Scientific Abstract Presentations: Reconstruction Session 3 Friday, October 16 Fri, Oct 16 2:00-3:30 p.m. CDT

Background: Lower extremity amputations (LEAs) are major surgical interventions completed in the setting of significant disease and/or trauma. LEAs can have devastating effects on a patient's physical and mental health, resulting in, among others, anxiety, depression, and PTSD. This study aimed to trend psychiatric diagnoses following LEAs, with a focus on uncovering how the incidence of psychiatric conditions change after surgery.

Methods: A retrospective cohort analysis was performed using the PearlDiver Mariner all-payer claims database (2010–2021). Adults undergoing hip disarticulation, above-knee amputation (AKA), through-knee amputation (TKA), below-knee amputation (BKA), or foot amputation (FA) were identified using respective CPT codes. Psychiatric diagnoses, including anxiety, depression, combined anxiety/depression, alcohol use disorder (AUD), opioid use disorder (OUD), post-traumatic stress disorder (PTSD), and self-inflicted injury, were captured using ICD-9/10 codes at baseline (<6 months pre-amputation) and within 6 , 12, 24, and 36 months post-amputation. Psychiatric medication use and psychotherapy engagement were also assessed using CPT codes. Trauma versus non-trauma amputations were compared using chi-square and Welch's t-tests.

Results: A total of 82,147 amputations were identified (437 HA, 17,542 AKA, 872 TKA, 39,729 BKA, 23,567 FA;), including 1,501 trauma-related and 80,646 non-traumatic amputations. Psychiatric diagnoses increased in the overall LEA cohort progressively across all categories over the 3-year follow-up. Anxiety increased from 8.2% pre-amputation to 24.2% at 3 years; depression from 11.9% to 31.1%; and combined anxiety/depression from 4.0% to 15.9%. AUD and OUD rose from 2.7% to 5.4% and 2.2% to 6.2%, respectively. PTSD increased from 0.7% to 2.4%, and self-inflicted injury from 0.8% to 2.5%. Compared to non-traumatic amputation, traumatic amputees demonstrated higher absolute increase of nearly every psychiatric condition, as well as self-inflicted injury (3.0% vs. 1.6%). Within the complete cohort, psychiatric medication use increased substantially throughout the study period, with SSRI/SNRI prescriptions rising from 16.1% to 33.3% and antipsychotics from 3.2% to 7.9%.

Conclusion: This study demonstrates a substantial increase in psychiatric diagnoses, particularly anxiety, depression, AUD/OUD, and PTSD, following LEA. The data suggests a growing psychological burden for patients after amputation, underscoring the importance of including psychiatric consultation and mental health support within comprehensive lower extremity reconstructive programs.

Figure 1. Psychiatric diagnoses and mental health treatment trends following traumatic lower extremity amputation. Line plots show the percentage of patients with psychiatric diagnoses and treatment utilization at baseline (<6 months pre-amputation) and at <6 months, <1 year, <2 years, and <3 years post-amputation, including anxiety, depression, combined anxiety/depression, PTSD, alcohol and opioid use disorders, self-inflicted injury, psychotherapy, and psychiatric medication use. Tables at the bottom of the figure provide corresponding counts and percentages for each outcome at each time point. Asterisks (*) denote post-amputation time points.

Background: Timely soft-tissue coverage is essential to limb salvage after severe open lower-extremity fractures. While British guidelines recommend definitive coverage within 72 hours, no national standard exists in the United States. In the absence of standardized benchmarks, access to flap reconstruction and variation in time to coverage may reflect structural differences in hospital resources and orthoplastic coordination. This study evaluates national patterns and predictors of flap utilization, access to free flap reconstruction, and timing to coverage following operative fixation of open lower-extremity fractures in the United States.

Methods: Adult patients undergoing operative fixation for open lower-extremity fractures were identified in the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2023. Flap reconstruction was defined as pedicled or free soft-tissue transfer during the index admission. Multivariable logistic regression identified predictors of flap utilization and free flap reconstruction. Multivariable linear regression evaluated predictors of time from admission to flap coverage. Surgical site infection (SSI) was assessed as a secondary outcome.

Results: Among 40,555 patients, 2,645 (6.5%) underwent flap reconstruction, including 486 free flaps. Flap utilization was strongly associated with vascular injury (odds ratio [OR] 2.24, p<0.001) and tibia/patella fractures (OR 1.90, p<0.001). Community (OR 0.85) and nonteaching hospitals (OR 0.60) had lower odds of flap reconstruction relative to university centers (both p<0.001).

Among flap patients, free flap reconstruction was independently associated with vascular injury (OR 2.49, p<0.001) and was less likely in women (OR 0.70, p=0.004) and in femur fractures (OR 0.26, p<0.001). Free flap reconstruction was also less common at community hospitals (OR 0.53, p<0.001), nonteaching hospitals (OR 0.31, p<0.001), and hospitals with 400 beds or fewer (p≤0.007).

Hospital bed size was independently associated with time to reconstruction. Compared with hospitals with more than 600 beds, coverage occurred earlier at hospitals with 200 or fewer beds (β −2.61 days, p<0.001), whereas delays were observed at hospitals with 401–600 beds (β 0.97 days, p=0.011). Hospitals with 201–400 beds demonstrated a non-significant trend toward delay (β 0.99 days, p=0.074). Older age (β 0.04 days per year, p<0.001), higher Injury Severity Score (β 0.20 days per point, p<0.001), and femur fractures (β 1.88 days, p<0.001) were independently associated with longer time to coverage.

