Scientific Abstract Presentations: Reconstructive Session 3 Friday, October 10 Fri, Oct 10 10:30 a.m.-12:30 p.m. CDT

Purpose: Periprosthetic pain, poor prosthetic fit, residual limb pain and phantom limb pain significantly impair mobility and quality of life for amputees. Osseointegration (OI) is a novel solution for poorly tolerated socket-based prostheses in which a titanium rod within the residual limb bears weight directly onto the skeletal system. Nerve and soft tissue reconstruction can be performed concurrently with OI implantation to further reduce limb pain and improve comfort. While OI prostheses offer improved prosthetic attachment and mobility compared to traditional socket-based systems, patient-reported outcomes regarding overall satisfaction and functional limitations remain underexplored. This study aims to assess lower limb amputees' satisfaction with OI prostheses and evaluate the extent of their mobility limitations.

Methods: This was a cross-sectional survey study including patients who received lower-limb OI implants at our institution. Participants were invited to complete a validated prosthesis experience survey at various time points post-operatively (ranging from 1 month to 6 years). Collected demographics included age, amputation level, and body mass indexes (BMI). Prosthesis experience and satisfaction was assessed via the Trinity Amputation and Prosthesis Experience Scales (TAPES). Participants rated overall satisfaction with their prosthesis on a scale of 1-10 with 10 being the highest level of satisfaction. Additionally, participants indicated how limited they are in daily activities from 0-2: 0=not limited at all, 1=limited a little, and 2=limited a lot. Activities assessed included walking half a mile, walking 100 meters, working on hobbies, and going to work, as well as six other daily movement activities. Total limitation scores combining all activities ranged from 0-20 with 0=no limitation and 20=most limited. Student's t-test was utilized to compare scores by amputation level.

Results: Our study includes 27 patients total, 12 transtibial and 15 transfemoral amputees. The average age at time of surgery was 50.9 years (range:21-70) and the average BMI was 28.8 (range:20.6-46.3). Participants reported an overall average satisfaction rating of 7.56 out of 10 (SD=2.59), indicating a moderate to high satisfaction with their OI prosthesis. Participants reported the greatest limitation in going to work (1.78, SD=1.25) and the least limitation in walking 100 meters (0.52, SD=0.75). Limitation scores for walking half a mile (0.81, SD=0.88) and working on hobbies (0.78, SD=0.64) were similar. The average total limitation score was 11.8 out of 20 (SD=5.0). Notably, total limitation scores were significantly lower in the transfemoral group compared to the transtibial group (9.1 vs 13.8, p=0.015). However, overall satisfaction scores did not significantly differ between the two groups (7.47 vs 7.67, p=0.85).

Conclusion: This is the first study to look at prosthesis satisfaction and experience in this unique patient population. Findings suggest that lower limb amputees with OI prostheses report high overall satisfaction with their prosthesis. On average, participants felt no limitation or only slightly limited in walking short distances and participating in hobbies. Although all had high satisfaction with their prosthesis, patients with transfemoral amputations may experience fewer limitations, potentially reflecting more significant mobility benefits. Understanding patient-reported satisfaction and mobility outcomes will help clinicians better guide amputees considering osseointegration.

Purpose There is a significant correlation between depression and functionality in lower limb amputees. Uncomfortable prostheses and chronic pain impair mobility and interfere with amputees' lives. Osseointegrated prostheses (OI) are a novel solution for poorly tolerated socket-based prostheses in which a titanium rod inserted into the residual limb bears weight directly onto the skeletal system. Nerve and soft tissue reconstruction can be done concurrently with OI implantation to further reduce limb pain and improve comfort. As up to 27% of amputees attempt suicide, OI implants are an important advancement in amputee care. This study aims to evaluate quality of life (QOL) outcomes in patients with OI prostheses with and without nerve reconstruction.

Methods: This was a cross-sectional survey study including patients who received lower-limb OI implants at our institution. Participants were invited to complete QOL surveys preoperatively and yearly post-operatively. Participant demographics were collected and included age, amputation level, and body mass index (BMI). QOL was assessed via the World Health Organization-Five Well-being Index (WHO-5), a validated measure of mental well-being, and the Patient Health Questionnaire-9 (PHQ-9), a depression screening instrument. WHO-5 is scored on a 0-100 scale with 100 being best possible well-being and PHQ-9 is scored 0-27 with a greater number indicating increased depression severity. Wilcoxon rank-sum test was used with an alpha=0.05.

Results: Our study included 32 patients total, 12 participants preoperatively and 20 participants one or more years postoperatively. Median age at time of surgery did not differ between groups and level of amputation did not differ between groups (49.5 preoperatively vs 49.5 postoperatively, p>0.05; 15 transtibial and 17 transfemoral). Median BMI was significantly higher in the postoperative group (29.75 vs 24.8, p=0.043). Median PHQ9 scores trended downward postoperatively with the difference approaching significance (2 (range:0-14) vs 4 (range:0-19) p=0.077). Additionally, the median WHO-5 score trended higher post-operatively (68 (range:40-88) vs 64 (range:28-96), p=0.48). Of the post-operative patient surveys, 70% received nerve reconstruction. Subgroup analysis of post-operative PHQ-9 and WHO-5 scores between patients with and without nerve reconstruction yielded no significant difference.

Conclusion: This was the first study to look at these psychosocial outcomes in this unique patient population. We found that depression scores trended lower and well-being scores trended higher in the postoperative period, suggesting that osseointegration with and without nerve reconstruction can improve quality of life in lower limb amputees. Information on the quality of life outcomes following the OI procedure will aid physicians in determining how to best guide patient on their decision to undergo osseointegration.

Purpose: Acral lentiginous melanoma (ALM) is a rare melanoma subtype that primarily affects the palms, soles, and subungual regions. Due to its atypical presentation and frequent delay in diagnosis, ALM is often identified at more advanced stages, resulting in poorer outcomes compared to other melanoma subtypes. Despite its clinical significance, evidence-based guidelines for the optimal surgical management of ALM remain limited. This review aimed to assess the efficacy of various surgical interventions on the recurrence of ALM.

Methods: PubMed, Web of Science, Scopus, Embase, and MEDLINE were queried on April 21, 2024 for original studies evaluating ALM-specific outcomes and recurrence following surgical management. Screening and data extraction were performed following PRISMA guidelines. A random effects meta-analysis was performed with significance set at p<0.05. The primary outcome was recurrence rates across different treatment approaches.

Results: Of 2241 studies queried, a total of 31 studies met inclusion criteria, comprising 1943 patients with 1979 cases of surgically-treated ALM. The most common treatments were wide local excision (WLE) (58.92%), amputation (21.73%), narrow margin excision (16.22%), and Mohs micrographic surgery (MMS) (1.92%). Patients were an average of 60.63 years old (standard deviation (SD): 7.88 years). Average post-surgical follow-up was 62.24 months (SD: 28.77 months). Recurrence occurred in 444 (22.43%) cases overall. Recurrence was relatively higher for amputation (28.14%) compared to WLE (22.47%) and MMS (18.42%).

There were 10 studies comparing WLE to amputation. These comprised 257 cases of WLE and 362 amputations, with 42 and 90 recurrences respectively. There was no significant difference found in the development of recurrence between two treatment methods (Relative Risk (RR): 0.87, 95% Confidence Interval (CI): [0.58, 1.30]).

There were 3 studies comparing WLE to narrow excision. These compared 404 cases of WLE and 321 of narrow excision, with 95 and 50 recurrences respectively. There was no significant difference in recurrence between the two excision widths (RR: 0.88, 95% CI: [0.50, 1.57]).

There were 6 studies comparing WLE to amputations for melanoma located subungually. These comprised 86 cases of WLE and 290 amputations, with 4 and 71 recurrences respectively. There was no significant difference found between the rates of recurrence for the two treatment types (RR: 0.65, OR: [0.29, 1.44]).

