Scientific Abstract Presentations: Resident Only On-Demand Abstracts Thursday, October 9 Thu, Oct 9 9:30 a.m.-5:00 p.m. CDT

Introduction:
Microsurgical reconstruction requires highly precise instruments. The high-cost of these instruments limits accessibility to both training and performing these procedures, particularly in resource-limited settings. This project aimed to design and manufacture microsurgical instruments that maintain the same quality and functionality as standard instruments while reducing costs by 90%.

Methods: Comparative analysis was conducted of materials and manufacturing techniques used in conventional microsurgical instruments. Cost-effective alternatives, including advanced 3D printing and precision machining, were explored. Ultimately the instruments tips were machine milled and heat treated stainless steel while the instrument handles were 3D printed using sterilizable plastic. (Fig. 1,2)

Results: The newly developed microsurgical instruments demonstrated equivalent performance in all key parameters, including suture performance, tissue handling, and feel/usability. Approximately 97% of those pulled noted no difference between the new novel instruments and the standard, baseline instruments. Most importantly, the instruments cost $2.87 to manufacture which is a ~96% cost reduction for an instrument set compared to current trays on the market.

Conclusion: This project successfully developed high-quality microsurgical instruments at a fraction of the traditional cost. The findings suggest that adopting cost-effective manufacturing methods can significantly enhance accessibility to essential surgical tools, particularly in low-resource settings, without compromising training environment. Further work will focus on regulatory approvals, scaling production, and determining feasibility of sterilization methods and longevity.

Background Scalp defects following Mohs present challenges due to large size and exposed calvarium. The scalp's limited soft tissue mobility often precludes coverage with primary closure or skin grafts (1,2,3). Prior to biologic agents like BTM and Integra, coverage required complex reconstructions such as local or free flaps-often unsuitable for older patients with comorbidities.

BTM, a synthetic dermal substitute, and Integra, derived from porcine bladder, are acellular matrices promoting dermal regeneration (4,5). Anecdotally, BTM is easier to apply and manage postoperatively, but no direct comparative studies exist. This study evaluates differences in healing time and complications between BTM and Integra for scalp reconstruction.

Methods A retrospective review (June 2022–June 2024) included patient history, cancer type, and defect details. Outcomes included time to re-epithelization, definitive coverage, and complication rates. SPSS was used to compare BTM and Integra groups.

Results Of 28 patients, 11 received BTM and 15 received Integra. The average age was 77.6 ± 11 years; BMI was 26.3 ± 4.3. Eight were former smokers, and 14 were on anticoagulation.

Eighteen patients (64%) underwent bone burring prior to matrix placement due to exposed bone. Mean defect size was 33.8 ± 21.9 cm². Average time to re-epithelialization was 58 ± 28.8 days, and to definitive coverage was 89.9 ± 47.2 days. Complications included exposed bone (2), delayed healing (4), and infection (3).

No significant difference was found in defect size (Integra: 38.4 ± 18.3 cm² vs. BTM: 26.9 ± 26 cm²; p = 0.22) or re-epithelialization time (Integra: 65 ± 21.7 days vs. BTM: 52.5 ± 31.4 days; p = 0.50). BTM complications included 2 infections; Integra had 2 exposed bone cases, 1 incomplete graft take, and 1 Pseudomonas infection (p = 0.257).

Conclusion BTM provides equivalent outcomes to Integra and may offer a more affordable, lower-maintenance option for scalp reconstruction.

References 1. Integra. In: Thornton J, Carboy J, ed. Facial Reconstruction After Mohs Surgery. 1st Edition. New York: Thieme; 2018. 2. Bascone CM, Deitermann A, Lin SK, McGraw JR, Raj LK, Nugent ST, Wang L, Broach RB, Miller CJ, Kovach SJ. Using Integra for Reconstruction of Facial Defects after Mohs Micrographic Surgery. Plast Reconstr Surg Glob Open. 2023 Dec 18;11(12):e5474. doi: 10.1097/GOX.0000000000005474. PMID: 38111719; PMCID: PMC10727678. 3. Harirah M, Sanniec K, Yates T, Harirah O, Thornton JF. Scalp Reconstruction after Mohs Cancer Excision: Lessons Learned from More Than 900 Consecutive Cases. Plast Reconstr Surg. 2021 May 1;147(5):1165-1175. doi: 10.1097/PRS.0000000000007884. PMID: 33890900. 4. Li H, Lim P, Stanley E, Lee G, Lin S, Neoh D, Liew J, Ng SK. Experience with NovoSorb® Biodegradable Temporising Matrix in reconstruction of complex wounds. ANZ J Surg. 2021 Sep;91(9):1744-1750. doi: 10.1111/ans.16936. Epub 2021 Jun 3. PMID: 34085755; PMCID: PMC8518801. 5. Frost SR, Deodhar A, Offer GJ. A novel use for the biodegradable temporizing matrix. Eur J Plast Surg. 2022;45(6):1015-1020. doi: 10.1007/s00238-022-01964-z. Epub 2022 May 26. PMID: 35637749; PMCID: PMC9134145

Introduction: The anterolateral thigh (ALT) and parascapular (PS) flaps are two commonly used fasciocutaneous free flaps for extremity reconstruction. Both flaps offer thin, pliable soft tissue coverage for large defects while minimizing donor site morbidity. However, the differences in functional donor site morbidity between these two flaps has not been well studied. This review aims to compare the donor site morbidity associated with ALT and PS fasciocutaneous free flaps.

Methods: A systematic review of MEDLINE, Embase, Scopus, and the Cochrane Library was conducted from inception of database to August 17 2024. Studies evaluating donor site morbidity following free ALT or PS flap harvest were included. Pediatric, animal, cadaveric, non-English studies, and conference abstracts were excluded. Four reviewers independently screened titles, abstracts, and full texts. Data were pooled for hematoma, seroma, delayed wound healing, dehiscence, donor site weakness, functional deficit, and numbness. Analyses were restricted to studies reporting binary outcomes. Comparisons were made using Fisher's exact or Chi-square tests.

