Scientific Abstract Presentations: Reconstruction Session 2 Thursday, October 15 Thu, Oct 15 5:00-6:00 p.m. CDT

Background: Muscle co-contraction resulting from motor aberrant reinnervation sequelae (MARS) is a debilitating outcome of brachial plexus birth injury (BPBI), leading to significant shoulder and/or elbow deformities. Surgical management remains controversial with no established consensus on the optimal strategy. Methods: A retrospective review was conducted on patients treated for BPBI-related MARS between 1986 and 2022. A total of 62 patients with shoulder deformities and 95 patients with elbow deformities were included in the study. Two-thirds of the patients had overlapping deformities. The surgical strategy was based on the hypothesis of aberrant reinnervation syndrome, which involved multiple muscle transpositions to convert antagonists to synergists. The strategy for shoulder deformity was prioritized with shoulder abduction and external rotation restoration by transferring the shoulder adductors to the abductors. The strategy for the elbow deformity was prioritized with the elbow extension restoration by transferring elbow flexors (biceps/ brachialis) to the triceps. Results: Postoperatively, the mean shoulder abduction improved from 70° to 148° (p<0.001), and the mean external rotation improved from 22° to 72° (p<0.001). For the elbow, the mean extension strength improved from M2 to M3-4 (p<0.0001). While initial elbow flexion strength decreased post-transfer, 78% of patients required second-stage gracilis functioning free muscle transplantation for augmentation, and the end result was successfully maintained at M3 or greater in all patients. Elbow flexion contracture also significantly improved from a mean of 40° to 10° (p=0.0293). Conclusion: The described surgical strategies by converting antagonists to synergists by multiple muscle transfers are proven effective, durable and long-lasting for treating MARS in BPBI.

References: 1. Sumner AJ: Aberrant reinnervation. Muscle Nerve 1990; 13: 80 1-803. 2. Weiss, P., and M. V. Edds. Sensory-motor nerve crosses in the rat. J. Neurophysiol. 1945; 30: 173-193. 3. Dey JK, Boahene KDO. Facial Aberrant Reinnervation Syndrome Following Facial Nerve Injury and Recovery. Facial Plast Surg Aesthet Med. 2024 Jul 1. doi: 10.1089/fpsam.2023.0351. Epub ahead of print. PMID: 38949952. 4. Chuang DCC. Management of traumatic brachial plexus injury in adults. Hand Clinics 15(4): 737-755, 1999. 5. Chuang DCC, Ma HS, Wei FC. A new evaluation system to predict the sequelae of late obstetric brachial plexus palsy. Plast Reconstr Surg 101:673-685, 1998.

Purpose: Tranexamic acid (TXA) is a hemostatic agent which has been shown to significantly reduce intraoperative blood loss. As such, it has become ubiquitous among surgeons across a variety of specialties. In the field of Plastic and Reconstructive surgery, TXA has been shown to have added effects of reducing post-operative complications such as hematoma and seroma. Despite its popularity, there remains concern among Plastic Surgeons that TXA may contribute to soft tissue ischemia by inducing microvascular thrombosis or sludging. This is of particular concern in the context of wound healing which demands a robust blood supply to adequately traffic oxygen and other growth factors to the site of injury. In this study we assessed the effect of perioperative TXA administration (either via topical or intraperitoneal [IP] routes) on wound healing in a rodent model.

Methods: Excisional wounds were created on the dorsum of thirty C57BL/6 mice using an 8mm punch biopsy. Wounds were splinted with silicone rings to minimize the effect of contracture on healing. Animals were treated with low dose TXA (10mg/kg), high dose TXA (30 mg/kg) or normal saline. Animals were randomized to receive TXA or normal saline via an IP injection or topical application directly onto the wound bed. All topical groups were mixed with 2% methylcellulose as a carrier (to prevent rapid dispersion). Gross images of each wound were taken on postoperative day (POD) 14. The rate of wound closure was assessed using planimetry compared to a baseline wound area of 8mm. The diameter of each would was also analyzed using Hematoxylin & Eosin (H&E) stained tissue specimens harvested on POD 14. CD31 immunofluorescent staining was performed in the dermal layer of each wound to assess the angiogenic response at POD 14 by quantifying the numbers of vessels per high powered field (HPF). Each of these analyses were carried out with two blinded independent raters using ImageJ.

