Scientific Abstract Presentations: Residents Breast and Reconstructive Abstracts Session 2 Friday, October 16 Fri, Oct 16 10:30 a.m.-12:30 p.m. CDT

Introduction: Chronic groin pain affects up to 10-63% of patients after open inguinal hernia repair and is often neuropathic, involving the ilioinguinal and iliohypogastric nerves, regardless of nerve management strategy. Regenerative peripheral nerve interface (RPNI) has demonstrated efficacy in preventing neuropathic pain but has not been applied in this setting. This study evaluates prophylactic RPNI for prevention of chronic groin pain following open inguinal hernia repair.

Methods: A retrospective study was performed of patients undergoing open inguinal hernia repair from November 2024 to December 2025. At our institution, identified nerves are typically ligated intraoperatively. Patients were divided into RPNI and non-RPNI cohorts; non-RPNI patients were subdivided into those who had nerve ligation. Prophylactic RPNI was performed on ligated nerves using a free internal oblique muscle graft. Postoperative pain outcomes were assessed qualitatively through chart review and follow-up phone calls. Comparisons were made using Fisher's exact and Student's t-tests (p<0.05).

Results: Ten patients underwent prophylactic RPNI, and 25 did not; among non-RPNI patients, 15 underwent nerve ligation while the remainder had nerve preservation. Thirty-four patients were male, with a mean age of 68.5 ± 13.0 years. At most recent follow-up (RPNI: 150 ± 100 days; non-RPNI: 83 ± 34 days), neuropathic or groin pain was reported in 2/10 RPNI patients and 4/25 non-RPNI patients (p=0.80). Among patients with ligated nerves, 4/15 non-RPNI patients reported pain compared to 2/10 in the RPNI group (p=0.80). Mean operative time was longer in the RPNI group (106.5 ± 20.9 vs. 82.0 ± 34.8 minutes, p=0.026).

Conclusion: Prophylactic RPNI during open inguinal hernia repair is feasible, has low morbidity, and has minimal increased operative time. No significant reduction in early postoperative neuropathic pain was observed in this small cohort. Larger studies with longer and more balanced follow-up are needed to determine true efficacy.

Introduction Routine pathologic examination of breast tissue following mastectomy or breast reduction is considered standard practice at some centers to screen for occult malignancies. However, the incidence of clinically significant pathology in the adolescent and young adult population has not been well described, with one prior report identifying lesions in approximately 12% of patients [1 ]. Therefore, the present study aims to characterize the incidence and clinical significance of breast lesions identified in young patients undergoing breast surgery for non-oncologic indications such as gender dysphoria, symptomatic macromastia, and gynecomastia, and to evaluate the financial impact of routine pathologic analysis in this demographic.

Methods Patients who underwent mastectomy or breast reduction whose breast tissue was sent for pathologic examination from 2020 to 2025 at a tertiary pediatric medical center were identified. All patients were aged 27 or younger at the time of surgery. Patients were admitted postoperatively if there were preoperative concerns regarding their medical comorbidities or postoperative concerns in the post-anesthesia care unit (including poor pain control, oxygen desaturations, etc). Demographic, clinical, and tissue pathology data were abstracted from the medical record. Financial estimates were provided by the Department of Pathology based on patients' ordered pathologic exams and their perioperative admission status.

Results The cohort included a total of 579 patients with a median age of 18.3 years. The primary surgical indications were gender dysphoria (82.7%), macromastia (14.3%), and gynecomastia (2.9%), with mastectomies accounting for 90.8% of the procedures. Of the 1156 tissue specimens analyzed, 1131 (97.8%) were entirely negative for pathology. 25 specimens (2.2%) across 15 patients were found to have positive pathologic findings, all of which were classified as benign. Identified lesions included fibroadenomas, stromal fibrosis, ductal hyperplasia, and a hemangioma. Crucially, none of the 15 patients with identified lesions required any further postoperative workup or intervention. Financially, subjecting all 1156 specimens to routine evaluation incurred substantial costs. Patients undergoing outpatient surgery were billed, at minimum, for pathology level I exam ($387.50), whereas those admitted for at least one night were billed for an inpatient level VI exam ($1,261.00), resulting in a total cost of at least $262,796.50 for this cohort of patients, or an annual cost of at least $52,559.30.

Conclusion The incidence of clinically significant breast pathology in young adults undergoing breast surgery for non-oncologic indications is exceptionally rare. In this cohort, all identified lesions were benign and required no further clinical action, demonstrating limited clinical utility for routine histopathology. Forgoing mandatory pathologic examination in this specific, low-risk population could safely prevent unnecessary testing and yield substantial healthcare savings.

References 1. Maroney J, Collins KC, Dannheim K, et al. Incidental Pathologic Findings in Young Adult Reduction Mammaplasty. Plast Reconstr Surg. 2021;147(3):391-400.

Introduction: Immunotherapy is primarily used in breast cancer for the treatment of triple-negative disease, most commonly in the neoadjuvant setting in combination with chemotherapy. However, its use is expanding to other subtypes, including hormone receptor positive and HER2-negative disease, and it may also be administered in the adjuvant setting. As the indications for immunotherapy broaden, it is important to evaluate its association with surgical outcomes, particularly in patients undergoing implant-based breast reconstruction, regardless of hormone receptor status.

Methods: A retrospective observational cohort study was conducted using the TriNetX database to identify breast cancer patients undergoing implant-based reconstruction. Patients were stratified into two groups based on immunotherapy exposure (immunotherapy vs non-immunotherapy). Demographics, comorbidities, prior tissue expander placement, radiotherapy, chemotherapy, and targeted therapy were collected as study variables. Propensity score matching (PSM) was performed to minimize confounding between cohorts. Ninety-day postoperative complications, including infection, wound dehiscence, delayed wound healing, and implant explantation, were analyzed. Capsular contracture at 1-, 3-, and 5-year follow-up, was also evaluated.

Results: A total of 1,661 patients were included in each cohort after PSM. At 90 days, immunotherapy was associated with an increased risk of infection (4.90% vs 3.13%; RR, 1.57; 95% CI, 1.08–2.28) and wound dehiscence (3.12% vs 2.01%; RR, 1.56%, 95% CI, 1.01–2.41). No significant differences were observed in delayed wound healing or implant explantation. Immunotherapy was not associated with an increased risk of capsular contracture at 1-, 3-, and 5-year follow-up after breast reconstruction.

