Scientific Abstract Presentations: Reconstructive Session 5 Saturday, October 11 Sat, Oct 11 10:30 a.m.-12:30 p.m. CDT

Introduction: Donor site morbidity following deep inferior epigastric artery perforator (DIEP) flap harvest, particularly hernias and bulges, can cause significant aesthetic and functional challenges. This study evaluates the impact of retrorectus polyglactin (Vicryl) mesh placement on abdominal morbidity.

Methods: A retrospective, single-center study was conducted on patients undergoing autologous DIEP flap-based breast reconstructions between March 2018 and September 2023. Propensity score matching was employed to mitigate selection bias, while multivariable regression analysis addressed potential confounding factors.

Results: A total of 554 DIEP flap reconstructions in 357 patients were identified, with 112 (31%) receiving a retrorectus polyglactin mesh. Unmatched comparisons demonstrated significantly lower rates of hernia (0.9% vs. 6.5%, p=0.02) and bulge (0.9% vs. 7.3%, p=0.01) with mesh placement, although cellulitis rates were significantly higher (8.9% vs. 3.7%, p=0.04). In propensity-matched comparisons, no significant differences were found in the rates of postoperative hernias, bulges, abscess formation, seroma, cellulitis, hematoma, skin necrosis, wound dehiscence, or delayed wound healing between the mesh and no-mesh groups, Table. Univariate regression analysis identified mesh as the sole factor significantly associated with reduced bulge occurrence (OR=0.1, p=0.035). Multivariable regression, adjusted for follow-up duration, indicated that mesh placement was not an independent predictor of hernia (OR=0.5; p=0.58). However, advanced age (OR=1.1; p<0.001), prior open abdominal surgery (OR=0.1; p=0.0.17), previous radiation therapy (OR=0.1; p=0.01), lateral row perforator harvest (OR=46.5; p=0.004), and the number of harvested medial row perforators (OR=2.6; p=0.012) were identified as independent predictors.

Conclusion: Retrorectus polyglactin mesh placement is significantly associated with decreased bulge rates but does not independently reduce the risk of hernia following DIEP flap harvest.

Background Complex abdominal wall reconstruction (AWR) is a demanding, multidisciplinary procedure requiring extensive tissue rearrangement. In cases of composite defects, additional tissue from a different body region may be necessary for optimal coverage. This study evaluates our experience with AWR using pedicled and/or free flaps, often in conjunction with mesh for fascial repair.

Methods An IRB-approved retrospective review was conducted on patients who underwent AWR using pedicled and free lower extremity flaps across two healthcare systems. Collected data included demographics, medical history, etiology, defect characteristics, reconstructive approach, and outcomes. Categorical variables were summarized as frequencies and proportions, while continuous variables were reported as medians with interquartile ranges (IQR).

Results: Twenty-four patients underwent AWR, with a median age of 53.5 years (IQR: 46.5–62) and a BMI of 29.89 kg/m² (IQR: 23.8–32.82). The cohort included 14 males (58.3%) and 10 females (41.7%), with 45.8% having a history of smoking. Prior abdominal surgery was reported in 66.7%, prior hernia repair in 50%, and prior radiation therapy in 8.3%.

66.7% of the patients had loss of domain, 33.3% underwent full-thickness oncologic resection, 4.8% underwent partial-thickness abdominal wall resection, and 4.8% had an open abdomen with an enterocutaneous fistula. The median skin defect measured 319 cm² (IQR: 190–603), while the median fascial defect was 750 cm² (IQR: 375–870). Reconstruction was performed using either free flaps (50%) or pedicled flaps (50%). All reconstructions included fasciocutaneous anterolateral thigh (ALT) flaps, with 45.8% also incorporating the vastus lateralis (VL). Additionally, 16.7% of patients received a chimeric flap, and 4.2% received an anteromedial thigh flap in addition to the ALT flap. Among free flap cases, the deep inferior epigastric (DIE) vessels were used in 75%, DIE vessels combined with the superficial inferior epigastric artery (SIEA) in 4.1% (n=1), and internal mammary vessels in 8.2%.

A total of 91.7% of patients required mesh reinforcement, with 63.6% receiving synthetic mesh and 36.4% receiving biologic mesh. The median flap size was 464 cm² (IQR: 310–562), and the median operative time was 654 minutes (IQR: 547–716). Flap success was achieved in 95.2% of cases, with one failure due to venous congestion. Intraoperative complications included one case of pedicle avulsion (4.8%), which was successfully salvaged. The median hospitalization duration was 14 days (IQR: 9.5–24.25), with a median follow-up of 7.5 months (IQR: 3–15).

Major complications requiring reoperation or intravenous antibiotics occurred in 20.8% of patients, including flap failure (4.1%), hematoma requiring takeback (4.1%), cellulitis requiring hospital admission and intravenous antibiotics (4.1%), and mesh infection/exposure requiring removal (8.3%). None of these complications occurred in patients undergoing post-oncologic resection. However, one oncologic resection patient required image-guided drain placement after accidental drain dislodgement.

No deaths were related to the surgical procedure. However, two-year mortality rate was 16.6%, attributed to their underlying malignancy.

Conclusion: AWR using free and pedicled flap-based techniques for full-thickness abdominal wall reconstruction and large loss-of-domain defects achieved a 95.2% success rate. Flap-based reconstruction remains a viable approach for restoring abdominal wall integrity, especially in patients with advanced malignancy with low complication.

Background: Immediate breast reconstruction after mastectomy offers superior functional and aesthetic outcomes but carries up to a 14% risk of mastectomy flap necrosis (1-3), leading to complications such as implant exposure and take-back surgeries. Hyperbaric oxygen therapy (HBOT) promotes angiogenesis, collagen deposition, and antibacterial effects but remains underutilized for post-mastectomy wound complications. This study evaluates the effectiveness of HBOT in promoting wound healing after mastectomy, regardless of reconstruction.

Methods: A single institution 10-year retrospective review (2014 - 2024) was conducted on patients who underwent simple, nipple-sparing or modified radical mastectomy regardless of reconstruction who experienced wound complications requiring HBOT. Primary outcomes included demographics, medical comorbidities, type of mastectomy and reconstruction, complications and revisions, time from diagnosis to complete wound healing, and the number of HBOT sessions completed. Secondary outcomes included the salvage rate of patients who developed wound healing problems following breast reconstruction and the incidence of adverse effects associated with HBOT.

