Scientific Abstract Presentations: Residents Aesthetic, Breast and Research & Technology Abstracts Session 5 Friday, October 16 Fri, Oct 16 10:30 a.m.-12:30 p.m. CDT

PURPOSE: Exosomes are nanoscale extracellular vesicles carrying bioactive cargo with proposed regenerative effects on collagen synthesis, inflammation, and tissue repair (1). Commercial adoption of exosome-based aesthetic therapies has outpaced high-quality clinical evidence, which remains dominated by in vitro work and small case series with heterogeneous protocols (2,3). This study evaluates the efficacy, safety, and patient-reported outcomes of adipose-derived stem cell exosome therapy (ASCE+) in a real-world plastic surgery cohort. METHODS: A prospective observational cohort study was conducted at a single tertiary plastic surgery center. Consecutive adults receiving lyophilized ASCE+ exosome therapy between October 2024 and April 2026 were enrolled. Variables captured included demographics, surgical context, product and delivery parameters, and adjunctive treatments. At 12-week follow-up, outcomes included clinician-rated global improvement, patient-reported satisfaction (0 to 10 scale), FACE-Q domain scores (4), willingness to repeat and recommend, and immediate and delayed adverse events. Descriptive statistics were used. RESULTS: Eighty-nine patients were enrolled (mean age 45.5 ± 10.4 years, 95.5% female, mean BMI 25.9 ± 4.3). Lyophilized ASCE+ was administered in 98.9% of cases, predominantly via direct injection (77.5%). Sessions ranged from 1 to 5, with 48.3% receiving multiple sessions. The primary indication was peri-operative wound healing in 59.6%, followed by skin texture (6.7%) and wrinkles (5.6%); treatment was most commonly delivered adjacent to facelift or brow lift incisions. Twelve-week follow-up was completed by 77.9% of patients with available data. Among patients with clinician-rated outcomes (n = 24), global improvement was excellent in 37.5%, moderate or mild in 37.5%, none in 4.2%, and worsened in 20.8%. Mean satisfaction was 4.6 ± 3.8, with 47.1% willing to repeat and 44.1% willing to recommend the procedure. Adverse events were rare: one patient (1.1%) reported transient discomfort, with no delayed adverse events, hypersensitivity, wound infections, or serious adverse events observed. CONCLUSIONS: Adipose-derived exosome therapy demonstrated an excellent safety profile in this 89-patient prospective cohort, with no serious adverse events. Efficacy signals were favorable in the peri-operative wound healing setting, though heterogeneous satisfaction and incomplete outcome capture underscore the need for condition-specific patient-reported outcome instruments and comparative studies. These real-world data support feasibility and safety while emphasizing that standardized protocols, validated outcome measures, and controlled comparisons are required before routine adoption. REFERENCES:

1. Kalluri R, LeBleu VS. The biology, function, and biomedical applications of exosomes. Science. 2020;367:eaau6977.
2. Ku YC, Omer Sulaiman H, Anderson SR, Abtahi AR. The potential role of exosomes in aesthetic plastic surgery: a review of current literature. Plast Reconstr Surg Glob Open. 2023;11:e5051.
3. Ash M, Zibitt M, Shauly O, et al. The innovative and evolving landscape of topical exosome and peptide therapies: a systematic review. Aesthet Surg J Open Forum. 2024;6:ojae017.
4. Klassen AF, Cano SJ, Schwitzer JA, et al. FACE-Q scales for health-related quality of life, early life impact, satisfaction with outcomes, and decision to have treatment: development and validation. Plast Reconstr Surg. 2015;135:375-386.

Background: A detailed understanding of the glabella musculature is essential for performing safe and effective chemodenervation, forehead rejuvenation surgery, and migraine trigger-site nerve decompression. Most existing studies focus primarily on defining surface anatomy rather than three-dimensional (3D) parameters. Additionally, previous studies obtained measurements using cadaver dissection, where dissection has the potential to distort the native regional anatomy. In this study, the authors employed advanced imaging technology to analyze the multi-dimensional characteristics of the corrugator supercilii and procerus muscles, including their relationships to key facial landmarks, depth beneath the skin across regions, and variations in muscle thickness.

Methods: Ten adult cadavers – 5 male, 5 female – were analyzed using high-resolution micro–computed tomography (micro-CT) to obtain precise 3D measurements of the glabella musculature. An advanced specimen staining protocol using triple 9% iodine was utilized to improve visualization of the procerus and corrugators. Corrugator depth from skin and thickness were measured bilaterally at the medial canthus (MC), midpupil (MP), and lateral limbus (LL), as well as the distance from the muscle's medial origin and lateral apex to the bony landmarks of the nasion and lateral orbital rim. Procerus depth from skin and thickness were measured at the superior, inferior, and most central aspect of the muscle. Regional differences were assessed by paired t-tests. Sex-based comparisons were performed using independent t-tests.

Results: Corrugator musculature was symmetric, as comparisons between left- and right-sided measurements did not reveal significant asymmetries (p > 0.05). Corrugator depth from skin decreased from 3.82 mm at the MC, to 3.41 mm at the MP, to 2.69 mm at the LL (-1.13 mm, p = 0.002). Corrugator thickness paralleled this pattern, decreasing from 1.52 mm at the MC, to 1.28 mm at the MP, to 0.95 mm at the LC (-0.57, p < 0.001). Procerus thickness inferiorly (0.87 mm) was thinner than both centrally (1.38 mm, p = 0.020) and superiorly (1.34, p = 0.006); central and superior aspects were equivalent (p = 0.77). Sex-based comparisons revealed no significant differences (all p > 0.05).

Conclusions: This study used high-resolution micro-CT technology to map the 3D structure and topography of the corrugator supercilii and procerus muscles without tissue distortion inherent in gross dissection, building upon the established literature. The corrugator becomes progressively thinner and more superficial laterally, while the procerus demonstrates relative inferior attenuation. Knowledge of these relationships can enhance surgical safety and efficacy by improving precision during injections and operations at the glabella.

Purpose US peptide imports from China nearly doubled from $164 million to $328 million between 2024 and 2025, reflecting social media-driven consumer demand (1). These agents are increasingly self-administered without medical oversight, yet rarely disclosed on preoperative intake forms. This review characterizes the hazards of unregulated melanotropic ("tanning") peptides and proposes a preoperative screening framework.

Methods A narrative review was conducted using PubMed from inception through April 2026. Melanotropic agents (Melanotan I/II, Afamelanotide, PT-141) were combined with complication-related search terms. Six reviewers independently screened 28 articles; 9 met inclusion criteria.

Results Nine studies (8 case reports, 1 case series of 15 patients) captured 23 patients ages 20 to 55 years, predominantly Fitzpatrick I to II. Follow-up ranged from initial presentation to 15 months. Routes included subcutaneous injection (n=7), intradermal implant (n=1), and intranasal spray (n=1). MT-II was implicated in 6 of 9 reports, with afamelanotide and synthetic MT-I implicated in nevus changes.