Conclusion: Immunotherapy may be associated with an increased risk of early postoperative infection and wound dehiscence; however, these complications do not appear to translate into higher rates of delayed wound healing or implant explantation, suggesting limited impact on more severe outcomes. Additionally, immunotherapy was not associated with capsular contracture at long-term follow-up.

References: 1. Shang, Q., et al., Exploration of Optimal Synergistic Treatment Strategies of Postoperative Radiotherapy and Immunotherapy in Early-Stage Breast Cancer. Cancers (Basel), 2026. 18(7). 2. Mei, J., et al., Precision immunotherapy for breast cancer: from biomarkers to clinical practice. Cancer Biol Med, 2026. 23(3): p. 320–6.

Background: Mastectomy skin flap necrosis remains a significant complication of immediate implant-based breast reconstruction (1). Intraoperative assessment of flap viability is commonly based on clinical judgment, which is subjective and may inadequately predict perfusion-related complications (2) . Near-infrared spectroscopy (NIRS) offers a noninvasive method for objective assessment of tissue oxygenation, but its predictive utility in alloplastic breast reconstruction remains unclear (3). Methods: A retrospective review was conducted of patients undergoing immediate implant-based breast reconstruction between January 2022 and February 2025. Intraoperative tissue oxygen saturation (StO₂) was measured preoperatively and immediately following mastectomy using the SnapshotNIR device. Saturation values were recorded across four breast quadrants and the nipple–areola complex, when applicable. The primary aim was to determine whether changes in saturation (ΔStO₂) correlate with mastectomy skin flap necrosis. A secondary aim was to evaluate whether Fitzpatrick skin type affects saturation measurements. Results: The study included 104 breasts from 85 patients. Ten breasts (9.6%) developed mastectomy skin flap necrosis requiring surgical intervention. Intraoperative SnapshotNIR measurements did not significantly predict flap necrosis. A quadrant-specific difference was observed in the lower medial quadrant; however, this reflected increased post-mastectomy saturation rather than hypoperfusion. Prior radiotherapy was significantly associated with flap necrosis. Patients with darker Fitzpatrick skin types demonstrated higher mean post-mastectomy saturation values averaged across the four quadrants compared with those with lighter skin types. Conclusions: Intraoperative NIRS measurements using the SnapshotNIR device were not associated with mastectomy skin flap necrosis in immediate implant-based breast reconstruction. Although NIRS provides rapid, objective assessment of perfusion, it may serve as an adjunct to clinical judgment rather than a standalone predictive tool.

(1) Moritz WR, Daines J, Christensen JM, Myckatyn T, Sacks JM, Westman AM. Point-of-Care Tissue Oxygenation Assessment with SnapshotNIR for Alloplastic and Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2023;11(7):e5113. doi:10.1097/GOX.0000000000005113 (2) Rinker B. A Comparison of Methods to Assess Mastectomy Flap Viability in Skin-Sparing Mastectomy and Immediate Reconstruction: A Prospective Cohort Study. Plast Reconstr Surg. 2016;137(2):395-401. doi:10.1097/01.prs.0000475744.10344.1e (3) Takaya A, Tsuge I, Nakano T, et al. Flap Viability Evaluation Using a Tissue Oximetry Camera as an Alternative to Indocyanine Green Fluorescence Imaging. Plast Reconstr Surg Glob Open. 2023;11(9):e5235. doi:10.1097/GOX.0000000000005235

Background: Deep inferior epigastric perforator (DIEP) flap reconstruction is widely regarded as the gold standard for autologous breast reconstruction. Despite its advantages, perioperative blood loss remains a clinically significant concern, with potential implications for flap perfusion, overall morbidity, and hospital length of stay (1). While transfusion may be necessary in select cases, it carries its own risks, including immunologic reactions and potential effects on microvascular outcomes (1,2). To date, there is a relative paucity of literature characterizing risk factors associated with blood transfusion in patients undergoing DIEP flap reconstruction. Methods: A retrospective study was performed for DIEP flap breast reconstruction over 7 years from January 2018 through December 2024. Patient and surgical characteristics including flap inset technique (buried versus unburied) and laterality (unilateral versus bilateral) were recorded. Outcomes included wound complications, surgical takebacks, microvascular anastomosis, need for transfusion, transfusion volume, and flap loss. Indication for transfusion was hemoglobin less than 8. Results: Overall, 182 patients who underwent DIEP breast reconstruction met inclusion criteria. Of these patients 71 (39%) received a blood transfusion during surgery or during the hospital stay. Of the 71 patients requiring transfusion 91% of patients initial transfusion was in the first 2 days post-operatively. Patients undergoing bilateral reconstruction were significantly more likely to receive a blood transfusion. There was no statistically significant association between transfusion rates and timing of reconstruction (immediate versus delayed), length of surgery (time > 7.5 hours),or flap inset technique (buried versus unburied). Conclusion: Blood transfusion is a relatively common occurrence following DIEP flap breast reconstruction. Bilateral reconstruction represents the primary operative risk factor associated with increased transfusion requirements. These findings may aid in preoperative risk stratification, patient counseling, and perioperative planning to optimize outcomes.

1. Ting J, Rozen WM, Le Roux CM, Ashton MW, Garcia-Tutor E. Predictors of blood transfusion in deep inferior epigastric artery perforator flap breast reconstruction. J Reconstr Microsurg. 2011 May;27(4):233-8. doi: 10.1055/s-0031-1275486. Epub 2011 Mar 30. PMID: 21452109.
2. Weber, R.S., Jabbour, N. & Martin, R.C.G. Anemia and Transfusions in Patients Undergoing Surgery for Cancer. Ann Surg Oncol 15, 34–45 (2008). https://doi.org/10.1245/s10434-007-9502-9