Results: Of 1167 studies screened, 72 underwent full text review and of these 46 met inclusion criteria: 43 assessed ALT flaps, 2 PS flaps, and 1 included both. This yielded 3380 ALT and 50 PS flaps. Pooled ALT complication rates were hematoma 1.3%, seroma 4.5%, delayed healing 7.5%, dehiscence 9.6%, weakness 5.0%, functional deficit 1.5%, and numbness 51.7%. For PS, respective rates were: 0%, 8.0%, 10.0%, 16.7%, 10.0%, 10.0%, and 26.3%. ALT flaps were associated with increased numbness (p=0.01) while PS flaps were associated with functional deficits (p=0.04). No other complications differed significantly between flaps.

Conclusions: Free ALT and PS flaps remain two workhorse fasciocutaneous flaps for large extremity defects with minimal donor site morbidity. ALT flaps are associated with increased numbness (p=0.01), while PS flaps are associated with functional deficits (p=0.04). If flap selection is equivocal, these differences may help guide the surgeon to optimize functional donor morbidity in extremity reconstruction.

Introduction: Recurrent ptosis remains a challenge following mastopexy, particularly in patients with poor dermal elasticity, such as post-bariatric individuals or those who have experienced massive weight loss due to medical therapy (e.g., semaglutide, liraglutide). In recent years, biological mesh materials have been introduced in internal bra techniques to enhance long-term structural support¹˒²; however, their use is limited by high costs, and the available scientific literature remains limited³˒⁴. We describe a novel technique employing an autologous meshed dermal flap to function as an internal bra, thereby eliminating the need for heterologous materials.

Methods: In this prospective single-center study, 8 patients underwent mastopexy with the described technique between January 2024 and March 2024. Following de-epithelialization, a dermal flap was harvested, meshed, and wrapped around the inferior pole of the breast parenchyma to provide additional structural support. Outcomes were evaluated at baseline, at 6, and 12 months postoperatively, assessing ptosis recurrence (via sternal notch to nipple distance), superior pole fullness, complication rate, and patient satisfaction (breast-Q).

Results: Preliminary results demonstrated preservation of breast shape and upper pole projection at one year, with minimal descent of the nipple-areolar complex. No major complications (e.g., seroma, infection, fat necrosis) were reported. The BREAST-Q scores at 12 months demonstrated a 78% increase, indicating a significant improvement in patient-reported satisfaction following surgery. The technique appears to offer a stable support mechanism that may reduce early relapse of ptosis.

Conclusions: The use of an autologous internal bra with meshed dermal tissue is a promising and biologically favorable approach to reinforce the breast parenchyma during mastopexy and may contribute to lowering operative costs by avoiding the use of commercial materials. It provides internal suspension without foreign materials and may be particularly beneficial in cases at high risk of recurrence. Limitations of the study include the single-center nature of the study and the relatively small sample size and the short follow-up period. Further multicentric trials with long-term follow-up are needed to validate the long-term efficacy and reproducibility of this technique.

References: 1. Watfa W, Zaugg P, Baudoin J, Bramhall RJ, Raffoul W, di Summa PG. Dermal Triangular Flaps to Prevent Pseudoptosis in Mastopexy Surgery: The Hammock Technique. Plast Reconstr Surg Glob Open. 2019;7(11):e2473. Published 2019 Nov 27. doi:10.1097/GOX.0000000000002473 2. Wagner RD, Lisiecki JL, Chiodo MV, Rohrich RJ. Longevity of ptosis correction in mastopexy and reduction mammaplasty: A systematic review of techniques. JPRAS Open. 2022;34:1-9. Published 2022 May 13. doi:10.1016/j.jpra.2022.05.003 3. Wallace L, Wokes JET. Internal Bra: A literature Review and Sub-Classification of Definitions. Aesthetic Plast Surg. 2024;48(17):3298-3303. doi:10.1007/s00266-023-03802-4 4. Rowe NM, Freund R. The autologous internal breast splint: A novel technique for the treatment of postaugmentation ptosis. Aesthet Surg J. 2005;25(6):587-592. doi:10.1016/j.asj.2005.09.014

Purpose: Glucagon-like-peptide-1 receptor agonists (GLP-1RAs) effectively treat hyperglycemia in patients with type 2 diabetes mellitus (T2DM) via stimulation of glucose-dependent pancreatic insulin secretion. In higher doses, GLP-1RAs slow gastric emptying and centrally inhibit appetite to increase satiety (1). Prolonged use of GLP-1RAs has also demonstrated tremendous weight loss of up to 15% total body weight in overweight and obese patients with and without a T2DM diagnosis (2,3). Despite their rapid rise in popularity and use in both diabetics and nondiabetics, little is known about the perioperative influence GLP-1RAs may have on the surgical patient. This study investigates the postoperative outcomes and complications of DIEP flap reconstruction in patients with and without history of preoperative GLP-1RA use.

Methods: A retrospective chart review was performed on all patients (n = 205) who underwent DIEP flap reconstruction from January 2023 to May 2024 at two institutions. Patients were stratified into two cohorts based on presence or absence of GLP-1RA use six months before surgery. Demographics, operative courses, and postoperative outcomes were reviewed. Key outcomes included population characteristics, overall complication rates, and wound-related complications.

Results: 12 patients were found with preoperative GLP-1RA use six months prior to DIEP flap reconstruction. A greater percentage of GLP-1RA users carried a diagnosis of diabetes or prediabetes (p < 0.001), endorsed prior tobacco use (p = 0.040), and experienced postoperative wound complications (p < 0.001) than patients without GLP-1RA use. Among nondiabetic patients, 50% of GLP-1RA users and 25% of nonusers experienced postoperative wound complications (p < 0.001). 100% of patients with diabetes and GLP-1RA use experienced postoperative wound complications versus 35.5% of diabetics without GLP-1RA use (p = 0.003). Patients with history of GLP-1RA use demonstrated a greater incidence of postoperative infections requiring antibiotics, wound dehiscence, and pulmonary embolism than nonusers.

