This novel approach to AWR is a safe and effective technique in liver transplant patients with complex incisional hernias. Dual mesh and running posterior fascia closure decreases wound dehiscence rates and the number of complications.