Introduction: Breast reconstruction following mastectomy may result in aesthetic deficiencies, including contour irregularities, scar deformities, and inadequate upper pole fullness, which can negatively impact patient satisfaction. While techniques such as fat grafting and revision procedures are commonly employed to address these concerns, each carries inherent limitations. Dermal fat grafts (DFGs) have been described for correction of soft tissue defects after breast-conserving therapy; however, their role in post-mastectomy reconstruction-both implant-based and autologous-remains underreported. Given the increasing emphasis on optimizing aesthetic outcomes in breast reconstruction, further evaluation of adjunctive techniques is warranted. This study evaluates the safety and utility of DFGs in improving contour and overall aesthetic outcomes following mastectomy. Methods: We conducted a retrospective review of patients who underwent mastectomy followed by implant-based or autologous breast reconstruction with adjunctive DFG placement, either immediate or delayed, between March 2019 and April 2026. Patient demographics, indications for DFG, number of grafts, donor sites, and graft surface area were recorded. Outcomes evaluated included aesthetic improvement based on photographic assessment, complications, and need for additional revision procedures. Results: A total of 104 female patients underwent 122 dermal fat grafting procedures. The mean age was 54 ± 16 years. Reconstruction types included autologous (50%), implant-based (39%), and combined approaches (11%). The primary indication for DFG was correction of contour irregularities (91%), followed by improvement of upper pole fullness (9%). Most patients underwent unilateral grafting (79%), while 21% underwent bilateral procedures. The lower abdomen was the most common donor site (46%), followed by the lateral thoracic region (19%) and inframammary fold (17%). The mean DFG surface area was 104 cm² per patient. Three patients (3%) underwent repeat dermal fat grafting. Three patients required reoperation: one for donor-site incision dehiscence and two for implant extrusion. Overall, the majority of patients demonstrated improved contour and did not require further revision procedures. Conclusion: Dermal fat grafting is a safe, effective, and well-tolerated adjunct for optimizing aesthetic outcomes in breast reconstruction following mastectomy. It provides reliable soft tissue augmentation for correction of contour deformities and enhancement of upper pole fullness, with a low rate of complications and reoperation. These findings support the incorporation of DFGs as a valuable adjunctive technique in both implant-based and autologous reconstruction, particularly in patients with persistent contour irregularities where traditional methods may be insufficient.

Purpose: The Keller Funnel (KF) was designed to facilitate "no-touch" implant delivery and reduce contamination during breast implant placement. While prior studies in aesthetic surgery suggest potential benefits, evidence in reconstructive settings-particularly via the inframammary fold (IMF) incision-is limited. The IMF approach inherently minimizes skin contact and bacterial exposure, potentially reducing the utility of the KF. This study evaluated whether omission of the KF during second-stage tissue expander–to–implant exchange is non-inferior or superior in terms of postoperative complications and complication-free survival.

Methods: A retrospective matched cohort study was conducted of patients undergoing second-stage expander-to-implant exchange between 2018 and 2024 at a single tertiary academic center. Institutional Review Board approval was obtained. The exposure was KF use during implant exchange. A 1:1 patient-level matching without replacement was performed to reduce confounding, including exact matching for radiotherapy exposure, laterality, and year of surgery (±3 years), and coarsened matching for age (±10 years), body mass index (±10 units), and smoking status. Only procedures performed on or before December 31 2024 were included to allow at least 12 months of follow-up. Complications were analyzed per breast. Kaplan–Meier analysis assessed time to first complication and return to the operating room.

Results: The matched cohort included 220 breasts (110 KF, 110 non-KF). Baseline demographics and comorbidities were comparable. Mean BMI was 26.7 ± 4.8 kg/m² (KF) versus 27.1 ± 5.3 kg/m² (non-KF) (p = 0.56), and median age was 52 versus 50 years (p = 0.87). Median follow-up was 476 days (KF) versus 492 days (non-KF) (p = 0.11). Overall complication rates were low and similar: 10.8% (KF) versus 15.7% (non-KF) (p = 0.15). Capsular contracture occurred in 7.2% versus 11.7% (p = 0.13), infection in 1.0% versus 3.0% (p = 0.16), wound dehiscence in 2.6% versus 2.0% (p = 0.72), and seroma in 0.5% versus 1.5% (p = 0.32). Return to the operating room occurred in 3.1% versus 5.6% (p = 0.22). Kaplan–Meier analysis demonstrated no difference in complication-free survival (log-rank p = 0.48) or reoperation-free survival (log-rank p = 0.22).

Conclusions: Keller Funnel use during implant exchange via the inframammary fold incision did not reduce complication rates or improve complication-free survival compared with manual placement. In this reconstructive cohort, omission of the funnel was non-inferior when direct IMF access minimizes contamination risk. These findings support selective rather than routine use of the Keller Funnel. Further multicenter studies are warranted to validate these results and identify clinical scenarios where funnel use may provide measurable benefit.

Purpose Surgical drains for deep inferior epigastric perforator (DIEP) flap reconstruction are used to manage dead space in both the abdominal donor site and breast recipient site. Drain placement is associated with an increased risk delayed recovery, discomfort, and increased risk of infection. Newer techniques have introduced drainless DIEP reconconstruction with comparable outcomes. Most studies rely on small patient cohorts with a focus on recipient/donor site morbidity. This systematic review aims to compare drain vs drainless DIEP flap breast reconstruction with reported outcomes at the donor and recipient sites. Methods Following PRISMA guidelines, a detailed search strategy including keyword searches and MeSH terms was conducted using PubMed, Web of Science, and Embase databases. Papers were screened by two independent reviewers for relevance, followed by a full-text analysis. Patient demographics were recorded, including, age, BMI, weight of mastectomy, along with major and minor complication rates. A Fisher's exact test was used for statistical analysis. Results 231 papers were identified and 5 publications underwent data extraction after screening. A total of 659 patients underwent DIEP reconstruction. Mean reported age was 49.6 years. A total of 197 abdominal drains were placed and 165 breast drains. There were 117 drainless breasts and 479 drainless abdomens. No significant differences in overall complications was identified among drain vs drainless abdominal groups (11.9% vs. 14.7%, p = 0.3). No significant differences were present in overall complications among drain vs. drainless breasts (13.7% vs. 17.6%, p = 0.37). Drain placement did reduce seroma formation risk significantly for the breast (5.1 % vs. 0.0%, p = 0.003). There were no significant differences among hematoma formation or wound dehiscence among drain vs drainless breast sites (p>0.05)

Conclusion Using a drainless approach conferred no significant benefit for overall complications. Further high-quality randomized controlled trials are needed to expand the current literature.

Purpose: Deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains the gold standard for autologous breast reconstruction, however, traditional harvest requires extensive dissection of the anterior rectus fascia, rectus abdominis muscle and disruption of motor nerves, contributing to donor site morbidity. Robotic-assisted DIEP flap harvest has emerged as a promising minimally invasive alternative, offering easier harvest from the external iliac artery, increased pedicle length and caliber, and decreases the length of the anterior fasciotomy and invasiveness of muscular dissection.1 This study aims to compare perioperative outcomes and complication rates between robotic and standard DIEP flap breast reconstruction.

