Scientific Abstract Presentations: Reconstructive Session 6 Saturday, October 11 Sat, Oct 11 5:00-6:00 p.m. CDT

Background: The management of deep sternal wound complications following cardiac surgery has evolved significantly over time. Despite the standardization of reconstructive techniques, data regarding temporal trends in patient complexity, surgical outcomes, and postoperative complications remain limited. This study provides a detailed analysis of three decades of sternal wound reconstruction cases, identifying shifts in patient demographic data, reconstructive indications and approaches, postoperative complications, reoperation rates, and 30-day mortality through analysis of one of the largest single-institution cohorts published to date.

Methods: A retrospective review of 640 patients undergoing sternal wound reconstruction at our institution by the senior author (J.A.A.) between 1995 to 2024 was conducted following institutional review board approval. Patients were stratified into three time periods: Period 1 (1995-2004, n=214), Period 2 (2005-2014, n=139), and Period 3 (2015-2024, n=231). Patient demographics, comorbidities, surgical details, and outcomes were analyzed for temporal trends. Primary outcomes included major and minor postoperative complications, rates of reoperation, and 30-day postoperative mortality. Multivariate analysis identified consistent trends across the three decades.

Results: Of the 640 patients identified during the study period, 584 had sufficient data for analysis. Analysis across time periods demonstrated increasing patient complexity with consistently higher rates of chronic kidney disease (Period 1: 4.2%, Period 2: 15.1%, Period 3: 20.8%, p<0.0001) and hyperlipidemia (Period 1: 38.8%, Period 2: 59.0%, Period 3: 66.2%, p<0.0001). The interval time between cardiac index and sternal surgeries increased (Period 1: 18 days, Period 2: 35 days, Period 3: 44 days, p<0.0001). Reconstructive technique changed with the increasing addition of omental flaps along with bilateral pectoralis major flaps (Period 1: 0%, Period 2: 1.4%, Period 3: 6.5%, p=0.0001). While rates of certain major and minor complications showed consistent significant increases, such as partial soft tissue dehiscence (Period 1: 4.7%, Period 2: 5.0%, Period 3: 14.3%, p=0.0003) and infectious signs not requiring reoperation (Period 1: 3.7%, Period 2: 7.2%, Period 3: 11.7%, p=0.0069), 30-day mortality showed improvement (Period 1: 10.3%, Period 2: 5.04, Period 3: 4.8%, p=0.0441) and postoperative hospitalization duration decreased significantly across periods (Period 1: 24.91 ± 26.95 days, Period 2: 15.10 ± 20.69 days, Period 3: 13.43 ± 16.05 days, p<0.0001).

Conclusions: In this large single-institutional analysis of a three-decade experience by a single surgeon, our data demonstrate an advancing reconstructive approach, utilizing additional flap donor sites to complement the reliability and versatility of bilateral pectoralis major flaps. Of note, the rate of major and minor complications increased, which may be explained by increasing patient complexity measured by comorbidity rates. Our data also support early plastic surgery consultation and prompt reconstruction when indicated, as longer intervals between index cardiac surgery and sternal reconstruction were noted alongside rising major and minor complication rates. Notably, the 30-day mortality rate did decrease during the study, and there was a significant reduction in postoperative hospitalization lengths, suggesting successful implementation of enhanced recovery protocols.

Background: Free tissue transfer is a critical component of limb salvage in lower extremity (LE) trauma, facilitating soft tissue coverage and structural support. However, donor-site morbidity remains a significant consideration, potentially impacting long-term functional outcomes, particularly ambulatory status. The effect of flap harvest laterality on postoperative ambulation has not been well characterized. This study aims to evaluate whether flap laterality (ipsilateral vs. contralateral) influences ambulatory function following free flap reconstruction for traumatic LE injuries.

Methods: A retrospective cohort study was conducted at a level 1 trauma center, including all patients who underwent LE free flap reconstruction between 2009 and 2022. Demographic variables, injury characteristics, flap type, and postoperative functional outcomes were collected. Flap laterality was categorized as ipsilateral or contralateral relative to the injured limb, and flaps were further classified as fasciocutaneous or muscle/myocutaneous. The primary outcome was ambulatory status at final follow-up, with secondary outcomes including time to ambulation and overall flap survival. Statistical analysis was performed using chi-squared and Mann-Whitney U tests to assess associations between flap laterality, flap type, and ambulatory outcomes.