Results: No significant differences in the rate of wound healing between groups was observed during this study (p=.45, R2 =.86) or with respect to TXA dosage (p=.67). Pooled analyses, comparing all animals treated with normal saline versus all animals treated with TXA, also demonstrated no significant difference in the rate of wound healing (p=.45). Similarly, histological analysis of wound diameter showed no significant differences between individual groups (p=.68) or during pooled analysis (p=.15). CD31 staining, likewise, revealed no significant difference in the number of vessels/HPF between groups. There were no cases of infection, hematoma, or seroma during this study.

Conclusions: These results suggest that perioperative administration TXA does not impair wound healing. Moreover, the route of delivery (local vs systemic) does not significantly impact postoperative wound healing. These data add to the increasing body of evidence that TXA should be used for its hemostatic benefits without concern regarding its effect on wound healing.

Background: Hindfoot ulceration presents a unique reconstructive challenge due to the heel's dual role in weight-bearing and pressure distribution. Heel ulcer outcomes are notoriously the poorest of any foot location, and current algorithms are limited. Ulcers on the posterior heel are typically caused by pressure, whereas those on the plantar heel are caused by gait abnormalities. This study proposes a function-first treatment algorithm for the surgical treatment of heel ulcers.

Methods: A retrospective review of 124 patients undergoing surgical management of heel ulceration at a tertiary limb salvage center was performed. Patients were managed according to a multidisciplinary algorithm incorporating infection control, vascular optimization, soft tissue reconstruction, and biomechanical correction (1) (2). Patients were stratified by anatomical ulcer location: posterior or plantar heel. Outcomes assessed included demographics, comorbidities, vascular details, ulceration, and long-term functional outcomes.

Results: The cohort consisted of 71 plantar (57.3%) and 53 posterior (42.7%) heel ulcers. Posterior ulcers occurred in older, less ambulatory patients (39.6% ambulatory vs 88.7% plantar, p=0.016). Plantar ulcers demonstrated larger wound area (40 vs 20 cm², p=0.020) and a higher rate of re-ulceration (49.3% vs 18.9%, p=0.003), compared to posterior ulcers. Reconstruction strategy differed significantly by ulcer location (p=0.004), with plantar ulcers more frequently requiring local or free flap reconstruction, and posterior ulcers more commonly managed with split-thickness skin grafting. Overall, both groups underwent calcanectomy at comparable frequency, with the most common type being partial calcanectomy. Rates of dehiscence, necrosis, and infection before 4 weeks post-op were comparable between groups. 23 (32.4%) of plantar ulcer patients and 10 (18.9%) of posterior ulcer patients underwent ipsilateral major amputation (p=0.092). Among preoperatively ambulatory patients, 75.0% remained ambulatory at final follow-up. Overall mortality was 21.8% with a median 22.6-month follow-up.

Conclusions: We propose a function-first multidisciplinary algorithm for hindfoot ulcer reconstruction that utilizes ulcer location to inform the cause, reconstruction, and then make corrections to prevent recurrence. In posterior ulcers, offloading is key. In plantar, correcting gait is paramount to prevent re-ulceration. These findings support a shift from limb-salvage-at-all-costs toward individualized, function-driven reconstructive decision-making.

References: 1. Li KR, Huffman SS, Gupta NJ, et al. Refining a Multidisciplinary "Vasculoplastic" Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps. Plast Reconstr Surg. 2025;155(5):879-891. doi:10.1097/PRS.0000000000011865

2. Li KR, Rohrich RN, Lava CX, et al. A Combined "Vasculoplastic" Approach to the Vasculopathic Patient Undergoing Limb Salvage: Understanding the Role of Endovascular Revascularization for Lower Extremity Free Tissue Transfer. J Reconstr Microsurg. 2025;41(8):693-702. doi:10.1055/a-2491-3381