Methods: A retrospective chart review was performed for all patients who underwent bilateral DIEP breast reconstruction by standard (sDIEP) or robotic (rDIEP) approach between 9/2023 and 6/2025 at a single institution. Patients who underwent immediate breast reconstruction were excluded, yielding a final cohort of 79 patients. Patient demographics, intra-operative details, and post-operative outcomes were collected. Categorical data were analyzed using chi-square or Fisher's exact test. Continuous data were analyzed using the Wilcoxon rank-sum test.

Results: Of 79 patients (158 breasts), 13 underwent rDIEP (26 breasts) and 66 underwent sDIEP (132 breasts). The robotic and standard groups did not differ significantly in age (mean 56.69 vs 50.43 years, p=0.069) or BMI (29.10 vs 31.43, p=0.11). However, they did differ significantly in racial composition (p=0.019). The robotic group also did not significantly differ in oncologic indications compared to the standard group (61.5% vs 48.5%, p=0.22). There were no significant differences in operating room (OR) time (p=0.27), length of hospital stay (p=0.74), or length of follow-up (p=0.81). Postoperative opioid requirements were lower in the robotic group but not significant (24.46 vs 38.79 MME/day, p=0.13). Donor site complications did not differ significantly between groups. Although not statistically significant, major and minor breast complication rates were numerically lower in the rDIEP group (major: 11.54% vs 21.97%, p=0.23; minor: 7.69% vs 23.48%, p=0.070), with minor complications trending toward significance. The rDIEP group had a significantly lower rate of delayed wound healing in the breasts (0% vs 13.64%, p=0.045). The average time spent on the console for robotic cases was 62.5 minutes.

Conclusion: Robotic DIEP flap breast reconstruction represents a safe and effective alternative to the traditional approach, with comparable operative times and length of stay. Notably, although not reaching statistical significance, postoperative opioid requirements and overall complication rates were numerically lower in the rDIEP group, suggesting a potential clinical advantage that warrants further investigation. Additionally, the rDIEP group demonstrated a significantly lower rate of delayed wound healing, further supporting its potential benefits. Further studies with larger sample sizes and increased randomization are needed to better delineate long-term outcomes and patient-reported benefits.

References:
1. Selber JC. The Robotic DIEP Flap. Plast Reconstr Surg. 2020 Feb;145(2):340-343. doi: 10.1097/PRS.0000000000006529. PMID: 31985617.

Introduction: Our safety-net hospital system serves a discrete patient population with a robust breast reconstruction program, yet the time to definitive reconstruction is often prolonged. Prior studies suggest that delays are associated with comorbidities and adjuvant treatment. This study identifies factors associated with delayed reconstruction following tissue expander (TE) placement in patients treated at two safety-net hospitals.

Methods: A retrospective review was conducted of women aged ≥18 years who underwent TE placement between October 2015 and November 2022. Patients who did not proceed to reconstruction were excluded. Delay was defined as >180 days from TE placement to definitive reconstruction, whether autologous, implant-based, or a combination. Patients were categorized as non-delayed (NDR) or delayed (DR). Demographic, socioeconomic, comorbidities, and surgical data were recorded, and univariate and multivariate analyses were performed.

Results: Of 373 patients, 324 (86.9%) met the inclusion criteria. 168 (51.9%) were categorized as NDR, while 156 (48.1%) were categorized as DR. There were no differences in demographic factors, including race, age, language, and median income, between groups. DR patients had higher rates of public/community insurance (50.0% vs. 39.3%, p = 0.004), reside in areas with higher SNAP reliance (19.6 vs. 16.9, p = 0.012), undergo immediate TE placement at the time of mastectomy (78.8 vs 68.5%, p = 0.043), receive adjuvant chemotherapy (44.2% vs. 25.0%, p < 0.001), adjuvant radiation (39.1% vs. 16.7%, p < 0.001), and undergo autologous reconstruction (11% vs. 4.2%, p < 0.001). DR patients also experienced higher rates of TE-related complications, including infection (25.6% vs. 11.4%, p = 0.002), hospitalization for infection (24.6% vs. 10.7%, p = 0.004), explantation (23.2% vs. 6.7%, p < 0.001), and TE replacement (17.0% vs. 6.1%, p = 0.004).

Conclusion: Delays in our safety-net system in definitive reconstruction were driven by medical and treatment-related factors rather than demographic variables. Targeted interventions focusing on managing these medical factors, improving patient education, and streamlining the treatment process could help minimize delays. By optimizing care for patients in safety-net hospitals, we can improve access to timely breast reconstruction and enhance outcomes for underserved populations.

Purpose: Nipple–areolar complex (NAC) neurotization during implant-based breast reconstruction has been increasingly adopted to restore sensation with promising patient outcomes-yet concerns about operative time and cost remain barriers to implementation (1–5). This study quantifies the incremental operative time and itemized charges (institution-based cost) associated with NAC neurotization during immediate direct-to-implant (DTI) reconstruction.

Methods: A single-institution retrospective cohort study included patients undergoing skin- or nipple-sparing mastectomy with immediate DTI reconstruction (January 2018 to December 2024). Patients were grouped by neurotization status; those undergoing free flap reconstruction or concomitant ancillary procedures (symmetry procedures, mastopexy, fat grafting) were excluded. Primary outcomes were plastics-specific and total operative time. Secondary outcomes included total reconstruction-related charges and per-breast charges for implants, acellular dermal matrix (ADM), and neurotization-specific materials (nerve grafts, wraps, conduits). Charges were summarized as medians with interquartile ranges (IQR) and compared using nonparametric tests. Multivariable linear regression assessed the independent association of neurotization with operative time and charges, adjusting for age, BMI, mastectomy type, laterality, ADM use, and surgeon. Significance was set at p 0.05.

Results: Of the 210 patients meeting inclusion criteria, 64 (30.5%) underwent neurotization and 146 (69.5%) did not. After multivariable adjustment, neurotization was independently associated with increased plastics-specific operative time, total operative time, and total reconstruction-related charges (p 0.05 for all).

Per-breast baseline component charges were comparable between cohorts: median implant charges were $185 (IQR $25–$216) vs. $216 (IQR $185–$216) (p=0.037), and median ADM charges were $7,352 vs. $7,528 (p=0.662). In contrast, neurotization-specific materials drove the cost differential, with median per-breast charges of $2,942 for nerve grafts (IQR $1,471–$13,352), $3,966 for nerve wraps (IQR $3,966–$4,398), and $12,593 for nerve conduit materials (IQR $7,196–$14,392).

