Scientific Abstract Presentations: Reconstruction Session 1 Thursday, October 15 Thu, Oct 15 3:30-4:30 p.m. CDT

PURPOSE: Patients with obesity or massive weight loss often present with a symptomatic pannus and may also require abdominal wall reconstruction for concomitant hernias. Previous studies compare panniculectomy with ventral hernia repair (PAN+VHR) to hernia repair alone, often noting higher complication rates with combined procedure. However, the more extensive intervention is typically the panniculectomy (PAN) itself. Direct comparisons between PAN alone and PAN+VHR remain limited, despite the morbidity associated with PAN. We aimed to compare postoperative outcomes of PAN versus PAN+VHR, hypothesizing that adding VHR would not increase complication rates.

METHODS: We conducted a retrospective cohort study using data extracted from the electronic health record of a large regional health system serving Norfolk and Virginia Beach, Virginia. Adult patients undergoing PAN with or without concomitant VHR between 2011 and Q1 2025 were identified. Demographic and clinical variables were compared using t-tests and Fisher's exact tests. Surgical site occurrences (SSOs) were defined as infection, wound dehiscence, hematoma, seroma, or bedside debridement within 30 days postoperatively. Complications requiring reoperation were also recorded. Multivariate logistic regression was used to assess predictors of SSOs and reoperation, while linear regression was used to evaluate length of stay (LOS). Models included procedure type as the primary predictor and adjusted for demographic factors.

RESULTS: A total of 586 patients were included in the study (PAN = 473, PAN+VHR = 113). Patients undergoing PAN+VHR had higher BMI (36.8 vs 33.8, p=0.001) and longer LOS (64.3h vs 39.0h, p<0.001). After adjustment, PAN+VHR patients stayed 16.7 hours longer than PAN alone (95% CI 6.6–26.7, p<0.01). SSOs occurred in 8.0% of PAN patients and 8.8% of PAN+VHR patients (aOR 0.65, 95% CI 0.17–2.35, p=0.51). Reoperation rates were low and not significantly different (2.7% vs 3.5%, aOR 1.34, 95% CI 0.17–10.28, p=0.78). No significant differences were observed in other postoperative complications.

CONCLUSIONS: Combining panniculectomy with ventral hernia repair did not increase the risk of SSOs or reoperations compared to panniculectomy alone. However, PAN+VHR was associated with significantly longer LOS, likely reflecting greater operative complexity and recovery needs. Careful patient selection and perioperative planning are warranted. Future work should prospectively evaluate patient-reported outcomes, including satisfaction and quality of life measures such as the BODY-Q, to better define the trade-offs of combined versus staged repair.

PURPOSE: Fractional CO2 laser therapy (FCO2LT) has emerged as an effective treatment for hypertrophic scars (HTS),1 but access and utilization remain low.2,3 METHODS: A retrospective cohort of 3,282 patients initially admitted to or treated at an American Burn Association-verified burn unit within a level 1 trauma center from 2017 to 2025, including those referred to affiliated institutions, was analyzed. Demographic, clinical, and insurance data were compared between patients receiving FCO2LT and non-laser controls. Multivariable logistic and linear regression identified predictors of FCO2LT treatment, time to initiation, and number of sessions. RESULTS: Of 3,282 burn patients treated during the study period, 290 met the inclusion criteria for hypertrophic scar evaluation (mean age 31.6 years). Compared with non-laser patients, FCO2LT recipients were younger (p < 0.01), more frequently female (p < 0.01), and more often Hispanic/Latino or Asian (p < 0.01), with the majority insured through Medicaid (p < 0.01). In multivariable analysis, younger age, female sex, race, and insurance were independently associated with receiving FCO2LT (all p < 0.05). Among FCO2LT recipients, larger TBSA (p < 0.001), psychiatric history (p = 0.006), and insurance (p = 0.006) predicted a greater number of sessions. Younger age was associated with longer time to initiation (p < 0.001), and psychiatric history with earlier initiation (p = 0.003). CONCLUSION: Psychiatric history was independently associated with earlier initiation and greater FCO2LT treatment numbers, highlighting the importance of psychosocial factors in scar care utilization. Consistent coverage policies, particularly through Medicaid, appeared to facilitate access, whereas variability among private insurers remained a barrier. Both clinical and insurance factors strongly influenced FCO2LT utilization, emphasizing that access is shaped by systems as much as patient need.