Five distinct hazard categories emerged:

1. Malignancy: Three reports documented melanoma temporally associated with peptide initiation, including superficial spreading melanoma (Breslow 0.32 mm) in a 20-year-old woman after MT-II (2), melanoma in situ in a darkening nevus after only two injections in a 23-year-old woman, and oral mucosal melanoma with chest metastases in a 22-year-old woman using intranasal MT-II for one month (3).

2. Diagnostic interference: Eruptive and atypical melanocytic nevi were the most common finding (4 of 9 reports), frequently meeting ABCDE criteria and prompting excisional biopsy with benign pathology. A prospective series of 15 afamelanotide patients documented dermoscopic globule counts increasing by 48% at 5 months, with pigment-network thickening resolving by 12 months. This demonstrates reversible mimicry that drives unnecessary intervention during peak exposure.

3. Vascular hazards: Acute hypertension was documented alongside renal infarction following 27 mg of subcutaneous MT-II over six months (4). Flushing and pressor responses characteristic of MC4R agonism represent an undisclosed perioperative variable.

4. Systemic toxicity: Two reports described ischemic priapism after subcutaneous MT-II, including one requiring penoscrotal decompression with persistent erectile dysfunction at 15 weeks (5).

5. Disclosure gap: Intranasal delivery and "beauty supplement" branding lead patients to perceive these agents as cosmetics rather than drugs. None of the cases in this review documented disclosure on standard preoperative intake forms.

Conclusions Unregulated tanning peptides present underrecognized perioperative hazards spanning oncologic, vascular, and systemic domains. Plastic surgeons should consider targeted measures in preoperative screening, including a "tan check" for diffuse pigmentation with sparing of palms and soles, explicit screening for peptide and nasal-spray use beyond traditional medication lists, and a low threshold for biopsy of new or changing pigmented lesions in exposed patients. Pharmacokinetic data are needed to inform an evidence-based preoperative washout interval.

References 1. Monjur R, et al. Grey-market peptides: an emerging public health challenge. InSight+ (Med J Aust). 2026. 2. Hjuler KF, Lorentzen HF. Dermatology. 2013;228(1):34-36. 3. Alsabbagh AY, et al. Int J Oral Maxillofac Surg. 2025;54(9):806-808. 4. Peters B, et al. CEN Case Rep. 2020;9(2):159-161. 5. Mallory CW, et al. Sex Med. 2021;9(1):100298.

Introduction Cosmetic surgery training during Plastic Surgery Residency is essential to be prepared for modern independent surgical practice. Residency clinics provide the opportunity for graduated autonomy in this notoriously demanding patient population and prior investigations have consistently demonstrated this can be done safely with complication rates similar to those of practicing physicians (1, 2, 3). Evidence is limited, however, on whether patients operated on by trainees require more revision surgery despite the similar incidence of major complications. This Quality Improvement project evaluated the revision rates of our institution's Resident Clinic.

Methods Chart review of all Chief Clinic cases from 2022-2025 was conducted. Procedures included in the analysis were abdominoplasties (inclusive of abdominoplasties, panniculectomies, fleur-de-lis abdominoplasties), face lifts, mastopexies, breast augmentations, breast reductions, brachioplasties, thighplasties, circumferential body lifts, blepharoplasties, and posterior body lifts. Rates of revisions among all the above cases were calculated, excluding the revision procedure itself.

Results We found a revision rate of 10.5% of 171 procedures performed (with the revision procedures themselves excluded) in 102 patients. Of those requiring revision, the index operations were were abdominoplasty (revision rate 14%), breast augmentation (revision rate 28%), brachioplasty (revision rate 7%), thighplasty (revision rate 14%), and breast reduction (revision rate 9%). Procedures for complications such as hematoma evacuation were excluded from cases defined as revision procedures. Only 23% of those index operations needing revision were performed during multi-procedural index cases. Average follow-up was 7.54 months for all cases

Conclusion Our institution offers Chief Residents the benefit of practical experience treating patients under supervision while giving patients affordable alternatives to cosmetic surgery, the quality of which compares to practicing surgeons.

1) Pandya S, Fedor CJ, Liu HY, et al. A 10-Year Analysis of Resident Aesthetic Surgery Clinic: Abdominoplasty Performed by Residents Is Safe and Leads to Comparable Outcomes to Attending Surgeons. Ann Plast Surg. 2025;94(4S Suppl 2):S184-S187. doi:10.1097/SAP.0000000000004260 2)Pyle JW, Angobaldo JO, Bryant AK, Marks MW, David LR. Outcomes analysis of a resident cosmetic clinic: safety and feasibility after 7 years. Ann Plast Surg. 2010;64(3):270-274. doi:10.1097/SAP.0b013e3181afa4e9 3) Walker NJ, Crantford JC, Rudolph MA, David LR. Outcomes Analysis of Chief Cosmetic Clinic Over 13 Years. Ann Plast Surg. 2018;80(6):600-606. doi:10.1097/SAP.0000000000001443

BACKGROUND Hematoma remains one of the most consequential complications of rhytidectomy, occurring in up to 15% of cases. Tranexamic acid (TXA) use in tumescent solution has emerged as a promising hemostatic adjunct; however, the optimal concentration for safe application to undermined facial skin flaps has not been established. Recent studies have raised concern for concentration-dependent cytotoxicity and wound ischemia with higher-dose local TXA in facelift surgery, yet no clinical study has systematically examined a concentration threshold. This study evaluates whether TXA concentration in tumescence influences the rate of ischemic complications in patients undergoing rhytidectomy.

METHODS A retrospective cohort study was performed of consecutive patients undergoing rhytidectomy at a single institution. Patients were stratified by TXA concentration in tumescence: low-concentration (>0 to ≤1 mg/mL) and higher-concentration (>1 mg/mL). The primary outcome was early postoperative ischemic changes defined as clinical findings suspicious for threatened skin perfusion, which was distinguished from eschar formation with definitive ischemic endpoint. Dimethyl sulfoxide (DMSO), a vasodilatory agent used to augment cutaneous perfusion, was applied in patients exhibiting signs of threatened perfusion. Secondary outcomes included need for debridement, dehiscence, minor or major infection or hematoma, and seroma. Fisher's exact test (one-tailed, based on a pre-specified directional hypothesis) was used for categorical comparisons.

RESULTS A total of 141 patients were analyzed. TXA concentrations ranged from 0.6–1.0 mg/mL in the low-concentration group (n=58) and 1.2–2.0 mg/mL in the higher-concentration group (n=83). Mean age ws 65.9 ± 6.6 vs. 64.0 ± 7.1 years (p=0.096). Early postoperative ischemic changes were significantly more frequent in the higher-concentration group (27.7% vs. 13.8%; OR=2.40; p=0.040). DMSO utilization was significantly higher in the higher-concentration cohort (75.9% vs. 53.4%; p=0.005). No significant between-group differences were observed for eschar (39.8% vs. 29.3%; p=0.216), debridement (24.1% vs. 20.7%; p=0.687), dehiscence (9.6% vs. 8.6%; p=1.000), early infection (16.9% vs. 22.4%; p=0.515), minor hematoma (3.6% vs. 1.7%; p=0.644), or seroma (9.6% vs. 10.3%; p=1.000). No thromboembolic events, significant hematomas, or need for return to the operating room were recorded in either cohort.