Results: Twenty patients were included for analysis. The average age was 60.4 ± 14.15 years, with a mean follow-up of 20.5 months (range: 2–64), and a mean BMI of 32.8 ± 7.6. Of these, ten had undergone breast reconstruction (four pre-pectoral and three subpectoral tissue expanders with acellular dermal matrix were used, and three direct prepectoral implants which included acellular dermal matrix in two cases and surgical mesh in one case), while ten had not. Eight patients (40%) were former or current smokers, five (25%) had diabetes, eight (40%) had prior breast surgeries, and thirteen (65%) had received radiation therapy. Four patients required wound debridement before hyperbaric therapy, and one patient had a tissue expander removed prior to hyperbaric therapy. Nineteen patients (95%) achieved complete wound healing following a mean of 41.64 ± 22.37 sessions of hyperbaric therapy. Four patients required additional wound debridement in the operating room 2–13 days after initiating HBOT. One patient, who had undergone extensive resection, including multiple ribs due to malignancy, showed improvement but did not achieve full wound healing with hyperbaric therapy. Only one patient (5%) experienced temporary vision changes, which resolved upon discontinuation of hyperbaric therapy.

Conclusions: Preliminary evidence suggests that hyperbaric oxygen therapy is an effective treatment modality for mastectomy flap wounds by reducing the need for extensive debridement, enhancing vascularization particularly in radiated wounds, and shortening overall healing time. Despite its potential benefits, further high-quality research is needed to establish definitive clinical guidelines.

References: 
1 Antony AK, Mehrara BM, McCarthy CM, et al. Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion. Plast Reconstr Surg. 2009;124(2):356-363. 2. Matsen CB, Mehrara B, Eaton A, et al. Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study. Ann Surg Oncol. 2016;23(1):257-264. 3. Hansen N, Espino S, Blough JT, Vu MM, Fine NA, Kim JYS. Evaluating Mastectomy Skin Flap Necrosis in the Extended Breast Reconstruction Risk Assessment Score for 1-Year Prediction of Prosthetic Reconstruction Outcomes. J Am Coll Surg. 2018;227(1):96-104.

Background Due to their dependent location, lower extremity (LE) free flaps are at increased risk for venous complications. Various factors such as patient medical history, flap type, flap size, wound characteristics, and number of venous anastomoses can determine success of the free flap. This study analyzes key risk factors of flap loss and venous complications in LE free flaps to optimize reconstruction and the possibility of limb salvage. Materials and Methods A retrospective review was conducted of adult patients (≥18 years old) who required free flap reconstruction of the LE from 2016-2024. Patient records were reviewed for demographic information, wound and operative characteristics, coupler size, and number of venous anastomoses. The primary outcome was venous complications, defined as a composite variable encompassing venous congestion, partial or complete flap loss due to venous causes, and flap hematoma. Fisher's exact tests, Chi-squared tests, and Mann-Whitney U tests were used for univariate analysis of variables. Multivariate logistic regression was performed for variables of interest. Results The cohort consisted of 333 free flap reconstructions with a median age of 40 (IQR: 30-50), and 73.3% of the patients were male. There was no significant association between age, sex, race/ethnicity, insurance status, and comorbidities with venous complications. The median time to reconstruction was 10 days with 69.7% of soft tissue coverage occurring within 14 days. The overall venous complication rate was 6.0%. For free flaps used, 114 (34.3%) were radial forearm (RF), 93 (28.0%) were latissimus dorsi (LD), 67 (20.2%) were anterolateral thigh (ALT), and 59 (17.7%) were other flaps. The complication rate was 1.8% for RF, 9.7% for LD, and 9.0% for ALT (p=0.048). RF flaps had significantly lower complication rates compared to LD (odds ratio [OR]: 6.0, confidence interval [CI]: 1.5-40.0, p=0.02) and ALT (OR: 5.5, CI:1.2-38.4, p=0.04) on multivariate analysis. One venous anastomosis was used in 106 (31.8%) of flaps, and two venous anastomoses were used in 227 (68.2%) flaps. Dual venous systems were associated with significantly lower complication rates both on univariate (p=0.02) and multivariate (OR: 0.36, CI: 0.14-0.89, p=0.03) analysis. Wound type (blunt, penetrating, etc), number of debridements prior to coverage, days to reconstruction, and flap size were not significant risk factors to venous complications. There was also no difference in coupler size in either single or dual venous systems. Conclusion Our results show a higher risk of venous complications in LE free flaps utilizing single venous anastomoses and with LD and ALT over RF free flaps. When feasible, performing a second anastomosis may improve outcomes. Understanding key risk factors for venous complications will be essential in managing venous outflow and optimizing flap survival.

Introduction: Devastating limb injury is often the result of high-energy trauma or malignancy and is characterized by destructive injury to soft tissues, bones, nerves, and vasculature.1 Defects in the distal third of the lower extremity often require free tissue transfer.2 Rectus abdominis free flap offers many advantages for wound coverage, but the traditional open technique for flap harvest can compromise abdominal wall integrity.3 Thus this otherwise versatile flap has fallen out of favor. A robotic-assisted approach offers a potential solution as it may reduce morbidity associated with rectus abdominis flap harvest. There are only a few case reports detailing implementation of a robotic-assisted approach; it is still a largely underutilized method for harvest despite its potential benefits.4 Methods: Four robotic rectus free flap harvests were performed for extremity coverage at a single institution via a trans-abdominal pre peritoneal approach. Demographic information, operative variables (incision length, operative time), and outcomes were recorded. Results: All four harvests were performed robotically utilizing 8 mm ports. Three were used for distal lower extremity reconstruction and one was used for upper extremity reconstruction; three injuries were a result of trauma and one was following oncologic reconstruction. One of the patients had unrecognized pedicle traction on inset that required revision at the index operation. There were no flap-related complications or donor site morbidities (hernia, bulge, seroma) at an average of 8 months post-operatively. Incision lengths were three 1.2 cm port sites and a 4 cm Pfannestiel incision for free flap extraction. Average robotic docking time was 7.5 minutes and average total robotic time was 2 hours 32.5 minutes. Discussion: Although it is considered a workhorse flap, there has been decreased popularity in the use of the rectus abdominis free flap in recent years due to potential donor site morbidity.5 A robotic-assisted harvest approach offers a safe and efficient method for reconstruction: there is reduced morbidity due to preservation of both anterior and posterior rectus sheaths, while allowing for a two-team approach where robotic harvest and recipient vessels may be prepared simultaneously. Although feasibility was shown by this study, further larger studies are warranted.

References 1. Cholok D, Saberski E, Lowenberg DW. Approach to Complex Lower Extremity Reconstruction. Semin Plast Surg. 2022 Nov 16;36(4):233-242. 2. Györi E, Fast A, Resch A., Rath T, Radtke C. Reconstruction of traumatic and non-traumatic lower extremity defects with local or free flaps. Eur Surg. 2022;54, 44–49. 3. Kroll SS, Marchi M. Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg. 1992 Jun;89(6):1045-51 4. Appel R, Shih L, Gimenez A, Bay C, Chai CY, Maricevich M. Robotic Rectus Abdominis Harvest for Pelvic Reconstruction after Abdominoperineal Resection. Semin Plast Surg. 2023 Jul 25;37(3):188-192. 5. Chevray PM. Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps. Semin Plast Surg. 2004 May;18(2):97-104.