1. Peng W, Zhang X, Kong X, Shi K. The efficacy and safety of fractional CO₂ laser therapy in the treatment of burn scars: A meta-analysis. Burns. 2021;47(7):1469-1477.
2. Bharadia S, Burnett L, Gabriel V. Hypertrophic scar. Phys Med Rehabil Clin N Am. 2023;34(4):783-798.
3. Hinson C, Green A, Sheckter C. Access to laser therapy for treatment of hypertrophic scars after burn injury. Burns. 2025;107714. doi:10.1016/j.burns.2025.107714

Purpose: Vascularized composite allotransplantation (VCA) involves transplantation of complex skin-containing tissues, enabling reconstruction of defects otherwise not amenable to conventional reconstructive techniques. However, VCA recipients and clinicians have noted allograft skin changes including hypopigmentation, though reports are sparse and anecdotal. This finding is particularly concerning for recipients with darker skin affecting cosmesis and psychosocial wellbeing. Unlike VCA, solid organ (SOT) and bone marrow transplants (BMT) do not transplant skin, a highly immunogenic organ. Nevertheless, reports also describe post-transplant hypopigmentation in SOT and BMT recipients suggesting broader transplant-related etiologies. We reviewed the literature to identify trends for future hypopigmentation research in VCA.

Methods: We conducted a systematic review of PubMed, Scopus, and Web of Science according to PRISMA guidelines using search terms related to transplantation and hypopigmentation. We included English-language primary literature and excluded cases with pre-existing autoimmune hypopigmentation. Two reviewers independently screened studies and a third reviewer resolved conflicts. We extracted data on patient demographics, type of transplant, indication for transplant, rejection status, timing and distribution of hypopigmentation, and the authors' proposed hypopigmentation pathogenesis.

Results: We identified 36 reports of hypopigmentation following BMT (n=33), SOT (n=2), VCA (n=1). Onset ranged from <1-month to >4-years post-transplant. BMT and VCA recipients manifested hypopigmentation within 48 months, and SOT recipients within one month, reporting generalized (n=25) and localized hypopigmentation: head/neck (n=5), extremities (n=3), trunk (n=2), and lesion-associated patterns (n=2). Proposed mechanisms included donor-derived autoimmunity (n=6), graft-versus-host (GVHD)-related causes (n=19), treatment effects (n=3), rejection-associated vasculopathy (n=2), and other immune/autoimmune causes (n=3), though some were idiopathic/unreported (n=3). Our analysis showed GVHD-related hypopigmentation predominated (19 of 31) BMT, one SOT study proposed hypopigmentation secondary to donor-derived autoimmunity, and the VCA case was attributed to graft vasculopathy.

Conclusions: We found that hypopigmentation is described in transplant recipients regardless of transplant type. This suggests that hypopigmentation in VCA may not only be due to pathology inherent to transplanted skin, but also from global complications associated with transplantation. By identifying trends in SOT and BMT, we provide a foundation for future investigations of hypopigmentation in VCA recipients and emphasize opportunities for standardized reporting in VCA outcomes.