Among flap patients, SSI occurred in 105 (3.97%) cases. In multivariable analysis, flap coverage at 4–7 days (OR 7.94, 95% CI 0.98–64.04, p=0.049) and ≥12 days (OR 8.20, 95% CI 1.03–65.50, p=0.047) were independently associated with increased SSI risk relative to coverage within 0–3 days.

Conclusions: In this national cohort, access to flap reconstruction, access to free flap reconstruction, and time to definitive coverage varied substantially across hospital types and bed sizes. Flap utilization was concentrated at university centers, while community and nonteaching hospitals demonstrated lower utilization of both flap and free flap reconstruction. These findings suggest that structural and institutional factors meaningfully shape access to orthoplastic care in the United States. National benchmarks for timely coverage and improved coordination pathways may reduce variation and improve equitable access to limb salvage.

PURPOSE: Full-thickness sternal defects arising from cardiac surgery or oncological resection carry substantial risk for serious morbidity and mortality, with significant impact on postoperative function. Though the gold standard for sternal repair is autologous flap reconstruction, consensus on the effectiveness and long-term outcomes of stand-alone flap or hybrid reconstructive techniques and optimal timing of surgical repair is lacking. This meta-analysis evaluates various sternal reconstructive approaches, compares outcomes for immediate versus delayed surgical timing, and assesses their impact on major complications, survival, and pulmonary function.

METHODS: Five databases (PubMed, EMBASE, Cochrane Library, Scopus, and Google Scholar) were systematically searched from inception through October 4th, 2025. Cohort studies, case-control studies, and case series including more than five patients were eligible if they reported outcomes of sternal reconstruction with sufficient data for meta-analytic pooling. Analyses were performed to compare complication rates between mesh-based reconstructions (nonrigid synthetic or biologic materials) and rigid prosthetic reconstructions, with or without flaps. Additional analyses evaluated immediate reconstruction (performed at the time of the index operation) versus delayed reconstruction (performed during a subsequent planned procedure). Subgroup analyses were conducted according to flap type. Primary outcomes included mortality, wound infection, and wound dehiscence. Secondary outcomes included perioperative changes in pulmonary function. Pooled estimates were calculated using random-effects models, and statistical heterogeneity was assessed using the I² statistic.

RESULTS: From 2,935 studies, 614 were reviewed in full, and 23 (1,363 patients) met all inclusion criteria and provided analyzable data. Delayed repair was associated with significantly reduced mortality (OR 0.34, 95% CI [0.21, 0.55], p<0.0001, I²=1%) and lower rates of wound dehiscence (OR 0.41, 95% CI [0.19, 0.87], p=0.02, I²=24%). Rigid reconstruction was associated with a fourfold greater risk of wound infection than nonrigid reconstruction (OR 4.24, 95% CI [1.20, 15.04], p=0.03, I²=0%). Postoperative pulmonary function improved significantly following reconstruction, with patients demonstrating greater FVC% (MD 6.49, 95% CI [1.88, 10.93], p=0.001, I²=16%) and DLCO% (MD 9.28, 95% CI [3.29, 15.3], p=0.002, I²=0%) compared to preoperative baselines. Subgroup analyses by flap type suggested heterogeneous complication profiles across reconstruction categories.

CONCLUSION: Intentionally delaying sternal reconstruction may reduce the risk of mortality and wound dehiscence, while implementing nonrigid over rigid sternal reconstruction techniques may confer a significant benefit to limiting rates of wound infections. Pulmonary function outcomes may also be improved following sternal reconstruction. These data suggest that operative timing and material selection are modifiable determinants of surgical planning that warrant active consideration by reconstructive surgeons. Future prospective studies with standardized outcome reporting will be essential to strengthen these findings and guide the development of clinical practice guidelines.

Purpose: Deep sternal wound complications following cardiac surgery are well described in adults; however, outcomes in pediatric and adolescent patients remain poorly characterized due to low incidence and limited dedicated analyses. Most benchmarks for complication rates derive from adult populations, leaving reconstructive outcomes in younger patients insufficiently defined. This study evaluates perioperative characteristics and outcomes of patients younger than 18 years undergoing sternal wound reconstruction within a 30-year single-surgeon experience.

Methods: A retrospective review was conducted of 584 consecutive patients who underwent sternal wound reconstruction between 1995 and 2024 by the senior author at a tertiary referral center. Patients younger than 18 years were identified and compared with the adult cohort (≥18 years). Demographics, comorbidities, index cardiac surgery indications, sternal reconstruction indications, reconstructive approach, operative variables, hospitalization duration, postoperative complications, reoperations, and 30-day mortality were analyzed. Reconstructive approaches were categorized by flap type, including bilateral pectoralis major advancement and omental adjuncts. Univariate comparisons were performed with statistical significance defined as p<0.05.