Introduction: Acquired buried penis (ABP), occurs when excessive surrounding soft tissue and skin folds obscure the penis, typically seen with obesity (1). The excess tissue is usually both above and on either side of the penis. It is often further worsened by Balanitis Xerotica Obliterans or Lichen Sclerosis. This leads to scarring of the shaft of the penis or foreskin, creating a ring of scar, obscuring the penile glans. ABP can affect the patient's relationships and mental health (2), and is also a risk factor for penile cancer (3). Limited literature exists describing patient outcomes following surgery for ABP. This study compares postoperative outcomes of a novel technique, the "Mantaray", versus the standard panniculectomy closure approach. Additionally, we provide a description of the Mantaray technique.

Methods We conducted a retrospective, single-center cohort study of 46 patients who underwent either the Mantaray technique (n = 24) or standard panniculectomy closure (SPC) (n = 22) between October 2019 and January 2025. Follow-ups occurred approximately 1 to 4 weeks postoperatively. The Mantaray technique removes excess tissue above and beside either side of the penis in a single resection specimen, elevating the penile base and flattening the tissues that shroud the shaft. It also provides a full thickness graft for the penile shaft, which is superior to split thickness grafting. Pearson chi-square, Student's t-test, and Fisher's exact test were used for analysis.

Results Age at the time of surgery was not significantly associated with postoperative complications in either group. Diabetes did not significantly impact postoperative complications. HbA1c was comparable between the groups (Mantaray 6.86 ± 1.01, SPC 6.85 ± 1.04). Reoperation rates were 31.8% (SPC) vs. 16.7% (Mantaray) (p = 0.307). Combined analysis showed that patients with a history of bariatric surgery/weight loss had lower wound dehiscence rates (p = 0.021). Postoperative complications were comparable, including mild infection (p = 0.146), wound dehiscence (p = 0.603), hematoma (p = 1.00), seroma (p = 0.478), and graft loss (p = 0.609). ABP recurrence rate was higher in the SPC group than in the Mantaray group (13.6% vs. 0%), though the difference was not statistically significant (p = 0.101).

Conclusion Surgical intervention is a safe treatment for ABP, with low overall postoperative complication rates. Preoperative weight loss should be considered, as it is associated with lower wound dehiscence rates. Age does not appear to influence outcomes and should not preclude patients from undergoing surgery for ABP. Presence of well-controlled diabetes does not impact postoperative outcomes. The Mantaray technique provides improved and aesthetic penile exposure in multiple vectors, with postoperative outcomes comparable to the standard panniculectomy approach.

References: 1. Higuchi, Ty T., et al. "Evaluation and treatment of adult concealed penis." Current urology reports 13 (2012): 277-284. 2. Amend, G.M., et al., The Lived Experience of Patients with Adult Acquired Buried Penis. J Urol, 2022. 208(2): p. 396-405. 3. Pekala, Kelly R., et al. "The prevalence of penile cancer in patients with adult acquired buried penis." Urology 133 (2019): 229-233.

Introduction: The leading cause of secondary lymphedema in developed countries is cancer treatment. Without intervention, breast cancer related lymphedema has been shown to affect up to 40% of patients. (1) However, immediate lymphatic reconstruction may decrease that risk. (1) Recently, Metformin has been studied for its anti-inflammatory and anti-fibrotic effects in reducing lymphedema in a mouse model. (2) The purpose of this study was to review the impact of metformin use on the development of lymphedema after axillary lymph node dissection.

Methods: The authors conducted a retrospective review of a prospectively maintained database of patients who underwent axillary lymph node dissection for breast cancer from January 2018 to August 2022. Study participants were categorized into four groups: Group 1 underwent immediate lymphatic reconstruction and was taking Metformin, Group 2 underwent immediate lymphatic reconstruction but was not taking Metformin, Group 3 did not undergo immediate lymphatic reconstruction but was taking Metformin, and Group 4 did not undergo immediate lymphatic reconstruction and was not taking Metformin. Chi-square tests and logistic regression analyses were performed.

Results: The study included 258 patients with a mean age of 54 years (range 25–89) and a mean BMI of 28.7 kg/m² (SD = 6.8). The average follow-up was three years. The majority of patients were in Group 4 (n = 185), followed by Group 2 (n = 39), Group 3 (n = 26), and Group 1 (n = 7). The rates of secondary lymphedema were: Group 1 = 12.5%, Group 2 = 28.2%, Group 3 = 11.5%, and Group 4 = 36.2%. Logistic regression demonstrated that Metformin use (OR = 0.24, 95% CI: 0.08–0.72, p = 0.011) and immediate lymphatic reconstruction (OR = 0.34, 95% CI: 0.14–0.83, p = 0.018) were significantly associated with a decreased likelihood of lymphedema, while chemotherapy (OR = 2.61, 95% CI: 1.25–5.45, p = 0.010) was associated with an increased risk. BMI showed a trend toward significance (OR = 1.14, 95% CI: 0.99–1.31, p = 0.060), while age (p = 0.312) and radiation therapy (p = 0.307) were not significant predictors. A significant relationship between immediate lymphatic reconstruction, Metformin use, and lymphedema development was identified (χ²(3, N = 258) = 8.2, p = 0.04).

Conclusions: Metformin use, independently or in conjunction with immediate lymphatic reconstruction, may provide a protective role against the development of secondary lymphedema in patients undergoing axillary lymph node dissection for breast cancer.

References:

1. Huang A, Koesters E, Garza RM, Hanson SE, Chang DW. A Single Institution Experience With Immediate Lymphatic Reconstruction: Impact of Insurance Coverage on Risk Reduction. J Surg Oncol. Published online December 29, 2024. doi:10.1002/jso.28067
2. Wei M, Wang L, Liu X, et al. Metformin Eliminates Lymphedema in Mice by Alleviating Inflammation and Fibrosis: Implications for Human Therapy. Plast Reconstr Surg. 2024;154(6):1128e-1137e. doi:10.1097/PRS.0000000000011363

Purpose: The latissimus dorsi (LD) flap is a versatile option for reconstructing defects from the head, to breast, and extremities. Traditionally, LD flap harvest has been performed using an open approach, which is associated with significant donor site morbidity and scarring (1). Recent advancements in robotic surgery have enabled minimally invasive LD flap harvest, though large-scale studies evaluating surgical outcomes remain limited (2,3). This study systematically reviews the available literature on robotic LD flap harvest outcomes.

Methods: A systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Randomized clinical trials, cohort studies, and case series published between January 1980 and November 2024 were included. Databases searched included CENTRAL, PubMed, Embase, and Scopus. Studies involving adult patients undergoing robotic-assisted LD flap harvest were analyzed for patient demographics, surgical technique, and postoperative outcomes.