In total, 30 studies with 1961 lesions were included in indirect proportion analysis, yielding a pooled recurrence proportion of 14% (CI: [0.09 - 0.20]), with significant heterogeneity across the included studies (I2: 90%, p<0.01).

Conclusion: Surgical treatment for ALM varies, with most tumors in these studies excised with traditional wide margins or amputation. There were no differences in the rate of recurrence for ALM when comparing WLE and amputation, or WLE and narrow margin excision. Overall, there was marked variability across studies. When treating ALM in areas such as the hands where preservation of function and cosmetic outcomes are crucial, WLE may be a viable alternative to amputation for subungual disease eradication and should be considered in cases where oncologic treatment fidelity will not be sacrificed.

Purpose: We have previously presented our optimization of a single-stage technique for grafting skin and subcutaneous adipose tissue to restore soft, pliable skin for full thickness burns and trauma. We validated this concept in a Yorkshire swine model, demonstrating multilaminar viability and significantly improved mobility of the grafted skin (p<0.05). We then successfully applied these principles to an index clinical case and have since modeled the effects of different adipose thicknesses and adherence strategies to optimize our technique. Now we present data for the use of this technique in large, complex full-thickness injuries spanning multiple muscles and fascial planes.

Methods: Here we utilize a Yorkshire swine model of full-thickness burns, with expanded 64 cm2 wounds. Wounds are centered over the cranial and caudal flank to cross over multiple muscle bodies and fascial planes, simulating complex injuries with mixed underlying and opposing forces during healing. Wounds were assessed over an 8-week period following escharectomy, and immediate multilaminar reconstruction. Control wounds were treated with STSG over fascia, while experimental groups were treated with: (A) thin adipose grafts (5 mm), (B) thick adipose grafts (10 mm), or (C) thin adipose with a fibrin sealant. We performed gross assessment of graft viability followed by serial photography, ultrasound, and tensiometry at harvest.

Results: We found extensive survival of multilaminar grafts regardless of position or crossing of muscle and fascial planes. Within our previously tested optimal range of for adipose graft hypodermal thickness and adherence strategies we noted no clear overwhelming evidence for loss of grafts or failure of reconstruction.

Conclusions: We have previously validated in animals that single stage layered-composite grafting improves mobility and pliability of the grafted skin and have demonstrated initial clinical success in small full-thickness wounds. Here we demonstrate that this technique is viable for coverage of large and complex wounds.

Background: Chronic neuropathic pain (NP) following sarcoma reconstruction is a well-documented complication, with Park et al. (2018) reporting a 25% prevalence of NP post-resection (1). Despite advancements in limb salvage techniques, surgical strategies for sarcoma defects do not prioritize sensory and functional outcomes. Martin et al. (2021) highlighted this gap, noting that only 21% of surgeons consider chronic pain risk when selecting flap type (2). The impact of flap selection (free vs pedicled) on NP remains underexplored. This study evaluates the impact of local flaps versus free flaps on the development of chronic postoperative pain.

Methods: A single-center retrospective review included adult patients undergoing extremity sarcoma reconstruction (2015–2024). Patients were grouped into free flap and pedicled flap cohorts, and rates of chronic NP at the recipient site were compared. Neuropathic pain was defined as pain lasting ≥3 months documented in clinic follow-up notes. Demographics, operative details, and comorbidities were analyzed and a multivariable logistic regression model was conducted to adjust for functional status, preoperative radiation, hypertension, and smoking status. Sub-analyses assessed upper and lower extremity cases separately.

Results: Among 64 patients (mean age 58.1 ± 16.1 years), 30 underwent free flap reconstruction and 34 underwent local flap reconstruction. Lower extremity reconstructions (67.2% [43/64]) included 18 free and 25 pedicled flaps; upper extremity (32.8% [21/64]) included 12 free and 9 pedicled flaps. Cohorts showed no significant differences in sex, age, hypertension, diabetes, smoking, or independent functional status (all p > 0.05), though neoadjuvant radiation was more prevalent in the free flap group (40.0% vs 17.6%, p = 0.047). Pedicled flaps had significantly higher chronic NP prevalence overall (26.5% [9/34] vs 6.7% [2/30], p = 0.036). Subgroup analyses revealed for lower extremity cases, chronic NP occurred in 28.0% (7/25) of pedicled vs 11.1% (2/18) of free flaps; upper extremity cases showed 22.2% (2/9) vs 0% (0/12) (p = 0.086). Our regression model confirmed that pedicled flaps were associated with 6.5 times greater odds of chronic NP (OR 6.50, 95% CI 2.24–42.1, p = 0.049). Patients with preoperative functional independence were less likely to experience chronic NP compared to dependent patients (OR 0.09, 95% CI 0.01–0.83, p = 0.03). Notably, preoperative radiation to the surgical site showed a non-significant increase in chronic NP risk (OR 4.87, 95% CI 0.78–30.5, p = 0.09).

Conclusion: Local flaps are independently associated with higher risk of chronic neuropathic pain following sarcoma reconstruction. While operative efficiency favors pedicled flaps when feasible, surgeons should consider potential long-term pain sequelae. Future studies are needed to validate these findings in larger prospective cohorts and to stratify patients at highest risk of developing chronic pain after reconstruction.

References: (1) Park JW, Kim HS, Yun JY, Han I. Neuropathic pain after sarcoma surgery. Medicine (Baltimore). 2018;97(21):e10852. doi:10.1097/MD.0000000000010852 (2) Martin E, Slooff WBM, van Houdt WJ, van Dalen T, Verhoef C, Coert JH. Surgical strategies and the use of functional reconstructions after resection of MPNST: An international survey on surgeons' perspective. Orthoplastic Surgery. 2021;4:12-19. doi:10.1016/j.orthop.2021.03.001

Purpose:

Microsurgical training requires extensive hands-on practice, but accessibility is limited by the high cost and availability of surgical microscopes (1). Additionally, the need for experienced instructors and the limited number of microsurgical cases further restrict hands-on training time, creating additional barriers to skill acquisition. Augmented Reality (AR) technology offers a cost-effective solution by providing a visual environment with expert instruction, adequate magnification, and depth perception for practicing microsurgical skills. This study evaluates the utility of a novel AR-based system to improve accessibility of microsurgical training for beginners.

Methods:

An AR microscope was developed to provide depth perception using two digital USB microscopes mounted on a 3D-printed stand, streaming independent video feeds to a Meta Quest 3 headset. An instructional video outlined the steps for placing and tying a suture. Using chicken thigh models for microsurgical suturing practice, 11 participants with no prior microsurgical experience completed a two-phase training session. In the first phase, they used a 2D computer screen to view an instructional video and practice on the model with simple magnification, but without depth perception. In the second phase, they used the AR headset for a 3D immersive visual environment with depth perception, magnification, and the instructional video for guided practice on the model. A foot pedal allowed playback control of the educational video. A post-session 5-point Likert scale survey assessed depth perception, hand-eye coordination, global user preference, and training effectiveness. Scores were compared using the Wilcoxon signed-rank test.

Results:

The total cost of the microscope setup was $575. The microscopes were positioned to achieve a working distance of 125 mm with a magnification of 65x. Participants found depth perception significantly easier in AR (median = 4, SD = 0.40) compared to the 2D screen (median = 1, SD = 0.50, p = 0.003). Hand-eye coordination also felt more natural in AR (median = 4, SD = 0.89) compared to 2D (median = 2, SD = 1.10, p=0.033). Participants reported greater confidence suturing in AR (median = 4, SD = 0.40) than in 2D (median = 2, SD = 0.52, p = 0.003). Suture placement accuracy was also higher in AR (median = 4, SD = 0.50) than in 2D (median = 2, SD = 0.81, p<0.05). No participants reported discomfort with the 2D screen; however, 27.3% (n = 3) experienced mild discomfort in AR. All participants preferred AR over 2D when rating their preference on a scale from 1 (2D screen) to 10 (AR), with a median score of 9 (SD = 0.83). Additionally, 63.6% (n = 7) "strongly agreed" and 36.4% (n = 4) "somewhat agreed" that AR may improve training effectiveness. Most (90.9%, n = 10) were "very likely" to recommend AR-based training to beginners.