Results: A total of 298 LE free flaps were included in the analysis, with 226 (75.8%) harvested from the ipsilateral limb and 63 (21.1%) from the contralateral limb. The overall flap survival rate was 95.4%. There was no significant difference in the proportion of patients achieving full ambulation between the ipsilateral (61.5%) and contralateral (68.6%) cohorts (p = 0.564), nor was there a significant difference in the time required to achieve full ambulation (p = 0.071). However, patients who received fasciocutaneous flaps demonstrated a higher likelihood of achieving ambulatory function at final follow-up compared to those who underwent muscle or myocutaneous flap reconstruction (68.4% vs. 51.3%, p = 0.003). These findings remained non-significant when stratifying for flap type within ipsilateral and contralateral cohorts or when comparing free flaps and local flaps separately.

Conclusion: This study found no significant association between flap harvest laterality and postoperative ambulatory outcomes in patients undergoing LE free flap reconstruction following traumatic injury. However, flap composition appeared to influence functional recovery, with fasciocutaneous flaps being associated with a higher rate of ambulation at final follow-up compared to muscle or myocutaneous flaps. These findings suggest that donor-site selection should be guided primarily by reconstructive needs rather than concerns regarding laterality. Further prospective studies incorporating standardized functional assessments may provide additional insight into the relationship between flap characteristics and long-term mobility outcomes in this patient population.

Introduction Reconstructing large pelvic defects is challenging due to the functional demands of the perineal region. Numerous locoregional reconstructive options exist for addressing the pelvic floor and perineum. Enhanced recovery after surgery (ERAS) protocols plays a crucial role in guiding the reintroduction of standing, walking, and sitting, all of which are believed to impact flap perfusion and surgical outcomes. However, there are currently no universally accepted, evidence-based guidelines. This review aims to summarize reported postoperative remobilization protocols for flap-based reconstruction of pelvic and perineal defects, categorized by regional donor sites.

Methods A scoping review of PubMed was conducted for articles from 2000 to the present concerning flap-based pelvic or perineal reconstruction using MeSH terms. Data extracted included study characteristics, types of flaps, detailed postoperative remobilization protocols, hospital stay duration, and complications related to early mobilization.

Results Out of 536 articles screened, 42 were included. The majority (n = 20) were retrospective cohort studies. The most commonly reported flaps, in order of frequency, included inferior gluteal artery perforator (IGAP) flaps (n = 10), vertical rectus abdominis myocutaneous (VRAM) flaps (n = 9), gracilis flaps (n = 8), internal pudendal artery perforator (IPAP) flaps (n = 5), and anterolateral thigh (ALT) flaps (n = 2). Studies including VRAM and IPAP flaps reported median bedridden recommendations of five days, while those with gracilis and IGAP flaps initiated mobilization at medians of 1-2 days postoperatively and as early as postoperative day 0. Studies including gracilis and IGAP flaps allowed sitting within the first week, while sitting was delayed to after two weeks for other flaps. Two studies comparing complication rates between early and late remobilization protocols found similar or fewer complications in patients with earlier mobilization compared to longer, more traditional protocols.

Conclusion This review is the first to consolidate reported mobilization protocols following various pedicled flaps used in pelvic reconstruction. The findings highlight the heterogeneity of existing protocols and the lack of associated complications related specifically to early mobilization. Importantly, there is growing evidence that early remobilization and sitting may be beneficial for patients. Therefore, clinical trials focused on postoperative protocols for this population are warranted.