Conclusions: NAC neurotization at the time of DTI reconstruction is associated with increased operative time and reconstruction-related charges driven primarily by neurotization-specific materials rather than baseline reconstructive components. These itemized per-breast data provide a foundation for value-based resource planning and future cost-effectiveness analyses incorporating sensory and patient-reported outcomes.

References: 1. Shyu S, Chang TN, Lu JC, et al. Breast neurotization along with breast reconstruction after nipple-sparing mastectomy enhances quality of life. Int J Surg. 2025;111:3235-3247. 2. Morris BE, Van Spronsen NR, Shrout MA, Teven CM, Rebecca AM. Neurotization during Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Nov 16;10(11):e4591. 3. Ghumman A, Kim PJ, McAlpine K, et al. Sensory restoration following breast reconstruction with operative reinnervation. J Plast Reconstr Aesthet Surg. 2025;78:512-521. 4. Raman S, Daniele E, Choudhary A, et al. A scoping review of innervated breast reconstruction. Ann Plast Surg. 2024;92:463-470. 5. Boyd CJ, Hemal K, Sorenson TJ, et al. Perioperative cost and complications of nipple-areolar complex neurotization. Ann Plast Surg. 2025;94:402-408.

Background: Traumatic ear amputations remain a challenging problem, especially in low-resource environments where microvascular capabilities are lacking. Although microsurgical replantation is considered the gold standard for total and subtotal auricular amputation, its technical and infrastructural demands preclude its widespread use. We present a reproducible, three-staged reconstructive approach incorporating platelet-rich plasma (PRP), autologous costal cartilage grafting, and tissue expansion, executed successfully in a community hospital without microsurgical equipment.

Methods: A 67-year-old male with traumatic left ear amputation underwent staged auricular reconstruction at a resource-limited community hospital beginning one month post-injury. Reconstruction was planned in three stages. Stage 1 involved autologous costal cartilage harvest from the right 5th–6th ribs and fabrication of an auricular framework (helix and antihelix with superior and inferior crura), which was implanted into an 8×4 cm subcutaneous pocket at the left auricular site after debridement of nonviable tissue. The construct was secured with 2-0 Vicryl, a Jackson-Pratt drain was placed, and the wound was closed in layers. Platelet-rich plasma was prepared via centrifugation and applied to the reconstruction site. Stage 2 consisted of placement of a 100 mL rectangular tissue expander in a subcutaneous plane deep to the cartilage framework via a cephalad incision, with wide undermining of the auricular and postauricular regions. The expander was secured with 3-0 Vicryl and the incision closed in layered fashion. The patient is currently undergoing serial tissue expansion in preparation for Stage 3, which will involve final framework shaping and definitive auricular reconstruction. Adjunctive planning includes consideration of laser hair removal due to hair-bearing scalp-derived soft tissue flaps.

Results: Staged auricular reconstruction utilizing autologous costal cartilage, platelet-rich plasma (PRP), and tissue expansion resulted in stable framework integration and progressive soft tissue accommodation. Tissue expansion provided reliable, well-vascularized skin coverage with favorable color and texture match, without the morbidity associated with flap-based or microsurgical reconstruction. This approach demonstrated that PRP may enhance graft incorporation, while autologous rib cartilage provided a durable and cost-effective structural framework. Serial tissue expansion allowed adequate soft tissue envelope creation to facilitate planned definitive reconstruction. Compared to microsurgical replantation techniques, this method avoided the need for vascular anastomosis, intensive postoperative monitoring, and adjuncts such as leech therapy, representing a practical and scalable reconstructive option in resource-limited or non-microsurgical settings.

Conclusions: In environments lacking microvascular capabilities, a PRP-assisted, staged approach to partial ear reconstruction using autologous cartilage and tissue expansion can yield successful cosmetic and structural outcomes. This strategy, grounded in current evidence, is adaptable, reproducible, and educationally relevant. Broader adoption may empower surgeons worldwide to deliver high-quality reconstructive care despite infrastructural limitations.

Purpose: Following massive weight loss patients often have functional and medical issues related to excess skin. Excess skin may cause rashes unresponsive to medical management; skin irritation and traction that interferes with activities of daily living. Notably, the massive weight loss population is expanding due to the rise in popularity of GLP-1 medications. While an abdominoplasty is a purely cosmetic procedure, a panniculectomy is a therapeutic procedure aimed at improving quality of life. As such, a panniculectomy may be covered by insurance.

Plastic surgeons should arm themselves with knowledge regarding their reimbursement. However, reimbursement data is not readily available and little has been published on this topic. Our study aimed to illuminate this rarely discussed but highly important topic of surgeon, facility, and anesthesia charges and reimbursement in insurance-covered panniculectomy.

Methods: Institutional review board approval was obtained to perform a retrospective review of patients undergoing therapeutic panniculectomy performed by the Division of Plastic Surgery between September 2022 and July 2025. Patients were identified via CPT code 15830. Working with our reimbursement department, payments were queried for insurance and patient responsibility for surgeon fees, anesthesia fees, and facility fees. Unpaid balances were also obtained. Types of insurance coverage were obtained and grouped into Medicaid, Medicare, Medicare Advantage, VA Health Care, and commercial insurance.

Results: Between September 2022-July 2025, 151 patients were identified as having undergone therapeutic panniculectomy after massive weight loss. Of these patients, 58 had an isolated panniculectomy. Statistics were performed exclusively on patients who underwent panniculectomy alone. The mean charge for the surgeon fee was $3,058.79 ± $51.12. The mean total reimbursement for surgeons fees (insurance and patient payments) was $1,426 ± $499.33. The mean collection ratio was 0.466 ± 0.16. Only in one case was the surgeon fee denied by insurance and unable to be billed to the patient. However, in 12 cases surgeon fees were only partially paid, denied by insurance, or applied to the patient's deductible, for which no payment was received. These instances were then forwarded to a collection agency. Of these 12 cases, eight were cases of private insurance. Preauthorization of medical necessity was obtained prior to surgery in all cases. Patient insurance was recorded and found to be 39.7% private insurance, 37.9% Medicaid, 12% Medicare or Medicare advantage, and 1.7% VA. An independent-Sample Kruskal Wallis Test was performed showing a significant difference in surgeon fee total reimbursement between private insurance and Medicaid (p=0.04), private insurance and Medicare (p=0.00), and Medicare and Medicaid (p=0.013).