Results: A total of 304 articles were screened, with 21 meeting inclusion criteria. Across these studies, 473 patients underwent robotic LD flap harvest, primarily for breast reconstruction (86.3%) and Poland syndrome correction (11.4%). 98.6% of flaps were pedicled. The mean patient age was 45.9 years, and the average BMI was 24.4 kg/m². Comorbidities included diabetes (4.5%), hypertension (11.1%), and active smoking (18.8%). Additionally, 57.4% of patients had prior radiation therapy, and 35.2% had undergone chemotherapy.

The mean hospital stay was 5.2 days, with an average follow-up of 19.4 months. Mean operative time, docking time, and robotic harvest time were 337.3, 43.8, and 84.8 minutes, respectively. Only one study reported conversion to an open procedure in a single patient. The overall complication rate was 30.1%, with seroma (23.2%), delayed wound healing (6.8%), and infection (2.9%) being the most common. Surgical revision was required in 6.0% of cases. Various scales assessed postoperative satisfaction, with all studies reporting ratings of "satisfied" or higher.

Conclusion: Robotic-assisted LD flap harvest is a safe and feasible alternative to the traditional open approach, demonstrating comparable operative times, low complication rates, and high patient satisfaction. Further comparative studies are needed to evaluate differences in scarring, donor site morbidity, and long-term functional outcomes.

References: 1. Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results. Plast Reconstr Surg. 1992 Apr;89(4):666-72; discussion 673-4. PMID: 1546078. 2. Selber JC, Baumann DP, Holsinger CF. Robotic harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg. 2012 Sep;28(7):457-64. doi: 10.1055/s-0032-1315789. Epub 2012 Jun 28. PMID: 22744894. 3. Clemens MW, Kronowitz S, Selber JC. Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction. Semin Plast Surg. 2014 Feb;28(1):20-5. doi: 10.1055/s-0034-1368163. PMID: 24872775; PMCID: PMC3946018.

Introduction Hernia repair following oncologic resection presents unique challenges due to poor tissue quality, immunosuppression, and prior radiation. Poly-4-hydroxybutyrate (P4HB) is a biosynthetic mesh that balances strength and biocompatibility, potentially optimizing outcomes in this high-risk population. Methods Patients with previous oncologic abdominal or pelvic resection who developed a hernia, which was repaired by the Plastic and Reconstructive Surgery team at Memorial Sloan Kettering Cancer from January 2018 to December 2023, were included. All hernias were repaired with P4HB. Primary outcomes included hernia recurrence and surgical site complications, including hematoma, abscess/infection/cellulitis, and wound dehiscence/breakdown. Results A total of 103 patients with a median age of 63 [55,70] years and body mass index of 26 [23,30] were included. The median follow-up duration was 24 months. The overall hernia recurrence rate was 7.8%, with a significant difference between clean (Class I) and contaminated (Class II–IV) cases (0% vs. 15%, p=0.006. Complications were reported in 25 patients (24%), with seroma (8.7%) and superficial wound dehiscence (8.7%) being the most common postoperative complications. Complication rates were comparable between clean (Class I) and contaminated (Class II–IV) cases. Significant differences were observed in key surgical characteristics when comparing patients with and without recurrence. Patients who did not experience recurrence had a significantly higher rate of bilateral external oblique release than those who did (73% vs. 25%, p=0.011). Furthermore, the plane of mesh placement differed between groups; patients who did not have a recurrence were more likely to have retrorectus mesh placement as compared to patients who did have a recurrence where onlay mesh placement was more common (73% vs. 63%, p=0.002). On univariate Fine-Gray Competing Risk Regression, accounting for the competing risk of death, patients who underwent retrorectus mesh placement were less likely to experience a recurrence (HR 0.06, 95% CI: 0.01–0.50, p=0.009). Similarly, those who underwent bilateral external oblique release were less likely to experience a recurrence (HR 0.12, 95% CI: 0.02– 0.60, p=0.01). Conclusion P4HB use in oncologic hernia repair demonstrates low rates of recurrence and complications. The protective effects of bilateral external oblique release and retrorectus mesh placement also highlight the importance of surgical technique in optimizing outcomes in oncologic hernia repair.

INTRODUCTION Glucagon-like peptide-1 (GLP-1) receptor agonists have become increasingly popular as a pharmacologic treatment for weight loss. While their metabolic benefits are well-documented, their effects on surgical outcomes are not well defined. Recent studies have suggested that GLP-1 agonists may impact wound healing, immune response, and fat metabolism, which are critical factors in reconstructive procedures. In implant-based breast reconstruction, these medications may alter the healing process and affect the overall aesthetic and functional results due to their role in fat reduction. This study aims to evaluate the effects of postoperative GLP-1 agonist use on complication and revision rates in patients undergoing two-stage expander-implant breast reconstruction.

METHODS This is a retrospective, single-institution study analyzing patients who underwent two-stage expander-implant breast reconstruction following oncologic resection from 2017 to 2022. Patients identified as using GLP-1 agonists postoperatively were included in the study. A control group of age-matched patients who did not use GLP-1 agonists was randomly selected from the same time period. Patient demographics, operative details, and postoperative outcomes were collected, including rates of complications and revision surgeries. Recorded complications included capsular contracture, infection, hematoma, implant malposition, and other relevant adverse events. Revision procedures performed up to the present date were documented. Statistical analysis was conducted to compare outcomes between the two groups.

RESULTS A total of 92 patients were included in this study, with 45 (49%) having used GLP-1 agonists at least once weekly for any duration following tissue expander placement. The cohort had a mean age of 52.1 years and a mean body mass index (BMI) of 26.1 kg/m². Among these patients, 27 underwent unilateral reconstruction, while 65 underwent bilateral reconstruction. The overall cohort had an average of 0.9 revision surgeries per patient. A total of 11 complications (12%) were recorded, including six cases of capsular contracture, three infections, one case of implant migration, and one hematoma. Patients who used GLP-1 agonists postoperatively had a significantly higher revision rate compared to those who did not (1.27 vs. 0.64, p=0.027). Additionally, postoperative GLP-1 agonist users experienced significantly more complications (22% vs. 2%, p<0.01), suggesting a potential negative impact on surgical healing and long-term outcomes. However, these results may have been confounded by BMI, as patients who took GLP-1 agonists postoperatively were noted to have significantly higher BMI compared to the control group (28.7 vs. 23.7, p<0.01), and as a result significantly higher rates of medical comorbidities.

CONCLUSION Our preliminary data indicate that the postoperative use of GLP-1 agonists is associated with a significantly increased risk of complications and revision surgeries in patients undergoing two-stage expander-implant breast reconstruction. These findings underscore the importance of thorough preoperative counseling for patients using GLP-1 agonists. Further studies with larger cohorts and prospective designs are warranted to better understand the mechanisms underlying these associations and to guide clinical decision-making in breast reconstruction surgery.