Conclusion:

An AR microscope may provide a low-cost alternative training platform for expert-guided hands-on microsurgical skill development and mastery. By integrating depth perception, hands-on feedback, and instructional guidance, this system overcomes key limitations of traditional training methods and provides an accessible, effective solution for microsurgical skill acquisition.

(1) Gavira N, Benayoun M, Hamel Q, Fournier HD, Bigorre N. Learning, teaching, and training in microsurgery: A systematic review. Hand Surgery and Rehabilitation. 2022;41(3):296-304. doi:10.1016/j.hansur.2022.02.001

Background: Microvascular compromise requiring re-exploration is a devastating complication following free tissue transfer (FTT), especially for the chronic lower extremity (LE) wound population who may face amputation following flap failure. Because microsurgical success rates are high, there is limited clinical data exploring patient and operative factors that contribute to successful flap salvage after takeback, especially in the heavily comorbid LE wound population. Thus, this study aims to identify factors that predict salvage after LE FTT takeback in the setting of limb salvage.

Methods: A retrospective chart review of LE FTT performed from February 2011 to June 2024 was performed. Patient characteristics, intraoperative details, and postoperative outcomes were collected. Flap takeback was defined as a return to the operating room for flap exploration due to concern for flap viability. Flaps that were salvaged were compared to flaps that were not.

Results: During the study period, 357 LE FTT were performed, of which 26 cases (7.2%) required takeback. A total of 19 (73.1%) flaps salvaged, while 7 (26.9%) were not. Although not statistically significant, the salvage group trended to be younger (52.6 ± 12.6 vs. 63.3 ± 12.0, p=0.064) and have a lower BMI (28.2 ± 6.7 vs. 33.6 ± 6.8, p=0.083). Median hospital length of stay was significantly higher in the salvage group (32, IQR: 10 vs. 23, IQR: 7; p=0.017). In the total cohort, diabetes (65.4%), peripheral vascular disease (42.3%), and chronic kidney disease (23.1%) were prevalent, with no differences between groups. A total of 6 patients (24.0%) required vascular intervention to optimize distal perfusion prior to reconstruction (p=1.000). Median wound area trended to be larger in the salvage group (112, IQR: 48 vs 60, IQR: 37; p=0.078). There was a higher incidence of flap monitoring devices used in the salvage group, notably the Cook Doppler (84.2% vs. 57.1%, p=0.293) and ViOptix (52.6% vs. 14.3%, p=0.178). The median time to takeback was 1 day (IQR: 7 days) in the salvage group and 5 days (IQR: 7 days) in the failure group (p=0.280). By a final follow-up of 8.1 (IQR: 9.6) months, 2 patients (7.7%) underwent major limb amputation (p=0.474). Univariate analysis demonstrated that Cook Doppler use was significantly associated with higher odds of flap salvage (OR:11.3, CI: 1.4-92.1, p=0.023).

Conclusion: This study represents the largest series of LE FTT takeback in the setting of atraumatic limb salvage. Our results reinforce the importance of close monitoring and early intervention, which may contribute to successful flap salvage.

Purpose: The impact of social determinants of health (SDOH) on patient health and postoperative outcomes has prompted the development of numerous comprehensive indices. Current validated indices include the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), which are contemporary measures of social disadvantage. In contrast, historic redlining represented a form of social disparity due to discriminatory lending practices in the 1930s propagating generational wealth gaps. Limited studies have explored the impact of these indices and this historical practice on surgical outcomes. As such, the present study aims to analyze the effects of these SDOH on patients who underwent Plastic and Reconstructive Surgeon (PRS)-assisted spinal wound closure procedures.

Methods: A retrospective chart review was conducted of patients who underwent cervical and lumbar spine surgery with PRS soft tissue closure between June 2020 and July 2022. Patient demographics, comorbidities, and complications were collected. Wound-specific complications included seroma, hematoma, surgical site infection (SSI), and wound dehiscence. Patient addresses were geolocated with ArcGIS (Geographic Information System) via Python script, and publicly accessible data was utilized to retrieve redlining, ADI, and SVI data. Patients with national ADI and SVI greater than the 50th and 90th percentiles were categorized as disadvantaged. Chi-square analyses, Wilcoxon rank sum tests, and adjusted linear/logistic regression were performed. Statistical significance was set at p <0.05.

Results: A total of 1,607 patients were identified, of which 719 (44.7%) underwent a cervical spine wound closure and 888 (55.3%) lumbar spine wound closure. Of these, 225 (14.0%) patients resided in redlined neighborhoods, 74 (4.60%) in high ADI communities, and 196 (12.2%) in high SVI communities. Higher rates of comorbidities were demonstrated among the redlined and high SVI cohort compared to the non-disadvantaged (p<0.05).

Patients in redlined areas had a higher overall number and rate of complications (0.22 vs. 0.10, p=0.004; 14% vs. 8.0%, p=0.005), sepsis (3.6% vs. 0.6%, p<0.001), and readmission (8.1% vs. 4.2%, p =0.010). Patients residing in high SVI communities had a higher overall number and rate of complications (0.22 vs. 0.10, p=0.007; 14% vs. 8.2%, p=0.009), deep SSI (1.6% vs. 0.3%, p<0.043), and sepsis (2.6% vs. 0.8%, p=0.010). Increased rates of organ SSI (2.7% vs. 0.1%, p=0.006) were noted in the high ADI cohort.

Regression analyses demonstrated that redlining was associated with an increased total number of complications (β 0.11, p=0.001), higher odds of any complications (OR 1.73, p = 0.014), sepsis (OR 6.37, p=0.001), and readmission (OR 2.01, p=0.014). High SVI was associated with an increased total number of complications (β 0.10, p=0.005) and higher odds of any complications (OR 1.62, p=0.043) and deep SSI (OR 5.53, p=0.037). High ADI was associated with higher odds of organ SSI (OR 69.99, p=0.002).

Conclusion: Historic redlining, ADI, and SVI are associated with an increased risk of postoperative complications in spinal wound closures. Identifying disadvantaged patients preoperatively is crucial to implementing equitable care.

Purpose: Perioperative infection prevention measures for immediate implant-based breast reconstruction (IBBR) have frequently become standard of care, although there remains significant variability in measures with varying levels of support. We describe the implementation and assessment of a standardized perioperative protocol for immediate IBBR with tissue expanders or implants at a single institution with aims to decrease perioperative infection rates and harness the synergistic effect of multiple infection mitigation strategies.

Materials and Methods: A quality improvement initiative was performed at our institution from February 2024 to present. An evidence-based and standardized protocol was reviewed and approved among all before implementation. The protocol was divided in pre-, intra-, and post-operative phases and compared in efficacy with a retrospective cohort of patients from June 1, 2022, up to February 1, 2024. All breast cancer survivors who underwent immediate IBBR were included for analysis. The intra-operative phase involved patient warming with bair huggers, skin preparation, draping by the plastic surgery team, and double gloving. After incision, clear communication and set-up were implemented with mastectomy flap evaluation using SPY mastectomy flap grading. The breast pocket preparation involved rinsing with normal saline (NS) followed by dilute betadine and/or vancomycin irrigation per side, or triple antibiotic solution with Ancef/Vancomycin/Tobramycin. For implant placement, skin was re-prepped with concentrated betadine followed by outer glove change. Prostheses were soaked according to attending preference with Irricept, Vancomycin, NS, or triple antibiotic irrigation. If implants were to be placed directly, no-touch techniques with Keller funnel or Tegaderm around the breast pocket were utilized.