Conclusion: While GLP-1RAs confer substantial benefits for glycemic control and weight loss, their perioperative use appears to parallel increased rates of wound-related complications following DIEP flap reconstruction in diabetics and nondiabetics alike. Further studies are essential to delineate the mechanisms behind these findings and better inform physicians regarding specific postoperative complication profiles of patients using GLP-1RA medications in the perioperative period.

References: 1. Seufert J, Gallwitz B. The extra-pancreatic effects of GLP-1 receptor agonists: a focus on the cardiovascular, gastrointestinal and central nervous systems. Diabetes Obes Metab. 2014;16(8):673-688. doi:10.1111/dom.12251 2. Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183 3. Rubino D, Abrahamsson N, Davies M, et al. Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial. JAMA. 2021;325(14):1414-1425. doi:10.1001/jama.2021.3224

Abstract:

Introduction: Postoperative adhesions, or soft tissue tethering, are a significant concern in hand and microsurgical procedures, often leading to impaired tendon gliding, nerve tethering, and functional limitations. These limitations are even more dramatic following complex procedures involving varying tissue types across multiple tissue planes. Various anti-adhesion solutions have been explored, but many are difficult to use and demonstrate inconsistent efficacy or foreign body reactions, often as a result of incomplete bioresorption or collagen remodeling. A novel hyaluronic acid/alginate hydrogel designed to provide a gliding surface that bioresorbs completely and can flexibly be applied as a sheet or a gel was used to prevent soft tissue tethering following complex hand and microsurgical procedures. The aim of this study was to characterize this hydrogel, specifically: 1) characterizing its use across a variety of tissue environments; 2) quantifying overall perioperative complication rates; and 3) comparing outcomes between sheet form, gel form, and both.

Methods: A retrospective review was conducted on 83 complex hand/microsurgery cases involving intraoperative application of the HA/alginate hydrogel at a single institution. After obtaining baseline patient demographics, the various tissue environments (tendon, nerve, vessel, and bone exposure) involving hydrogel application were documented/tabulated. Primary outcomes included surgical complications such as infection, revision surgery, tendon rupture, and nerve complications. Secondary outcomes included presence of adhesions during second-look planned or unplanned revision procedures. Descriptive statistical analysis was performed, and a chi-square test was conducted to compare complication rates between the sheet and gel forms.

Results: Intra-operative application of the hydrogel was most common during tendon (98%), nerve (60%) and vessel exposure (35%). Overall complication rate was 4.8%, with no reported cases of vessel thrombosis, tendon laceration repair failure, or fracture nonunion. There were no cases of free flap or replantation loss. A single postoperative cellulitis (1.2%) was successfully managed with oral antibiotics. Six (6) planned and three (3) unplanned revision surgeries occurred, though for reasons unrelated to hydrogel application. There was no scarring observed where the hydrogel was previously placed in any acute unplanned revision procedure, and in only half (3/6) of the planned revisions. No significant differences in complication rates were observed between the sheet and gel forms (P = 0.76).

Conclusion: The HA/alginate hydrogel implanted in sheet or gel form demonstrated a favorable safety profile across various tissue environments in hand surgery. Evidence of adhesion prevention was observed during second-look opportunities. The adaptability of the hydrogel to be used in such a variety of procedures, along with a low complication rate supports its role as a valuable adjunct in complex procedures including those requiring microsurgical repair. Further multi-center studies with extended follow-up are needed to confirm the long-term benefits when compared to other adhesion barriers.

Background: Surgical therapies are effective methods to treat resistant stable vitiligo, with each method having advantages and disadvantages. Objective: This study aimed to compare the efficacy and safety of ultrathin skin grafting (UTSG) and micrografting to treat stable vitiligo. Methods: A total of 40 patients with 72 vitiligo patches were recruited. A retrospective analysis was conducted to evaluate the results achieved in the patients, focusing on primary endpoints such as the extent and quality of repigmentation and any adverse effects from the procedure. The analysis took into account various factors such as the site of vitiligo, morphological type, duration of stability, post-procedure treatment, and age and gender of the patient. Repigmentation rate, relative melanin index (RMI), and relative erythema index (REI) were assessed at multiple time points over a three-month period. Results: Excellent repigmentation was observed in 96% of patches that underwent UTSG and 93% that underwent micrografting. The RMI and REI at 1, 2, and 3 months after the grafting procedure did not significantly differ between the 2 methods. At the recipient site, incomplete fall-off of the graft occurred in 4% of patches that underwent UTSG, 7% was occurred in micrografting. Complications at the donor site did not differ. Conclusion: Micrografting is known to produce more favorable results in particular body parts, such as the lips, eyebrows, ear lobules, and external genitalia. In contrast, both micrografting and UTSG produce comparable cosmetic outcomes at the donor and recipient sites for other body parts. Additionally, micrografts are suitable for covering larger vitiliginous areas compared to UTSG. UTSG is generally considered a more convenient and quicker procedure than micrografting.

Background/Purpose: Enhanced recovery after surgery (ERAS) protocols have been shown to decrease inpatient opiate usage after pediatric plastic surgery, but little research has been done on the effect of ERAS protocols on outpatient opiate prescribing. This study analyzes the authors ERAS protocols and their effects on outpatient opiate prescribing rates in comparison to other participating United States hospitals using the 2023 ACS NSQIP Pediatric Opiate Stewardship report.

Methods: In 2018 ERAS protocols were established at the authors institution for commonly performed procedures such as cleft lip and palate repair, alveolar bone grafting, surgery for velopharyngeal insufficiency (VPI), all cranial remodeling procedures, mandibular distraction osteogenesis, breast reductions, and minor lesion or mass excisions. Patients are not prescribed outpatient opiates for cleft lip repair, cranial springs placement and removal, mandibular distraction osteogenesis, or minor lesion/mass excisions. For the other listed procedures only 3 doses of oral oxycodone are prescribed.