Conclusion: While it is well established that body contouring procedures increase quality of life (1-4), reimbursements for these interventions are remarkably low. Furthermore, even when prior authorization is obtained, coverage is not guaranteed-particularly among private insurers. Awareness of these reimbursement and coverage challenges is essential not only for surgeons but also for patients seeking body contouring surgery.

References

Rios-Diaz AJ, Agrawal N, et al. Impact of panniculectomy and/or abdominoplasty on quality of life: a retrospective cohort analysis of patient-reported outcomes. Plast Reconstr Surg. 2022;150(4):767e-775e. doi:10.1097/PRS.0000000000009551

Suijker J, Troncoso E, Pizarro F, et al. Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort. Aesthet Surg J. 2018;38(3):279-288. doi:10.1093/asj/sjx090

Toma T, Harling L, Athanasiou T, et al. Does body contouring after bariatric weight loss enhance quality of life? A systematic review of QOL studies. Obes Surg. 2018;28(10):3333-3341. doi:10.1007/s11695-018-3323-8

Van der Beek ESJ, Geenen R, de Heer FA, et al. Quality of life long-term after body contouring surgery following bariatric surgery: sustained improvement after 7 years. Plast Reconstr Surg. 2012;130(5):1133-1139. doi:10.1097/PRS.0b013e318267d51d

Introduction: Acellular dermal matrices (ADM) are commonly used in complex abdominal wall reconstruction for high-risk or contaminated cases. However, concerns exist for recurrent hernia and bulge with ADM alone. To address this concern, we have recently created a biosynthetic mesh by adding a lightweight synthetic mesh to the ADM. This study compares outcomes between ADM alone and biosynthetic reconstruction.

Methods: We conducted a retrospective review of patients undergoing abdominal wall reconstruction by a single academic plastic surgeon. Patients were grouped by the reconstruction type: Porcine ADM alone versus biosynthetic mesh. The primary outcome was hernia recurrence; secondary outcomes included wound complications, re-operation and mortality. Univariate analyses evaluated predictors of recurrence and stratified analyses assessed confounding and effect modification.

Results: A total of 293 patients were included, 188 (64.2%) undergoing ADM and 105 (35.8%) undergoing biosynthetic reconstruction with mean follow up of 14 months. There were 75% underlay repairs in the ADM group versus 59.1% in the biosynthetic group and 11.9% inlay repairs in the ADM group versus 36.5% in the biosynthetic group. ADM patients had higher rates of smoking, heart disease, renal disease and functional dependence whereas biosynthetic patients were predominantly female with higher BMI. Both groups had similar rates of complications like infection and delayed wound healing, but hernia recurrence was lower in the biosynthetic group (7.6% versus %16.55, p=0.0347). Subgroup analysis revealed that underlay repairs had significantly higher rates of recurrence with ADM repair (17.9% versus 4.4%, p=0.0067). Univariate analysis identified mesh type, functional status, and recurrent hernia defects as predictors of recurrence.

Conclusions: Incorporation of light-weight synthetic mesh to ADM reconstruction was associated with lower hernia recurrence without increased complication risk.

Purpose: Wound complications following abdominal wall reconstruction (AWR) remain common, with reported rates ranging from 18% to over 60% depending on patient and case complexity(1,2). Prior studies have identified hernia defect size as a key determinant of post-operative morbidity, with larger defects associated with increased complication rates(3). However, patient-level factors, including obesity(4) and diabetes(5), have also been shown to independently influence outcomes. The relative contribution of metabolic risk factors compared to anatomic characteristics such as defect size remains incompletely defined. Methods: This retrospective cohort study utilized the 2023 and 2024 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Files. Patients undergoing initial ventral hernia repair (CPT codes 49591-49596) performed by plastic surgeons were identified. The primary outcome was composite wound morbidity, defined as superficial, deep, or organ space surgical site infection or wound dehiscence within 30 days of surgery. Patient demographics, comorbidities, operative time, and hernia defect size (categorized by CPT code as <3cm, 3-10cm, and >10cm) were analyzed. Univariate comparisons were performed, and multivariable logistic regression was used to identify independent predictors of wound complications. Results: A total of 322 patients were included, with an overall wound complication rate of 9.0% (29/322). On multivariable analysis, both BMI and diabetes were independently associated with wound complications. Each 1-unit increase in BMI was associated with a 6% increase in the odds of a wound complication (OR 1.06, 95% CI 1.00-1.12, p = 0.039), while diabetes was associated with a more than threefold increase in odds (OR 3.4, 95% CI 1.43-7.87, p = 0.005). Hernia defect size (3-10cm: p = 0.268; >10cm: p = 0.979) and smoking (p = 0.483) were not significantly associated with outcomes. Predicted probability modeling demonstrated increasing wound complication risk with rising BMI, with consistently higher risk among patients with diabetes across all BMI levels. Conclusions: Metabolic risk factors, rather than defect characteristics, appear to be key drivers of wound morbidity following AWR. These findings underscore the importance of preoperative metabolic optimization in patients undergoing abdominal wall reconstruction and suggest that patient-level factors may play a more substantial role than anatomic defect size in determining postoperative outcomes.

References 1. Al-Mansour MR, Ding DD, Yergin CG, Tamer R, Huang LC. The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis. Am J Surg. Published online March 2024:S0002961024001247. doi:10.1016/j.amjsurg.2024.02.028 2. Satterwhite TS, Miri S, Chung C, Spain D, Lorenz HP, Lee GK. Outcomes of Complex Abdominal Herniorrhaphy: Experience With 106 Cases. Ann Plast Surg. 2012;68(4):382-388. doi:10.1097/SAP.0b013e31823b68b1 3. Kerr SW, Mead BS, Holland AM, et al. Are outcomes of giant ventral hernia repair inferior? A propensity-matched analysis. Surg Endosc. 2025;39(9):6124-6131. doi:10.1007/s00464-025-11999-5 4. Giordano SA, Garvey PB, Baumann DP, Liu J, Butler CE. The Impact of Body Mass Index on Abdominal Wall Reconstruction Outcomes: A Comparative Study. Plast Reconstr Surg. 2017;139(5):1234-1244. doi:10.1097/PRS.0000000000003264 5. Huntington C, Gamble J, Blair L, et al. Quantification of the Effect of Diabetes Mellitus on Ventral Hernia Repair: Results from Two National Registries. Am Surg. 2016;82(8):661-671.