Results: A total of 491 patients were identified with 54 (11.0%) infectious cases. Since February 2024 following implementation of the protocol, 214 patients with 7 (3.27%) infectious cases were identified. All 7 cases were classified as major complications requiring readmission and/or reoperation. The most common pathogen was Staphylococcus aureus (26.0%) followed by Pseudomonas aeruginosa (10.6%) and Corynebacterium species (4.1%). Most patients had estrogen receptor positive tumors (57.1%), received neoadjuvant chemotherapy (57.1%), and underwent reconstruction with tissue expanders (92.9%). Infectious outcomes were significantly lower (p<0.05) in the protocol cohort compared to the retrospective group.

Conclusions: This study describes the largest cohort of a standardized perioperative protocol used for immediate IBBR with a largely successfully infectious outcomes rate of only 3.27%. We demonstrate that implementation of our institution's protocol using a quality improvement approach is associated with a significant reduction in implant infections.

Purpose There is a significant correlation between depression and functionality in lower limb amputees. Uncomfortable prostheses and chronic pain impair mobility and interfere with amputees' lives. Osseointegrated prostheses (OI) are a novel solution for poorly tolerated socket-based prostheses in which a titanium rod inserted into the residual limb bears weight directly onto the skeletal system. Nerve and soft tissue reconstruction can be done concurrently with OI implantation to further reduce limb pain and improve comfort. As up to 27% of amputees attempt suicide, OI implants are an important advancement in amputee care. This study aims to evaluate quality of life (QOL) outcomes in patients with OI prostheses with and without nerve reconstruction.

Methods: This was a cross-sectional survey study including patients who received lower-limb OI implants at our institution. Participants were invited to complete QOL surveys preoperatively and yearly post-operatively. Participant demographics were collected and included age, amputation level, and body mass index (BMI). QOL was assessed via the World Health Organization-Five Well-being Index (WHO-5), a validated measure of mental well-being, and the Patient Health Questionnaire-9 (PHQ-9), a depression screening instrument. WHO-5 is scored on a 0-100 scale with 100 being best possible well-being and PHQ-9 is scored 0-27 with a greater number indicating increased depression severity. Wilcoxon rank-sum test was used with an alpha=0.05.

Results: Our study included 32 patients total, 12 participants preoperatively and 20 participants one or more years postoperatively. Median age at time of surgery did not differ between groups and level of amputation did not differ between groups (49.5 preoperatively vs 49.5 postoperatively, p>0.05; 15 transtibial and 17 transfemoral). Median BMI was significantly higher in the postoperative group (29.75 vs 24.8, p=0.043). Median PHQ9 scores trended downward postoperatively with the difference approaching significance (2 (range:0-14) vs 4 (range:0-19) p=0.077). Additionally, the median WHO-5 score trended higher post-operatively (68 (range:40-88) vs 64 (range:28-96), p=0.48). Of the post-operative patient surveys, 70% received nerve reconstruction. Subgroup analysis of post-operative PHQ-9 and WHO-5 scores between patients with and without nerve reconstruction yielded no significant difference.

Conclusion: This was the first study to look at these psychosocial outcomes in this unique patient population. We found that depression scores trended lower and well-being scores trended higher in the postoperative period, suggesting that osseointegration with and without nerve reconstruction can improve quality of life in lower limb amputees. Information on the quality of life outcomes following the OI procedure will aid physicians in determining how to best guide patient on their decision to undergo osseointegration.

Purpose: Periprosthetic pain, poor prosthetic fit, residual limb pain and phantom limb pain significantly impair mobility and quality of life for amputees. Osseointegration (OI) is a novel solution for poorly tolerated socket-based prostheses in which a titanium rod within the residual limb bears weight directly onto the skeletal system. Nerve and soft tissue reconstruction can be performed concurrently with OI implantation to further reduce limb pain and improve comfort. While OI prostheses offer improved prosthetic attachment and mobility compared to traditional socket-based systems, patient-reported outcomes regarding overall satisfaction and functional limitations remain underexplored. This study aims to assess lower limb amputees' satisfaction with OI prostheses and evaluate the extent of their mobility limitations.

Methods: This was a cross-sectional survey study including patients who received lower-limb OI implants at our institution. Participants were invited to complete a validated prosthesis experience survey at various time points post-operatively (ranging from 1 month to 6 years). Collected demographics included age, amputation level, and body mass indexes (BMI). Prosthesis experience and satisfaction was assessed via the Trinity Amputation and Prosthesis Experience Scales (TAPES). Participants rated overall satisfaction with their prosthesis on a scale of 1-10 with 10 being the highest level of satisfaction. Additionally, participants indicated how limited they are in daily activities from 0-2: 0=not limited at all, 1=limited a little, and 2=limited a lot. Activities assessed included walking half a mile, walking 100 meters, working on hobbies, and going to work, as well as six other daily movement activities. Total limitation scores combining all activities ranged from 0-20 with 0=no limitation and 20=most limited. Student's t-test was utilized to compare scores by amputation level.

Results: Our study includes 27 patients total, 12 transtibial and 15 transfemoral amputees. The average age at time of surgery was 50.9 years (range:21-70) and the average BMI was 28.8 (range:20.6-46.3). Participants reported an overall average satisfaction rating of 7.56 out of 10 (SD=2.59), indicating a moderate to high satisfaction with their OI prosthesis. Participants reported the greatest limitation in going to work (1.78, SD=1.25) and the least limitation in walking 100 meters (0.52, SD=0.75). Limitation scores for walking half a mile (0.81, SD=0.88) and working on hobbies (0.78, SD=0.64) were similar. The average total limitation score was 11.8 out of 20 (SD=5.0). Notably, total limitation scores were significantly lower in the transfemoral group compared to the transtibial group (9.1 vs 13.8, p=0.015). However, overall satisfaction scores did not significantly differ between the two groups (7.47 vs 7.67, p=0.85).

Conclusion: This is the first study to look at prosthesis satisfaction and experience in this unique patient population. Findings suggest that lower limb amputees with OI prostheses report high overall satisfaction with their prosthesis. On average, participants felt no limitation or only slightly limited in walking short distances and participating in hobbies. Although all had high satisfaction with their prosthesis, patients with transfemoral amputations may experience fewer limitations, potentially reflecting more significant mobility benefits. Understanding patient-reported satisfaction and mobility outcomes will help clinicians better guide amputees considering osseointegration.

Introduction

Modern lower extremity limb salvage offers a wide arsenal of reconstructive techniques. Fasciocutaneous flaps have offer advantages including muscle preservation, sensory nerve incorporation, and thin, pliable coverage with improved aesthetic outcomes [1-2]. However, higher risk of delayed wound healing, partial flap loss and infection have resulted in hesitance to utilize fasciocutaneous flaps, particularly in complex traumatic wounds or areas with compromised vascularity [2]. Studies have shown comparable long-term outcomes for fasciocutaneous versus muscle flaps for lower extremity reconstruction [1-2]; however, flap selection remains provider-dependent. This study examines lower extremity reconstructive trends over 30 years at a high-volume institution to evaluate utilization and complications of fasciocutaneous flaps relative to other reconstructive options.

Methods

A retrospective case series evaluated patients undergoing soft tissue reconstruction for lower extremity injuries at a Level-I trauma center over 20-year period. Demographics, comorbidities, injury characteristics, and operative management were abstracted. Patients were grouped into time intervals based on year of reconstruction: 1994-2004, 2005-2014, or 2015-2024. Flaps were grouped into local/pedicled and free, then subdivided into muscle and fasciocutaneous. Trends in flap type selection were analyzed across time intervals. Chi square and ANOVA tests compared outcomes between patients undergoing fasciocutaneous reconstruction within each period.