References: 1. Rahmel, A. (2014). Vascularized Composite Allografts: Procurement, Allocation, and Implementation. Curr Transplant Rep, 1(3), 173-182. https://doi.org/10.1007/s40472-014-0025-6 2. Honeyman, C., Stark, H. L., Fries, C. A., Gorantla, V. S., Davis, M. R., & Giele, H. (2021). Vascularised composite allotransplantation in solid organ transplant recipients: A systematic review. J Plast Reconstr Aesthet Surg, 74(2), 316-326. https://doi.org/10.1016/j.bjps.2020.08.052 3. Petruzzo, P., Lanzetta, M., Dubernard, J. M., Landin, L., Cavadas, P., Margreiter, R., Schneeberger, S., Breidenbach, W., Kaufman, C., Jablecki, J., Schuind, F., & Dumontier, C. (2010). The International Registry on Hand and Composite Tissue Transplantation. Transplantation, 90(12), 1590-1594. https://doi.org/10.1097/TP.0b013e3181ff1472 4. Emmanuel Morelon, J. K., Palmina Petruzzo, Lionel Badet & Olivier Thaunat (2015). Immunological Challenges in Vascularised Composite Allotransplantation. Current Transplantation Reports, Volume 2, pages 276–283. 5. Rao, M., Young, K., Jackson-Cowan, L., Kourosh, A., & Theodosakis, N. (2023). Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options. J Clin Med, 12(3). https://doi.org/10.3390/jcm12031243

Purpose: Autologous breast reconstruction using the Deep Inferior Epigastric Perforator (DIEP) flap is considered the gold standard for breast reconstruction. Reinforcement of the abdominal wall following flap harvest with synthetic or bioprosthetic mesh products has been shown to reduce abdominal-site morbidity, such as abdominal bulge or hernia (1). In an effort to explore cost-effective resorbable mesh options, OviTex 1S, a reinforced ovine tissue matrix, has recently been used for abdominal wall reinforcement at our institution. This study evaluates whether retro-rectus reinforcement at the time of flap harvest using OviTex is associated with lower post-operative abdominal-site morbidity compared with primary fascial closure alone.

Methods: We performed a retrospective analysis of DIEP flap breast reconstruction procedures conducted between January 2023 through September 2024. Patients with abdominal hernia at the time of reconstruction were excluded, as well as patients with less than 6 months of documented follow-up. The primary outcome of composite abdominal-site morbidity, defined as either abdominal bulge or incisional hernia, was identified by explicit report in follow-up clinical documentation; incisional hernia was identified by confirmatory imaging or intraoperative identification. Abdominal-site complications, including seroma, hematoma, infection, and need for operative intervention were also recorded. Demographics, medical history (e.g. smoking status, hypertension, oncologic treatment), and operative variables (e.g. perforator harvest, procedure laterality) were compared across cohorts. Multivariable regression analysis controlling for demographics and procedural data, including the pattern and number of perforators harvested, was utilized to identify predictors of abdominal-site morbidity.

Results: A total of 123 patients were included, with 43 patients receiving OviTex and 80 patients undergoing primary closure. Median follow-up time was 13.5 months (range 6.3–30.6 months). Mean age was 50.8 years old (SD 8.7 years). Most patients were white (84.6%), never smoked (70.7%), and had undergone prior abdominal surgery (60.2%). Average BMI was 28.0 (SD = 3.6). There were no significant differences in demographic data, medical history, or operative data between cohorts.

Abdominal bulge occurred less frequently amongst patients who received OviTex (0% vs. 12.5%, p = 0.01). Upon controlling for medical history and operative characteristics, reinforcement of the abdominal wall using OviTex was associated with lower odds of developing abdominal bulge (OR 0.87, 95% CI 0.79–0.97, p = 0.01). Rates of donor-site complications were similar yet low between cohorts (OviTex vs. primary closure: seroma 4.7% vs. 6.2%, hematoma 2.3% vs 2.5%, abdominal-site infection 0% vs 1.2%).

Conclusion: Reinforcement of the abdominal wall with OviTex at the time of flap harvest was associated with lower rates of post-operative abdominal bulge following DIEP flap-based autologous breast reconstruction. The impact of mesh reinforcement on prevention of incisional hernia remains uncertain; larger cohort sizes may offer greater statistical power in identifying predictors of composite abdominal-site morbidity, as well as greater understanding of the impact of OviTex mesh reinforcement on donor-site complications.