Background Severe periprosthetic joint infection (PJI) after total knee arthroplasty can be managed with revision total knee arthroplasty (rTKA) alone, rTKA with flap-based soft-tissue reconstruction as part of limb salvage, or major amputation. Prior national work has demonstrated socioeconomic gradients in amputation risk after knee PJI, but contemporary evidence is limited regarding how hospital reconstructive capacity intersects with patient sociodemographics to shape treatment pathways and inpatient outcomes. We evaluated national predictors of (1) amputation versus limb salvage and (2) flap reconstruction among limb-salvage admissions, and we assessed in-hospital mortality and total charges across pathways. Methods Using the National Inpatient Sample (2016–2022), we identified admissions for prosthetic knee PJI treated with rTKA and/or knee-level or above amputation. Within limb-salvage admissions (rTKA without amputation), we identified flap-based reconstruction using procedure codes for pedicled or free, muscle or fasciocutaneous flaps. Multivariable models adjusted for demographics, payer and neighborhood income quartile, rural–urban classification, comorbidity burden (Elixhauser index), acute severity markers (including sepsis, septic shock, osteomyelitis, severe cutaneous infection, and acute kidney injury), and hospital characteristics, including hospital-year plastic surgery volume quartiles. Mortality was assessed using penalized logistic regression; charges among survivors were modeled with log-linear regression and back-transformed to multiplicative effects. Results We identified 183,445 weighted admissions for knee PJI requiring rTKA or major amputation: 171,715 (93.6%) rTKA only, 4,010 (2.2%) rTKA+flap, and 7,720 (4.2%) amputation. Amputation admissions demonstrated the highest comorbidity burden and acute severity marker prevalence, with flap recipients generally intermediate. After adjustment, higher neighborhood income and private insurance were associated with lower odds of amputation (highest vs lowest income quartile OR 0.72, 95% CI 0.65–0.78; private vs Medicare OR 0.58, 0.53–0.62). Hospital plastic surgery volume was strongly associated with pathway selection: higher volume was associated with greater odds of flap reconstruction within limb salvage (top vs bottom quartile OR 2.10, 1.79–2.47) and also higher odds of amputation overall (top vs bottom quartile OR 1.52, 1.35–1.71. Amputation was associated with higher in-hospital mortality (OR 2.77, 2.28–3.35), whereas rTKA+flap was not associated with a statistically significant mortality increase versus rTKA alone. Relative to rTKA only, flap reconstruction increased total charges (×1.70, 1.67–1.73), while amputation was associated with lower charges (×0.88, 0.87–0.89). Conclusions Treatment pathways for severe knee PJI are patterned by socioeconomic context and hospital reconstructive capacity. High-volume reconstructive centers concentrate flap-based limb salvage and also manage a disproportionate share of patients undergoing amputation, while major amputation carries substantially higher inpatient mortality. These findings support timely referral and coordinated orthoplastic pathways for complex PJI evaluation and highlight persistent structural gradients in limb loss risk.

Purpose:

The da Vinci Single-Port robotic (SPR) allows abdominal access through a single incision while providing enhanced visualization and instrument articulation compared to traditional approaches. In Plastic and Reconstructive Surgery (PRS), SPR has emerged as a novel approach for omental harvest in vascularized omental lymph node transfer (VOLT) for lymphedema. Compared to traditional laparotomy, minimally invasive platforms are associated with decreased tissue trauma and postoperative pain. While our team's prior work has demonstrated the technical feasibility and safety of SPR for VOLT, its impact on postoperative opioid utilization remains unknown. We hypothesized that SPR omental harvest would be associated with reduced inpatient opioid consumption compared to an open approach.

Methods:

A retrospective cohort study of adults undergoing VOLT via SPR or open laparotomy between 2020 and 2024 at a single institution was performed. The primary outcome was inpatient postoperative morphine milligram equivalents per day (MME/day). Secondary outcomes included total MME and length of stay (LOS). Standardized opioid conversion factors were applied. Groups were compared using Mann–Whitney U and Fisher's exact tests. Multivariable linear regression evaluated the interaction between surgical approach and LOS on MME/day. Spearman correlations assessed associations between LOS and opioid use within each group.

Results:

There were 28 patients in the SPR group (average age 56.7, 71.4% female) and 23 patients in the open group (average age 53.7, 78.2% female). Groups were comparable in age, sex, BMI, diabetes status, prior abdominal surgery, and lymphedema characteristics. In univariate analysis, median MME/day was lower in the SPR group (17.1 ± 17.9) compared with the open group (28.4 ± 29.2), though this did not reach statistical significance (p=0.1933). LOS did not differ between groups (p=0.77).