CONCLUSION Higher TXA concentration in tumescent solution (>1 mg/mL) was associated with a significantly greater incidence of early postoperative ischemic skin changes during rhytidectomy; however, this did not translate into a significantly increased risk of eschar formation or need for debridement compared to the lower-concentration group. The higher rate of DMSO administration observed among patients receiving greater than 1 mg/mL TXA is consistent with its use as an agent in response to detected ischemic changes and may have played a protective role in limiting progression to more definitive ischemic endpoints such as eschar. Taken together, these findings suggest that TXA concentration above 1 mg/mL in tumescent solution increases the burden of clinical vigilance required during rhytidectomy and that lower concentrations may offer a comparable hemostatic effect with a more favorable cutaneous safety profile. Prospective, multi-institutional studies with standardized dosing protocols are needed to validate this threshold and establish evidence-based guidelines for tumescent TXA use in rhytidectomy.

PURPOSE: Dermal filler injections to the face have become increasingly popular while the Hyaluronic acid (HA) is the most commonly used material. While it provides satisfactory and long-lasting aesthetic results, some complications may still occur, the most concerning one being the vascular compromise due to intravascular injections, thrombosis or external compression. Ultrasound (US) guided hyaluronidase injections have previously been described although literature remains limited. This systematic review aims to assess the outcomes of US-guided hyaluronidase injections for the management of vascular complications of HA dermal fillers in the face and offer a guide for plastic surgeons.

METHODS: A systematic review utilizing the PRISMA guidelines was performed. Literature involving the clinical reports of US guided hyaluronidase injections to treat vascular complications after HA filler to the face on human subjects were reviewed using several databases. Exclusion criteria were articles in the form of abstracts, clinical overviews, clinical reviews, systematic reviews, opinion pieces, editorial letters, media reports and theses/dissertations, and any studies with animal models as well as non-English material. A case from our institution was also reported in this study.

RESULTS: After the initial screening of 39 articles, a total of 9 studies met the inclusion criteria, comprising three case reports, four case series, one retrospective study, and one comparative series. These included publications from the Netherlands, France, Italy, Korea, Brazil, and the United States, spanning from 2017 to 2024. A total of 82 patients were reported in these articles. Most participants were female, with reported ages ranging between 18 and 58 years. The nasolabial fold, lips, nose, forehead, and chin were the most frequent sites of ischemia, reflecting occlusions of the angular, labial, supratrochlear, supraorbital, submental, and facial arteries. All studies performed real-time, ultrasound-guided injection of hyaluronidase into the occluded vessel, obstructing HA pocket or the perivascular space. Across all studies, rapid reperfusion and clinical recovery followed ultrasound-guided hyaluronidase injection. Complete reversal of ischemia occurred within 1 – 7 days in all patients. Pain, blanching, and livedo reticularis typically resolved within minutes to hours after injection. No study reported recurrence, scarring, or functional deficits. Long-term follow-up (up to nine months) confirmed durable results and complete hair regrowth in one case report. None of the reports identified serious adverse events or hypersensitivity reactions to hyaluronidase. Recent studies highlighted that precise, lower-dose enzyme delivery under ultrasound minimized the risk of allergic or matrix-degrading effects associated with high-dose flooding.

CONCLUSION: US-guided injection of hyaluronidase warrants a safe and effective approach of treatment of vascular complications of HA dermal filler injection to the face. Overall, the collective evidence demonstrates that ultrasound guidance enhances diagnostic accuracy, reduces hyaluronidase dosage, and accelerates recovery in filler-related vascular adverse events.

Purpose: Cosmetic medical tourism (CMT) continues to grow as patients seek lower costs, shorter wait times, and access to procedures unavailable locally. (1,2) Postoperative complications are common, with reported rates as high as 74% and continuity of care is often absent, leaving local plastic surgeons to manage complications from procedures they did not perform. This places a clinical and ethical burden on surgeons, as many patients require hospital-level care while surgeons often receive little or no compensation. (3) Despite the frequency of these encounters, expectations for postoperative responsibility remain poorly defined. This study characterizes plastic surgeons' experiences managing CMT complications and perceptions of postoperative and revision responsibility.

Methods and Materials: A cross-sectional survey was distributed to board-certified and board-eligible plastic surgeons practicing in the United States. Survey domains included practice characteristics, frequency and setting of CMT complications, types of complications encountered, provider attitudes, management protocols, and responsibility for postoperative follow-up. Survey responses were analyzed using descriptive statistics. Results: Thirty-eight plastic surgeons completed the survey (response rate: 14%). Most respondents practiced in academic settings (89%) and urban environments (71%), with most reporting regular emergency department call (65%). All participants reported encountering CMT complications. The average number of complications treated per surgeon in the prior year was 5.8, with a median of 3 and a range of 0 to 20. Complications were encountered most commonly quarterly to semiannually, although some surgeons reported monthly or weekly encounters. The most commonly reported complications included tissue necrosis, infection, wound dehiscence, fat necrosis, seroma, and hematoma. Central America and the Caribbean were the most frequently reported regions of origin. Provider attitudes toward patients presenting with major complications from CMT were predominantly negative (76%), reflecting frustration with direct-to-consumer marketing and lack of continuity of care. Management approaches varied widely, with most surgeons relying on personal protocols and training-based decision-making rather than published or societal guidelines. Several respondents reported lacking a standard protocol.

Conclusions: CMT complications are regularly encountered by the respondent plastic surgeons of this study and managed without formal guidance . Lack of universal guidelines contributes to uncertainty and provider frustration. Most respondents indicated that responsibility for postoperative management should rest primarily with the operating surgeon. When surgery is performed abroad, the operating surgeon should ensure access to qualified local follow-up care through preoperative confirmation or formal postoperative care agreements. Professional societies can support accountability by promoting continuity-of-care standards, model consent language, and requirements for documented postoperative plans. Cosmetic surgery without borders must not mean surgery without follow-up.

1. McCrossan, S., Martin, S., & Hill, C. (2021, August). Medical tourism in aesthetic breast surgery: A systematic review. Aesthetic plastic surgery.
2. Melendez MM, Alizadeh K (2011) Complications from international surgery tourism. Aesthet Surg J 31(6):694–697
3. Belza CC, et. al. Management of Plastic Surgery Complications at a Tertiary Medical Center after Aesthetic Procedures. Plast Reconstr Surg Glob Open. 2024 Oct 23;12(10):e6250.

Introduction Rhinoplasty remains one of the most commonly performed plastic surgery procedures in the United States, yet racial and ethnic minorities remain underrepresented among patients seeking nasal surgery (1). Understanding demographic factors influencing surgical outcomes is vital to delivering equitable care. This study evaluated racial and ethnic disparities in patient demographics, clinical profiles, and postoperative complications following primary and secondary rhinoplasty.