Results

Among 283 flaps in 253 patients within the study period, 63 (22.3%) were fasciocutaneous (Table 1). Utilization was distributed evenly across each time interval: 29.4% (1994-2004), 18.6% (2005-2014), and 22.2% (2015-2024). Notably, use of free fasciocutaneous flaps increased from none in the earliest group to 59.5% of all fasciocutaneous flaps in the most recent interval (p=0.001). Postoperative outcomes, including soft tissue or bony infection, tissue necrosis, bony nonunion, return to the operating room, and amputation, were similar across all interval periods (p>0.05, Table 2).

Conclusion

Despite popularity in the literature, the utilization of fasciocutaneous flaps remains low in trauma reconstruction. This preference may be influenced by historical beliefs that muscle flaps carry lower infection and complication rates, though this has not been substantiated in the literature []. This large series further supports the safety of fasciocutaneous flaps as no complications were found to be statistically significant across all study time intervals between groups. We did observe adoption of free fasciocutaneous flaps over the study period without an increase in complications even during the expected "learning curve" period. Flap selection is influenced by various patient and surgeon factors, including body habitus and OR availability that retrospective studies cannot fully capture. Future studies should explore these surgeon preferences, patient selection factors, and long-term functional outcomes to better understand the role of fasciocutaneous versus muscle flap choice in lower extremity trauma reconstruction.

[1] Cho EH, Shammas RL, Carney MJ, et al. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg. 2018;141(1):191-199. doi:10.1097/PRS.0000000000003927

[2] Dow T, ElAbd R, McGuire C, et al. Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis. J Reconstr Microsurg. 2023;39(7):526-539. doi:10.1055/a-2003-8789

Introduction: Body mass index (BMI) is a well established predictor of postoperative complications, but its impact varies by surgical site and fat distribution. Patients with obesity and comorbidities face higher risks. Despite this, no clear guidelines define a maximum BMI for safe surgery or the amount of weight loss required before surgery. Given BMI's variable effects across procedures, a universal threshold is impractical. This study aims to determine the highest BMI at which surgery remains safe, considering comorbid status.

Methods: We analyzed the 40 most common plastic surgery procedures in the ACS-NSQIP using multivariable logistic regression with stepwise selection, incorporating comorbid status, BMI, and body location as predictors. Surgical location (abdomen/trunk, flaps/grafts, head/neck, upper extremity) was determined from CPT codes. Comorbid status, including diabetes, hypertension requiring medication, ventilator dependence, chronic obstructive pulmonary disease, dyspnea, renal failure, cerebrovascular accident, and a history of angina was treated as binary predictor. The outcome variable was all-cause complications, including bleeding complications, urinary tract infection, superficial surgical site infection, pneumonia, sepsis, deep vein thrombosis (DVT), organ-space surgical site infection, reintubation, septic shock, wound infection, failure to wean from ventilation, wound dehiscence, pulmonary embolism, cardiac arrest, renal failure, myocardial infarction, and cerebrovascular accident. Additional models focused on wound dehiscence, superficial infection, and DVT/pulmonary embolism (PE). The model included three-way interactions and third-degree polynomial terms for BMI to capture nonlinear effects. Model performance was assessed using Akaike Information Criterion (AIC), McFadden's pseudo R², Hosmer-Lemeshow goodness-of-fit test, and 10-fold cross-validated area under the receiver operating characteristic curve (AUROC).

Results: Analysis of 229,847 plastic surgery cases found BMI to be a significant predictor of complications, with effects varying by anatomical site. Increased BMI raised the odds of complications (Beta 0.381, 95% CI 0.363-0.398, p<0.001), wound dehiscence (Beta 0.115, 95% CI 0.096-0.134, p<0.001), superficial interactions (Beta 0.140, 95% CI 0.127-0.152, p<0.001), and DVT/PE (Beta 0.102, 95% CI 0.081-0.123, p<0.001). Nonlinear relationships of BMI on all complications were evident through quadratic (Beta = -133.910) and cubic (Beta = 209.240) terms. Comorbidities further elevated risk, particularly all cause complications (Beta 8.010 95% CI 7.516-8.505, p<0.001). An interaction effect (Beta = -0.148) indicates that BMIs impact was less pronounced in those with comorbidities. In breast surgery, BMI effect on wound dehiscence was lower compared to other locations (Beta -1.638, 95% CI -2.607 to -0.669, p<0.001). The model shows strong performance (AUROC 0.968 for infection, 0.939 for DVT/PE). These findings show the need for BMI thresholds tailored by procedure and patient comorbidities rather than a universal cutoff.

Conclusion: BMI and comorbidities impact complication risk in plastic surgery, with effects varying by procedure. Nonlinear trends and interaction effects highlight the need for individualized risk assessment. Strong model performance supports procedure specific BMI thresholds rather than universal cutoffs to improve patient safety and surgical decision making.

Purpose: Over 400,000 ventral hernia repairs (VHR) are performed annually in the United States. Retrorectus mesh repair is the gold standard for reducing recurrence. To minimize complications associated with permanent synthetic mesh such as infection, erosion, and pain, novel meshes have been developed. Coated polypropylene meshes combine a bioabsorbable scaffold with a permanent polytetrafluoroethylene (PTFE) knit, whereas poly-4-hydroxybutyrate (P4HB) biosynthetic meshes are fully absorbable, providing temporary support, during the critical healing phase, before degrading over 12–18 months. Comparative data on recurrence, complications, and long-term outcomes remain limited. This study evaluates the clinical effectiveness of these mesh types in clean wound VHR.

Methods: This single-center, retrospective cohort study included patients who underwent retrorectus VHR with coated synthetic (PTFE, Synecor) or biosynthetic (P4HB, Phasix) mesh between June 2017 and December 2022. Propensity score matching was used to adjust for BMI, age, gender, American Society of Anesthesiologists classification, and Ventral Hernia Working Group grade. Outcomes included surgical site occurrences (SSO), hernia recurrence, and reoperations.

Results: A total of 94 patients (47 per group) were analyzed, with a median follow-up of 26 months (IQR 69.8–55.2). Baseline characteristics, including age (62 vs 64 years, p=0.5), BMI (33 vs 34 kg/m², p=0.5), smoking history (47% vs 43%, p>0.9), diabetes (13% vs 8.5% p=0.7), COPD history (2.1% vs 2.1%, p>0.9), and defect size (218 vs 218 cm2 p=0.5), were similar between synthetic and biosynthetic. The coated synthetic group had a higher rate of concurrent transversus abdominis release (66% vs 34%, p=0.002) and shorter operative time (180 vs 215 min, p=0.01).

There was no significant difference in hernia recurrence (0% vs. 2.4%, p=0.5) or overall SSO rates (26% vs. 40%, p=0.12). Surgical site infection (SSI; 2.1% vs. 15%, p=0.059) neared statistical significance, while rates of cellulitis, seroma, delayed wound healing were non-significant (p>0.05). There were no cases of mesh infection or enterocutaneous fistula. The biosynthetic group had higher rates of SSO requiring procedural intervention (2.1% vs 17%, p=0.03) and all-cause reoperation (2.1% vs. 21%, p=0.004).

Multivariate analysis found no significant predictors of SSI. Biosynthetic mesh showed a non-significant trend toward increased odds (OR 7.69, 95% CI: 0.79 –75.04, p=0.07), as did higher ASA class (OR 7.69, 95% CI: 0.80 –60.79, p=0.07) and reoperation time (OR 1.005, 95% CI: 0.994 –1.017, p=0.37).

Conclusion: Both coated synthetic (PTFE, Synecor) and biosynthetic meshes (P4HB, Phasix) demonstrated comparable recurrence and overall complication rates in clean wound retrorectus VHR. However, biosynthetic mesh was associated with higher rates of SSO requiring procedural intervention and all-cause reoperation. These findings suggest that while both mesh types are viable options, caution should be exercised when selecting biosynthetic mesh due to its increased need for secondary procedures. Further studies are needed to determine long-term implications.