Notably, 21.7% of Open patients required patient-controlled analgesia (PCA) pumps compared to 0% in the SPR group (p=0.016). In multivariable regression, LOS was independently associated with increased MME/day (p=0.0013). A significant interaction between surgical approach and LOS was observed (p=0.017), surgical technique alters the trajectory of postoperative opioid utilization. In the Open cohort, longer LOS strongly correlated with higher MME/day (r=0.627, p=0.002), whereas no significant association was observed in the SPR cohort (r=0.173, p=0.38).

Conclusion: 

Our results highlight the benefits of SPR for VOLT. Although SPR did not significantly reduce average daily opioid consumption in univariate analysis, it was associated with reduced PCA utilization and fundamentally altered the relationship between LOS and opioid requirements. Open surgery patients demonstrated escalating opioid use with prolonged hospitalization, while SPR patients maintained stable analgesic needs regardless of LOS. These findings suggest that SPR may provide more predictable postoperative pain control and mitigate opioid escalation in patients requiring extended inpatient recovery. The use of SPR in omental harvest is still considered to be off-label and experimental. Therefore, the results of this study provide further validation in support of SPR for this unique purpose, as well as showcase the necessity of a validated training program for the use of robotic technology within the PRS residency programs.

Both keloids and hypertrophic scars (HTSs) are fibrotic skin disorders with high levels of recurrence, rendering treatment and reconstructive efforts difficult. Despite their clinical impact, major gaps exist in our understanding of their pathophysiologies. In this study, we analyzed publicly available bulk RNA-sequencing datasets to identify commonalities in RNA regulation patterns in keloid and HTS. The datasets were integrated and analyzed to identify differentially expressed genes (DEGs) using the DESeq2 package in R and subjected to Gene Ontology (GO) and Gene Set Enrichment Analysis (GSEA) pathway enrichment via the clusterProfiler package in R. Potential drug candidates capable of reversing the expression signatures observed in keloids and HTSs were predicted using the Connectivity Map (CMap) tool. Our results illustrate keloids as displaying a tumor-like pattern with fibroblast-driven excessive structural protein deposition and concerted inflammatory patterns, whereas HTSs show more variable protein deposition and non-specific inflammatory signaling. Despite these differences, both share significant transcriptonomic overlap as over 80% of upregulated genes in keloids were also upregulated in HTSs, suggesting these two scar types existing on a biological spectrum rather than as distinct pathologies. Additionally, distinct upregulation of Th17 pathways were seen in keloid scars, a cell lineage less frequently described in keloid pathogenesis. Finally, we identified 11 candidate compounds capable of reversing key keloid and HTS gene expression signatures. Future work should explore keloid-specific inflammation, ancestry-based gene expression differences, and clinical testing of candidate compounds to improve treatment strategies.

Background: Hidradenitis suppurativa (HS) of the groin presents significant reconstructive challenges, necessitating durable soft-tissue coverage while minimizing donor-site morbidity and preserving mobility. This study evaluated the pedicled gracilis muscle flap for groin reconstruction in patients with stage III HS, focusing on functional outcomes and complication rates.

Methods: A retrospective review identified 24 patients referred to a single surgeon between November 2023 and July 2025 who underwent groin reconstruction with a pedicled gracilis flap. Patient demographics and clinical information, such as comorbidities and surgical outcomes, were extracted from medical records.

Results: Postoperative complications occurred in 8 patients (33%), most commonly infection, contracture, and hematoma. No flap failures were reported. Mean follow-up was 214 days, and the average time from gracilis reconstruction to split-thickness skin graft (STSG) was 24 days. The cohort had an average age of 38 years and an average BMI of 33.1. Comorbidities included type 2 diabetes mellitus in eight patients, hypertension in 10, and autoimmune disease in three. Prior or current biologic therapy was reported in 20 patients.

Conclusions: The pedicled gracilis muscle flap is a critical step in groin reconstruction following HS excision. It reliably obliterates dead space by creating a flat contour that facilitates subsequent skin grafting and reduces redundant tissue. In our study, the viability of the gracilis flap was consistently maintained and there were no cases of flap failure. The gracilis flap provides reliable reconstructive outcomes with low donor-site morbidity and continues to represent a flexible and effective solution for complex groin defects.