Results: Six patients (1.0%) were younger than 18 years (mean age 5.67 ± 5.92 years) compared to 578 adults (mean 64.74 ± 12.48 years, p<0.0001). Pediatric patients had significantly lower rates of diabetes mellitus (0.0% vs. 43.43%, p=0.0325) and hypertension (16.67% vs. 69.72%, p=0.0051). Index cardiac surgery differed substantially. All pediatric patients underwent congenital cardiac procedures (100.0% vs. 1.56%, p<0.0001), and none underwent CABG (0.0% vs. 67.65%, p=0.0005). Reconstruction indications also differed. Pediatric patients more frequently presented with congenital sternal absence (16.67% vs. 0.0%, p<0.0001), including one case of Goltz syndrome, and were less likely to present with wound drainage (0.0% vs. 53.46%, p=0.0091). Rates of culture-positive infection (66.67% vs. 56.23%), wound dehiscence (50.00% vs. 67.13%), and bone dehiscence (16.67% vs. 16.78%) were similar (p>0.05). Reconstructive strategies were consistent across age groups. Bilateral pectoralis major advancement flaps were utilized in 83.33% of pediatric patients and 97.21% of adults (p=0.7930). Omental flaps were used more frequently in pediatric patients (16.67% vs. 2.77%, p=0.0439). Limited debridement occurred in 16.67% of pediatric patients versus 13.53% of adults (p=0.8056). Median total length of stay was longer in pediatric patients (54.5 days [IQR 17–104.5] vs. 18 days [IQR 9–39], p=0.0982), while postoperative hospitalization was 29.5 days [IQR 5.75–50.25] versus 11 days [IQR 6–22] (p=0.4043). Importantly, no pediatric patients experienced partial or complete dehiscence, seroma, hematoma, infectious complications, reoperation, or death within 30 days. Overall, 83.33% of pediatric patients experienced no postoperative complications compared to 57.96% of adults (p=0.2099).

Conclusions: Sternal wound reconstruction in pediatric patients is rare but was performed with zero 30-day mortality and no reoperations in this series. Despite fundamentally different cardiac etiologies and comorbidity profiles, pediatric patients achieved favorable postoperative outcomes using established reconstructive techniques. Bilateral pectoralis major advancement remains a reliable strategy across age groups. These findings provide benchmark data for a rarely described population and support the safety and durability of standardized reconstructive principles in younger patients.

Introduction

Ischial pressure ulcers represent significant morbidity among patients with spinal cord injury and prolonged immobility. When conservative management fails, surgical reconstruction is required to achieve wound closure and restore soft tissue coverage over the ischial tuberosity. This study aimed to compare posterior thigh fasciocutaneous flap and gracilis muscle flap.

Methods

A retrospective review of patients who underwent flap reconstruction for ischial pressure ulcers between January 2015 and July 2024 was done. Patients were stratified by flap type: posterior thigh fasciocutaneous flap or gracilis muscle flap. Baseline demographic and clinical variables were recorded. Primary outcomes were postoperative complications and ulcer recurrence. Secondary analyses examined the association of comorbidities and perioperative factors with each outcome. Statistical significance was at p < 0.05.

Results

266 flaps were included in the analysis, with 190 (71.4%) posterior thigh flaps and 76 (28.6%) gracilis flaps. The majority were stage IV ulcers (93.6%). Patient demographics revealed no significant differences in age (52.93 vs 51.51 years; p=0.4789) or BMI (26.96 vs 26.85; p=0.9090). Mean wound size was larger in the posterior thigh flap group (28.51 ± 50.52 cm² vs 19.32 ± 26.78 cm²; p=0.2501). Similarly, wound duration did not differ significantly (16.66 ± 20.15 vs 14.12 ± 12.19 months; p=0.40). Common comorbidities included hypertension (43.2%), psychiatric comorbidity (36.8%), hyperlipidemia (28.6%), and diabetes mellitus (21.8%).

Regarding complications, posterior thigh flaps had a significantly higher rate of recurrence compared to gracilis (23.16% vs 11.84%; p=0.037). Similarly, wound dehiscence was significantly more frequent in the posterior thigh flap (18.95% vs 7.89%; p=0.025). No significant differences were observed for flap necrosis (6.84% vs 3.95%; p=0.568), seroma (1.58% vs 1.32%; p=1.00), hematoma (5.26% vs 5.26%; p=1.00), infection (5.79% vs 3.95%; p=0.76), DVT (0.53% vs 0; p=1.00), PE(0), or death (0 vs 1.32%; p=0.28). The rate of complications requiring return to the operating room was not significantly different (34.04% vs 26.03%; p=0.21).

In the overall cohort, factors significantly associated with postoperative complications included diabetes mellitus (p = 0.021), hypertension (p = 0.026), ASA class (p = 0.004), non-compliance with postoperative restrictions (p = 0.001), wound infection (p < 0.001), older age (p = 0.023), and elevated CRP (p = 0.011). Preoperative antibiotic regimen, wound size, wound duration, preoperative hemoglobin, albumin, and prealbumin were not significantly associated with complications.

On stratified analysis, among posterior thigh flaps, current tobacco use (p = 0.008), non-compliance with postoperative restrictions (p = 0.002), and elevated CRP (p = 0.058) were significantly associated with higher recurrence. Among gracilis flaps, hypertension (p = 0.008), psychiatric comorbidity (p = 0.05) and non-compliance (p = 0.04) were significantly associated with recurrence.

Conclusion

The gracilis muscle flap demonstrated significantly lower rates of ulcer recurrence and wound dehiscence compared to the posterior thigh flap, and was preferentially selected for smaller wounds, suggesting it may offer more durable reconstruction. Non-compliance with postoperative restrictions, diabetes, hypertension, elevated CRP, and higher ASA class were associated with worse outcomes, underscoring that surgical success depends not only on flap selection but on perioperative optimization and patient adherence.