Background: Effective pain management at the donor site of split-thickness skin grafts (STSG) is important, particularly in the challenging atraumatic lower extremity (LE) wound population. Exparel (liposomal bupivacaine) and Marcaine (bupivacaine) are commonly used for donor site analgesia, yet no studies have directly compared their efficacy in this specific patient population. Additionally, the role of neuropathy in postoperative pain perception in this context has not been well characterized. This study evaluates the efficacy of Exparel, Marcaine, and lidocaine in controlling donor site pain and also assesses differences in pain outcomes between neuropathic and non-neuropathic patients. Methods: A retrospective review was conducted on patients who underwent STSG for chronic atraumatic LE wounds at a single institution from December 2014 to December 2022. Patients received either Exparel, Marcaine, a combination of Exparel and Marcaine, or lidocaine for donor site analgesia. Primary outcomes included postoperative pain scores on postoperative day (POD) 0 and at the first follow-up visit. Results: A total of 246 patients were included, with a mean age of 62.8 ± 14.7 years. The distribution of analgesic strategies was as follows: Exparel (25.5%), Marcaine (21.6%), Exparel + Marcaine (12.0%), and lidocaine (40.9%). Median pain scores on POD 0 were significantly lower in the Exparel (0 [3]) and Marcaine (0 [2.5]) groups compared to lidocaine (2 [0], p=0.020). At the first follow-up, pain scores remained lowest in the Exparel (0 [4]) and Marcaine (0 [3]) groups compared to lidocaine (2.5 [5]), though this difference was not statistically significant (p=0.241). When comparing neuropathic to non-neuropathic patients, neuropathic patients experienced significantly lower postoperative pain both immediately after surgery (p=0.008) and at the first follow-up (p=0.026). Among neuropathic patients, pain scores did not significantly differ between analgesic groups at any time point. Conclusion: This study is the first to compare Exparel and Marcaine for donor site analgesia in patients undergoing STSG for chronic atraumatic LE wounds. Both agents provided superior immediate postoperative pain control compared to lidocaine, with Exparel demonstrating a potential trend toward prolonged analgesia. Additionally, neuropathic patients exhibited significantly less postoperative pain than their non-neuropathic counterparts, independent of the analgesic used. These findings highlight the importance of individualized pain management strategies in this population.

Background: Adequate venous outflow is an essential factor for microvascular free flap survival. Decreasing resistance in outflow is believed to be essential to prevent thrombus and maintain patency of a microvascular anastomosis. In laminar flow of fluids, increasing the radius of a conduit has an exponential relationship in decreasing resistance to flow and has a greater effect of doing so than increasing number of conduits. The purpose of this study was to understand the effect of the number of veins and size of veins used in free flaps have on reoperation due to vascular compromise.

Methods: We conducted a retrospective review of free flaps performed at our academic institution from June 2011 to November 2023. Free flaps with intraoperative documentation of anastomosis technique, number of veins anastomosed, and coupler size used were included in the study. Only flaps with venous coupler anastomoses were included in the analysis of vein size to ensure accurate measurement of vein caliber. The primary outcome was rate of reoperation due to vascular compromise.

Results: In total, 751 free flaps were included in this study. Of these, 645 flaps (85.9%) had one venous anastomosis and 106 (14.1%) had two venous anastomoses. Overall, 80 (10.7%) flaps underwent reoperation for vascular compromise. There was no significant difference in the rate of reoperation for flaps with one vein (11.0%) or two veins (12.1%, p=0.729). However, analyzing the subset of flaps performed with venous couplers (N=656) multivariate logistic regression adjusting for age, gender, recipient site, and flap type demonstrated an increased odds of reoperation in patients who had a 1.5 mm coupler (OR 4.44, p=0.028). Couplers of 2 mm, 2.5 mm, 3 mm, 3.5 mm, and 4 mm did not show a difference in rate of reoperation.

Conclusion: The majority of microvascular free flaps performed at our institution used one venous anastomosis. We observed no difference in the rate of reoperation using one or two veins. Venous anastomoses of 1.5 mm were more likely to require reoperation due to vascular compromise. This may indicate smaller veins have a higher risk of loss.

PURPOSE: GLP-1RA medications are gaining increasing popularity for the treatment of diabetes and, more recently, weight loss. While the study of perioperative GLP1-RA use has primarily focused on delayed gastric emptying and aspiration risk, the impact on postoperative surgical outcomes remains poorly understood. A recently published propensity score matched cohort study demonstrated that GLP-1RA may decrease postoperative complications in diabetic patients. As GLP-1RA users make up a growing share of plastic surgery patients, understanding their effect on the postoperative outcomes is paramount. Here, we examined rates of surgical complications and readmissions in both diabetic and nondiabetic plastic surgery patients and compared outcomes between patients with active perioperative GLP-1RA prescriptions and those without.