References: 1. Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg. 2013;132(6):1383-1391.

Introduction Reconstruction of large, complex abdominal wall defects is a challenging and costly problem. More than 100,000 incisional ventral hernia repairs are performed annually in the United States, with associated costs reaching up to $22.5 billion. High rates of recurrence and reoperation impose substantial physical and financial burdens on patients. As such, it is imperative to optimize mesh selection and surgical technique to minimize recurrence and complications. While biologic and synthetic meshes are common, long-term comparative data, particularly involving newer hybrid models, are sparse and largely limited to animal studies and observational case studies. Therefore, this study aims to provide a rigorous, long-term, head-to-head comparison of biologic, synthetic, and hybrid mesh types in complex abdominal wall hernia repair.

Methods A retrospective review was conducted of patients undergoing complex abdominal hernia repair at a single institution between 2000 and 2022. Patients with a minimum of 2 years of follow-up from their index hernia repair were included and stratified by mesh type (synthetic, biologic, hybrid). Postoperative complications assessed included hematoma, seroma, infection, and dehiscence. Demographic and comorbidity variables included age, BMI, smoking status, diabetes, coronary artery disease, pulmonary disease, liver disease, and renal disease. Adjusted Cox proportional hazards models were used to compare recurrence and reoperation and capped at 4 years postoperatively to account for unequal follow-up time between groups. Kaplan-Meier curves were constructed accordingly. Adjusted multivariable logistic regression was used to compare complication rates.

Results The cohort included 165 patients: hybrid (27%, n = 45), synthetic (38%, n = 63), and biologic (35%, n = 57). Groups differed significantly in the presence of comorbid pulmonary disease (p = 0.03). Recurrence rates were significantly different among mesh groups, with hybrid mesh demonstrating the lowest recurrence rates (11.1%) and biologic mesh demonstrating the highest recurrence rates (40.4%, p = 0.001). Median time to recurrence was longest in the hybrid group at 2.5 years (IQR 2.4-3.5) and shortest in the synthetic group at 1.2 years (IQR 0.8-2.4). On adjusted Cox proportional hazards modeling, biologic mesh was associated with a 4.9-fold increased hazard of reoperation due to recurrence (HR 4.94, 95% CI: 1.36 – 18.01, p = 0.02), while synthetic mesh demonstrated a similar but nonsignificant increase in hazard (HR 2.24, 95% CI: 0.60 – 8.42, p = 0.23) compared to the hybrid group. Risk of individual complications did not differ significantly among groups.

Conclusion Mesh selection is associated with meaningful differences in hernia recurrence and postoperative complications following complex abdominal wall reconstruction. In addition to favorable early complication outcomes, hybrid mesh demonstrated the lowest cumulative recurrence, suggesting superior durability beyond the immediate postoperative period. These findings support the consideration of hybrid mesh materials in surgical planning, particularly when balancing patient comorbidities with long-term reconstructive goals.

Background: Traumatic lower extremity injuries often require free tissue transfer (FTT) for limb salvage when local tissue is insufficient (1,2). Traditionally, reconstruction within 72 hours has been considered optimal; however, advancements in wound management and perioperative care have challenged this paradigm (4,5).

Objective: To evaluate outcomes of lower extremity FTT based on time from injury to reconstruction.

Methods: A retrospective review was performed on patients undergoing lower extremity FTT after trauma at a single Level 1 trauma center (2014–2022). Patients were grouped by time from injury to flap: (<3 days, 4–21 days, 22–90 days, and >90 days). 99% of patients were managed with negative-pressure wound therapy (NPWT) prior to definitive reconstruction. Outcomes included flap loss, complications, infection, osteomyelitis, nonunion, and amputation. Associations with comorbidities, surgical techniques, and fracture characteristics were assessed.