Methods A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2012 to 2023 identified rhinoplasty patients using Current Procedural Terminology codes for primary and secondary rhinoplasty. Patients were stratified by race (White, Black/African American, Other) and Hispanic ethnicity. Demographics, preoperative comorbidities, ASA classification, BMI, smoking status, and 30-day outcomes were analyzed. Multivariable logistic regression assessed associations between race, ethnicity, and complications, adjusting for age, sex, BMI, ASA class, smoking, diabetes, operative time, and rhinoplasty type.

Results A total of 1201 patients were included (87.2% White, 8.1% Black, 4.7% Other). Primary rhinoplasty comprised approximately 80% of cases across all groups with no racial (p=0.339) or ethnic (p=0.623) difference. Hispanic patients were significantly younger (35.81 versus 40.76 years; p<0.001) with lower hypertension prevalence (8.4% versus 15.1%; p=0.015). Black patients demonstrated higher BMI (p<0.001) and ASA classification (p=0.009). Overall 30-day complications occurred in 68 patients (5.5%), including wound complications in 40 (3.2%) and operative complications in 28 (2.3%), with no significant differences between primary and secondary rhinoplasty (p=0.651) or across racial (p=0.728) or ethnic groups. On multivariable analysis, advancing age (OR: 1.020; 95% CI: 1.003–1.038; p=0.025) and higher ASA classification (OR: 2.105; 95% CI: 1.301–3.405; p=0.002) independently predicted increased overall complications. Race, ethnicity, BMI, smoking, and rhinoplasty type were not significant predictors (all p>0.1). Minority representation increased over the study period, with African American patients rising from 0.0% in 2014 to 10.8% in 2023 and Hispanic patients from 11.1% in 2011 to 16.7% in 2023 (2).

Conclusion While racial and ethnic minorities remain underrepresented among rhinoplasty patients, short-term outcomes do not significantly differ across groups when equitable care is provided. Complications are primarily driven by age and ASA classification rather than race or ethnicity (3). These findings underscore the importance of optimizing preoperative health and addressing socioeconomic barriers to ensure equitable access to rhinoplasty.

References 1. Rhee BS, Pham J, Tanzer JR, et al. Using Microeconomic Spending Traits to Inform Trends in Utilization of Cosmetic Procedures by Race and Ethnicity. Plast Reconstr Surg Glob Open. 2024;12(7):e5963. 2. Knoedler S, Knoedler L, Wu M, et al. Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis. J Craniofac Surg. 2023;34(6):1722-1726. 3. Skorochod R, Wolf Y. Racial Disparities in Plastic Surgery Outcomes: A Systematic Literature Review and Meta-Analysis. Plast Reconstr Surg Glob Open. 2024;12(10):e6220.

Background: Rising rates of major depressive disorder (MDD) and elective cosmetic procedures among U.S. adults highlight the intersection of mental health and aesthetic surgery (1,2). Mental health disorders are highly prevalent among cosmetic surgery patients, yet frequently unidentified preoperatively - one prospective study found only 29.9% of affected patients had a formal diagnosis documented in their medical records (3,4). Unrecognized psychiatric conditions can contribute to unrealistic expectations, postoperative dissatisfaction, and adverse psychosocial outcomes (5). Yet large-scale data on cosmetic procedure utilization and psychosocial risk factors among these patients remain lacking. This study utilized antidepressant use as a pharmacologic proxy for underlying mental health conditions and, leveraging a national federated database, examined the association with cosmetic procedure rates, substance use disorders, and socioeconomic stressors.

Methods: Using TriNetX, a federated research network providing de-identified electronic health record data from over 117 million patients, two cohorts were identified: patients with antidepressant use within five years and those without. Cohorts were propensity score–matched on age, sex, and ethnicity. Primary outcomes included rates of breast augmentation, facial procedures, and trunk/extremity procedures. Secondary outcomes included alcohol use disorder, substance use disorder, and socioeconomic stressors. Risk ratios (RR) with 95% confidence intervals were calculated; significance was set at p 0.05.

Results: After matching, females on antidepressants had significantly higher rates of breast augmentation (RR = 2.65, p 0.001), facial procedures (RR = 3.07, p 0.001), and trunk/extremity procedures (RR = 4.21, p 0.001) compared with controls. Males on antidepressants similarly showed elevated rates of facial procedures (RR = 2.72, p 0.001) and trunk/extremity procedures (RR = 4.77, p 0.001). Both sexes had significantly higher rates of alcohol use disorder (RR = 3.93 females; 3.56 males), substance use disorder (RR = 4.46 females; 4.52 males), and socioeconomic problems (RR = 4.17 females; 4.60 males; all p 0.001).

Conclusion: Patients on antidepressants undergo cosmetic procedures at two- to nearly fivefold higher rates than matched controls, with similarly elevated rates of substance use disorders and socioeconomic stressors. These co-occurring risk factors underscore the need for safe practice in this population. Standardized mental health screening should be integrated into preoperative assessment to optimize patient selection and minimize postoperative dissatisfaction or psychological harm. Future prospective studies should evaluate whether preoperative psychiatric optimization improves surgical outcomes and patient satisfaction.

References 1. Brody DJ, Hughes JP. Depression Prevalence in Adolescents and Adults: United States, August 2021–August 2023. NCHS Data Brief. 2025;(527):1-8. 2. Triana L, et al. Trends in Surgical and Nonsurgical Aesthetic Procedures: A 14-Year Analysis of ISAPS. Aesthetic Plast Surg. 2024;48(20):4217-4227. 3. Bunia E, et al. Psychiatric Disorders in Aesthetic Surgery: A Prospective Study. Aesthetic Plast Surg. 2025. 4. Marron Mendes V, et al. Prevalence of Psychiatric Disorders in Aesthetic Surgery. Ann Plast Surg. 2023;91(4):413-421. 5. Honigman RJ, et al. A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery. Plast Reconstr Surg. 2004;113(4):1229-1237.

Background: Breast implant registries are essential infrastructure for patient safety, long-term device surveillance, and quality improvement. However, suboptimal enrollment remains a persistent challenge even in well-established international registries. The Australian Breast Device Registry achieves an overall capture rate of 69% (1), the Dutch registry captures only 49% of explantations despite near-complete implant tracking (2), and the US National Breast Implant Registry captures fewer than 10% of annual case volumes (3). As Canada develops its first national breast implant registry, the experiences of established international registries offer important lessons in registry design (4). We hypothesize that manual data entry is the primary barrier to complete and timely data capture. The purpose of this study is to conduct a multi-institutional pilot of the Canadian breast implant registry and evaluate natural language processing (NLP) as a scalable modality for automated data collection.

Methods: Consecutive patients undergoing alloplastic breast reconstruction or augmentation across public and private practice settings in British Columbia were prospectively enrolled. Following informed patient consent, surgeons completed a 42-item REDCap or paper form following each case, capturing the International Collaboration of Breast Registry Activities (ICOBRA) consensus minimum dataset (5). A modified Delphi consensus process is underway to optimize the dataset for a Canadian healthcare context and provide strategic direction for the Canadian breast implant registry.