Purpose:  Immunotherapy is increasingly incorporated into breast cancer treatment regimens (1). However, its impact on the outcomes of breast reconstruction, particularly Deep Inferior Epigastric Perforator (DIEP) procedures, remains poorly understood, as most existing literature assesses chemotherapy-related complications (2-4). Therefore, it is crucial to evaluate its potential effects on postoperative complications. This study aims to examine this knowledge gap, comparing outcomes and complications of DIEP flap breast reconstruction in patients whose treatment regimens included immunotherapy with chemotherapy versus those who had chemotherapy without immunotherapy.

Methods:  A retrospective cohort study was done using the University of Colorado School of Medicine's and Rush University Medical Center's electronic medical records. Patients who underwent DIEP flap breast reconstruction surgery and received neoadjuvant and/or adjuvant chemotherapy, with or without immunotherapy, between 2018 and 2024 were included in this study. The collection time for complications noted was within 30 days of the procedure. Summary statistics of clinical variables were presented for both cohorts. Statistics were presented as either counts/percentages for the categorical variables. Chi-square/Fisher tests were done to compare the categorical variables.

Results:  A total of 375 patients met the inclusion criteria, with 81 patients who received chemotherapy and immunotherapy and 294 patients who received chemotherapy alone. The chemotherapy group had a higher rate of postoperative flap loss (0% vs. 11.54% p=0.05). However, there were no statistically significant differences between groups for other postoperative complications, which included hematoma, fat necrosis, infection, recipient site wound dehiscence, abdominal hernia, bulge, venous thrombosis, arterial thrombosis, or seroma.

Conclusion:  Our findings suggest that the addition of immunotherapy treatment to chemotherapy regimens does not increase complication rates compared to patients who have received chemotherapy alone. Complication rates of postoperative takeback, hematoma, fat necrosis, infection, wound dehiscence, and other major complications did not differ significantly between the groups. Interestingly, the cohort who received chemotherapy alone was found to have a higher flap loss complication rate (0% vs. 11.54%, p=0.05), though not statistically significant. Based on the findings of our study, complication rates are comparable between cohorts who received chemotherapy alone versus chemotherapy with immunotherapy. Therefore, reconstructive surgery remains a viable option in patients receiving oncologic treatment with immunotherapeutic components.

References: 1.Capucine Barjot, Thomas Gaillard, Romain-David Seban, Lauren Darrigues, Delphine Loirat, Luc Cabel, Jean-Guillaume Feron, Virginie Fourchotte, Benoit Couturaud, Claire Bonneau, Kim Cao, Fabien Reyal, Enora Laas. Impact of neoadjuvant immunotherapy on postoperative complications in oncoplastic breast cancer surgery. European Journal of Surgical Oncology, Volume 51, Issue 12, 2025, 110511. ISSN 0748-7983, https://doi.org/10.1016/j.ejso.2025.110511.

2. Liu K, Mao X, Li T, Xu Z, An R. Immunotherapy and immunobiomarker in breast cancer: current practice and future perspectives. Am J Cancer Res. 2022 Aug 15;12(8):3532-3547. PMID: 36119833; PMCID: PMC9442024. 

3. Beugels J, Meijvogel JLW, Tuinder SMH, Tjan-Heijnen VCG, Heuts EM, Piatkowski A, van der Hulst RRWJ. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat. 2019 Jul;176(2):367-375. doi: 10.1007/s10549-019-05241-9. Epub 2019 Apr 27. PMID: 31030303; PMCID: PMC6555777. 

4. Varghese, J., Gohari, S. S., Rizki, H., Faheem, M., Langridge, B., Kümmel, S., Johnson, L., & Schmid, P. (2021). A systematic review and meta-analysis on the effect of neoadjuvant chemotherapy on complications following immediate breast reconstruction. Breast (Edinburgh, Scotland), 55, 55-62. https://doi.org/10.1016/j.breast.2020.11.023 

Background: Extensive soft-tissue defects of the male genitalia that cannot be closed primarily or with local advancement flaps present a challenging reconstructive problem requiring techniques that restore durable coverage, pliability, and function in a sensitive anatomical region. While multiple reconstructive options exist, few studies have compared outcomes across the spectrum of approaches. Clarifying which clinical and procedural factors are associated with plastic surgery involvement is important for informing multidisciplinary planning, optimizing reconstructive strategy selection, and improving patient outcomes. This study characterizes the indications, reconstructive strategies, and outcomes of genital soft-tissue reconstruction for defects not amenable to primary closure. Among these, a notable subset involved cutaneous malignancy-related resections, the reconstructive management of which remains severely underrepresented in the plastic surgery literature.

Methods: A retrospective review was performed of all patients with male genitalia who underwent genital soft-tissue reconstruction at our institution between 2010 and 2024. Only patients requiring reconstruction beyond primary closure or local flap closure were included. Demographic, clinical, and operative data were collected, including etiology, defect size, reconstruction service, technique, and timing. Outcomes assessed included wound complications, reconstructive success at 30 and 365 days, and oncologic margins or recurrence where applicable.