Results: Among 102 patients, timing of reconstruction showed no significant differences in flap loss (p=0.56), complications (p=0.42), nonunion (p=0.54), osteomyelitis (p=0.19), or amputation (p=0.58). No independent predictors of flap loss or complications were identified. Nonunion was associated with middle/proximal fracture levels (p=0.0092), Masquelet technique (p=0.0004), and higher Modified Frailty Index (p=0.05). Osteomyelitis correlated with male gender (p=0.01), proximal fracture level (p=0.0098), and Masquelet technique (p=0.0095). Amputation was associated with latissimus and radial forearm flaps (p=0.0081), ipsilateral femur fracture (p=0.0063), hypertension (p=0.011), and higher ASA score (p=0.0021).

Conclusion: In this series, delayed FTT beyond 72 hours was not associated with increased flap loss or limb-threatening complications. Delayed reconstruction may optimize patient and wound factors, though aggressive wound management is essential. Given the retrospective design, varying group sizes, and small early reconstruction cohort, these findings should be interpreted cautiously. Further research with larger cohorts and long-term outcomes is warranted.

1. T. J. Francel et al. Microvascular Soft-Tissue Transplantation for Reconstruction of Acute Open Tibial Fractures: Timing of Coverage and Long-Term Functional Results. PRS. March 1992
2. John P. Fischer et al. A Retrospective Review of Outcomes and Flap Selection in Free Tissue Transfers for Complex Lower Extremity Reconstruction. JRM. July 2013.
3. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. PRS. Sep 1986.
4. Putnis S, Khan WS, Wong JM. Negative pressure wound therapy - a review of its uses in orthopaedic trauma. Open Orthop J. 2014

Background Visiting medical student sub-internship scholarships have emerged as a strategy to reduce financial barriers and enhance access to away rotations for underrepresented medical students. Prior work has characterized the prevalence and structure of such scholarships; however, it remains unknown whether the presence of these scholarships is associated with greater resident diversity within participating training programs. Furthermore, many programs have recently renamed, restructured, or removed these initiatives, further motivating the need for updated analysis. The objective of this study is to evaluate the relationship between visiting student sub-internship scholarship availability and the racial and ethnic diversity of integrated plastic surgery programs.

Methods A cross-sectional analysis of 2024-2025 self-reported resident race and ethnicity data was performed using the Association of American Medical Colleges (AAMC) Residency Explorer™ Tool for all Accreditation Council for Graduate Medical Education (ACGME)-accredited integrated plastic surgery programs (n=89). Program websites were systematically reviewed to determine the presence or absence of visiting student sub-internship scholarships. Two-tailed independent sample t-tests were used to compare the mean percentage of residents from groups underrepresented in medicine (UiRM), including Black/African American, Hispanic/Latino, American Indian/Alaska Native, and overall URiM, between programs with and without sub-internship scholarships. Statistical significance was defined as (p ≤ 0.05).

Results Of the 89 integrated plastic surgery programs, 42 (47%) offered sub-internship scholarships and 47 (53%) did not. Complete resident demographic data was available for 59 programs (66%), including 29 scholarship-offering programs and 30 non-scholarship programs. Across all programs with complete data, mean resident representation was 5.9% Black/African American, 10.5% Hispanic/Latino, 1.0% American Indian/Alaska Native, and 17.4% overall URiM. Programs offering sub-internship scholarships demonstrated higher mean representation of Black/African American (8.7 ± 7.5% vs 3.2 ± 4.7%), Hispanic/Latino (11.0 ± 7.0% vs 10.1 ± 11.4%), American Indian/Alaska Native (1.1 ± 3.2% vs 0.9 ± 2.2%), and overall URiM residents (20.8 ± 10.3% vs 14.2 ± 13.3%) compared to programs without scholarships. These differences were statistically significant for Black/African American (p = 0.001) and overall URiM representation (p = 0.039), but not for Hispanic/Latino (p = 0.69) or American Indian/Alaska Native (p = 0.85) representation.