Background: Understanding the factors impacting mortality and recovery in geriatric burn patients can help risk stratify burn population subgroups, guide treatment strategies and improve patient outcomes. This study examines the epidemiological characteristics, mortality rates, total burn surface area (TBSA), and predictors of mortality in geriatric burn patients via comparative analysis of burn-injured elderly to help guide treatment algorithms in this heterogeneous and at-risk population. Methods: A literature search was conducted on February 2, 2024, using PubMed, Scopus, and Web of Science. Keywords including "burn," "thermal injuries," and "geriatric." Data extracted included epidemiological details, mortality rates, and TBSA. Geriatric patients were stratified into younger (60-80) and older / super geriatric (80+) groups. Statistical analyses were performed using R software version 4.4.1. Odds ratios (OR) and relative risks (RR) were calculated, with p-values <0.05 denoting significance. Heterogeneity was managed with leave-one-out tests and subgroup analyses. Results: The younger geriatric group (60-80 years) demonstrated lower ICU admission rates (RR: 0.75, 95% CI: 0.63 - 0.88, I² = 0%) and significantly lower mortality (RR: 0.65, 95% CI: 0.58 - 0.73, I² = 39%) compared to the super geriatric group (80+ years). No significant differences were observed between age groups for TBSA categories (<10% [OR: 1.06, 95% CI: 0.83 - 1.35, I² = 65%], 10-19% [OR: 1.07, 95% CI: 0.81 - 1.41, I² = 48%], and ≥20% [OR: 1.08, 95% CI: 0.94 - 1.22, I² = 48%]) or burn etiologies (scald [OR: 0.99, 95% CI: 0.80 - 1.23, I² = 0%], flame [OR: 0.86, 95% CI: 0.66 - 1.12, I² = 32%], electrical [OR: 1.61, 95% CI: 0.42 - 6.12, I² = 0%], and chemical burns [OR: 1.27, 95% CI: 0.38 - 4.22, I² = 56%]). TBSA remained a strong predictor of mortality, with significantly lower mortality in patients with TBSA of 1-9% compared to 10-19% (RR: 0.31, 95% CI: 0.21 - 0.44, I² = 28%) and in patients with TBSA of 10-19% compared to ≥20% (RR: 0.17, 95% CI: 0.11 - 0.27). Flame burns increased mortality risk by 298% relative to scald burns (3.98; 95% CI: 2.68 - 5.91, I2 = 79%). Inhalation injury raised mortality risk by 195% (RR: 2.95, 95% CI: 2.31 - 3.78, I2 = 86%), and intubation increased mortality risk by 466% (RR: 5.66, 95% CI: 2.61 - 12.30). Grafting was associated with a 33% reduction in mortality compared to conservative management (RR: 0.67, 95% CI: 0.54 - 0.82, I² = 54%). No significant mortality differences were observed between genders (RR: 1.09, 95% CI: 0.92 - 1.30). Conclusion: This study emphasizes TBSA, burn etiology, inhalation injuries, and intubation as critical predictors of mortality in all geriatric burn patients. Younger geriatric patients (60-80) had significantly better survival outcomes than super geriatric patients (80+), and surgical interventions like grafting reduced mortality risks. These findings can guide tailored clinical decisions and intervention strategies aimed at improving outcomes for geriatric burn patients, particularly for those at higher mortality risk.

Background: Microsurgery offers transformative reconstructive solutions for complex soft tissue defects in the breast, head and neck, and extremities, yet its intricate nature often results in prolonged operative times linked to complications such as flap failure, infections, and poor wound healing . (1) The independent effect of operative duration remains unclear due to limited, small-scale studies that treat it as a secondary variable, often yielding exaggerated and conflicting results. To date, no study has specifically evaluated the relationship between operative times and complications in microsurgery . (2) (3) (4) Given the associated morbidity, extended hospital stays, and higher costs, our study employs a novel multivariate meta-regression accounting for ischemia time, device use, and patient comorbidities to clarify this relationship and bridge the gap between theory and practice. We also explore strategies to reduce operative times, including the use of anastomotic coupling devices (ACDs) and co-surgeon utilization.

Methods: Pre-registered on PROSPERO (CRD42024544010) and following PRISMA guidelines, we systematically searched CENTRAL, Embase, Medline, and Web of Science from inception until June 2024, without restrictions. Two reviewers independently screened studies and extracted data, excluding low-quality studies per the Newcastle-Ottawa Scale. A random-effects multivariate meta-regression using REML assessed the association between operative time and complications, adjusting for moderators (e.g., ischemia time, age, obesity) while subsequent univariate analysis validated findings.

Results: Multivariate meta-regression on 34,790 patients revealed operation time (β=0.0338 , p<0.001) and ischemia time (β=0.2590 , p<0.001) as significant independent predictors of complication rates. Covariates such as age, hypertension, smoking, obesity, and diabetes were also significant. Univariate analyses demonstrated strong associations of ischemia time with reoperation (β=1.00 , p<0.0001) and infection (β=0.4242 , p<0.0001), while operation time was significantly associated with wound complications (β=0.015, 95% CI: 0.001–0.029, p=0.036) and medical complications (β=0.045 , p=0.003). ACD's reduced operative times (Δ=−47.17 minutes , p=0.0396) and co-surgeon's reduced complication rates (β^= - 5.6852 , p < 0.001). Heterogeneity remained high across all analyses (I^2 = 99.9%).

Conclusion: Our findings reveal that prolonged operative and ischemia times independently heighten complication risks in microsurgery, challenging the traditional 6-hour threshold . (4) By treating these factors as continuous variables, we demonstrate that even small increments in time can increase risk. We believe our study identified key methodological flaws in previous investigations, which may explain the conflicting "thresholds" reported in the literature.

1. Villavisanis DF, Zhang D, Shay PL, Taub PJ, Venkatramani H, Melamed E. Assisting in Microsurgery: Operative and Technical Considerations. J Hand Surg Glob Online. 2023;5(3):358-362. doi:10.1016/j.jhsg.2023.01.011

2. Haddock NT, Teotia SS. Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours. Plastic and Reconstructive Surgery – Global Open. 2021;9(9):e3801. doi:10.1097/GOX.0000000000003801

3. Cheng H, Clymer JW, Po-Han Chen B, et al. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res. 2018;229:134-144. doi:10.1016/j.jss.2018.03.022

4. Hardy KL, Davis KE, Constantine RS, et al. The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J. 2014;34(4):614-622. doi:10.1177/1090820X14528503

Introduction

Radiation is a known risk factor of lymphedema development but the extent of its damage on truncal lymphatics has never been assessed. Using indocyanine green (ICG) lymphography, damage can be visualized as areas of dermal backflow or absent lymphatic flow following severe destruction. We aim to analyze the effects of radiation on lymphatic structures of the chest, exploring the incidence of no flow zones and identifying associated complications.

Methods

We performed a retrospective review of breast cancer patients who received ICG lymphography of their chest from December 2014 to January 2024. Patients were separated into radiation and non-radiation groups. Using ICG lymphography, truncal subunits (superior and inferior mastectomy flaps, inframammary fold, medial abdomen, and lateral abdomen) were assessed, and zones of no lymphatic flow were recorded. These zones were identified by observing ICG migration from the injection point, creating dermal backflow in certain regions of the trunk, while adjacent areas displayed no lymph flow. Data on breast cancer treatment modalities were collected. Multivariate analysis was conducted to assess associations between radiation, no flow zones, and breast complications, while controlling for other treatment modalities and BMI.