Results: Thirty-two male patients (mean age 53.8 ± 16.2 years) underwent genital reconstruction following excision, resection, or debridement. The most common etiologies were necrotizing fasciitis (21.8%), squamous cell carcinoma (18.8%), and massive lymphedema (18.8%). Excision was most frequently performed by urology (81.3%), and reconstruction by urology (56.3%) or plastic surgery (31.2%). Between 2016 and 2021, urology performed the majority of excisions and reconstructions (85.7%), but service involvement is more heterogeneous outside this timeframe, with a greater plastic surgery involvement in reconstruction (75%). Median defect size was 131 cm² (IQR 47.5–300). Reconstructive techniques included split-thickness skin grafts (STSG, 71.9%), full-thickness skin grafts (15.6%), and advancement flaps from the thigh (12.5%). Wound complications occurred in 4 patients (12.5%), including wound dehiscence (9.4%) and graft loss (3.1%). Reconstruction success was achieved in 87.5% of patients at 30 days and 81.2% at one year. Delayed reconstruction (85.7%) and postoperative vacuum-assisted closure (VAC) therapy (88.9%) demonstrated numerically higher one-year success rates compared with immediate reconstruction (80%) and non-VAC cases (78.3%). Split-thickness grafts demonstrated the highest one-year success rate (91.3%), followed by full-thickness grafts (80%) and advancement flaps (25%). Among oncologic cases (n = 9), all achieved clear margins, with one recurrence (11.1%) during follow-up. Median follow-up duration was 12 months (IQR 4.25–14.75).

Conclusions: Genital soft-tissue reconstruction for large or complex defects not amenable to primary closure can be performed safely and effectively using graft-based techniques. Split-thickness skin grafts provided durable, reliable coverage across a range of etiologies and defect sizes, with favorable long-term success. Delayed reconstruction and postoperative VAC therapy may further improve outcomes. These findings highlight the importance of coordinated multidisciplinary care, particularly in complex or oncologic cases, where early involvement of reconstructive expertise may optimize operative planning, tissue preservation, and long-term functional results.

INTRODUCTION Severe open lower extremity fractures represent a complex soft tissue challenge in reconstructive plastic surgery. Across US institutions, reconstruction timing and orthoplastic collaboration vary widely without formalized national standards. In the United Kingdom, the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons' guidelines (BOAST 4) mandate joint orthoplastic management with definitive soft tissue coverage within 72 hours, with national audit reporting 48% compliance (1). Using national trauma registries, we aimed to benchmark US orthoplastic practice against the UK standard and evaluate the impact of reconstruction timing on surgical outcomes.

METHODS US data were obtained from the Trauma Quality Improvement Program (TQIP, 2017-2023). Open tibial fractures managed with an orthoplastic approach were identified based on limb reconstruction or primary amputation following debridement. The primary analysis compared outcomes between patients achieving coverage within 72 hours versus after 72 hours. Multivariable regression adjusted for ISS, age, transfer status, and comorbidities. UK data were derived from Wilson et al., a national audit of 3,359 Gustilo IIIB/IIIC tibial fractures across 23 Major Trauma Centres (TARN registry, 2014-2020). Secondary analysis benchmarked US practice against the UK cohort.

RESULTS The US cohort comprised two distinct populations: 1,900 reconstruction patients (ISS 15.9, vascular injury 18.2%, mortality 0.5%) and 1,447 primary amputation patients (ISS 17.9, vascular injury 37.8%, mortality 6.2%). Despite greater injury severity than the UK cohort (ISS 16.8 vs 14.1), in-hospital mortality was equivalent (3.0% vs 2.8%). Unlike the UK cohort, where amputation was an outcome of attempted salvage, US data required separate identification of limb salvage and amputation populations.

In the US, soft tissue coverage within 72 hours was achieved in only 16.3% of flap patients, with median time to reconstruction of 167 hours. Early reconstruction (≤72h) was associated with improved outcomes versus late (>72h): any infection 1.4% vs 8.5% (p<0.0001), reoperation 1.0% vs 5.1% (p=0.004), and mean LOS 13.5 vs 25.7 days (p<0.0001). On multivariable analysis, early reconstruction predicted lower infection (OR 0.17, 95% CI 0.06-0.48, p=0.001) and reoperation rates (OR 0.22, 95% CI 0.07-0.72, p=0.012). The 72-hour reconstruction rate was similar in transferred versus directly admitted patients (14.9% vs 16.7%), suggesting the timing gap is systemic rather than logistical.

Compared to the UK cohort, US patients underwent less complex reconstruction: free flap utilization 11.4% vs 23.0% and six-fold higher pedicled muscle flap use (31.6% vs 5.0%). Only 1.8% of US patients with complete data met all measurable BOAST targets: debridement timing, antibiotic administration, VTE prophylaxis, and soft tissue coverage timing (n=1,112).

CONCLUSION Early soft tissue reconstruction within 72 hours was independently associated with 83% lower infection and 78% lower reoperation rates. US patients undergo later and less complex reconstruction than UK counterparts, a gap not explained by transfer logistics. These findings support the development of a coordinated US orthoplastic care pathway with national reconstruction timing targets, analogous to BOAST 4.