Results: Of pediatric plastic surgery postoperative patients, only 10.96% were prescribed outpatient opiates compared to 51.81% of pediatric plastic surgery postoperative patients at other NSQIP participating centers. In adolescents, (12-17 years old) 23.81% of patients were prescribed opiates vs. 63.20% at other facilities. Children aged 5-11 years old had opiates prescribed 5.88% of the time vs 52.82% at other facilities. Infants and small children (0-4 years old excluding neonates) were prescribed 6.45% vs 45.85%. Finally, no neonates received outpatient opiates vs 13.83% at other centers.

Conclusions: There remains a trend in pediatric plastic surgery to prescribe outpatient opiates to most postoperative patients. Often times these prescriptions are unnecessary and implementing ERAS protocols for commonly performed procedures can help reduce the number of postoperative patients receiving opiate prescriptions.

Purpose: Tissue expander (TE)-based breast reconstruction is the most common reconstructive technique following mastectomy, but it has notable limitations, including the risk of infection. Previously, we identified predictors of TE infection at our safety-net hospital, including body mass index, diabetes, acellular dermal matrix (ADM) use, and prolonged surgical drain use. To improve outcomes in this unique patient population, we explored the use of local antibiotic delivery systems. This study evaluates infection rates in patients at our safety-net hospital who received antibiotic plates at the time of TE placement compared to those who did not.

Methods: A retrospective review was conducted on women aged 18 and older who underwent TE-based breast reconstruction at two safety-net hospitals from October 2015 to September 2024. Data collected included demographics, medical history, operative details, and postoperative course. Patients with ADM placement were excluded. The intervention group included patients who received antibiotic plates at the time of TE placement, while the control group included those who underwent TE placement without antibiotic plates. The antibiotic plates were made from bone cement (methylmethacrylate) containing tobramycin and vancomycin and were removed at the time of TE-to-Implant exchange. The primary outcome was TE infection rate, with secondary outcomes including timing of infection and other complications.

Results: A total of 181 TEs were placed, with 25 (13.8%) receiving antibiotic plates. Median age was 48 (IQR: 43-56). The cohort was predominantly Hispanic/Latino (52.5%), followed by Black (17.1%), White (12.7%), and Asian (2.2%). There were no differences in patient demographics between the groups. Patient comorbidities, including obesity (52.6% vs. 50.8%), diabetes (20.0% vs. 19.2%), and hypertension (28.0% vs. 36.5%) were also similar between groups. The TE infection rate was lower in the antibiotic plate group compared to the control (n=2, 8% vs. n=25, 16%, p=0.38). When excluding patients who underwent adjunctive radiation after TE placement, the infection rate remained lower in antibiotic plate group (n=1, 7.1% vs. n=16, 17.0%, p=0.69). Infections also occurred later in this group compared to controls (median: 187 days vs. 28 days, p=0.18). No significant differences were observed in other TE-related complications, including exposure (antibiotic plates: 0% vs. control: 3.3%), seroma (6.4% vs. 6.1%), wound dehiscence (7.1% vs. 6.6%), or flap necrosis (3.9% vs. 3.3%). Explantation rates were lower in the antibiotic plate group (n=2, 6.0%) compared to the control group (n=23, 14.7%; p=0.56).

Conclusion: Antibiotic plates demonstrate a promising reduction in TE infection rates in our safety-net hospital. Infections occurred later in patients with antibiotic plates, potentially allowing more patients to complete expansion and proceed with definitive reconstruction before an infection develops. Further studies with larger sample sizes are needed to validate these findings.

Purpose:

This study aimed to investigate frontal sinus volume as a potential indicator of cranial compensatory growth in unoperated normocephalic nonsyndromic sagittal craniosynostosis (NNSC) patients. Previous research has suggested that frontal sinus volume may be suppressed in unoperated craniosynostosis due to intracranial space conservation. This multi-institutional study combines patient cohorts from two institutions to further explore this phenomenon.

Methods:

Head computed tomography (CT) scans from 49 unoperated NNSC patients (22 from our initial cohort and 27 new patients from UTSW) were analyzed and compared to age- and sex-matched controls. Frontal sinus volumes were measured using Syngo.via, and statistical analysis was performed. Inclusion criteria required the presence of a frontal sinus for volume measurement in both cases and controls. The presence or absence of frontal sinus pneumatization was compared between the groups.

Results:

Out of 49 NNSC patients, 14 (28.6%) demonstrated the presence of a frontal sinus, compared to 100% of age- and sex-matched controls. Among the 27 newly included patients from UTSW, 8 (29.6%) had a frontal sinus, reinforcing prior findings of reduced frontal sinus development in this population. When compared with controls, Pearson correlation analysis continued to show a strong association between NNSC and decreased-to-absent frontal sinus volume (r = 0.987, P < 0.001).

Conclusion:

The expanded dataset from two institutions confirms a strong correlation between NNSC and decreased frontal sinus volume, suggesting that the frontal sinus may serve as a radiographic marker of compensatory cranial growth restriction. This study provides further evidence that frontal sinus absence may be an indicator of altered skull development and potentially elevated intracranial pressure in these patients. Future studies should investigate the clinical implications of this finding, particularly in relation to surgical decision-making.

Achieving long-lasting aesthetic results in mastopexy remains a technical challenge, particularly in maintaining upper pole fullness and minimising postoperative ptosis. Since its original description by Ribeiro in 1975, the inferior pedicle "autoprosthesis" technique has offered an effective means of achieving central and upper pole support by repositioning and stabilizing a dermoglandular flap to the chest wall [1]. While this approach remains widely practiced, the recurrence of bottoming-out and glandular descent continues to drive innovation in internal support mechanisms [2]. Among contemporary refinements, the use of internal scaffolding-often described as an "internal brassiere"-has gained popularity for enhancing tissue stability during healing [3,4]. Techniques incorporating synthetic mesh (e.g., poly-4-hydroxybutyrate) or absorbable sutures have been reported to reduce pseudoptosis and preserve shape over time [5]. However, concerns over foreign body reactions, cost, and accessibility persist, particularly in resource-conscious environments.