Background: Despite advances in burn care, morbidity and mortality remain high. There is a large gap in research focusing on resource-limited Appalachian burn victims. Appalachia is unique in many different ways. The region is well known nationally for poor healthcare outcomes, household income below the national average, ranking high in addiction and drug use crisis, and characterized with a high prevalence of comorbidities such as chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), coronary artery disease, and obesity. To complicate this devastating imbalance, Cabell Huntington Hospital is the sole burn intensive care unit in the state of West Virginia, with only six beds available. It is crucial to understand the factors that prolong the length of stay (LOS), as LOS is a key indicator for healthcare resource utilization, especially in this resource-limited population. This study aims to identify factors that influence LOS among burn patients in Appalachia, focusing on demographic and clinical variables. Methodology: A retrospective analysis was conducted among 748 patients between January 1, 2017, and January 1, 2023. Demographic and clinical variables, including age, gender, COPD, DM, smoking history, inhalational injury, burn source, body mass index (BMI), total burn surface area (TBSA), and total ventilation duration (TVD), were collected. Multiple linear regression was used to identify predictors of LOS. Statistical significance was set at p-values <0.05. Results: Significant predictors of prolonged LOS included TVD (β = 1.25, p < 0.001), TBSA (β = 0.60, p < 0.001), inhalational injury (β = 6.02, p < 0.001), and burn source (thermal contact with metal: β = 10.68, p = 0.003). Discharge status (dead) was associated with shorter LOS (β = −17.09, p < 0.001). For every additional day of ventilation, LOS increased by approximately 1.25 days. Each percentage increase in TBSA contributed to a 0.6-day increase in LOS. Patients who died had a hospital stay approximately 17 days shorter than those who survived. The presence of inhalational injury extended the LOS by an average of six days. Age, gender, COPD, DM, BMI, and smoking history were not significantly associated with LOS. Conclusions: Newer predictor models should be used to combine TBSA with other demographics, comorbidities, and burn factors, such as inhalation injury and TVD, to provide a more accurate LOS for patients, their loved ones, and caregivers. The rule that for every 1% TBSA burned LOS increases with one day does not hold in our population. These findings provide valuable insights for optimizing burn care in resource-limited settings.

Introduction: Stimulant use poses significant challenges in burn care, complicating pain management and leading to poorer outcomes, including longer hospital stays, higher complication rates, and increased healthcare costs. This study evaluates burn-related outcomes in stimulant-positive patients, as well as tabulates how frequently addiction medicine consultations are used in burn patients with positive stimulant screens. Methods: Patients with positive urine toxicology screens for stimulants, including amphetamines and cocaine, were identified. The primary predictor variable was stimulant use, while primary outcomes included length of hospital stay, burn severity, complications, and overall outcomes of care. Results: Out of 3,403 burn patients (34% female, 66% male, with a mean age of 39.2 ± 22.8 years), 572 patients (16.8%) had positive urine toxicology screens for stimulants. Stimulant-positive patients had significantly longer hospital stays compared to stimulant-negative patients (17.7 vs. 10.7 days, p<0.001), more severe burns (p=0.001), and a higher incidence of complications (15.6% vs. 11.5%, p=0.006). Despite these risks, only 12.6% (72 patients) of stimulant-positive burn patients received an addiction medicine consultation during their hospitalization. The use of addiction medicine consultations increased over time, rising from three consults in 2015 to 42 in 2023. Conclusions: A multidisciplinary approach that includes addiction medicine can help address both the complexities of pain management and substance use, leading to improved patient outcomes. Early involvement of addiction medicine could enhance pain management and recovery, emphasizing the need for more systematic integration of addiction medicine into burn care protocols.

Purpose: The corset repair is a novel surgical technique that modifies the classic onlay approach by suspending mesh in a hybrid plane partially below the external oblique muscles, providing enhanced support for complex abdominal wall defects. This technique has shown promise in offering long-term solutions for abdominal defects, especially in cases following abdominal flap harvest. This study aims to provide long-term follow-up data on the effectiveness of the corset repair for abdominal wall defects, including those arising after abdominally-based flap harvests.

Methods: This study involves a single-center, retrospective review of adult patients who underwent corset repair of abdominal wall defects between January 2016 and February 2024. The review included demographic, comorbidity, perioperative, and outcome-related data from patients undergoing this technique. A particular focus was placed on patients with defects resulting from abdominal flap harvest, including DIEP and TRAM flaps, as well as those with incisional hernias from other surgical interventions. Data collected for analysis included defect size, mesh type used, surgical complications, recurrence rates, and follow-up duration.

Results: A total of 63 patients were identified, with a median body mass index (BMI) of 31.3 kg/m² (IQR 28.1–34.3) and a median age of 56.8 years (IQR 50.1–65.7). The cohort included patients with various comorbidities: 39.7% were current or former smokers, 39.7% had a history of cancer, and 11.1% had undergone chemotherapy within 12 months before surgery. The primary indications for corset repair were defects following abdominal flap harvest (30.2%), incisional hernias from general (25.4%) or gynecologic surgeries (22.2%), and 41.2% had previously undergone hernia repair. The median fascial defect size was 250 cm² (IQR 140–408 cm²), with biosynthetic mesh used in 98.4% of cases. Overall, 28.6% of patients experienced a surgical site occurrence, which included 10 surgical site infections, 6 seromas, and 2 hematomas. The recurrence rate was 4.8%, with 3 patients developing recurrences, all of which were initially recurrent incisional hernias. The median follow-up time was 11.1 months (IQR 3.0–20.4 months). For the subset of 19 patients who had abdominal wall defects following flap harvest (median age 53.2 years), 84.2% had a history of cancer, and 31.3% received chemotherapy within the year preceding surgery. In this group, defects were primarily the result of DIEP (36.8%) and TRAM (63.2%) flap harvests. All defects were successfully closed, and the median fascial defect size was similar to the broader cohort at 250 cm² (IQR 140–408 cm²). Surgical site occurrences were reported in 26.3% of these patients, including 3 infections and 2 seromas. One recurrence was observed in this group.

Conclusion: The corset repair, utilizing a hybrid plane mesh suspension technique, has demonstrated efficacy in closing complex abdominal wall defects, including those arising after abdominal flap harvests. With low rates of recurrence and complications, this technique offers a promising alternative to traditional repair methods, especially when paired with biosynthetic mesh. The results highlight the value of corset repair in enhancing options for abdominal wall defect management in challenging clinical scenarios.

Introduction

Perineal complications after perineal resection occur commonly ranging from 25% to 60%.1 Flap-based reconstructions can help mitigate this, yet the increasing dominance of minimally invasive (MIS) resections have diminished the traditional benefit of rectus flaps (RF). The thigh-based gracilis flap (GF) has emerged as an alternative that offers a simple harvest with a low donor-site morbidity. Further evidence is thus needed to characterize outcomes of the GF in high-volume centers performing MIS resections.