Results

Our cohort included 173 hemi-trunks (95 patients). Of these, 73 sides (42%) underwent radiation and 100 (58%) did not. Most patients had mastectomy (79%), chemotherapy (65%), and axillary dissection (27%), with an average BMI of 30.16. Zones of no lymphatic flow were observed in 79% of the radiation group and 63% of the non-radiation group (p=0.03). Most no flow zones were in inferior mastectomy flaps, correlating with clinical symptoms of lymphedema. On multivariate analysis, radiation increased the odds of absent lymphatic flow by 158% (OR 2.58, CI 1.10–6.02, p=0.03).

Breast complications were more frequent in the radiation group (52.1%) than the non-radiation group (28.0%, p=0.002), including infection (26.0% vs. 13.0%, p=0.048) and seroma (37.0% vs. 19.0%, p=0.014). Radiation therapy was associated with 162% greater risk of seroma compared to no radiation therapy, when controlling for confounders (OR 2.62, CI 1.15-5.97, p=0.02). When controlling for radiation and other confounders, diffuse and absent lymphatic flow were associated with 31% greater risk of seroma compared to less severe dermal backflow patterns (OR 1.31, CI 1.01-1.70, p=0.04).

Conclusion

Radiation is significantly associated with zones of absent lymphatic flow, reflecting severe lymphatic damage and stasis. These zones are significantly correlated with an increased risk of seroma formation, and radiation independently increases the likelihood of seroma development. These findings suggest that radiation-induced lymphatic disruption is a critical factor in seroma formation, highlighting the need for targeted interventions to mitigate radiation-associated complications in breast cancer patients.

Background

Pressure ulcers (PU) are commonly treated by plastic surgeons. Optimal management is necessary to limit potential burdens on the health care system. All stage IV PU require surgical debridement and, if appropriate, may proceed to flap reconstruction. The term single-stage PU reconstruction refers to management of these wounds with debridement and reconstruction in a single procedure. Multi-staged PU reconstruction refers to performing debridement(s) in a separate procedure from the reconstruction. It is believed that the additional time between debridement and reconstruction can improve vascularization of the wound bed for optimization prior to reconstructing; however, evidence for this is conflicting as there is a lack of comparative studies. We sought to assess if there is a difference in 180-day reoperation and recurrence rates of pelvic pressure ulcer flap reconstructions when reconstruction is performed in a single-stage vs multi-stage operation.

Methods

A retrospective cohort study was performed on all adult patients at a single institution who underwent PU flap reconstruction from 2013 to 2023. Inclusion criteria included documented diagnosis of a single stage IV ischial, trochanteric, or sacral pressure ulcer with at least 6 months of follow-up. The multistage cohort was defined by those who had surgical debridement in a separate procedure prior to flap closure. Demographic information, PU characteristics, and treatment details were collected. The primary outcome included reoperation and wound recurrence within 6 months. Secondary outcomes comprised other flap complications including flap failure, wound dehiscence, hemorrhage, infection, seroma, and donor site breakdown. Data was analyzed with unpaired 2-sample t-test, two-tailed Fisher's exact text, and Chi-squared.

Results

A total of 110 patients met our inclusion criteria. 60 were reconstructed as in a single-stage and 50 underwent multi-staged reconstruction. The only significant differences between the two cohorts were more active smokers were included in the single stage-cohort as compared to the multi-stage (13.3% vs 2.0%; p = .0382) and more patients with some level of paralysis in the multi-stage cohort (86.7% vs 96%; p = .0370). There were no other significant differences between the two groups. The rates of reoperation (18% vs 8.3%; p = .1574) and recurrence (14% vs 5%; p = 0.1808) were higher for the multistage cohort however, this was not statistically significant. We found no significant differences between multi-stage and single-stage reconstructions in postoperative complications including dehiscence (16% vs 15%; p = 1.00) and flap failure (4% vs 0%; p = 0.2043).

Conclusion

The results of this study suggest that multi-stage reconstruction of PU does not significantly reduce the rates of complications or reoperations. This suggests that single-stage reconstruction could be the preferred option for surgical management of stage IV PU as this has also been shown to be associated with shorter hospitalizations and greater cost effectiveness. This study is limited by its retrospective nature and the lack of randomization. Providers may be inadvertently self-selecting patients into each cohort based on the extent of the PU. Further comparison with a randomized control trial is warranted for further evaluation and comparison.

Background The selection of recipient vessels is critical for successful free tissue transfer in the lower extremity (LE). Traditional teaching advocates that microsurgical anastomosis should be performed to uninjured vessels outside the zone of injury (ZOI) to decrease the risk of complications from perivascular inflammatory changes. However, there is no defined way to assess the extent of the ZOI, and uninjured vessels may not be available or readily accessible. To evaluate the complications ascribed to the ZOI and injured vessels, we compared the outcomes between arterial anastomoses fashioned from within the ZOI versus non-injured recipient vessels.

Methods A retrospective review was conducted of adult patients (≥18 years old) who required free flap (FF) reconstruction of the LE from 2016-2024. Injury to the recipient artery (transection, avulsion, or thrombosis) was determined by intraoperative assessment or pre-operative computed tomography angiography (CTA). The primary outcome, complications attributed to the arterial anastomosis, was a composite variable defined as return to the operating room (OR) during the index hospitalization for arterial thrombosis, partial flap loss, and/or total flap loss. Fisher's tests and chi-squared tests were performed to examine differences between complications in anastomoses using injured vs non-injured vessels..

Results A total of 285 cases met our inclusion criteria, with 87 (30.5%) FF arterial anastomoses performed to an injured recipient artery. The latissimus dorsi (30.6%) was the most common FF, followed by the radial forearm (27.5%), and the anterolateral thigh (23.2%). The anterior tibial artery was the recipient vessel in 50.9% of cases and most anastomoses were performed in an end-end fashion. Of the 285 cases in this study, 20 (7.0%) required OR takeback for arterial thrombosis and/or partial/total flap loss. However, there was not a significant difference between the incidence of these complications for FFs anastomosed to injured (6.9%) versus non-injured (7.1%) recipient arteries (p > 0.9).

Discussion We found that there were no significant differences in the rate of arterial thrombosis or flap necrosis for arterial anastomoses fashioned with non-injured vs injured recipient vessels within the ZOI. While healthy vessels outside the ZOI are preferred for LE reconstruction, the selection of recipient vessels can be guided by surgeon expertise and microsurgical technique when they are unavailable, broadening the options for limb salvage.

Background: Obesity is a known risk-factor for developing breast cancer–related lymphedema (BCRL) after axillary lymph node dissection (ALND). It is unclear if there is body mass index (BMI) threshold for increased risk of development of lymphedema after immediate lymphatic reconstruction (ILR). The purpose of this study is to assess the influence of obesity on the incidence of BCRL after ILR and determine a BMI threshold using a receiver operating characteristic (ROC) curve analysis.

Study Design: We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 across a university hospital system. Rates were compared across World Health Organization (WHO) obesity categories using logistic regression. An optimal BMI threshold predictive of BCRL was derived via ROC-based curve analysis, employing the Youden Index to identify the BMI cut-off with maximal combined sensitivity and specificity.

Results: We identified 172 patients with a mean age 50.9±11.6 years, BMI of 29.5±6.9 kg/m², and follow-up time of 23.1±15.2 months. Most patients (58.1%, n=100) had BMI <30 kg/m² (non-obese), 23.3% had BMI 30–34.9 kg/m² (class I), and 18.6% had BMI ≥35 kg/m² (class II/III). Patients with class II/III obesity had non-significantly elevated BCRL rates (12.5%) compared to class I (5.0%) and non-obese (6.0%) (p=0.39). The ROC-derived BMI threshold of >28 kg/m² demonstrated a significantly higher BCRL rate (11.1% vs. 2.4%; p=0.034), corresponding to a five-fold increase in lymphedema odds (OR 5.00; 95% CI 1.06–23.55).