METHODS: All patients who underwent a plastic surgery procedure (defined by CPT/HCPCS code) at a multicenter quaternary-care healthcare system between February 2020 to July 2023 were retrospectively identified, and all procedures included. Patients were split into diabetic (type 1 or 2) and non-diabetic cohorts. The following outcomes were analyzed in patients with and without an active GLP-1 RA prescription: 30-day readmission, and/or documented dehiscence, infection, hematoma, and bleeding within 180 days after surgery. The occurrence of at least one complication (dehiscence, infection, hematoma, bleeding) was defined as 'any complication'. In the non-diabetic cohort, propensity score matching was performed based on comorbidities and demographics, and the outcomes reanalyzed. The diabetic cohort was not matched due to limited sample size.

RESULTS: 10,505 surgical procedures in 6,788 patients were identified, of which 2.9% were performed in the setting of an active GLP-1RA prescription. In 1,069 plastic surgery procedures in 731 diabetic patients (38.4% men, median [IQR] age, 65 [56, 73], BMI, 29.3 [25.8, 33.8]), the active GLP-1RA prescription group had reduced rates of any complication (n=13, 7.8% versus n=99, 11.0%) and readmission (n=9, 5.4% versus n=66, 7.3%), though this did not reach statistical significance (potentially because of an underpowered cohort). In 9436 procedures in 6057 nondiabetic patients (30.0% men, age, 56 [43, 69], BMI, 25.9 [22.7, 30.1]), the active GLP-1RA prescription group had a significantly higher rate of postoperative hematoma (n=3, 2.1%) versus no GLP-1RA use (n=10, 0.1%; p<0.001) as well as a higher rate of any complication (n=14, 10.0% versus n=399, 4.3%; p=0.002). Of note, in both diabetic and nondiabetic unmatched cohorts, GLP-1RA users had a significantly higher median BMI than non-users (diabetic, 31.6 [28.3, 35.9] versus 28.8 [24.9, 33.0]; nondiabetic, 33.1 [28.9, 6.5] versus 25.7 [22.6, 29.8]). After propensity score matching of nondiabetic patients (including for BMI), active GLP1-RA use was still associated with a significantly greater risk of any complication (n=12, 12.1% versus n=16, 5.5%; p=0.048).

CONCLUSIONS: Nondiabetic plastic surgery patients with an active perioperative GLP-1RA prescription, presumably for weight loss, may be at higher risk for postoperative complications than non-users. Conversely, this increased risk was not apparent in the diabetic population; in fact, previous studies suggest a potential protective GLP-1RA effect in diabetic patients. These data suggest a differential effect of the GLP-1RA mechanism of action for diabetic and nondiabetic patients in the postoperative period.