Material and Methods

A retrospective cohort study was conducted at the University of Washington of all adult patients undergoing a perineal resection from 4/6/2021-12/31/2024 by a colorectal surgeon. Chart abstraction was performed for patient background, clinical, and surgical characteristics of patients.

The primary outcome is the rate of donor and perineal morbidity, quantified by delayed (> 1 mo.) wound healing (DWH), perineal or donor-site infections requiring antibiotics, or the need for procedural re-intervention. Descriptive statistics and multivariate logistic regression were used to examine risk factors for these adverse outcomes.

Results

109 patients were identified via CPT code, 99 of these were confirmed to have perineal resections. 63% (n = 62) underwent GF with 29% (n = 29) undergoing primary closure (PC), and the rest either undergoing RF or ALT flap. 81% (n = 80) of perineal resections were performed solely via a MIS approach. All RFs were performed in open cases (38%, n = 6), yet even so the GF remained the predominant (44%, n = 7) flap for open cases.

Non-oncologic indications were 8.7 times more likely in PC patients (95% CI, 3.56 -21.19) who were 13 years younger on average than flap patients (95% CI, 7.4 - 19) and only 24% (n = 7) had prior chemoradiation. Most GFs were performed for rectal or anal cancer (87%, n = 54) and had prior chemoradiation (89%, n = 55).

Donor site DWH occurred in 9.7% (n = 6) of GFs, and infection occurred in 16% (n = 10) of the cases (95% CI, 10 to 27%). Perineal DWH in those with a GF occurred in 27% (n = 17) of cases (95% CI, 18% to 40%). Perineal infections occurred in 27% (n = 17) of patients with a GF, with 59% (n = 10) of those requiring drainage. Accounting for age, race, sex, BMI, diabetes, prior/current tobacco usage, EBL, and medical compilation, BMI (p = 0.014) and lower EBL (p = 0.03) were significantly associated with perineal DWH while only diabetes was statistically significant for perineal infections (p = 0.002).

Conclusion

GF is a highly functional flap after perineal resection, particularly in MIS cases. Using a liberal definition for DWH rates remain acceptable without any additional abdominal RF harvest morbidity, and with low rates of any donor site complication. Diabetes, BMI, and tobacco usage are risk factors for perineal complications.

Citations
1. Eseme EA, Scampa M, Viscardi JA, Ebai M, Kalbermatten DF, Oranges CM. Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis. Cancers (Basel). 2022;14(17):4300. doi:10.3390/cancers14174300

Introduction The landmark paper by Godina in 1986 provided evidence for the importance of early soft tissue coverage of lower extremity traumatic injuries within 72 hours to reduce complications. [1] Advancements in wound care and reconstructive techniques since then have allowed for more flexibility on the timing of reconstruction, however reconstruction within 3 days remains the standard. We sought to review our outcomes as a single institution Level I trauma center to shed a more modern light on the characteristics of injury and management that affect outcomes.

Methods A retrospective review identified adult patients from 1994-2023 who required soft tissue reconstruction during the index hospitalization following lower extremity trauma at our institution. Demographics, comorbidities, and characteristics and management of traumatic injuries were abstracted from the medical record. Those with less than 30 days of follow up were excluded. Soft tissue complications assessed include flap circulation compromise, flap loss, infection, hematoma, seroma, or necrosis of the tissue surrounding the flap. Bony complications assessed include hardware infection, hardware failure, nonunion, malunion, osteomyelitis, and need for amputation. Univariate analysis was conducted via Student's t-test, Chi square test, and Fisher's exact test. Multivariable logistic regression models were then developed to examine the independent association of risk factors with each complication.

Results Of the 253 patients in this review, 77% were male (n=108), 82.7% were White (n=116), the average age was 41.9 (18-78.9), and the average BMI was 28 (16.5-41.6). At least one year follow up was obtained for 70% of patients. Soft tissue and/or bony complications were found in 55.6% of patients (n=141), with infection found in 29.7% (n=58), and 12.4% (n=28) went on to require amputation. The average time to soft tissue reconstruction from the time of injury was found to be 12 days, and the timing of soft tissue coverage was not shown to significantly affect complication rates (p=0.28). Instead, independent predictors of postoperative complications were found to be antibiotic spacer placement for staged bone grafting with OR 2.08 (1.04-4.31) (p=0.042), the use of latissimus dorsi free flaps with OR 2.4 (1.03-5.75) (p=0.045) and whether vascular surgery was consulted at the time of injury presentation with OR 2.59 (1.42-4.77) (p=0.002). Local or regional flap reconstruction was found to be protective from infection with OR 0.08 (0-0.48) (p=0.024), whereas BMI with OR 1.1 (1.03-1.17) (p=0.004) and history of IVDU with OR 4.93 (1.52-16.24) (p=0.007) showed a higher risk of infection.

Conclusion Although Godina's landmark paper serves as a standard for early reconstruction in lower extremity traumatic injuries, our experience shows that reconstruction can be safely delayed without timing being a factor for complications. Overall complication rates were instead associated with the use of antibiotic spacers, latissimus flaps, and vascular consults, all of which serve as proxy markers for the severity of the injury. These important considerations to help guide shared decision-making with patients when discussing limb salvage and the risks based on severity of injury.

References: 1. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292. doi:10.1097/00006534-198609000-00001

Introduction: Ventral hernias are a burdensome condition that significantly impact patients' quality of life. These hernias frequently occur in patients with obesity and multiple comorbidities, complicating surgical management. Recurrence remains a major challenge, as each failed repair weakens the abdominal wall, increasing the risk of future herniation and higher morbidity. [1]

Component separation is commonly used to restore midline fascial continuity while minimizing tension. The senior author employs a technique combining component separation with onlay placement of acellular dermal matrix (ADM) and multipoint progressive tension suture fixation to reinforce the abdominal wall. This study evaluates recurrence and complication rates following this approach, comparing outcomes between primary and recurrent ventral hernia repairs.

Methods: A retrospective cohort study was conducted on all ventral hernia repairs performed by the senior author at a single institution from 2017 to 2024. Patient demographics, operative details, and postoperative outcomes were collected. Data analysis included t-tests, Fisher's exact tests, and chi-squared analysis.

Results: A total of 213 patients were included. Most were female (156, 73.2%), with an average age of 53.2±13.0 years and average BMI of 32.3±6.3 kg/m². Of these, 99 (46.5%) underwent primary repair, while 114 (53.5%) had secondary repair. Concomitant panniculectomy was performed in 31.0% of cases, and an additional 26.3% underwent at least one other concurrent procedure, with no significant difference between groups (p=0.2674). Patients were followed for an average of 122.5 weeks, with no significant difference between groups (p=0.5008). No patients died within 30 days of surgery.