Conclusions: Standard WHO obesity classification was not significantly associated with higher BCRL risk. However, BMI threshold of >28 kg/m² effectively predicted higher lymphedema incidence indicating the WHO classification range may be too broad for ILR. Patients with a BMI> 28 kg/m² should be given greater consideration for ILR when undergoing ALND.

Background: Obesity is a known risk-factor for developing breast cancer–related lymphedema (BCRL) after axillary lymph node dissection (ALND). It is unclear if there is body mass index (BMI) threshold for increased risk of development of lymphedema after immediate lymphatic reconstruction (ILR). The purpose of this study is to assess the influence of obesity on the incidence of BCRL after ILR and determine a BMI threshold using a receiver operating characteristic (ROC) curve analysis.

Study Design: We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 across a university hospital system. Rates were compared across World Health Organization (WHO) obesity categories using logistic regression. An optimal BMI threshold predictive of BCRL was derived via ROC-based curve analysis, employing the Youden Index to identify the BMI cut-off with maximal combined sensitivity and specificity.

Results: We identified 172 patients with a mean age 50.9±11.6 years, BMI of 29.5±6.9 kg/m², and follow-up time of 23.1±15.2 months. Most patients (58.1%, n=100) had BMI <30 kg/m² (non-obese), 23.3% had BMI 30–34.9 kg/m² (class I), and 18.6% had BMI ≥35 kg/m² (class II/III). Patients with class II/III obesity had non-significantly elevated BCRL rates (12.5%) compared to class I (5.0%) and non-obese (6.0%) (p=0.39). The ROC-derived BMI threshold of >28 kg/m² demonstrated a significantly higher BCRL rate (11.1% vs. 2.4%; p=0.034), corresponding to a five-fold increase in lymphedema odds (OR 5.00; 95% CI 1.06–23.55).

Conclusions: Standard WHO obesity classification was not significantly associated with higher BCRL risk. However, BMI threshold of >28 kg/m² effectively predicted higher lymphedema incidence indicating the WHO classification range may be too broad for ILR. Patients with a BMI> 28 kg/m² should be given greater consideration for ILR when undergoing ALND.

Background: In the United States, over 5.5 million patients are diagnosed with skin cancer annually. Mohs Micrographic Surgery (MMS) is widely utilized for precise excision of skin cancers, often necessitating advanced reconstructive techniques to address post-surgical defects. Though plastic and reconstructive surgeons (PRS) are often integral to treatment, data regarding the sociodemographic, oncologic, and surgical variables that drive referrals remain sparse.

Methods: The Massachusetts All-Payer Claims Database (2016-2020) was analyzed to evaluate patients treated via MMS for head and neck skin cancers, including melanoma, melanoma in situ (MIS), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and carcinoma in situ (CIS). Claims data were reviewed to identify MMS and referrals for reconstructive procedures. We applied a multivariable regression analysis to identify independent predictors of patients receiving referrals for reconstructive care. Financial analyses compared reimbursement data for physician service fees between MMS-surgeon vs. PRS-surgeon led reconstructions.

Results: Of 70,308 patients who underwent MMS, only 5,090 (7.24%) were referred to PRS, with referrals down-trending over the study period (8.07% in 2016 to 6.38% in 2020). Younger patients (mean 67.60 years vs. 70.02, p<0.001) and female patients (8.59% vs. 6.03% males, p<0.001) were more frequently referred to PRS. The only reconstructive procedures performed by PRS more often than MMS were free flaps, pedicled flaps, composite dermis/fat/fascial grafts, and skin grafts with cartilage. Patients with Melanoma or MIS had significantly higher odds of PRS referral (OR 1.771, p<0.008), as did those with tumors at cosmetically sensitive regions (e.g., eyelid OR=10.399; nose OR=2.889; lip OR=2.175, p<0.001). Patients treated in the Boston Metropolitan Area had lower odds of referral to PRS (OR=0.731, p<0.001), whereas publicly insured patients had higher odds of referral (OR=1.08, p=0.016). Stratified by insurance type, patients in the PRS cohort were younger than the MMS cohort across both public and private insurance holders.

Financial analyses revealed significant disparities in reimbursements. The median charge for MMS-led reconstruction was $1198.02, with median payments of $206.72 for privately insured patients vs. $51.18 for publicly insured patients (p<0.001). PRS-led reconstructions had higher median charges ($1,885.12) but similarly low median reimbursements ($531.33 privately insured, $165.26 publicly insured, p<0.001).

Conclusions: PRS referrals following MMS are declining, despite evidence that involvement of PRS improves reconstructive outcomes. With increased use of MMS in managing melanoma and MIS, PRS may see an evolution in practice patterns, shifting toward a greater emphasis on treating patients affected by those cancers. Public insurance status independently increased odds of PRS referral; in light of our results on payments, our findings suggest that reimbursement schemes may independently affect delivery of reconstructive care. Incentive structures within value-based care models, such as the Merit-Based Incentive Payment System (MIPS), may further inadvertently discourage judicious interdisciplinary collaboration by incentivizing per-practice cost-saving. Policy reforms aimed at aligning reimbursement structures are needed to ensure equitable access to high-quality reconstructive care.

Introduction: Upper extremity flaps are important procedures following trauma, tumor resections, infections and post-operative complications. This study characterizes wound complications and re-operation rates within 30 days following upper extremity flap surgery using a national database with analysis by surgical indication.

Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2022 for patients who underwent upper extremity "pedicled axial" flap reconstruction (CPT 15736). Cases were grouped into five categories by ICD-9 and ICD-10 diagnosis codes: cancer/neoplasm, infection, post-operative complications (i.e. surgical site/hardware infection or wound breakdown), open wounds/trauma, and other indications. All cases with non-upper extremity or non-postoperative complication-related ICD codes were excluded. Predictive variables included patient demographics and reconstructive indication. The primary outcome was postoperative complication defined as re-operation or wound complications including surgical site infections (SSIs) and dehiscence within 30 days of surgery. Bivariate and multivariate statistical analysis was performed to analyze the association of predictors with surgical outcomes (significance defined as p < 0.05).

Results: Of 592 cases that met inclusion criteria, the mean age was 53.9 (SD 17.7), with 59.1% males (n=350) and 40.9% females (n=242). One-third of cases were for neoplastic indications (n=199, 36.0%), 19.1% for trauma and wounds (n=113), 13.9% due to postoperative complications (n=82), 2.9% for infections (n=17) and 30.6% for other indications (n=181). The majority of surgeries were completed by plastic surgeons (n=383, 64.7%). The mean operative time was 125.8 (SD 103.5) minutes There were 43 patients (7.3%) that experienced postoperative wound complications (n=24, 4.1%) or required reoperation (n=23, 3.9%). Specifically, there were 28 superficial SSIs (3.1%), 11 deep incisional SSIs (1.2%), 4 organ space SSIs (0.4%), and 15 cases of wound dehiscence (1.7%).

On bivariate analysis, in terms of operative indications, cases related to complications from a prior surgery were significantly associated with further wound complications and re-operation (17.1%) compared to cases for neoplastic (5.5%), open wound/trauma (5.3%), infection (11.8%) and other indications (5.5%).Those who experienced wound complications/reoperation were older on average (58.9 vs. 53.5, p=0.028) than those who did not, while there was no significant difference in operative time. American Society of Anesthesiologists (ASA) Class 4 was also associated with higher frequency of complications (29.4%, p = 0.002).

There was no association between surgeon specialty, diabetes mellitus, smoking history and frequency of wound complications or reoperation. Binary logistic regression analysis adjusted for age, diabetes, smoking, and ASA class, redemonstrated that age and surgical indication of postoperative complication were significant predictors of subsequent wound complication or re-operation.

Conclusion: Patients undergoing salvage upper extremity flap reconstruction secondary to complications from a prior operation may experience greater rates of wound complications and re-operation compared to those undergoing primary flap reconstruction. These findings may help guide clinical risk management and patient counselling.