Conclusions Sub-internship scholarships were significantly associated with higher representation of Black/African American residents and greater overall UR-M diversity in integrated plastic surgery programs. Although similar trends were observed in Hispanic/Latino and American Indian/Alaska Native representation, these differences did not reach statistical significance. These findings suggest that visiting student scholarships may contribute to improved diversity in plastic surgery, and highlight the need for further evaluation of similar initiatives.

Introduction: Post-splenectomy patients are predisposed to reactive thrombocytosis secondary to loss of splenic platelet sequestration and regulatory function. The spleen serves as a secondary lymphoid organ composed of red pulp, responsible for sequestration and destruction of senescent erythrocytes and platelets, and white pulp, which mediates adaptive immune responses. While postoperative thrombocytosis is common after major surgery, post-splenectomy patients may develop extreme thrombocytosis (≥1,000,000/µL). Because thrombocytosis is a known risk factor for thrombotic complications following free tissue transfer, its specific implications for microsurgical outcomes in asplenic patients remain poorly defined. We performed a PRISMA-guided systematic review of microsurgical reconstruction in the setting of post-splenectomy thrombocytosis, present an institutional case of successful free flap reconstruction despite extreme thrombocytosis, and include expert commentary to contextualize the hematologic mechanisms and perioperative risk profile.

Methods: A systematic review of PubMed and Web of Science (1990–2025) was conducted in accordance with PRISMA guidelines. Search terms included ((postsplenectomy) OR (splenectomy)) AND ((microvascular) OR (microsurgical)). Studies reporting microsurgical reconstruction in patients with prior splenectomy or post-splenectomy thrombocytosis were included. Extracted variables included platelet count at reconstruction, flap type, perioperative hematologic management, and outcomes. An institutional case report is presented. Expert opinion was incorporated to synthesize mechanistic insights relevant to perioperative management.

Results: Three studies met inclusion criteria: two clinical case reports and one experimental animal model. The animal study demonstrated preserved microvascular patency despite moderate thrombocytosis (>600,000/µL). In contrast, both clinical case reports described free flap thrombosis in patients with severe to extreme thrombocytosis (≥800,000–1,800,000/µL), with successful reconstruction achieved following platelet-lowering interventions.

Our institutional case describes a 28-year-old woman who underwent successful osteocutaneous free fibula flap reconstruction following traumatic splenectomy despite extreme thrombocytosis (~1.3 million platelets/µL), without thrombotic or hemorrhagic complications. Multidisciplinary perioperative management included hematologic consultation and individualized antiplatelet therapy.

Expert commentary emphasizes that extreme post-splenectomy thrombocytosis reflects not only loss of platelet sequestration but also cytokine-mediated upregulation of platelet production, particularly through interleukin-6 and thrombopoietin. Severe thrombocytosis may increase risk of macrovascular thromboembolism and microvascular thrombosis compromising flap perfusion, while platelet counts exceeding one million per microliter may paradoxically predispose to acquired von Willebrand disease. These competing thrombotic and hemorrhagic risks complicate perioperative decision-making in microsurgical reconstruction.

Conclusions: Evidence regarding microsurgical outcomes in post-splenectomy thrombocytosis remains limited. Severe thrombocytosis may increase thrombotic risk; however, successful reconstruction appears achievable with multidisciplinary coordination and individualized antithrombotic strategies informed by underlying hematologic mechanisms.