In this article, we present a case series of 43 patients from January 2022 to October 2024, that describes a pragmatic adaptation of the widely used Ribeiro technique developed by a senior surgeon at our institution. The method involves securing the de-epithelialized dermoglandular flap to the chest wall using interrupted PDS (polydioxanone) sutures reinforced with a sutured PDS hammock, providing temporary internal support while maintaining flap perfusion and minimizing added operative complexity. This internal net acts as a resorbable scaffold that mimics the tension-distributing properties of permanent meshes, yet avoids foreign body burden. Herein, we present the technique rationale, operative steps, and aesthetic outcomes.

References: 1. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg. 1975;55(3):330–334. 2. Foustanos A, Zavrides H. Update on vertical mammaplasty. Plast Reconstr Surg. 2007;120(1):28–36. 3. Góes JC. Periareolar mammaplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg. 1996;97(4):959–968. 4. Di Summa PG, Oranges CM, Watfa W, et al. Systematic review of outcomes and complications in nonimplant-based mastopexy surgery. J Plast Reconstr Aesthet Surg. 2019;72(9):1491–1500. 5. Wallace L, Wokes JET. Internal Bra: A literature Review and Sub-Classification of Definitions. Aesthetic Plast Surg. 2024 Sep;48(17):3298-3303.

Purpose: Health literacy, the ability to understand and act on medical information, is essential for effective physician-patient communication. Experts recommend that patient education materials (PEMs) be written at a 6th grade reading level (1). It is critical that patients seeking plastic and reconstructive surgery have access to materials that match the recommended reading level. Therefore, this study aimed to 1) assess readability of current PEMs, and 2) assess patients' health literacy and satisfaction with current educational clinical materials.

Methods: A cross-sectional study was conducted between January 2024 and April 2025 among patients at a Midwest private practice plastic surgery clinic. Patients aged 18 years and older were included. Clinic PEMs were analyzed using three validated readability algorithms: Coleman-Liau Index, Simplified Measure of Gobbledygook Readability Formula and Flesch-Kincaid Grade Level. Patients' health literacy level was assessed using the Newest Vital Sign tool, and a custom outpatient satisfaction survey was used to measure patients' satisfaction with current PEMs and the overall visit (satisfaction score range: 0-15). Descriptive statistics, ANOVA, and chi-square tests were used for data analysis.

Results: Thirty-nine patients were enrolled in the study (mean age: 47.3±13 years; 43.6% male, 38.5% female). Educational attainment included college degree (53.8%), postgraduate degree (18%), and high school diploma (15.4%). The majority were White (31/39; 79.5%), followed by Black (3/39; 7.7%), Asian/Pacific Islander (2/39; 5.1%), Hispanic/Latino patients (1/39; 2.6%) respectively. PEMs available at the clinic were written at a 9th to 10th grade reading level, exceeding the American Medical Association recommended 6th grade reading level.

Most patients (87%) demonstrated adequate health literacy while 10% had possible limited literacy, and 3% had limited literacy. Patients primarily used internet search results (48.7%) and the providers' plastic surgery website (41%) prior to the visit. Similarly, most patients preferred to continue to learn more about surgical options utilizing the internet (46.2%) and the providers' plastic surgery website (48.7%) after the visit. 90% (35/39) of patients reported being satisfied with how they received information. Information preferences did not differ by health literacy groups (p>0.05). Lastly, the overall mean satisfaction score was 14.4±1.23. The satisfaction score did not differ by health literacy levels (adequate literacy: 14.4±1.28; possible limited literacy: 14.5±0.58; limited literacy: 15 [n=1]; p>0.05).

Conclusion: Most patients demonstrated adequate literacy level and reported high satisfaction levels with their visit. The majority preferred the internet or practice website for aiding their education on surgical treatments. These findings suggest that higher readability level may not impair patient satisfaction in this population. However, the limited diversity and sample size highlight the need for larger studies, and improving PEMs to the recommended readability level may help improve understanding for the greater patient population.

References: 1) W Rooney MK, Santiago G, Perni S, Horowitz DP, McCall AR, Einstein AJ, Jagsi R, Golden DW. Readability of Patient Education Materials From High-Impact Medical Journals: A 20-Year Analysis. J Patient Exp. 2021 Mar 3;8:2374373521998847.

Purpose Vascularized Lymph Node Transfer (VLNT) and Lymphovenous Anastomosis (LVA) have become popular treatments for secondary lymphedema involving extremities [1]. However, little is known about the efficacy of these treatments in primary lymphedema. The primary aim of this study is to evaluate the improvement of lymphedema through physiological procedures (VLNT and LVA) in primary lymphedema. The secondary aim is to compare other outcomes, including quality of life (QOL), cellulitis, and complications between the two procedures. Methods A systematic review and meta-analysis was conducted based on PRISMA guidelines. Articles between January 2000 and December 2023 were searched in PubMed, Medline by Ovid, Scopus, and Embase databases. Studies involving patients with primary lymphedema of extremities and physiological procedures (VLNT or LVA) with limb measurements (circumference or volume) were included. The primary outcome measure was improvement of lymphedema as measured by volume or circumference and further divided into change in circumference (in percent) and absolute circumference measure. The secondary outcomes were quality of life (OQL), cellulitis episodes, and complications. Results A total of 228 LVAs (83.2%) and 52 VLNTs (16.8%) in 15 included studies were reviewed. Comparison of pooled mean change in circumference in percentage between LVA (3.76; 95% CI, 1.99-5.54) and VLNT (20.90; 95% CI 0.97-40.63) showed no significant difference between the two groups (p=0.09). The pooled mean change in absolute circumference in centimeters for LVA and VLNT was 3.52 (95% CI, 1.58-5.46) and 4.06 (95% CI, 2.49-5.63). There was no significant difference between the two groups as well (p=0.67). Determining factors for selection between LVA and VLNT were lymphatic distribution, flow, and patency. In particular, lymphatic distribution (aplastic, hypoplastic, hyperplastic) and lymphatic flow or patency can be evaluated with two imaging modalities: lymphoscintigraphy and Indocyanine Green Lymphography, respectively [2,3]. All studies assessing QOL and cellulitis episodes reported improvements after LVA/VLNT with minimal complications. Conclusions Both LVA and VLNT can be effective treatments for primary lymphedema [4], and treatment should be individualized to achieve the best outcome for patients [5]. Future, larger studies are needed to explore the benefits of each treatment in primary lymphedema