Introduction Cranioplasty after decompressive hemicraniectomy is associated with failure rates as high as 30-50%. The search for optimal material for cranioplasty with excellent complication profile continues. Using high quality data from Kaplan Meier curves of level 1-4 studies, the goal of this study was to evaluate survival data for most commonly utilized cranioplasty implant materials. Methods We analyzed 21 Kaplan Meier curves from 10 high quality studies. All industry sponsored studies, and curves with <50 were excluded. Curves were digitized using WebPlotDigitizer (autometris.io), and data were collected. 1-phase exponential decay non-linear regression analysis NLRA allowed us to calculate overall survival, while 2-phase exponential decay NLRA enabled us to determine the proportion of patients that will develop a failure. Curves fitting 2-phase decay model on NLRA means there are two subsets within the population: those that are stable (repairs unlikely to fail), and those that are destined to have a procedural failure (% Short). Results A total of 21 Kaplan Meier curves representing 2,379 patients were analyzed. Cranioplasty materials assessed were autologous bone grafts, titanium, polymethyl methacrylate PMMA, and Polyetheretherketone. PMMA had the longest overall survival half-life and autologous bone graft had the shortest. Among the included biocompatible implants, titanium implants had the shortest overall half-life, with its survival data similar to that of autologous cranioplasty. (Table 1). PMMA had the smallest subset of population that will fail (7%) and again, autologous cranioplasty (22.8%) and titanium plate (22.95%) cranioplasty had the highest. Half-life short is the half-life for those that will potentially have a procedural failure to indeed develop a failure. Interestingly, this was similar across all cranioplasty materials, except for PMMA that is slightly higher (19 months). Finally, long term outcome predictions for a specific cranioplasty material can be easily made using the basic half-life formula [EXP(− tn × 0.693/t1/2)" where "tn" is the time interval of interest and "t1/2" is the subpopulation's short half-life. Similarly, this formula can be used to determine the proportion of patients within the potentially cured subgroup that will eventually relapse. Conclusion We have demonstrated that cranioplasty survival data fit into the 2-phase decay model and developed the first ever population survival kinetics data on cranioplasty. This model also validates the existing data suggesting PMMA may have slightly better long term outcomes compared to than other cranioplasty materials.

Background: Autologous breast reconstruction using abdominal tissue has become the gold standard approach to reconstruction following mastectomy. However, long term sensory loss at the donor site is a common but understudied complication. This study aims to characterize abdominal sensory changes over time (> 3 years) to guide patient-surgeon discussions. Methods: 71 patients who underwent unilateral or bilateral abdominal free flap reconstruction (MS-TRAM or DIEP) were stratified by follow-up time into four cohorts (<1 year, >1 year, >2 years, and >3 years post-op, ranging 0.24 to 6.79 years). Sensation was assessed using Semmes-Weinstein monofilaments at 93 abdominal sites. Data were analyzed using generalized linear models in R, and heat maps were generated to visualize sensory changes. Patient-reported outcomes were evaluated via the BREAST-Q 2.0 questionnaire. Results: Sensory heat maps revealed improved sensation over time, with the infraumbilical midline and areas below the transverse scar most affected by sensory loss. Generalized linear models showed time significantly improved sensation and abdominal scar appearance, while higher BMI and bilateral reconstruction were associated with reduced sensory recovery. Conclusion: Abdominal sensory loss and scar appearance are common concerns following autologous breast reconstruction, but both improve significantly over time. Sensory recovery is most limited in infraumbilical midline zones, while lateral zones show near-complete recovery, with bilateral reconstruction and higher BMI associated with poorer outcomes. These findings can enhance preoperative counseling by providing a comprehensive picture of anticipated sensory changes.

PURPOSE: Burn injuries significantly contribute to accidental injuries and fatalities worldwide, affecting an estimated eight million people annually. At the same time, diabetes impacts approximately 422 million people globally, with the majority living in low- and middle-income countries, and is directly responsible for 1.5 million deaths each year. Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades. As a chronic metabolic disease, diabetes is characterized by elevated blood glucose levels, which impair small blood vessels and hinder wound healing, posing unique challenges for burn management. Our study, conducted at a single institution, provides a comprehensive 12-year analysis of outcomes and complications in diabetic patients undergoing lower extremity burn reconstruction, addressing these complex interactions between diabetes and burn recovery.

METHODS: A retrospective analysis was carried out on diabetic patients with lower extremity burns treated at a single ABA-verified burn center from 2012 to 2023. The data collected included demographics, burn characteristics, treatment methods, and outcomes. Logistic regression was used to examine the associations between burn-related factors and the probability of requiring surgical intervention.

RESULTS: A total of 571 patients were included in the analysis, 65.3% of whom were male. Among them, 100 patients (18.0%) had diabetes, while 454 (82.0%) did not. The overall surgery rate was 52.5%, with no significant difference between diabetic and non-diabetic patients (p=0.691). There were no significant differences in the risk of hypertrophic scarring (p=0.091), contracture formation (p=0.326), or graft loss (p=0.250). However, diabetic patients had a higher risk of reoperation (54.0% vs. 38.6%, p=0.004), osteomyelitis (5.8% vs. 0.48%, p<0.001), and cellulitis (46.2% vs. 27.5%, p<0.001). In multivariate analysis, adjusting for age and total body surface area (TBSA), diabetes was associated with twice the odds of re-intervention (OR=2.00, 95% CI [1.25, 3.20], p=0.004) and six times the odds of developing osteomyelitis (OR=6.04, 95% CI [1.10, 33.22], p=0.038). However, after adjustment, diabetes was no longer a significant predictor of cellulitis (OR=1.55, 95% CI [0.94, 2.55], p=0.084).