Purpose: Supermicrosurgery (anastomoses less than 0.8mm in size) has gained popularity as a reconstructive option for challenging problems where conventional approaches have limitations. Potential benefits include defect- centered reconstruction that replaces "like with like" and expanded indications for reconstruction with perforator- to-perforator techniques. Supermicrosurgical perforator-to-perforator anastomosis may confer advantages in lower extremity reconstruction, however, limited reports exist in the US population to support the safety and feasibility of these techniques. The purpose of this study is to characterize the safety and outcomes of perforator-to-perforator anastomoses in a diverse patient population undergoing lower extremity reconstruction. Methods: This is a prospective matched cohort study of patients undergoing lower extremity reconstruction at a tertiary care center between January 2021 and January 2025. Operations involving a vessel anastomosis of 0.3mm to 0.8mm were considered perforator-to-perforator cases and were compared to conventional cases where a major artery was used as the recipient vessel. Patients were matched on defect location and defect size (sq.cm) for analysis. Demographics, comorbidities (Charleson Comorbidity Index, CCI), and outcomes were analyzed. Functional limb salvage was defined as flap success with ambulation at 6 months post-operative. Results: 70 patients comprised the study population: 35 patients in the conventional microsurgery cohort and 35 patients in the supermicrosurgery cohort. Mean BMI in the study population was 31.1 kg/m2. Mean CCI was 4.4, indicative of a highly comorbid population. SCIP flaps (N = 13, 37.1%) and MSAP flaps (N = 13, 37.1%) with perforator-to-perforator anastomoses were the most common supermicrosurgery reconstructions whereas ALT flaps (N = 20, 57.1%) to the posterior or anterior tibial vessels were most common conventional reconstructions. Functional limb salvage rates were similar in the cohorts: 97.1% (34/35) in supermicrosurgery perforator-to- perforator cases versus 94.2% (33/35) in conventional cases (p > 0.15). Overall complications (p > 0.15) did not significantly differ in the cohorts, but partial flap failure rates were lower in perforator-to-perforator cases (p = 0.041). Perforator-to-perforator cases had significantly shorter operative times compared to conventional cases (p = 0.011). Conclusions: Supermicrosurgical techniques with perforator-to-perforator anastomoses are reliable in lower extremity reconstruction, including obese and comorbid patients. This technique confers similar limb salvage success rates as conventional techniques. We advocate for a patient-centered approach to reconstruction and consideration of perforator-to-perforator techniques when defects don't require a long vascular pedicle, shorter operative time is advantageous (high-risk patients), and/or main-line vessels are depleted or injured.

Purpose: Obesity is a public health epidemic. For lower extremity reconstruction, this is challenging as conventional muscle and fasciouctaneous flaps can impair recovery by limiting shoe fit/ambulation and requiring multiple debulking operations. Superthin flaps offer a potential solution, but their role in a predominantly high-BMI population has not been well defined. This study compares outcomes of thin versus conventional flaps in obese patients requiring lower extremity reconstruction. Methods: A retrospective review was performed of patients undergoing lower-extremity free-flap reconstruction between January 2020 and January 2025. Thin flaps were elevated above the superficial fascia (superthin, ultrathin, or pure skin-perforator), while conventional flaps included muscle and fasciouctaneous flaps. Patient variables, operative details, and complications were compared between cohorts using Welch t-tests and Fisher's exact tests. Results: A total of 204 patients were included: 74 (36.3%) thin versus 130 (63.7%) conventional flaps. Mean BMI was 33.0 ± 6.8 kg/m2, with no significant difference between groups (thin 32.2 ± 6.3 vs conventional 33.6 ± 7.0; p=0.20). Demographics and comorbidities were comparable. Thin flaps demonstrated fewer complications (13.0% vs 42.6%, p<0.001) and secondary debulking requirements (1.7% vs 50.0%, p<0.001). Limb salvage (pain-free ambulation) rates were similar (thin 98.6% versus conventional 90.2%, p=0.037). Functional ambulation was achieved, on average, 3.3 months earlier in thin versus conventional flaps. Conclusions: Thin flaps demonstrated lower rates of complications and secondary debulking procedures compared to conventional flaps. In obese patients undergoing limb salvage, superthin flaps are a safe and effective technique that optimizes functional recovery compared to standard of care.