[1] Phillips GSA, Gore S, Ramsden A, Furniss D. Lymphaticovenular anastomosis improves quality of life and limb volume in patients with secondary lymphedema after breast cancer treatment. Breast J. 2019;25(5):859-864. doi:10.1111/tbj.13348 [2] Goss JA, Maclellan RA, Greene AK. Primary Lymphedema of the Upper Extremities: Clinical and Lymphoscintigraphic Features in 23 Patients. Lymphat Res Biol. 2019;17(1):40-44. doi:10.1089/lrb.2017.0085 [3] Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128(4):314e-321e. [4] Fallahian F, Tadisina KK, Xu KY. Efficacy of Microsurgical Treatment of Primary Lymphedema: A Systematic Review. Ann Plast Surg. 2022;88(2):195-199. doi:10.1097/SAP.0000000000002862 [5] Allen RJ Jr, Cheng MH. Lymphedema surgery: Patient selection and an overview of surgical techniques. J Surg Oncol. 2016;113(8):923-931. doi:10.1002/jso.24170

Purpose: Carpal tunnel syndrome (CTS) is amongst the most common pathologies in hand surgery accounting for 90% of compressive neuropathies, with a 3.8% prevalence in the general population.(1) While various imaging studies and measurements have been suggested for diagnosing CTS, there is a paucity of normative data for the carpal tunnel, specifically the transverse carpal ligament (TCL) thickness.(2) This study aims to establish normative measurements of the carpal tunnel in cadaveric specimens to aid in the interpretation of imaging findings.

Methods: Five cadaveric specimens were dissected and analyzed by two blinded reviewers using calipers for measurements. Three measurements of the TCL thickness were taken at the carpal tunnel: inlet (pisiform), central (hook of hamate), outlet (base of first metacarpal). Additionally, the total length and width of the TCL along with the diameter of the median nerve within the carpal tunnel were measured.

Results: The measurements from the five specimens (age and sex unknown) were averaged. TCL thickness demonstrated a trend of increasing distally within the carpal tunnel, with averages of 1.05 mm at the inlet (pisiform), 1.57 mm at the central (hook of hamate), and 1.61 mm at the outlet (base of first metacarpal). The average length of the TCL was 3.6 cm, and the average width was 3.5 cm. The average diameter of the median nerve within the carpal tunnel was 4.5 mm.

Conclusion: Establishing normative data is crucial for accurate interpretation of imaging in CTS diagnosis. Our study provides average measurements from cadaveric specimens, which align with existing cadaveric studies (3,4,5) while also introducing new normative measurements for three specific intervals within the carpal tunnel (inlet, central, outlet). Future planned research involving larger cadaver sample size and cross-modal imaging comparisons (e.g. Magnetic Resonance Imaging) is necessary to further validate these findings and establish definitive normative data. Ultimately, this data could help identify patients with CTS and provide insight into how these measurements may correlate with symptomatology.

References: 1. Aboonq MS. Pathophysiology of carpal tunnel syndrome. Neurosciences (Riyadh). 2015;20(1):4-9. 2. Goitz RJ, Fowler JR, Li ZM. The transverse carpal ligament: anatomy and clinical implications. J Wrist Surg. 2014;3(4):233-234. 3. Pacek CA, Chakan M, Goitz RJ, et al. Morphological analysis of the transverse carpal ligament. Hand (N Y). 2010;5(2):135-140. 4. Cobb TK, Dalley BK, Posteraro RH, Lewis RC. Anatomy of the flexor retinaculum. J Hand Surg Am. 1993;18(1):91-99. 5. Tanzer RC. The carpal-tunnel syndrome; a clinical and anatomical study. J Bone Joint Surg Am. 1959;41-A(4):626-634.

Background: Applicants to plastic surgery (PRS) residency programs who identify as underrepresented in medicine (URM) or who graduated from either an Osteopathic medical school (DO) or one without a home residency program (WHP) must surmount unique inequities to successfully navigate the match. Applicants have a significantly higher likelihood of matching to their home institution, and the transition of Step I to pass/fail has placed a higher emphasis on letters of recommendation. The goal of this study was to determine how current PRS residents in this position navigated the match to advise future applicants. We aimed to determine how they sought mentorship, planned away rotations, and prepared their applications.

Methods: Integrated PRS residency program websites were reviewed in August 2024. Current residents were identified as graduating from an osteopathic medical school, a medical school without a home program, or as a potential URM based on photograph/surname (n=282). A survey was sent to these residents including questions to confirm self-identification with either of these groups. Consenting residents were interviewed, and responses transcribed for qualitative thematic analysis.

Results: The response rate was 21.6% (n=61). Of those who responded, 70.5% identified as female, 3.3% DO, 67.2% WHP, and 44.3% URM. As applicants, these individuals prepared for away rotations by studying textbooks and using online resources (90.2%), reviewing program websites or social media (75.4%), and speaking with residents at the institution (59%). Approximately one-third of respondents reported attending a preparation course (29.5%), and 16.4% received financial scholarships for away rotations. Half of respondents reported their Step scores or letters of recommendation were the strongest aspects of their application. Of those who received financial scholarships to fund away rotations (n=10), 100% identified as URM and 40% identified as WHP. Most credited an academic plastic surgeon as being the individual most influential to their successful match (65.6%), while 14.8% did not have a faculty mentor before applying. Interviews were conducted with five residents (four WHP residents and one URM resident). "Research" was the most common code utilized during thematic analysis, followed by "mentorship" and "lacking." Residents identified initiation of mentorship founded on shared identities, intrinsic motivation to seek opportunities, serendipity/chance, and demonstrating a willingness to learn during sub-internships as key components to their success. Residents also discussed the importance of minimizing the role of research experiences and valuing leadership roles in the match process.