Background Fleur-de-lis (FDL) panniculectomy offers enhanced cosmesis and quality of life in patients with massive weight loss (>50 lbs). However, it remains unclear how outcomes of this technique compare to the traditional panniculectomy. Therefore, the aim of this research was to determine whether there are differences in post-operative complications for patients undergoing FDL compared to traditional panniculectomy.

Methods A retrospective cohort study of patients that underwent either FDL or traditional panniculectomy at our institution from 2014-2024 was performed. Patients were identified using CPT code 15380. Medical records were queried to collect patient demographics, complications, and revisions. The primary outcome was the incidence of a complication following FDL versus traditional panniculectomy, with secondary outcomes being major (dehiscence, hematoma, seroma, skin necrosis) and minor (delayed closure, fat necrosis, recurrence, revision standing cones) complications.

Results Among 424 patients (mean age 50, 86% female, 67% White), 74.0% underwent traditional panniculectomy. The overall complication rate was 41.0%, with no significant difference between traditional or FDL panniculectomy (38.7% vs 47.7%, p=0.107). Patients undergoing FDL panniculectomy were more likely to develop a seroma (5.71% vs 25.7%, p<0.001) and undergo a revision (15.9% vs 25.7%, p=0.038). On logistic regression, patients with a history of anticoagulant use (OR 2.78, 95% CI 1.34-5.75, p=0.005), prior abdominal surgery (OR 2.30, 95% CI 1.16-4.58, p=0.019), or preoperative rash (OR 0.56, 95% CI 0.34-0.92, p=0.021) were more likely to develop a complication. Panniculectomy type was not predictive of a complication (OR 1.38, 95% CI 0.85-2.26, p=0.20).

Conclusions While there was no significant difference in overall complications, patients undergoing FDL panniculectomy had a significantly greater rate of major complications, specifically seroma. This study identified several previously unreported risk factors for postoperative complications, including anticoagulant use, prior abdominal surgery, and preoperative rash. We hope for these findings to inform shared decision making between surgeon and patients undergoing panniculectomy following massive weight loss.

Introduction Concurrent panniculectomy during abdominal wall reconstruction(CP-AWR) improves exposure, reduces repair tension, and enhances aesthetics, but concerns persist regarding increased wound morbidity. This study evaluated CP-AWR outcomes with defect size(HDS) ≥255 cm2 versus <255 cm2.

Methods A prospectively maintained institutional database of CP-AWR patients was reviewed. The median HDS (255 cm2) was used as the threshold for group stratification. Standard statistical analyses were performed. Backward stepwise regression identified independent predictors of wound complications.

Results Of 592 total CP-AWR patients, 297 had HDS≥255 cm2; 295 had HDS<255 cm2. The HDS≥255 cm2 group had higher BMI (35.3±7.3 vs. 33.9±7.0kg/m2), diabetes (37.0% vs. 28.8%), comorbidities (5.0±2.4 vs. 4.4±2.5), defect size (440.6±305.5 vs. 170.9±42.7cm2), recurrent repairs (65.3% vs. 53.6%), and CDC 3/4 wounds (23.3% vs. 10.5%)(all p<0.05). Most cases were CDC class 1/2 (73.1% vs. 86.8%; p<0.001), using synthetic mesh (64.6% vs. 66.4%; p=0.631) in the preperitoneal space (91.6% vs. 93.2%; p=0.896). Component separation (CST)(47.8% vs. 21.0%; p<0.001) and botulinum toxin A (BTA) (13.1% vs. 3.7%; p<0.001) were more frequent in HDS≥255 cm2, as was bridging (3.7% vs. 0.0%; p<0.001). Postoperatively, HDS≥255 cm2 had higher rates of wound breakdown (18.9% vs. 11.5%; p=0.018), though no differences in cellulitis (14.5% vs. 10.8%), infection (14.1% vs. 13.9%), seroma requiring intervention (15.5% vs. 12.2%), hematoma (2.7% vs. 3.4%), mesh infection (3.0% vs. 2.7%), or unplanned 30-day reoperations (6.4% vs. 3.7%)(all p>0.05). HDS≥255 cm2 had higher rates of respiratory insufficiency (10.8% vs. 2.4%), re-intubation (5.4% vs. 1.0%), and pneumonia (4.7% vs. 0.3%)(all p<0.05). Recurrence was comparable (7.4% vs. 4.1%; p=0.081) over similar follow-up (46.4±55.2 vs. 41.2±53.5 months; p=0.204). Backward stepwise regression identified BMI (OR: 1.08, 95% CI: 1.04, 1.12; p<0.001), diabetes (OR: 1.98, 95% CI: 1.19, 3.27; p=0.008), and defect size (OR: 1.002, 95% CI: 1.001, 1.004; p=0.004) as independent predictors of wound complications.

Conclusion Among patients who underwent CP-AWR, HDS≥255 cm2 was associated with more comorbidities, increased use of CST, and higher wound and pulmonary complication rates, while recurrence remained similar.

Background/Purpose: Obesity is a well-established risk factor for complications following total hip arthroplasty, including delayed healing, wound dehiscence, infection, seroma formation, and reoperation. Optimizing initial surgical wound closure in this high-risk population is an important strategy for reducing postoperative morbidity. The impact of plastic surgery closure has been investigated in spine and revision total joint arthroplasty. However, plastic surgery wound closure in primary total hip arthroplasty remains unexplored. The purpose of this study was to evaluate postoperative complications in morbidly obese patients undergoing primary total hip arthroplasty when surgical wound closure was performed by a plastic surgeon.

Methods and Materials: A retrospective review was conducted for patients who underwent primary total hip arthroplasty with plastic surgery closure between May 2024 and September 2025. All cases were performed with a posterior approach by a single Orthopaedic surgeon and a single Plastic surgeon completed the wound closure. Postoperative wound healing was evaluated for complications such as infection, dehiscence, fluid collections, or delayed healing.

Results: A total of 11 patients (13 hips) underwent primary total hip arthroplasty with plastic surgery closure. All patients were obese with a mean body mass index of 45.2 kg/m2. The cohort was predominantly female (91.7%) with a mean age of 55.8 years. All patients were ASA class III. The most common comorbidities were hypertension (66.7%) and diabetes (33.3%). All procedures were performed via a posterior approach. Mean duration of subcutaneous drain placement was 14.3 days. Mean operative time was 105 minutes, and mean hospital length of stay was 1.6 days. At mean follow-up of 7.2 months, there were no wound complications, including no cases of infection, wound dehiscence, fluid collections, or delayed healing. There were no readmissions or unplanned returns to the operating room.