Baseline characteristics were largely similar between groups, with no significant differences in gender distribution, smoking status, or medical comorbidities. However, patients undergoing secondary repair were older (55.5 vs. 50.7 years, p=0.0076), had a higher BMI (33.1 vs. 31.3, p=0.039), and were more likely to present with an incarcerated or non-reducible hernia (45.6% vs. 27.3%, p=0.0069). The mean hernia defect size was larger in the secondary repair group (178 cm² vs. 91.3 cm², p=0.0043). Additionally, secondary repairs more frequently involved ADM placement (82.5% vs. 37.4%, p<0.0001) and had longer operative times (4.08 vs. 3.48 hours, p=0.0028).

Postoperative complications requiring interventional radiology or reoperation were more common in the secondary repair group (26.3% vs. 13.1%, p=0.0392), though rates of minor complications not requiring intervention were similar (22.8% vs. 22.2%)

Overall, recurrence was uncommon (9 cases, 4.2%). Recurrence rates were significantly lower in the primary repair group (1.0% vs. 7.0%, p=0.0392). Among the eight recurrences in the secondary repair group, only one occurred in a patient with more than one prior repair.

Conclusion: Despite some differences, the groups were largely comparable. As expected, recurrence rates were higher in the recurrent hernia cohort, yet both groups demonstrated recurrence rates lower than those reported in the literature. These findings suggest that component separation with ADM reinforcement may help interrupt - or at least slow - the cycle of recurrence and reoperation in ventral hernia repairs.

1. Holihan, J.L., et al., Adverse Events after Ventral Hernia Repair: The Vicious Cycle of Complications. J Am Coll Surg, 2015. 221(2): p. 478-85 doi: 10.1016/j.jamcollsurg.2015.04.026.

Purpose: Autologous fat transfer (AFT) is widely used in reconstructive and aesthetic surgery; however, its efficacy is often limited by suboptimal fat graft survival. Various pharmacological adjuncts have been proposed to enhance fat graft viability. This study aims to assess and rank potential adjuvant agents based on their effectiveness, safety, FDA approval for human use, and clinical applicability to identify the most promising candidate for further clinical trials.

Methods: A weighted scoring analysis was conducted to evaluate several adjuncts proposed to improve fat graft viability. The analysis considered six key factors: FDA approval for human use (scored as 1 point if approved), effectiveness demonstrated in animal models (scored 1–5 points), dosage optimization (1–5 points), safety in humans (1–5 points), pharmacological mechanisms supporting fat graft survival (1–5 points), and cost-effectiveness (1–3 points). The total score for each adjunct was calculated by summing the values assigned across these factors, allowing for a comparative ranking of their overall potential. The adjuncts evaluated in this study included Deferoxamine (DFO), Insulin combined with β-Fibroblast Growth Factor (β-FGF), Poloxamers, ADE4+ Endothelial Cells, Hyaluronan Hydrogel, BoNTA, and a combination of Prostaglandin E2 and PDRN.

Results: The weighted scoring analysis revealed that Deferoxamine (DFO) ranked the highest with a total score of 22 out of 24. DFO demonstrated strong preclinical evidence of promoting angiogenesis and reducing oxidative stress, leading to up to a 50% improvement in fat graft retention. Insulin combined with β-Fibroblast Growth Factor (β-FGF) followed with a score of 18, showing promising effectiveness, though its overall ranking was limited by the lack of FDA approval for β-FGF. Poloxamers scored 17, and Hyaluronan Hydrogel scored 16, both displaying moderate performance, largely due to inconsistencies in clinical data. BoNTA, with a score of 15, was noted for its FDA approval and safety but showed limited effectiveness in the context of fat grafting. Prostaglandin E2 and PDRN also scored 15 points, while ADE4+ Endothelial Cells scored the lowest with 14 points, both ranking lower due to limited FDA approval and less compelling evidence in improving fat graft viability.

Conclusions: Deferoxamine (DFO) emerged as the most promising adjunct for improving fat graft viability due to its dual mechanism of reducing oxidative stress and enhancing angiogenesis. As an iron chelator, DFO reduces the formation of free radicals, preventing oxidative damage to grafted fat, and promotes neovascularization, which is critical for graft survival. Further research will involve exposing fat to DFO and measuring fat viability to assess its clinical potential.

BACKGROUND: Total nasal reconstruction is among the most technically demanding procedures in plastic surgery due to the intricate anatomical, functional, and aesthetic complexities of the nose [1-2]. Each layer – the external skin, the cartilaginous and bony support, and the inner mucosal lining – must be meticulously reconstructed [2]. The cartilage grafts in particular play a crucial role in structural support and shaping the final contour and appearance of the nose [3]. Traditional reconstruction relies on autologous grafts, such as costal cartilage, but these may be limited by donor site morbidity or patient comorbidities. Non-porous implants such as solid titanium or polyether ether ketone (PEEK) offer robust structural support but do not permit soft tissue ingrowth, causing the overlying flap to sit unadhered to the implant surface, increasing the risk of implant exposure or flap erosion. We present a case of near-total nasal reconstruction using a novel, 3D-printed porous titanium implant for osseocartilaginous support that allows tissue integration, offering a customized alternative to conventional techniques.

CASE REPORT: A 51-year-old female with class 3 obesity and basal cell carcinoma of the dorsal nose underwent Mohs resection, leaving a near-total nasal defect measuring 22.5 cm². Given the extent of the defect and the patient's comorbidities, the decision was made to utilize a 3D-printed porous titanium implant for structural support in conjunction with a three-staged paramedian forehead flap (PMFF). Contiguous axial helical CT images were obtained from the vertex through the mandible with image reformats. The 3D reformats were utilized to design the custom 3D-printed titanium implant and optimize surgical planning using the 3DMD imaging system. Postoperatively, her hospital course was uncomplicated and she was discharged on day one with no wound-healing concerns. At 8 weeks post-initial stage of PMFF, she demonstrated a well-vascularized flap with soft tissue ingrowth into the implant's porosity with no complications. At 10 months post-reconstruction, she reported high cosmetic satisfaction and maintained patent nasal airways.

DISCUSSION: Foreign implants in nasal reconstruction remain largely unexplored, especially regarding long-term tissue integration. We present a successful subtotal nasal reconstruction using a novel, 3D-printed porous titanium implant to restore the osseocartilaginous structural framework of the nose. The porosity represents an innovative advancement that facilitates soft tissue ingrowth, enhancing flap adherence after debulking, improving stability, and reducing the likelihood of flap erosion. Additionally, its custom design optimizes functional and aesthetic outcomes. This case highlights the potential of 3D-printed porous titanium implants as a groundbreaking long-term solution for restoring nasal structure, particularly in patients with challenging anatomy or comorbidities that may limit the use of traditional grafts. Continued follow-up is essential to assess implant durability, tissue integration, and functional outcomes over time.