Conclusion: Our analysis suggests that successful URM and WHP PRS applicants primarily utilize self-initiated interpersonal relationships and independent preparation to perform well on away rotations and obtain strong letters of recommendation. Increasing attendance at preparatory courses and providing financial scholarships to fund away rotations are areas for improvement, as these resources were not heavily utilized. Potential mentors can help increase the chances of a successful match for these PRS applicants by providing diverse mentorship opportunities, encouraging participation in preparation courses, suggesting meeting attendance, and accounting for differences in research availability based on an applicant's background. Reforms to diminish research quantity in favor of research quality are supported by residents of diverse backgrounds.

Background Self-reported penicillin allergy is a significant risk factor for surgical site infection.(1) While up to 20% of patients report a penicillin allergy, a majority of these are not true allergies.(2) This investigation, inspired by the orthopedics literature, sought to identify an association between self-reported penicillin allergy and risk of tissue expander infection.

Methods This retrospective review included female patients receiving tissue expanders after mastectomy between 2014 and 2024. We identified a subgroup of patients with self-reported penicillin allergy and matched this to a group of patients based on age, body mass index (BMI), diabetes status, pre-operative chemotherapy, and pre-operative radiation.

Results A total of 26 patients were included; 13 patients with penicillin allergy (PCN) were matched to 13 patients without penicillin allergy (no PCN). There was no difference in mean age between the PCN group, 53.15 (±14.8) years, and the no PCN group, 52.4 (±13.36) (p = 0.8907). There was no difference between mean BMI between the PCN group, 30.6 (± 6.19) kg/m2, and the no PCN group, 30.6 (±6.21) (p = 0.9825). There was no difference in proportion of patients with diabetes, unilateral vs bilateral procedures, number of patients receiving pre-operative chemotherapy, or number of patients receiving pre-operative radiation between the groups. There was a difference in number of tissue expander infections between the groups. Two patients in the group with self-reported penicillin allergy experienced infections while no patients in group without penicillin allergy experienced tissue expander infections (p = 0.002569).

Conclusions Similar to findings from other surgical fields, our results demonstrate that self-reported penicillin allergy is a risk factor for breast tissue expander infection. Additional studies are needed to better understand what is driving this association.

References 1. Blumenthal, Kimberly G et al. "The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk." Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 66,3 (2018): 329-336. doi:10.1093/cid/cix794

2. Stone, Andrea H et al. "The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty." The Journal of the American Academy of Orthopaedic Surgeons vol. 27,22 (2019): 854-860. doi:10.5435/JAAOS-D-18-00709

The purpose of the study was to evaluate the efficacy of surgical nerve decompression for the treatment of frontal and occipital migraine headaches. Currently, surgery is not considered in the routine management algorithm for the treatment of refractory migraine headaches.1,2,3 We performed a single institution retrospective review of the patients who underwent surgical decompression for the treatment of refractory migraine headaches. A total of 38 patients were included in our analysis with 43 surgical nerve decompression procedures performed. No patients were excluded from our analysis. The median follow-up was 7 months. Surgical decompression of the greater occipital nerve was performed in 33 of those cases, supraorbital and supratrochlear nerve in 7 cases, and auriculotemporal nerve in 2 cases. 86% of patients had prior nerve blocks, 14% of patients had prior nerve ablations, and 60% of patients had prior Botox injections. 74% of patients reported an improvement in their headaches post-operatively with 46% of those reporting a greater than two-fold reduction in the intensity and frequency of their headaches. The results were similar when comparing the efficacy of greater occipital nerve decompression to supraorbital and supratrochlear nerve decompression. Our analysis includes demographic data and migraine symptomology data including the duration, frequency, and intensity of headaches both pre-operatively and post-operatively. We also explored the practical implications of surgical nerve decompression by comparing patients' post-operative migraine medication regimen to their pre-operative medication regimen.

Bibliography

1. Hatef DA, Gutowski KA, Culbertson GR, Zielinski M, Manahan MA. A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy. Plastic & Reconstructive Surgery. 2020;146(2):187e195e. doi:https://doi.org/10.1097/prs.0000000000007020

2. ElHawary H, Barone N, Baradaran A, Janis JE. Efficacy and Safety of Migraine Surgery. Annals of Surgery. 2021;Publish Ahead of Print. doi:https://doi.org/10.1097/sla.0000000000005057

3. Guyuron B. The Evolution of Migraine Surgery: Two Decades of Continual Research. My Current Thoughts. Plastic & Reconstructive Surgery. 2021;147(6):1414-1419. doi:https://doi.org/10.1097/prs.0000000000007979

Background: Hand surgery is a required component of plastic surgery training, yet clinical exposure varies by referral patterns, training sites, and curricula. This study assesses national trends in hand therapy exposure among residency programs and explores areas for curriculum refinement.

Methods: We distributed a voluntary survey to program directors of ACGME-accredited plastic surgery programs starting in October 2024. The survey assessed hand fellowship training, rotation structure, surgical case types and complexity, and resident interaction with hand therapists, including exposure to splinting techniques and therapy protocols. T-tests were used to compare Likert scale responses between programs with and without formal exposure to hand therapy components. Data collection is ongoing; preliminary results are presented.

Results: Thirteen directors responded, representing integrated (n=6), independent (n=2), and combined (n=5) programs across the South (n=5), Northeast (n=4), Midwest (n=2), and Mountain West (n=2). Twelve programs had dedicated hand surgery rotations. Rotation lengths varied: 1–2 months (n=5), 2–3 months (n=2), 3–6 months (n=1), and ≥6 months (n=4). Rotations spanned all PGY levels in integrated programs and all years in independent programs. All programs train residents with hand fellowship-trained surgeons, and most involve certified hand therapists (n=11). T-test analysis revealed significant differences in reported exposure levels between those who agreed vs. disagreed about formal exposure to static splinting (p<0.001), dynamic splinting techniques (p<0.001), early active motion protocols (p<0.001), and early passive motion protocols (p<0.001). On a Likert scale (1=never, 4=frequently), residents with formal exposure to hand therapists more frequently managed elective cases requiring rehabilitation when exposed to static splinting (3.56 vs. 2.5, p<0.05), dynamic splinting (3.57 vs. 2.50, p<0.05), and early active motion protocols (3.63 vs. 2.50, p<0.05).