Introduction: Microvascular free flap reconstruction represents the standard of care for complex head and neck defects. With advancements in understanding of perforator anatomy, increased comfort with microsurgery, and oncologic therapies, reconstructive surgeons will likely be called upon to reconstruct more complex defects. In certain cases, a single free flap is insufficient to achieve the most optimal outcomes, making reconstruction with multiple simultaneous free flaps necessary. The authors hypothesize that multiple free flaps can be performed safely in this challenging patient population with high success rates comparable to single free flaps. This study evaluates a 15-year experience with multiple free flap reconstruction following oncologic resection of head and neck malignancies.

Methods: A retrospective review was performed of all patients undergoing microvascular head and neck reconstruction January 2005 and December 2020 at a tertiary cancer center. Patients reconstructed with multiple simultaneous free flaps were included. Demographics, comorbidities, smoking history, chemotherapy and radiation therapy, and operative details were collected. Flap types, flap combinations, recipient vessels, use of vein grafts, and flow-through configurations were recorded. Postoperative complications, unplanned reoperation and total flap loss were recorded. Univariate and multivariate Firth logistic regression analyses were performed to identify predictors of complications and flap failure.

Results: Overall, 277 patients underwent reconstruction using multiple free flaps, comprising a total of 565 flaps. The median patient age was 58.6 years, with a mean BMI of 24 kg/m2. Nearly half the patients received prior radiation therapy (47.3%), 43.3% underwent chemotherapy, and 31.0% received combined treatment. Reconstruction most commonly followed mandibulectomy defects (n=208), with additional indications including midface defects, pharyngeal or esophageal reconstruction, osteoradionecrosis, and functional facial reanimation.

Most patients received two free flaps (94.6%), while 15 patients required triple free flaps for even more extensive defects. The most frequent reconstructive combination was a free fibula osteocutaneous flap paired with a soft tissue flap, most commonly an anterolateral thigh flap. Recipient vessels were diverse, with the facial artery and facial vein most frequently utilized; flow-through configurations were used in select cases to facilitate multi-flap perfusion.

The overall complication rate was 17.2%. Sixty-four patients required reoperation, and 12 total flap losses occurred in 10 patients, yielding an overall flap success rate of 97.9%. Elevated BMI and morbid obesity as well as coronary artery disease were associated with complications on univariate analysis but were not significant on multivariate analysis. Preoperative chemotherapy demonstrated an association with flap loss on univariate analysis but was also not significant on multivariate analysis.

Conclusions: Multiple simultaneous free flaps can be performed safely and reliably for reconstruction of extensive head and neck defects, comparable to single free flap reconstruction. Careful patient selection, algorithmic planning for recipient vessels, and experienced microsurgical teams are an essential part of optimizing outcomes. When defect characteristics exceed the capacity of a single flap to achieve the best possible outcomes, the use of multiple free flaps represents a viable and effective strategy that should be considered in the modern era of reconstructive microsurgery.

Purpose: Exchange implant sizing in two-stage pre-pectoral implant-based breast reconstruction is largely guided by surgeon preference, and quantitative data defining its downstream impact remain limited. Existing literature has emphasized rippling as a binary aesthetic endpoint without evaluating whether implant–expander mismatch influences the magnitude of secondary revision burden. We examined whether the implant–expander ratio predicts clinically meaningful, high-burden secondary aesthetic revision.

Methods: We conducted a retrospective cohort study of 198 consecutive immediate two-stage pre-pectoral implant-based breast reconstructions with documented maximum tissue expander (TE) fill and final implant size. The primary exposure was implant–expander ratio (implant volume / maximum TE fill), dichotomized at ≤1.1 vs >1.1. The primary endpoint was clinically significant secondary contour correction, defined as ≥75 cc of cumulative fat grafted per breast (index plus all subsequent sessions). Multivariable logistic regression adjusted for body mass index (BMI), post-mastectomy radiation therapy, acellular dermal matrix use, and fat grafting at implant exchange.