In parallel, a retrospective cohort of all breast implant operative notes from January 2024 to December 2025 was curated to develop an NLP training dataset. Records were de-identified and will be annotated in Doccano (open-source annotation tool) using the ICOBRA and Canadian consensus dataset established previously. Documentation completeness for each variable will be assessed, with ordinal logistic regression identifying factors associated with completeness across surgeons, procedure types, and practice settings. Inter-annotator reliability will be evaluated using Cohen's kappa. A transformer-based NLP pipeline (BERT architecture) is being fine-tuned for automated variable extraction from structured and unstructured operative notes, with performance reporting using accuracy, precision, recall, and F1 score.

Results: Between February 18 and April 30, 104 patients were eligible, 60 consented, and 30 registry entries were completed across 7 surgeons, a consent-to-completion ratio of 0.50. Incomplete entries were attributed primarily to time constraints, workflow interruptions at the point of care. Reconstructive cases comprised 63% of eligible patients but accounted for 97% of completed entries. Median entry time was 215 seconds (IQR 134–284 seconds). Delphi voting is planned for May 2026; the majority of current variables are expected to be retained.

For the NLP pipeline, 1,161 operative notes with associated implant labels have been curated and annotation is in progress. We anticipate that standardized structured fields, such as implant size and manufacturer, will achieve higher extraction accuracy than technique-dependent free-text variables. Implementation in surgical workflows is expected to increase capture rate.

Conclusions: Manual data entry is a primary barrier to complete breast implant registry data capture, with participation varying significantly across practice settings. NLP-based operative note extraction offers a scalable, low cost, passive alternative that could enable near-complete, surgeon-independent data capture when integrated into existing EMR infrastructure.

References: 1. Ahern S G, P, Herbert D, Earnest A, Kalbasi S, Heriot N,, McInnes S AD, Nejati H, Pourghaderi AR, Ioannou L, Tansley P,, Walker M CY, Topchian D, Dusseldorp J, Tsao S and Scoble J. The Australian Breast Device Registry 2024 Annual Report. 2024:134. February 2026. 2. Melse PE, Vrolijk JJ, Becherer BE, et al. Data quality assessment of the Dutch Breast Implant Registry by automated data verification using medical billing data. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2024;99:96-102. doi:10.1016/j.bjps.2024.08.051 3. McCarthy C AA, Pusic A, Der J, d'Incelli R, Lavingia S, Pathmajeyan M, Saul S, Marinac-Dabic D, Yoon S, Cockburn M, Adams H, Diaz AL. The National Breast Implant Registry Annual Report 2025. 2025:24. 4. Rea VMS, Gowda R, Nicholson E, Isaac KV. Recommendations for a Canadian Breast Implant Registry. Plast Surg (Oakv). Jul 15 2025:22925503251355977. doi:10.1177/22925503251355977 5. Spronk PER, Begum H, Vishwanath S, et al. Toward International Harmonization of Breast Implant Registries: International Collaboration of Breast Registry Activities Global Common Data Set. Plastic and Reconstructive Surgery. 2020;146(2):255-267. doi:10.1097

Introduction: Nipple-sparing mastectomy (NSM) with immediate tissue expanders (ITE) is preferred over direct-to-implant reconstruction due to improved cosmesis and reduced nipple-areolar complex (NAC) necrosis. Prior studies report increased surgical site infections (SSI) with NSM versus skin-sparing mastectomy (1). We speculated that fissures and clefts of NAC prevent adequate coverage with a single ChloraPrep stick. We hypothesized that isolated NAC preparation (INACP) with a separate ChloraPrep stick followed by full-breast preparation with another would reduce SSI in NSM with ITE. Methods: We conducted a prospective single-institution study of patients undergoing NSM with ITE from November 2024 - December 2025. All patients received INACP using one ChloraPrep stick, followed by breast preparation with another. The primary outcome was SSI within 30 days requiring incision/drainage, tissue expander removal/exchange, or antibiotics in addition to standard prophylaxis. Data was analyzed for indication for mastectomy, patient comorbidity, drain removal time, and bacterial species. Outcomes were compared to patients that underwent routine breast preparation (RBP) from December 2022 - September 2024. All procedures were performed by the same surgeon using same perioperative antibiotics and TE handling. Results: Sixteen patients underwent RBP and twelve underwent INACP. SSI occurred in 4 patients (25%) in the RBP group, all requiring antibiotics and expander removal. No infections occurred in the INACP group. The numbers needed to treat was four. Conclusion: INACP eliminated infections in patients undergoing NSM with ITE. Although limited by small sample size, utilizing an additional prep stick may be a cost-effective way to prevent infections and their associated cost in this challenging population.

1. Olsen, Margaret A PhD, MPH; Nickel, Katelin B MPH; Margenthaler, Julie A MD, FACS; Myckatyn, Terence M MD, FACS, FRCSC; Warren, David K MD, MPH. Nipple-Sparing Mastectomy and Infection Risk after Immediate Breast Reconstruction. Journal of the American College of Surgeons 241(2):p 254-260, August 2025. | DOI: 10.1097/XCS.0000000000001424

Background: Lymphoscintigraphy is a noninvasive nuclear medicine technique used to assess lymphatic function and may help identify surgical candidates among patients with extremity lymphedema1. This study aims to describe postoperative nuclear medicine imaging findings, including SPECT/CT, following lymphovenous bypass (LVB) in breast cancer patients undergoing plastic surgery reconstruction after unilateral mastectomy and axillary lymph node dissection. Subsect & Method: In this study, we recruited five female patients ages 59-76 years old with a history of breast cancer who were status post mastectomy and unilateral axillary lymph node dissection with adjuvant radiation therapy. All patients were diagnosed with, or considered at risk of developing, unilateral upper-extremity lymphedema and underwent lymphovenous bypass at our institution. Three months postoperatively, unilateral nuclear medicine lymphoscintigraphy was performed after subcutaneous injection of 0.5 mCi Tc-99m filtered sulfur colloid into the second webspace, followed by SPECT/CT. Imaging was assessed for postoperative lymphatic functional status, including residual or recurrent lymphedema, lymphatic leak/dermal backflow, and the location of draining lymph nodes. Gadolinium-enhanced unilateral MR lymphangiogram (MRL) was also performed in selected patients to further characterize lymphatic channels and postoperative changes within the operative extremity. Results: All patients tolerated the lymphoscintigraphy procedure well. Lymphoscintigraphy and SPECT/CT demonstrated common postoperative findings, including absence of axillary draining lymph nodes, focal dermal radiotracer flow or leakage, and collateral drainage to nonaxillary nodal basins in the subpectoral region. Collateral draining lymph nodes may reflect postoperative lymphatic rerouting and/or recruitment of alternate pathways. Additionally, prominent lymphatic vessels at previous lymphovenous bypass sites are noted with focal regions of improved lymphatic drainage. Tracer accumulation in the liver was seen on delayed images at approximately 3 hours, demonstrating effective lymphatic transport through the extremity of interest with return of contrast to the venous circulation. MRL also demonstrated similar imaging findings. However, there are no corresponding collateral draining lymph nodes between the two imaging approaches. Conclusion: Nuclear medicine lymphoscintigraphy with SPECT/CT may provide valuable information for assessing outcomes after lymphovenous bypass. Improvement in focal dermal backflow on NM lymphoscintigraphy/MRL status post lymphovenous bypass represents a promising postoperative change and should be monitored with longitudinal clinical and imaging follow-up.