Conclusions: Plastic surgery closure during primary total hip arthroplasty in morbidly obese patients was associated with an absence of wound-related complications in this cohort. Despite the presence of multiple risk factors, no cases of infection, dehiscence, seroma, or hematoma were observed. Plastic surgery closure in this high-risk patient population may mitigate wound-related morbidity. However, this study is limited by small sample size, single-surgeon involvement, and a lack of a comparison cohort. Further investigation with larger, comparative studies is recommended to determine whether plastic surgeon-performed closure consistently reduces wound complications.

Introduction: Obesity is one of the most consequential health crises in the United States. Prior studies have demonstrated its negative impact on surgical outcomes, particularly wound complications. These complications present a dual challenge: they prolong recovery and reduce patient satisfaction. This concern is especially relevant in plastic surgery, where wound-related complications affect both clinical outcomes and aesthetic goals. Clinically, surgeons often observe that increasing severity of obesity appears to correlate with a greater risk of wound complications; however, this relationship has not been clearly quantified across BMI classes in a large, representative plastic surgery population. Accordingly, this study seeks to evaluate and more precisely define this association.

Purpose: To evaluate the association between obesity status, defined by body mass index (BMI) categories, and postoperative wound infectious complications among plastic surgery patients.

Methods: We conducted a retrospective cohort study of 86,136 adult patients undergoing plastic surgery at NSQIP-participating hospitals. A previously validated methodology was used to select five procedures using CPT codes: breast reduction, prosthetic breast reconstruction, autologous breast reconstruction, free-flap procedures, and pressure ulcer repair (1). BMI was categorized per NIH definitions: normal weight (18.5–24.9 kg/m²), overweight (25.0–29.9 kg/m²), obesity class I (30.0–34.9 kg/m²), class II (35.0–39.9 kg/m²), and class III (≥40.0 kg/m²). The primary outcome was 30-day postoperative wound complication, defined as superficial, deep, or organ/space surgical site infection, or wound disruption. The secondary outcome was unplanned reoperation within 30 days.

Results: Wound complication risk increased monotonically across BMI classes, from 4.0% in normal-weight patients to 4.7% in overweight, 6.0% in obesity class I, 7.3% in class II, and 9.7% in class III (p<0.001). Superficial SSI increased from 2.0% to 5.5%, deep SSI from 0.6% to 1.2%, organ/space SSI from 0.9% to 1.5%, and wound disruption from 0.8% to 2.2% across BMI categories (all p<0.001). After adjustment (n=8,461), higher BMI remained independently associated with increased wound complication risk. Compared with normal-weight patients, class II (aRR 1.79, 95% CI 1.25–2.56) and class III obesity (aRR 3.35, 95% CI 2.33–4.81) had significantly higher risk. Class III obesity was also associated with increased superficial SSI (aRR 3.57, 95% CI 2.20–5.78), organ/space SSI (aRR 3.15, 95% CI 1.04–9.56), and wound disruption (aRR 3.55, 95% CI 1.68–7.48). Reoperation risk increased with BMI in unadjusted analysis (4.9% vs 7.6%, p=0.009) but was not significant after adjustment.

Conclusions: Postoperative wound complications increase in a dose-dependent fashion with higher BMI, with the greatest risk in class II and III obesity. Even after adjustment, severe obesity remains independently associated with substantially increased risk of wound complications, including surgical site infections and wound disruption.

Reference: 1. Veith J, Collier W, Simpson A, Magno-Padron D, Mast B, Murphy RX Jr, Agarwal J, Kwok A. A Comparison of Common Plastic Surgery Operations Using the NSQIP and TOPS Databases. Plast Reconstr Surg Glob Open. 2020 May 27;8(5):e2841. doi: 10.1097/GOX.0000000000002841. PMID: 33133901.

Introduction: Systemic peripheral gangrene (SPG) is a rare but devastating complication of critical illness associated with substantial morbidity among survivors. Although vasopressor use has historically been regarded as the primary etiologic factor, emerging evidence suggests that disseminated intravascular coagulation (DIC) may be the principal driver. The existing evidence base remains constrained to isolated case reports and limited case series, and no validated, consensus-based treatment guidelines have been established.

Methods: A systematic review was conducted in accordance with PRISMA guidelines using PubMed, EMBASE and Cochrane databases from inception to November 1, 2025. Two independent reviewers screened 4.427 records and evaluated 509 full-text articles against pre-specified eligibility criteria. Studies reporting cases of SPG in critically ill patients were included. Extracted data encompassed patient demographics, underlying diagnoses, vasopressor type and number, DIC status, causative organism, therapeutic interventions, and clinical outcomes. Outcomes were classified as improved, stabilized or worsened. Findings were analyzed using descriptive statistics and co-occurence analysis of treatment combinations.

Results A total of 183 patients from 108 studies met inclusion criteria. Norepinephrine was the most frequently implicated vasopressor; however, neither vasopressor number or dose demonstrated a meaningful association with the occurrence or severity of SPG. In contrast, DIC was present in 77 of 92 (84%) patients with documented coagulation status. Gram-negative organism - principally Escherichia coli, Klebsiella pneumonia, and Capnocytophaga canimorsus - were the predominant precipitants. Twenty-seven distinct treatment strategies targeted to the ischemic limbs were identified. Notably, 69 studies (64%) reported no specific targeted therapy, and among those patients, 65% experienced worsening of their condition. Conversely, patients in whom 3 or 4 different treatment strategies were trialed experienced an improvement in 67% of the cases. Anecdotally, case reports in which botulinum toxin, Iloprost, lepirudin or sulodexide were employed demonstrated the highest single-agent improvement rates. Combination of anticoagulation and vasodilatory or sympatholytic agent consistently outperformed mono-therapy, illustrating a potential pathophysiologic synergy between the micro thrombi formed within the DIC and the distal hypoperfusion caused by vasopressors. Given the predominance of case-level evidence, substantial heterogeneity in therapeutic approaches and outcome reporting methodology was observed across included studies.

Conclusion: This systematic review highlights the limited and heterogeneous evidence base currently informing SPG management. Contrary to prevailing clinical assumptions, vasopressor exposure alone does not adequately explain the development or severity of SPG, whereas DIC emerges as a key therapeutic target. Early institution of sympatholysis in combination with anticoagulation represents the most consistently beneficial management strategy. These findings provide foundational data to support the development of prospective multicenter registries and to enable the randomized evaluation of targeted treatment protocols for this rare but highly morbid condition.