Conclusion: Early hand therapy and interdisciplinary care improve outcomes, yet resident exposure remains inconsistent despite case requirements. Programs with formal exposure to hand therapists report greater resident involvement in postoperative rehabilitation decisions, highlighting an opportunity to enhance curricula through structured collaboration.

Background: Dog bite injuries present a unique reconstructive challenge due to their avulsive, high-energy nature and unpredictable involvement of both functional and aesthetic subunits. Unlike oncologic or elective defects, these injuries lack standardized guidelines for initial assessment, timing of debridement, or sequencing of definitive reconstruction. The purpose of this presentation is to review the literature on the use of free tissue transfer in dog bite trauma as well as present a case from our own institution of a patient who sustained a near-total facial degloving injury requiring staged free tissue transfer, highlighting the complexity of decision-making and the psychosocial impact of such injuries.

Methods: A systematic review was conducted to identify published cases of free tissue transfer following traumatic dog bites. Data were extracted regarding patient demographics, anatomical site, flap type, timing of reconstruction, adjunctive techniques, and aesthetic or functional outcomes. Emphasis was placed on perioperative decision-making and reconstructive staging.

Results: Nine cases were identified in the review involving facial, auricular, upper extremity, and lower extremity trauma. Flap selection varied by site and included radial forearm, parascapular, gracilis, latissimus dorsi, ulnar artery perforator, vertical rectus abdominis perforator, and superficial branch of the radial artery flaps. Patients ranged from 18 months to 68 years of age. Reconstructive timing was highly variable, with no consensus on ideal delay for soft tissue demarcation or definitive flap inset. Aesthetic considerations were inconsistently reported, though techniques such as prelamination and non-cultured autologous epidermal cell spray were described. No studies proposed trauma criteria analogous to those used in vascular or craniofacial trauma. Additionally, we present a case of an 89-year-old male patient with a near-total facial degloving injury following a dog mauling at his home which required staged free anterolateral thigh flap to the left face and nasal region.

Conclusions: Free flap reconstruction for dog bite injuries remains highly individualized, with no standardized approach to timing, workup, or staging. These injuries exist outside the traditional reconstructive paradigm-unpredictable, emotionally complex, and often crossing multiple subunits. Further study is needed to define flexible, trauma-informed management that incorporates aesthetic and functional recovery.

Purpose: Patients undergoing microvascular breast reconstruction often seek further refinement of their aesthetic outcomes. Secondary procedures can improve contour, symmetry, and satisfaction following autologous reconstruction (1-2). This study describes the senior author's standard aesthetic enhancement procedure–termed "trifecta surgery"–which combines bilateral breast revision with flap donor site revision in a single operation. Breast revision consists of removal of previous flap skin paddle with or without mastopexy and fat grafting for symmetry and enhancement. Flap donor site revision often consists of abdominal enhancement with scar revision as well as extensive trunk liposuction to contour the torso. We present outcomes and safety data for the trifecta surgery.

Methods: A retrospective review of a single-surgeon cohort was conducted of all patients who underwent trifecta surgery from 2020 to 2025. Inclusion criteria consisted of all patients who had previous microvascular autologous breast reconstruction and later returned for a scheduled trifecta surgery. Patients who had scheduled trifecta surgeries that had not yet been performed were excluded.

Results: A total of 134 patients were identified who underwent trifecta surgery during the study period. The mean patient age was 49.0 years and the average BMI was 29.4. The average time from original autologous reconstruction to trifecta surgery was 188 days. Trifecta surgery was completed in an outpatient setting in 92.5% of cases and the mean operative time was 108 minutes. Complications were minor and included hematoma (4.1%), fat necrosis (2.4%), wound dehiscence of the breast (8.7%) or abdomen (4.8%), and uncomplicated infections treated with oral antibiotics (14.3%). No flap losses were observed. Complication rates were similar regardless of time interval between original autologous and trifecta surgeries (p = 0.47). Average follow-up time from trifecta surgery was 7.5 months. Approximately 77.7% of patients did not pursue any additional revision procedures after their trifecta surgery, supporting high satisfaction with their results. Of the patients who pursued additional revision surgeries, most commonly they underwent an additional round of fat grafting to the breasts (82.4%).

Conclusion: Trifecta surgery represents a safe and efficient approach to enhancing aesthetic outcomes in patients who have undergone autologous breast reconstruction. Previous studies have discussed breast reconstruction patients seeking additional elective procedures, underscoring the value of aesthetic refinements and patient satisfaction following secondary reconstruction procedures (3-4). By combining breast and donor site revision into a single outpatient setting, trifecta surgery offers meaningful aesthetic improvements with minimal complications. These findings support the senior author's integration of trifecta surgery as a routinely planned stage in the aesthetic enhancement of reconstructive care.

References: 1. O'Neill ES, Toms JA 3rd, Hansdorfer MA, Kokosis G. Beyond Mastectomy: The Incidence of Subsequent Aesthetic Procedures after Mastectomy with and without Breast Reconstruction. Plast Reconstr Surg Glob Open. 2024;12(7):e5947. Published 2024 Jul 3. doi:10.1097/GOX.0000000000005947 2. Turner A, Abu-Bhname A, Davis MJ, Winocour SJ, Hanson SE, Chu CK. Fat grafting in Breast Reconstruction. Semin Plast Surg. 2020;34(1):17-23. doi:10.1055/s-0039-1700959 3. Losken A, Pinell XA, Sikoro K, et al. Autologous fat grafting in secondary breast reconstruction. Ann Plast Surg. 2011;66(5):518-522. doi:10.1097/SAP.0b013e3181fe9334 4. Nelson JA, Voineskos SH, Qi J, et al. Elective revisions after breast reconstruction: results from the MROC study. Plast Reconstr Surg. 2019;144(6):1280-1290. doi:10.1097/PRS.0000000000006225