CONCLUSION: Diabetic patients undergoing lower extremity burn reconstruction have significantly higher risks of reoperation and osteomyelitis, emphasizing the need for targeted surgical strategies and careful postoperative management. While diabetes does not increase scarring, contracture, or graft loss, its link to serious complications underscores the importance of early intervention.

Purpose: Diabetic patients undergoing soft tissue reconstruction for foot ulcers are at risk for postoperative complications, including surgical site infections (SSI), wound dehiscence, and amputation. Glucagon-like peptide-1 receptor agonists (GLP1-RA) have been shown to improve glycemic control, reduce inflammation, and enhance vascular function which may impact surgical outcomes and healthcare utilization. However, their effect on this population remains unclear. This study aims to evaluate whether GLP1-RA use is associated with improved surgical outcomes, reduced complications, and lower healthcare utilization in diabetic adults with soft tissue reconstruction for foot ulcers.

Methods: Using the TriNetX database, we conducted a retrospective cohort study of adult patients with diabetes mellitus who underwent soft tissue reconstruction for foot ulcers between January 2016 and February 2025. Using ICD-10 and CPT codes, we queried procedures to include split and full-thickness skin grafts, local flaps, pedicled flaps, and free flaps. Baseline demographic and clinical variables were collected including age, sex, BMI category (underweight, normal weight, overweight, obese) tobacco use, A1C (below and above 6.5), hypertension, peripheral artery disease, stroke, heart failure, and chronic kidney disease. 1:1 propensity score matching was performed to adjust for these variables. Cohorts were stratified by GLP1-RA use. Risk ratios compared 90-day postoperative outcomes, including surgical revisions, surgical site infections, emergency department utilization, amputation rates, wound dehiscence, DVT, pulmonary embolism, sepsis, and mortality.

Results: A total of 5875 procedures were identified, with 1061 patients in the GLP1-RA group and 4814 patients in the non-GLP1-RA group. After propensity score matching based on baseline demographic and clinical variables, 1049 patients were included in each of the cohorts. All baseline characteristics were similar between the cohorts after matching (p>0.05). Postoperatively, GLP1-RA users had significantly lower rates of surgical site infections (4.58% vs. 7.25%, RR: 0.63; CI: 0.45-0.90, p=0.0095) and surgical revisions (3.72% vs. 6.29%, RR: 0.59; CI: 0.40-0.87, p=0.0069) compared to non-users. Additionally, GLP1-RA users had a significantly lower risk of deep vein thrombosis (2.10% vs. 4.96%, RR: 0.42; CI: 0.26-0.69, p=0.0004), emergency department utilization within 90 days (19.16% vs. 23.07%, RR: 0.83; CI: 0.70-0.98, p=0.0283), and all-cause mortality (2.38% vs. 4.58%, RR: 0.52; CI: 0.32-0.83, p=0.0061). No significant differences were observed between the cohorts in rates of wound dehiscence, pulmonary embolism, sepsis, and amputation rates (p>0.05).

Conclusion: GLP-1 receptor agonist use in diabetic patients undergoing soft tissue reconstruction for foot ulcers was associated with lower rates of surgical site infections, surgical revisions, DVT, emergency department utilization, and all-cause mortality compared to non-users. These findings suggest a potential protective role of GLP1-RA in surgical recovery. However, the lack of significant differences in wound dehiscence, pulmonary embolism, amputation rates, and sepsis indicates that further investigation is needed to clarify the full impact of GLP1-RA on surgical outcomes. Future research should focus on elucidating the mechanisms of GLP1-RA in driving these associations in diabetic foot reconstruction.