Works Cited 1. Kwon, H.R., Hwang, J.H., Mun, GH. et al. Predictive role of lymphoscintigraphy undergoing lymphovenous anastomosis in patients with lower extremity lymphedema: a preliminary study. BMC Med Imaging 21, 188 (2021). https://doi.org/10.1186/s12880-021-00713-1

Introduction The impact of breast implants on the immune system has been debated since their introduction.1 A constellation of nonspecific symptoms related to the presence of silicone breast implants (SBI) has been called breast implant illness (BII). However, no standardized diagnostic criteria currently exist. 2 Case Report We report the case of a 49-year-old woman who developed vitiligo and fibromyalgia following SBI placement, with near-complete resolution of symptoms after implant explantation. In 2011, at age 34 and with no significant comorbidities, she underwent augmentation mastopexy with bilateral subglandular SBI. In 2012, she developed sharply demarcated, symmetric depigmented patches consistent with a clinical diagnosis of vitiligo (figure 1). Treatment with topical tacrolimus was initiated. In 2013, progressive polyarticular pain developed without objective signs of arthritis. A comprehensive rheumatologic evaluation led to a diagnosis of fibromyalgia, and systemic prednisone was initiated. Only partial control of vitiligo and fibromyalgia symptoms was achieved. In November 2024, she was referred for plastic surgery evaluation due to new-onset severe bilateral breast pain. Baker grade IV capsular contracture was diagnosed. Magnetic resonance imaging demonstrated retroglandular implants without evidence of intra- or extracapsular rupture. Surgical management was recommended. In April 2025, she underwent implant explantation, total bilateral capsulectomy, and mastopexy. The postoperative course was uneventful, and both prednisone and tacrolimus were temporarily discontinued. At the 3-month postoperative follow-up visit, the patient reported unexpected improvement in vitiligo lesions. Tacrolimus therapy was not resumed. Improvement persisted over subsequent months, and at nearly 1 year of follow-up, most lesions had almost completely resolved, with significant improvement in the remainder (figure 2). Discussion The temporal correlation between implant placement and the onset of autoimmune symptoms, along with marked clinical improvement following explantation, supports the hypothesis that breast implants may function as immune adjuvants. Although isolated reports have described worsening of preexisting vitiligo after SBI placement, with partial repigmentation following explantation. 3 To our knowledge, no prior reports have documented the de novo onset of vitiligo after implantation nor such marked clinical improvement after implant removal. These observations expose critical gaps in our understanding of the pathophysiology and management of implant-associated autoimmune manifestations, underscoring the need for a more rigorous and mechanistic approach to this complex and poorly understood clinical entity. References 1. González A, Ortega-Muñoz L, Quibano-Ordoñez D, Moreno PA, Vélez-Varela PE. Silicone Breast Implants and Autoimmunity: A case report. JPRAS Open. 2024 Nov 1;43:67-73. doi: 10.1016/j.jpra.2024.10.017. 2. Kasielska-Trojan A, Antoszewski B, Zadrożny M, Pluta P. The Problem of Diagnostic Criteria of Breast Implant Illness in Women After Breast Reconstruction: Review and Discussion of a Case. Aesthetic Plast Surg. 2024 Sep;48(17):3323-3330. doi: 10.1007/s00266-023-03832-y. 3. Del-Giacco SR, Firinu D, Piludu G, Settembrini AM, Tulli M, Pirari P, et al. Raynaud's Phenomen and Scleroderma Associated with Silicone Gel Breast Implants: An Example of ASIA Syndrome. Eur J Inflamm. 2012 Aug 10;2:233- 238. doi: https://doi.org/10.1177/1721727X1201000209.

PURPOSE: Seroma formation is a well-recognized complication following tissue expander (TE)-based breast reconstruction, contributing to patient morbidity, prolonged recovery, readmission, and risk of reconstructive failure. While established risk factors such as BMI, axillary surgery, and drain management have been described, the potential influence of seasonal variation driven by increased physical activity during peak summer months remains poorly characterized. This study evaluates whether seroma incidence following TE-based breast reconstruction is higher during the Pennsylvania peak summer months of June through September.

METHODS: A retrospective review was performed of all patients who underwent tissue expander placement for breast reconstruction at our institution between 2019 and 2024. Data collected included acellular dermal matrix (ADM) use, drain removal timing, seroma occurrence and timing, treatment modality (clinic aspiration, operative washout, or other), wound cultures and causative organisms, antibiotic use, and reconstructive outcomes including salvage versus explantation. Additional complications including wound healing delay were recorded. Seroma was defined as any fluid collection documented in the medical record, inclusive of both observed and treated collections. Seroma incidence was compared between patients who underwent surgery during peak summer months (June - September) versus the remaining calendar months (October - May) using chi-square analysis.

RESULTS: A total of 465 patients underwent tissue expander-based breast reconstruction during the study period. Seroma was identified in 179 patients (38.5%), and 30 patients (6.5% of the total cohort) required readmission within 30 days for seroma-related complications. Seroma incidence was higher among patients who underwent surgery during peak summer months compared to the remaining calendar months (45.5% vs. 35.4%, p = 0.051). Mean time to seroma development was 23.8 days.

CONCLUSION: In this single institution cohort of patients undergoing TE-based breast reconstruction, seroma occurred in over one-third of patients and was associated with a 30-day readmission rate of 6.5%. Surgery during peak summer months was associated with a nearly significant increase in seroma incidence (p = 0.051), suggesting that seasonal activity patterns may contribute to postoperative fluid accumulation. These findings support prospective investigation with objective activity data to better characterize the relationship between warm-weather activity and seroma risk following tissue expander reconstruction. Further investigation of factors such as the correlation with drain removal timing may also provide valuable data for postoperative management.

Introduction: Selecting the most appropriate approach for reconstruction after surgery for breast cancer requires careful consideration of individual patient factors. Increased perioperative risk has historically been associated with decreased rates of breast reconstruction. As reconstructive techniques have improved, it is unknown if there has been any improvement in opportunities for reconstruction for comorbid patients. This study assesses how patients' comorbidity score, or Charleson Deyo (CD) score, influences decision-making in individuals undergoing breast reconstruction.

Methods: Using the 2022 National Cancer Database (NCDB), we analyzed women aged 18 and older with T1-T3 Invasive Ductal Carcinoma. Multinominal and logistic regression were used to assess reconstruction type and CD score, focusing on implant-based and autologous tissue reconstruction. CD Score is rated on a scale of 0-3, with 0 being no comorbidities and 3 being three or more comorbidities. Comorbidities that factor into CD scoring include peripheral vascular disease, chronic kidney disease, previous myocardial infarction, diabetes, and diabetes with chronic complications.