Results: Among reconstructions with complete volumetric and covariate data (n=126), clinically significant contour correction occurred in 15.9% (20/126). Mean age was 47±10 years and mean BMI 24.6±4.5. Median maximum TE fill was 350 cc (IQR 270–450), and median implant size was 403 cc (IQR 308–485). Patients with implant–expander ratio ≤1.1 experienced higher rates of significant contour correction compared to those with ratio >1.1 (22.2% vs 9.5%), corresponding to an absolute risk reduction of 12.7% (Number Needed to Treat ≈ 8). In multivariable analysis, ratio >1.1 remained independently associated with lower odds of clinically significant contour correction (adjusted OR 0.31, 95% CI 0.11–0.91; p=0.032).

Conclusions: The implant–expander relationship is a measurable determinant of major aesthetic revision burden following two-stage pre-pectoral reconstruction. An implant-expander ratio >1.1 was independently associated with substantially lower odds of high-burden secondary contour correction. By quantifying a sizing threshold linked to revision magnitude, this study presents ratio-based sizing at TE exchange as a modifiable, data-informed strategy to reduce secondary revision burden in two-stage reconstruction.

Purpose: Bilateral pectoralis major advancement flaps are a reliable and standardized reconstructive strategy for deep sternal wound infection following median sternotomy. Despite improved outcomes with flap coverage, recurrent deep infection remains a devastating complication requiring reoperation and prolonged care. The specific predictors of recurrence following definitive flap reconstruction remain incompletely defined. We evaluated a 30-year single-surgeon experience to identify independent predictors and outcomes of recurrent deep infection following flap-based sternal wound reconstruction.

Methods: Records of sternal wound reconstructions performed by the senior author between 1996 and 2024 were retrospectively analyzed. The final cohort included 584 patients. Bilateral pectoralis major advancement flaps were utilized in 99.3% of cases. Patients were stratified into those requiring reoperation for recurrent deep infection (Group 1) and those without recurrence (Group 2). The primary outcome was reoperation for recurrent deep infection. Demographic variables, comorbidities, reconstruction indications, and operative approach were analyzed. Multivariable logistic regression identified independent predictors of recurrence, with p<0.05 considered significant.

Results: Recurrent deep infection occurred in 21 of 584 patients (3.6%). Baseline demographics were similar between groups, including age (64.9 vs. 64.1 years, p=0.79) and sex distribution. Major comorbidities, including diabetes mellitus (42.9% vs. 43.0%), chronic kidney disease (19.1% vs. 13.1%), end-stage renal disease (4.8% vs. 4.8%), congestive heart failure (14.3% vs. 21.9%), myocardial infarction, valve disease, and prior cardiac surgery, did not significantly differ. No systemic comorbidity independently predicted recurrence. In contrast, reconstruction indication and operative strategy demonstrated strong associations with failure. Culture-positive wound infection was present in 85.7% of recurrence patients compared with 55.2% of the remainder of the cohort (p=0.0057). Limited debridement with partial flap closure was performed in 42.9% of recurrence patients versus 13.5% of non-recurrence patients (p=0.0014). Structural indications such as wound dehiscence, bone exposure, and sternal instability were not independently predictive. On multivariable logistic regression, reconstruction performed for culture-positive wound infection (OR 5.28, p=0.0215) and wound drainage (OR 6.79, p=0.0091) were independently associated with higher odds of recurrent deep infection. Sternal click was not independently significant. Thirty-day mortality did not differ between groups (0% vs. 7.1%, p=0.21). Compared with patients without recurrence, those requiring reoperation had shorter median total length of stay (8 vs. 20 days, p<0.0001) and postoperative hospitalization (6 vs. 11 days, p=0.0046), reflecting recurrence after discharge rather than greater perioperative severity.

Conclusions: Recurrent deep infection following pectoralis major flap reconstruction occurred in 3.6% of patients and was strongly associated with infectious reconstruction indications and limited debridement strategies. Culture-positive infection and wound drainage conferred five- to seven-fold increased odds of recurrence, whereas baseline patient comorbidity burden was not independently predictive. These findings suggest that reconstructive durability is driven primarily by infectious burden and operative strategy rather than systemic medical risk profile. Debridement after full exposure of the sternum and comprehensive flap coverage at the index operation, may be critical to minimizing recurrent deep infection and improving long-term reconstructive durability.