1. Wilson E, Young K, Kwasnicki R, Hettiaratchy S. An evaluation of the management of severe open tibial fractures in the United Kingdom's major trauma centres. Injury. 2024;55(6):111475. doi:10.1016/j.injury.2024.111475

INTRODUCTION More than 50,000 microsurgical procedures are performed annually in the United States, making microsurgical proficiency a fundamental component of training in Plastic and Reconstructive Surgery. The acquisition of microsurgical skills requires deliberate, structured practice that emphasizes ambidexterity, precision, and refined proprioception. Despite its central role in training and clinical practice, there remains no universally accepted gold-standard curriculum or assessment tool to support the development of foundational microsurgery skills. This multi-institutional study extends our prior two-phase, single-institution work by examining the validity evidence for updated tasks within the novel Fundamentals of Microsurgery Skills (FMS) curriculum delivered via a 3D-printed FMS kit, with comparisons between trainees and expert microsurgeons METHODS Between October 2025 and January 2026, 61 participants completed all FMS tasks at three national meetings: American Society for Reconstructive Microsurgery (ASRM) 2025, Plastic Surgery The Meeting (PSTM) 2026, and ASRM 2026. Participants included 30 residents (trainees) and 31 fellows and attendings (experts). The task set included: (1) vessel dilation, (2) needle loading and transfer, (3) venous coupling, (4) suturing, and (5) vessel preparation. Following completion of each task, participants rated its relevance to clinical practice, perceived level of difficulty, and their ability to successfully complete the task using 5-point scales. Participants additionally evaluated the clarity of task instructions and penalty criteria, as well as the overall educational value of the curriculum as a training tool, using 4-point rating scales. Welch's t-test was used to compare differences in mean ratings between groups, and Hedge's g was calculated to estimate effect sizes.

RESULTS All tasks were rated as highly relevant to microsurgery and were reasonably difficult for the average participant, with no differences in ratings across trainees and attending surgeons. Suturing and vessel preparation were identified as the most technically demanding tasks, whereas vessel dilation was rated as least challenging task. Clarity of directions ranged from 3.04 ("reasonably clear") to 3.72 ("very clear") and penalties ranged from 3.42 ("reasonably clear") to 3.79 ("very clear"), with no differences in ratings between trainees and experts for all tasks (p ≥ .09).

CONCLUSION This multi-institutional study corroborates the findings of our prior single-institution investigation and provides additional validity evidence supporting the inclusion of all tasks in our curriculum, delivered through a 3D-printed training kit designed specifically for plastic surgery trainees. In contrast to simulation models that focus exclusively on arterial anastomosis, the Fundamentals of Microsurgery Skills kit is well-suited to support deliberate practice across multiple foundational microsurgical competencies. As such, it offers a comprehensive framework that may inform the development of a future gold standard in microsurgical education. Future directions include refinement of objective assessment metrics and evaluation of the curriculum's impact on resident skill acquisition through a multi-center, national study.

Purpose: Pressure sores unfortunately remain prevalent among individuals with prolonged immobility, paraplegia, or wheelchair use. Management often involves a choice between conservative and surgical treatment, with a variety of flap options available to the surgeon. However, literature over the past decades has reported high recurrence rates, which has discouraged surgical intervention in this patient population. The fundamental components of wound healing and recurrence prevention consist of adequate excision of wound and pressure sore reconstruction (PSR) followed by proper wound care, adherence to pressure relief programs, and social support to enable healing (1). Moreover, time-to-recurrence has not been well characterized, and a palliative wound-free interval provided by reconstruction may itself represent meaningful clinical value for patients. This study aimed to review recurrence data at our institution and, more importantly, to evaluate time-to-recurrence.

Methods: A single-surgeon retrospective study of adult patients undergoing PSR between 2007 and 2025 was performed. Demographic data, perioperative details, and postoperative outcomes were collected and analyzed. Recurrence was defined as a new injury at the site of prior reconstruction after achieving complete healing, whereas recalcitrance was defined as wounds that never healed despite prior attempted reconstruction. Those with concurrent hidradenitis suppurativa or those who did not undergo reconstruction were excluded.

Results: A total of 159 pressure injuries were identified in 125 patients. After exclusion, the final cohort comprised of 124 pressure injuries in 101 patients. The mean age and BMI at index surgery were 45.8 ± 15.6 years and 25.2 ± 6.2 kg/m², respectively. The cohort consisted of 76.6% male, 49.2% Caucasian, 46.8% African American, and 4.8% Hispanic or Latino patients. Among medical comorbidities, 20.1% were current smokers, 29.8% former smokers, 33.1% had hypertension, and 22.6% had diabetes. The most common pressure injuries were stage IV (78.7%), chronic ≥ six weeks (94.4%), ischial in origin (41.1%), and with paraplegia as an etiology (65.3%). Musculocutaneous flaps were used in 78.3% of cases, while fasciocutaneous flaps were used in 21.7%. The rate of superficial wound dehiscence was 46.8%. Other postoperative complications included hematoma (0.8%), seroma (2.4%), surgical site infection (4.8%), partial flap loss (1.6%), and complete flap loss (0.8%). The mean number of flap-related readmissions and emergency department visits was 2.56 ± 2.58 and 1.7 ± 0.95, respectively. Median follow-up was 11.8 months (IQR 43.3). Among the 124 pressure injuries, 27 (21.8%) never healed, 23 (18.5%) healed but later recurred, and 74 (59.7%) healed without recurrence. The median time to recurrence was 37 months (IQR 50.5).

Conclusions: This study demonstrated that although PSR is challenging and associated with complications, only 21.8% of patients experienced wound recalcitrance, while most achieved initial healing. Even among the 18.5% who experienced recurrence, the median wound-free interval exceeded three years, which may represent a meaningful clinical outcome, as well as palliation from the need for extensive wound care.