Results: There were 54,626 patients included in this analysis, with 80% (43,743) having a CD score of 0 and 2.9% (1,598) having a higher CD score of 3 or higher. Patients with a CD score of 3 were less likely to receive a tissue expander or go directly to implant reconstruction than those with a CD score of 0, respectively. (Tissue Expander: 36 (0.9%) vs. 3,601 (87%), p<0.001, q<0.001; OR 0.48 [95% CI 0.33-0.69] and Direct to Implant: 7 (0.6%) vs. 1,012 (87%), p=0.005, q=0.012; OR 0.32 [95% CI 0.41-0.71]). Patients with a CD score of 3 were also less likely to undergo autologous tissue reconstruction (with tissue from sites other than the abdomen) relative to those with a CD score of 0, [0 (0%) vs 130 (88%)], p<0.001, q<0.001; OR 0 [95% CI 0-0]). Of those who underwent autologous reconstruction, there was a trend toward a higher likelihood of receiving abdominal-based tissue flaps in comorbid patients compared to other types of autologous reconstruction. Out of the 15 patients with a CD score of 2 or higher, who received autologous reconstruction, 10 of those had abdominal autologous flap reconstruction, with the remaining 5 patients receiving autologous reconstruction with tissue from another site. 14 out of these 15 patients undergoing autologous reconstruction of any origin had a CD score of 2 and only 1 patient with a CD score of 3+, underwent autologous reconstruction.

Conclusion: In patients with T1-T3 Invasive Ductal Carcinoma, patients with a higher comorbidity score of 3 were less likely to undergo tissue expander placement, implant-based reconstruction, and autologous tissue reconstruction compared to those with a CD score of 0. However, we see an emerging trend that some autologous reconstruction, such as abdominal flap-based reconstruction, may be becoming more common and less restrictive in the higher comorbid population with a CD score of 2+. Further prospective studies are needed to validate these trends.

Background: Long-gap peripheral-nerve injuries are a reconstructive challenge.¹–³ Autograft is the treatment gold-standard but is limited by donor-site morbidity and limited availability. Large-animal models better replicate human regenerative biology than rodents. This meta-analysis evaluates experimental interventions versus autograft in non-rodent models to provide more clinically relevant insights. Methods: A systematic review of large-animal studies with >3 cm nerve-gaps was performed using PubMed, Ovid, Scopus, and Web-of-Science Meta-analysis was performed to compare experimental groups vs autograft. Results: 53studies were included. Experimental groups underperformed autograft, demonstrating reduced motor nerve conduction velocity (MNCV) (-6.03 m/s, p=0.04), CMAP (-2.06 mV, p=0.01), greater wet muscle weight (WMW) loss (−20.12%, p<0.00001), and decreased axon count (AC) (−1.35, p=0.02), fiber diameter (FD) (−0.42, p=0.01), and myelin thickness (MT) (−0.34, p=0.004). Subgroup/sensitivity analyses showed no interspecies differences (p>0.05), confirming autograft superiority across large-animals. Biological grafts most closely approximate autograft in CMAP/MNCV (MD 3.08 m/s; p=0.11), without significant differences for histomorphometry. Acellular constructs were inferior, with significant reductions in MNCV (−12.25 m/s; p=0.01), FD (−1.23; p<0.00001), MT (−0.53; p=0.03), and WMW (−3.43; p=0.01). Advanced therapies demonstrated reduced CMAP (−3.25 mV; p=0.03; I²=39%) and FD (−0.77; p=0.02). In the sensitivity analysis by follow-up ,MNCV remained non-significant at 6 and 12 months (p=0.10; p=0.29). CMAP was comparable at 6mo (p=0.12) but significantly lower at 12mo (p=0.04). Muscle atrophy was significant from 6mo onward (p=0.0006; p=0.008). AC was reduced at 6mo (p=0.004), while FD and MT significantly declined at 12mo. Conclusions: Autograft outperforms experimental groups across all outcomes in large-animals. Acellular constructs perform worst, advanced therapies show partial recovery, and biological strategies approach but do not match autograft. Deficits are consistent across species indicating continued opportunity for improved nerve reconstruction strategies.

References: Asplund M, et al. Neuroepidemiology. 2009;32:217-28. Murphy RNA, et al. J Plast Reconstr Aesthet Surg. 2022;80:75-85. Padovano WM, et al. Hand (N Y). 2022;17:615-23. Li A, et al. Curr Neuropharmacol. 2022;20:344-61. Kaplan HM, et al. J Mater Sci Mater Med. 2015;26:226

Background Academic research is crucial to advancing medical knowledge. While there is a trend toward increasing organization and investment in research infrastructure, research in academic centers remains heterogeneous and driven by individual investigators. This is compounded by demanding residents and attending schedules that limit productivity. Preliminary studies suggest that integrating research fellows may improve productivity and academic outcomes. This study aims to evaluate our institutional experience following the implementation of a formal research fellow model and to assess changes in divisional scholarly output and trainee involvement.

Methods Our previous research model relied on students and residents to complete projects, with students participating either informally or through our institution's yearly summer research program (SRP). In 2020, we implemented a formal research model incorporating 1-3 dedicated research fellows per year while continuing to onboard students through the SRP. In this model, research fellows provided longitudinal project support and facilitated coordination among students, residents, and faculty. We analyzed all published manuscripts and abstracts from January 2015 to January 2025. To account for the delay between the implementation of the research-fellow-based model and measurable scholarly output, cohorts were defined with a 1-year lag: Group 1 (2015-2020) and Group 2 (2021-2025). Data collected included total scholarly output, trainee authorship, and journal impact factors (IFs) as surrogates for publication visibility. Fisher's exact test and chi-squared test were used to compare groups.

Results From 2015 to 2025, we recorded 94 manuscripts and 284 abstracts. For manuscripts, Group 1 had 26 (28%) while Group 2 had 68 (72%), a 162% increase (p < 0.001). The mean journal IF in Group 1 was 1.5 (SD 0.8) versus 1.8 (SD 0.8) in Group 2 (p = 0.24). In Group 1, students authored 18 (69%) manuscripts, of which 11 (61%) were first authors. In Group 2, students authored 55 (59%) manuscripts, of which 27 (49%) were first authors (p = 0.18 and p = 0.95, respectively). Research fellows authored 46 (49%) manuscripts, of which 18 (39%) were first authors.

For abstracts, Group 1 had 97 (34%) while Group 2 had 187 (66%), a 93% increase (p < 0.001). In Group 1, students authored 48 (49%) abstracts, of which 19 (40%) were first authors. In Group 2, students authored 161 (86%) abstracts, of which 85 (53%) were first authors (p < 0.001 for both, respectively). Research fellows authored 138 (74%) abstracts, of which 45 (35%) were first authors. Overall, individual research fellows averaged 13 (SD 6) manuscripts and 33 abstracts (SD 16).

Conclusions The implementation of a formal research-fellowship model was associated with substantial gains in divisional scholarly output and robust trainee participation in academic work. Beyond increasing publication and abstract volume, research fellows may improve project continuity, strengthen research coordination, and expand opportunities for academic engagement and development.

Osteonecrosis of the mandible is a challenging complication that can be caused by various medications, radiation therapy, infection, trauma, and other conditions. When conservative measures fail, partial or segmental mandibulectomy may be indicated. The extent of debridement is often guided by subjective measures such as visual inspection of viability including vascularity, as well as tactile feedback of bone.