REFERENCES: 1. Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010 Apr;125(4):138e-150e. doi: 10.1097/PRS.0b013e3181d0ae2b. PMID: 20335833. 2. Fernandes JR, Pribaz JJ, Lim AA, Guo L. Nasal Reconstruction: Current Overview. Ann Plast Surg. 2018 Dec;81(6S Suppl 1):S30-S34. doi: 10.1097/SAP.0000000000001608. PMID: 30247189. 3. Menick FJ. An approach to the late revision of a failed nasal reconstruction. Plast Reconstr Surg. 2012 Jan;129(1):92e-103e. doi: 10.1097/PRS.0b013e3182362226. PMID: 22186590.

Background: Firearm-related injuries overtook motor vehicle crashes as the leading cause of injury-related death among children (1). Firearm injuries produce an extensive amount of bodily trauma, thus surgeons and multidisciplinary approaches are integral to the management of this public health crisis. The purpose of this study is to investigate the involvement of plastic surgeons on a national level and determine the relationship between pediatric firearm injury incidence, childhood opportunity index (COI), and state-level gun laws.

Methods: Using the Pediatric Health Information System (PHIS) database, we identified firearm injuries in children aged 18 years and younger from 43 children's hospitals across the U.S. requiring inpatient surgical care from 2015 to 2023. Patient demographics, injury characteristics, and geographic data were analyzed. Social vulnerability was assessed using the Child Opportunity Index (COI), and state gun laws were categorized as restrictive, moderate, or permissive based on the Giffords Annual Gun Law Scorecard. Surgical specialties involved in the management of these injuries were identified, with a specific focus on plastic surgery. Statistical analyses included univariate tests, t-tests, logistic regression, and population-adjusted incidence analyses.

Results: A total of 1,636 pediatric firearm injury cases met inclusion criteria. The majority of patients were male (79.8%) and White (64.8%), with a mean age of 11.8 ± 5.0 years. Children from neighborhoods with low COI scores had significantly higher mortality rates (OR 1.010, p=0.025). Increased distance from trauma centers was associated with higher odds of mortality (OR 1.01, p=0.002). Population-adjusted analyses revealed that firearm injuries were significantly more common in permissive gun law states (76.4%), compared to restrictive states (13.2%) and moderate states (10.4%) (p<0.01). Among surgical specialties, pediatric surgery, orthopedic surgery, and plastic surgery were the most frequently involved. Plastic surgeons played a vital role in managing soft tissue injuries, complex wound closures, and facial reconstruction. The need for staged reconstructive procedures underscores the importance of plastic surgery in restoring form and function in these patients. Additionally, disparities in access to specialized reconstructive care were noted, particularly in underserved regions.

Conclusions: Pediatric firearm injuries remain a significant public health crisis. Children from disadvantaged neighborhoods, younger age groups, and those living further from hospitals faced higher mortality rates, while permissive state gun laws were linked to increased injury incidence. The frequent involvement of plastic surgeons emphasizes the complexity of firearm injuries and the necessity of a multidisciplinary approach for optimal care. This study provides valuable insight into the essential role of plastic surgeons in reconstruction and functional restoration. Future research should explore the impact of early reconstructive intervention on long-term recovery and quality of life in pediatric firearm injury survivors.

References: Grinshteyn E, Hemenway D. Violent death rates in the US compared to those of the other high-income countries, 2015. Prev Med. 2019;123:20-26. doi:10.1016/j.ypmed.2019.02.026

Background: Body Mass Index (BMI) has been commonly used to determine appropriateness for surgery. However, it fails to account for variations in lean mass and fat distribution, prompting the development of alternative anthropometric indices such as the Body Roundness Index (BRI), A Body Shape Index (ABSI), Body Adiposity Index (BAI), Conicity Index (CI), Abdominal Volume Index (AVI), Waist-Hip Ratio (WHR), and Waist-Height Ratio (WHtR). The present study evaluates which index best predicts adverse outcomes following deep inferior epigastric perforator (DIEP) flap surgery.

Methods: A retrospective cohort study was conducted on patients who underwent DIEP flap breast reconstruction between 2017 and 2023. Patient demographics and comorbidity data were collected. Hip and waist circumference were measured using standardized bony landmarks on preoperative imaging. These measurements, along with height and weight, were used to calculate the various anthropomorphic indices. Primary outcomes included complications requiring intervention, 90-day readmissions, hospital length of stay (LOS), and total operative time. Univariable and multivariable regression models assessed the predictive utility of anthropometric indices, with statistical significance set at p < 0.05.

Results: Of the 384 patients, 84 patients (21.9%) experienced complications requiring intervention, while 300 (78.1%) did not. Diabetes was significantly more prevalent in the complication group (15.5% vs. 6.7%, P = 0.010), while age, race and remaining comorbidities were comperable between groups. Complications differed significantly between BMI-based weight classifications (P < 0.001), occurring in 47 (34.8%) obese patients compared to 22 (15.7%) normal-weight patients. On multivariate regression controlling for age, race, and diabetes, BMI (aOR 1.09, P < 0.001), BRI (aOR 1.26, P = 0.010), AVI (aOR 1.09, P = 0.01), and WHtR (aOR 88.66, P = 0.02) were significant predictors of overall complications. In addition, BMI (aOR 1.09, P = 0.04), BRI (aOR 1.55, P = 0.01), BAI (aOR 1.13, P = 0.01), AVI (aOR 1.17, P = 0.01), and WHtR (P = 0.01) were significant predictors of 90-day readmissions while BMI (P = 0.02), BRI (P = 0.010), AVI (P = 0.001), WHtR (P = 0.020), and WHR (P = 0.01) were significant predictors of prolonged LOS. Only AVI significantly predicted longer procedure times (P = 0.009). ABSI and Conicity Index did not significantly predict any outcomes.

Discussion: Compared to BMI, both AVI and BRI demonstrated more robust predictive value for LOS (standardizd betas 0.17 and 0.14 vs 0.13 for BMI), and higher likelihoods for 90-day readmissions (aOR 1.17 and 1.55 vs. 1.09 for BMI). In addition, BRI showed a higher likelihood for complications requiring revision (aOR 1.26 vs 1.09 for BMI) while AVI alone predicted longer procedure times (P=0.01 vs 0.07 for BMI) compared to BMI. These findings underscore the role of body composition and fat distribution in determining surgical risk. While WHtR and WHR also showed predictive value for complications and LOS, their clinical utility may be limited by the narrow range of observed values.

Conclusion: BRI and AVI outperformed BMI in predicting complications, 90-day readmissions, and LOS following DIEP flap surgery. Incorporating these indices in preoperative assessments could improve risk stratification.