References: 1. Brown, A. L., et al. (2022). SPINE: An Initiative to Reduce Pressure Sore Recurrence. Plastic and reconstructive surgery. Global open, 10(11), e4625.

Purpose: Weight gain, as a result of interstitial perfusate extravasation and cellular dysfunction, during ex vivo normothermic limb perfusion (EVNLP) correlates with microscopic muscle injury and is recognized as an early indication of viability. Disruptions of endothelial junctions, cell vitality, and overlying glycocalyx layer are possible etiologies of vascular hyperpermeability. Von Willebrand Factor (VWF) is stored in Webel-Palade bodies of endothelial cells and released in large quantities when endothelial damage occurs. Endothelial cell injury also increases shedding of soluble vascular endothelial cadherin (sVE-cadherin) from its membrane-bound form. Syndecan-1, a glycoprotein within the glycocalyx, is released when the glycocalyx layer over the endothelium is degraded or sheared. We hypothesize that concentrations of VWF, sVE-cadherin, and synecan-1 reflect disruptions of endothelial integrity when interstitial edema occurs and they may therefore function as biomarkers for EVNLP outcomes.

Methods: Forty total perfusate samples were analyzed from four EVNLP experiments (two successful and two failed). Enzyme-linked immunosorbent assay kits from LSBio (Seattle, Washington) for each experimental protein were used to obtain perfusate concentrations every two hours. Repeated-measures correlation analysis evaluated how each protein's concentration correlated with hemodynamic parameters (mean arterial pressure (MAP) and arterial flow), perfusate gases, chemistry (lactate, creatinine kinase (CK), myoglobin, lactate dehydrogenase (LDH), and haptoglobin), and weight gain relative to the baseline. Receiver operating characteristic (ROC) analysis was performed on each experimental protein to determine their respective predictive values for limb viability. Statistical analyses were performed using R software with significance set to P < 0.05.

Results: Perfusate sVE-cadherin concentration decreased with increasing MAP (r = −0.28, p = 0.09) and decreasing venous PO₂ (r = 0.36, p = 0.07). SVE-cadherin perfusate concentration significantly decreased as venous lactate increased (r = −0.77, p = 0.00007) and a similar trend arose with relative weight gain (r = −0.41, p = 0.059). ROC analysis demonstrated acceptable discrimination of sVE-cadherin as a viability marker (AUC = 0.716). Syndecan-1 perfusate concentrations increased with elevations in CK (r = 0.91, p = 0.0042), LDH (r = 0.90, p = 0.004), and haptoglobin (r = 0.87, p = 0.012). No association was observed between syndecan-1 and myoglobin or weight gain. ROC analysis demonstrated fair discrimination of syndecan-1 as an injury marker (AUC = 0.66). VWF perfusate concentrations decreased with increasing concentrations of CK (r = −0.95, p = 0.0003), myoglobin (r = −0.77, p = 0.02), LDH (r = −0.91, p = 0.0019), and haptoglobin (r = −0.80, p = 0.018). No association was observed with weight gain. ROC analysis demonstrated poor discriminatory performance of VWF (AUC = 0.58).

Conclusions Early findings suggest that syndecan-1 is associated with markers of muscle injury (CK, LDH) while sVE-cadherin may correlates with organ weight gain. We therefore conclude that sVE-cadherin is a promising viability marker during vascularized composite allograft machine perfusion, whereas syndecan-1 may function as an injury marker.

Background: Microvascular free flaps are considered the gold standard for reconstruction of complex head and neck defects following oncologic resection and have witnessed tremendous advancements in recent years. However, despite high success rates at high-volume institutions, flap thromboses are unavoidable and can result in catastrophic loss of the free flap. A long-standing debate remains whether one or two separate venous anastomoses should be performed for additional venous drainage.

While some advocate for two venous anastomoses to maximize venous outflow, others favor a single venous anastomosis. Numerous studies have examined the impact of "supercharging" on flap success and unplanned reoperations. Unfortunately, given the high success rates of head and neck free flaps in the modern age, most studies perform a meta-analysis to achieve sufficient numbers for statistical power. However, combining outcomes from various institutions with different free flap volume, surgeon experience, surgical technique and post-operative management introduces bias. The authors hypothesize "supercharging" or performing two venous anastomoses for a single free flap does not improve flap survival compared to flaps with a single venous anastomosis.

Methods: A retrospective review was performed for 3324 head and neck free flaps at a single tertiary academic cancer center following IRB approval. Patient demographics, comorbidities, smoking history, radiation exposure, flap types, and oncologic characteristics were captured, and operative notes were reviewed to stratify patients by number of venous anastomoses. Multivariable logistic regression to identify independent predictors for the two primary endpoints 1) unplanned reoperation for flap thrombosis and 2) total flap loss.

Results: Among 3,324 flaps, 3,039 (91.4%) had a single venous anastomosis and 285 (8.6%) received dual venous drainage. Baseline characteristics were comparable between the two groups: age, sex, and most comorbidities did not differ significantly. Patients receiving dual-venous anastomoses had significantly higher BMI (27.5 vs. 26.7; p = 0.021). Overall flap survival was 97.8%. Flap loss occurred in 2.2% of both single- and dual-vein flaps, and takeback rates were similarly low (5.1% for single-vein vs. 4.9% for dual-vein flaps). On multivariable analysis, dual venous drainage was not associated with flap loss (OR 0.717, 95% CI 0.215–1.770, p = 0.524) or takeback (OR 0.594, 95% CI 0.264–1.155, p = 0.161). While the absolute odds for takeback and flap loss were lower with supercharged flaps, the difference was not statistically significant. However, diabetes mellitus significantly increased the risk of flap loss (OR 2.072, p = 0.041), while advanced age (OR 0.986 per year, p = 0.024), hypertension (OR 1.719, p = 0.006), and preoperative radiation (OR 1.831, p = 0.002) were associated with increased risks for takeback.