Fluorescence-guided surgical techniques can serve as adjuncts in the delineation of healthy bone margins intraoperatively (1). Tetracycline-radiolabeled bone immunofluorescence may help identify healthy bone by administering doxycycline prior to surgery and allowing it to be incorporated into mineralizing bone. When visualized under UV light (365-405nm), viable bone fluoresces green (500-550nm) (2). To be effective, doxycycline needs to achieve adequate penetration into bone, with no clear consensus on the preoperative loading timeline. While most patients have adequate time to begin radiolabelling due to the elective nature of mandibulectomy, this technique does impose delays and potential risks.

Radiolabelling with indocyanine green (ICG) can provide a dynamic assessment of bone perfusion, by using a handheld near-infrared camera (750-800nm), such as SPY-PHI by Stryker (3). It can be used in the assessment of free flaps, vascular anastomoses, cholangiography, and lymphangiography (3).

We describe the novel use of SPY technology compared to doxycycline fluorescence assessment for partial mandibulectomy in this case study. The patient is a 17-year-old male with a history of arteriovenous malformation of the left mandible s/p multiple embolizations, resection via mandibulotomy with mental nerve reconstruction at age 10. His recovery course was complicated by unilateral vocal cord paralysis and recalcitrant bleeding from the tumor bed, requiring selective angioembolization and inferior alveolar nerve neuroma s/p neurectomy followed by multiple rounds of laser and bleomycin treatments. He later developed avascular necrosis of the left mandibular ramus and an intraoral wound with exposed bone, requiring multiple debridements. Bone biopsy revealed chronic osteomyelitis with Actinomyces, Prevotella, and Schaalia turicenis treated with intravenous antibiotics. The patient was referred to the vascular anomalies specialty clinic for continued pain and bleeding. Given chronicity and significant morbidity, he was preoptimized with advanced MRI/MRV/MRA imaging with TRICKS protocol, prophylactic angioembolization, and doxycycline loading for 10 days.

During mandibular exploration, we utilized both traditional UV light fluorescence and ICG angiography to guide surgical debridement. Both techniques identified similar margins of viability, with SPY providing greater intensity in ambient OR lighting and had superior visual discrimination. This single case report has many limitations, but does show proof of concept for a further case series with objective metrics such as percentage of intensity, maximum ingress time, and dosage of ICG needed to accurately penetrate bone. If corroborated, ICG fluorescence bone debridement could spare risks associated with preoperative antibiotics and delays in treatment.

References: 1) Via GG, Jerele JL. J Orthop Rep. 2023;2:100120. 2) Alander JT, et al. Int J Biomed Imaging. 2012;2012:940585. 3) Elliott JT, et al. OTA Int. 2022;5:e222.

Purpose: Microvascular anastomoses are particularly sensitive to alterations in flow dynamics as evidenced by decreased flap success rates in end to side and disturbed vessel lumen architectures. Fluid flows are significantly affected by rapid changes in lumen diameter such as those seen with venous coupler applications in size mismatched vessels. The aim of this study is to identify the relationship between vessel size mismatch ratios and flow stagnation and propose alternative flow coupler designs for optimization of flows in scenarios of mismatch.

Methods: Computational fluid dynamic (Ansys, Fluent R1 2024) models were created to simulate sudden expansion of end to end microvascular anastomoses. Model assumptions included blood as a Carreau Newtonian fluid under laminar flow. Five models were created representative of anastomoses with the following vessel size mismatches (VSM): 1mm to 2mm, 1mm to 3mm, 1mm to 4mm, 2mm to 3mm, and 3mm to 4mm. An additional model was utilized to assess the effect of venous coupler modification on fluid dynamics. Specifically, the use of intraluminal projections for the purposes of turbulence and boundary layer prevention. Post-processing analysis was completed using visualizations of fluid flows and line integral convolution plots.

Results: The cross sectional areas of blood stagnation increased with the ratio of sudden expansion in a logarithmic relationship (R^2 = 0.989). The area of stagnated flow for a VSM ratio of 4 was 81.84% compared to 26.59% for a VSM ratio of 1.33. Qualitative assessment of reversed flow shows significant increases with VSM ratio. Alteration of the anastomotic lumen for VSM ratio of 4 with a modified venous coupler device decreased stagnation from 81.84% to 56.21%.

Conclusion: Sudden expansion in microvascular anastomoses promotes blood stagnation and reversal. Strategies to mitigate this phenomenon, such as additions to the venous coupler device, are an important area of future investigation.

INTRODUCTION
 Severe thermal burns remain a major cause of global morbidity and mortality. Timely removal of devitalized tissue is a cornerstone of burn care; however, conventional tangential excision is physiologically demanding and inherently non-selective. Bromelain-based enzymatic debridement has emerged as a selective, minimally invasive alternative capable of dissolving eschar while preserving viable dermis. This study aimed to compare survival and key clinical outcomes between early enzymatic debridement and traditional tangential excision in patients with severe burns.

METHODS
 We conducted a single-center retrospective cohort study (January 2013 – January 2023) including adult patients (≥18 years) with thermal burns involving ≥20% total body surface area (TBSA) and deep partial- to full-thickness injury. Patients were stratified by initial debridement strategy: tangential excision (Surgery Group) or bromelain-based enzymatic debridement (Enzymatic Group). Primary endpoints were in-hospital mortality and overall survival (OS). Secondary outcomes included hospital and ICU length of stay (LOS), requirement for autologous skin grafting, unplanned additional surgeries, and early scar quality at 12 months assessed by the Vancouver Scar Scale (VSS) and POSAS.

RESULTS
 A total of 259 patients were included (147 Surgery; 112 Enzymatic), with comparable baseline characteristics, including age, TBSA and Baux scores. In-hospital mortality was significantly lower in the Enzymatic Group (5.4% vs 19.0%; p=0.002). Mortality rates per 100 patient-days were 0.09 versus 0.48, respectively, yielding an incidence rate ratio of 0.19 (95% CI 0.08–0.44; p=0.001). Kaplan–Meier analysis demonstrated significantly improved survival with enzymatic debridement (log-rank p<0.01), confirmed as an independent protective factor at multivariate Cox regression (p<0.01). Median LOS was 42.6 days in the Surgery Group versus 53.2 days in the Enzymatic Group (p=0.06). The Enzymatic Group required fewer unplanned surgeries (9.8% vs 36.7%; p<0.001) and less autografting (67.9% vs 89.1%; p<0.001). Scar outcomes favored enzymatic treatment, with lower VSS (1.9 vs 2.6; p<0.01), improved POSAS (23 vs 27; p<0.01), and fewer scars requiring treatment (8% vs 15%; p=0.04).

CONCLUSIONS Early bromelain-based enzymatic debridement is associated with a marked and clinically meaningful survival advantage, alongside reduced surgical burden and improved early scar quality compared with conventional tangential excision in severe burns. These findings extend beyond procedural refinement, supporting a clinically meaningful shift toward a more selective and less invasive paradigm of burn care. Its integration as a first-line approach in appropriately selected patients warrants strong consideration and further validation in prospective, multicenter studies to redefine standards of care in modern burn management.

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