Conclusions: While some previous studies advocate for supercharging to reduce flap loss rates, the present study challenges the validity of prior studies reporting the advantages of performing two venous anastomoses. However, other factors such as controlling blood glucose levels and blood pressure should be prioritized over routine dual venous drainage. The decision to perform a second venous anastomosis should be based on clinical judgement where flap physiology dictates the need for an alternate additional venous outflow.

Background: Burn injuries require specialized surgical expertise, yet the U.S. faces a persistent shortage of burn surgeons. General surgery (GS) has historically been the primary pathway into burn surgery. However, the removal of a required burn rotation from Accreditation Council for Graduate Medical Education (ACGME) GS requirements in the mid-2000s has reduced trainee exposure to burn care, potentially affecting burn care competency.

Purpose: To compare burn care exposure and curricula between general surgery (GS) and plastic surgery (PS) residents and to assess the impact of exposure on self-reported confidence in burn management.

Methods: A national, cross-sectional survey was distributed electronically to U.S. general surgery and plastic surgery residents via Qualtrics. The survey collected data on burn rotation requirements, exposure to burn patients outside dedicated rotations, and confidence levels in burn assessment, wound care, and burn surgery using 5-point Likert scales. Group differences were analyzed using Mann–Whitney U tests and chi-square analyses.

Results: Ninety-two residents completed the survey (76 GS; 16 PS). PS residents were more likely to have a required burn rotation compared with GS residents (100% vs 68.4%, p=0.033). Among respondents to the questions on exposure outside dedicated burn rotations (n=85), the proportion of those who reported being assigned to care for burn patients on other services (e.g., trauma, ICU) did not differ between groups (GS 64.8% vs PS 78.6%, p=0.49). Frequency of off-service burn care was also similar (p=0.53), with occasional involvement (<5 hours/month) being the most common exposure pattern across both specialties. Confidence did not differ for initial assessment/resuscitation (GS 4 [3–4] vs PS 4 [4–5], p=0.19) or wound care (GS 4 [3–5] vs PS 4.5 [4–5], p=0.19). PS residents reported higher confidence in operative burn management (e.g., excision, grafting) compared with GS residents (GS 3 [3–4] vs PS 5 [3.25–5], p=0.021).

Conclusion: Plastic surgery residents receive more structured burn exposure and report higher confidence in operative burn management compared with general surgery residents. Despite similar off-service exposure and comparable confidence in burn assessment and wound care, differences in operative confidence highlight variability in burn training and suggest that structured experiences may help better prepare residents for operative aspects of burn care. Given the national shortage of burn surgeons and limited access to burn centers, strengthening burn education across surgical residencies may have important implications for ensuring adequate burn care capacity nationwide.

Purpose: Surgical treatment of cleft palate has traditionally been a single stage procedure, usually performed between eighteen months and three years of age. Two-stage palate repair evolved as a strategy to optimize speech development by establishing anatomic continuity of the palatal musculature through repair of the soft palate (intravelar veloplasty) as early as three months of age, while minimizing interference with facial growth by delaying repair of the hard palate (von Langenbeck palatoplasty) until after age eighteen months. This study evaluates the safety, efficacy, and speech outcomes of this two-stage approach for repair of isolated secondary cleft palate.

Methods: A retrospective chart review was conducted of all children undergoing two-stage palate repair by a single surgeon, using the same technique, over a twenty-year period in a community hospital setting. Patients with isolated clefts of the secondary palate were identified through office surgical records, and longitudinal follow-up data were obtained from clinic notes at the Louisiana Department of Health Regional Cleft Lip and Palate Clinic where the senior author serves as medical director. The primary outcome is the presence of velopharyngeal insufficiency (VPI) with hypernasality severe enough to interfere with normal speech development and warrant surgery. Secondary outcomes include the incidence of surgical complications (bleeding, wound dehiscence, and fistula formation). Data analysis was conducted using Microsoft Excel.

Results: Data were obtained on 17 patients with isolated clefts of the secondary palate, with follow-up period averaging 11.94 years (range, 1-19 years) following intravelar veloplasty. Mean age at soft-palate closure was 28.71 weeks (range, 10-62 weeks), and mean age at hard-palate closure was 85.88 weeks (range, 51-151 weeks). The mean interval between stage-one and stage-two repair was 57.00 weeks (range, 34-111 weeks). There were no instances of significant wound dehiscence warranting return to the operating room and no fistula severe enough to interfere with speech. In one patient, mild VPI was detected years following hard-palate closure, which was managed by speech therapy alone. At the final follow-up, 16 of 17 patients (94.1%) demonstrated normal speech development.

Conclusion: Two stage palate repair – early intravelar veloplasty followed in 18–24 months by hard palate closure – is a safe and effective option for repair of isolated cleft palate, with few surgical complications and minimal interference with speech development.