Scientific Abstract Presentations: Research & Technology Session 3 Friday, October 16 Fri, Oct 16 5:00-6:00 p.m. CDT

Purpose: Geographic distribution of the physician workforce contributes to disparities in access to specialty care across the United States. Plastic and reconstructive surgery (PRS) provides essential reconstructive, oncologic, and trauma-related care, yet national patterns in PRS distribution remain incompletely characterized. This study evaluates the county-level distribution of PRS in the United States relative to overall physician supply, quantifying geographic access disparities and travel burden. Methods: County-level workforce and sociodemographic data from 2023 were obtained from the Area Health Resources File and merged with 2023 U.S. Census county boundaries. All counties from the 50 U.S. states and the District of Columbia were included. PRS supply, defined as the total number of plastic surgeons per county, was drawn from the American Medical Association Physicians Master File. To assess disparities in PRS distribution relative to overall physician supply, PRS supply was modeled using negative binomial regression with a log link to account for rightward skew. An offset was used for the log of total active physicians, thereby estimating the relative rate of plastic surgeons per physician within each county. Demographic, socioeconomic, rural–urban continuum category (RUCC), and state fixed effects were included as independent variables. Geographic access was assessed by computing straight-line distances from each county centroid to the nearest county with ≥1 plastic surgeon. Results: Among 3,144 counties, 2376 (76%) had no plastic surgeons and 148 (5%) had no active physician at all. The 90th and 95th percentiles for PRS density per 100,000 population were 2.39 and 3.8, respectively, with a maximum of 46.7. After adjustment for physician supply and state fixed effects, higher median income was associated with increased PRS supply (3.7% increase per $10,000, p=0.017), while higher unemployment was associated with reduced PRS supply (1.3% decrease per 10-percentage-point increase, p<0.001). Compared with metropolitan counties (RUCC 1-3), micropolitan counties (RUCC 4-6) had 48.5% lower relative PRS rates and rural counties (RUCC 7-9) had 63.9% lower rates (both p<0.001). A 10-percentage-point increase in population aged ≥65 years was associated with an 15.3% higher relative PRS rate (p=0.026). Geographically, the median distance to the nearest county with a plastic surgeon was 27.8 miles (44.7 kilometers) (75th percentile 46.8 miles; 90th percentile 71.4 miles; 95th percentile 96.4 miles). Maximum distance was 886.6 miles, reflecting remote Alaskan counties. Population weighted median travel distance to the nearest plastic surgeon was highest for Wyoming (64.6 miles), North Dakota (35.4 miles), South Dakota (27.0 miles), and Oklahoma (26.1 miles). More than 100,000 Americans resided in counties located over 200 miles from the nearest plastic surgeon, and nearly 15,000 resided over 500 miles away. Conclusion: Plastic surgeon distribution in the United States is strongly correlated with economic structure and rural–urban geography. PRS availability relative to total physician supply is concentrated in urban and economically advantaged counties, while rural and economically distressed regions face substantially reduced access and increased travel burden. Addressing these disparities will likely include targeted strategies such as support for regional referral networks, expansion of telehealth-based perioperative care, and development of rural surgical infrastructure.

Introduction: Skin fibrosis is characterized by extracellular matrix deposition and dermal remodeling, driven primarily by transforming growth factor beta (TGFβ-1) mediated fibroblast activation and myofibroblast differentiation. Dipeptidyl peptidase-4 inhibitors (DPP4i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have demonstrated antifibrotic activity in pre-clinical models, with evidence suggesting modulation of TGFβ-1-associated pathways.[1,2] The effects of DPP4i and GLP-1RA on human skin fibrosis remain uncharacterized. In this study, we use an ex vivo model of fibrosis using normal human skin stimulated with TGFβ-1. Fibrotic skin explants were then used to evaluate whether treatment with sitagliptin, a DPP4i, or liraglutide, a GLP-1RA, alters histologic features of fibrosis compared with untreated fibrotic control.

Methods: Normal abdominal skin was obtained from patients undergoing elective abdominoplasty. The epidermal-dermal explants were maintained in culture with daily skin media changes for 3 days to allow acclimation. Following acclimation, the explants were subjected to one of four treatment groups: (1) TGFβ-1 injection alone, (2) TGFβ-1 + liraglutide, (3) TGFβ-1 + Sitaliptin, or (4) normal saline injection control. Treatments were administered every other day for a total of 7 days. At the completion of the study, the tissues were harvested, fixed, and processed for histologic evaluation. Hematoxylin and eosin (HE) staining, along with immunohistochemical analysis of a-smooth muscle actin (aSMA), collagen I (COL1), and collagen 3 (COL3), was performed to assess differences in fibrotic architecture across groups.

Results: A qualitative assessment of the explants after TGFβ-1 stimulation revealed successful induction of a fibrotic phenotype, as demonstrated by HE staining, with dermal thickening, increased collagen bundle density, and flattening of the dermal papillae compared with no-treatment controls. Immunohistochemical analysis further supported fibrosis induction. TGFβ-1 treatment resulted in increased COL1 deposition, particularly localized to the epidermal-dermal junction and within the dermal papillae. Co-treatment with sitagliptin (DPP4i) did not change TGFβ-1-induced COL1 deposition when compared to TGFβ-1 alone. In contrast, co-treatment with liraglutide (GLP1RA) qualitatively reduced COL1 deposition and prevented the prominent epidermal/dermal and papillary collagen accumulation observed with TGFβ-1 alone.

Discussion/Conclusion: TGFβ-1 reliably induced a fibrotic phenotype in ex vivo human skin, validating this model for the study of skin fibrosis. GLP-1RA treatment with liraglutide demonstrated antifibrotic effects, reducing TGFβ-1-induced COL1 deposition, whereas DPP4i with sitagliptin showed comparatively limited antifibrotic activity. These findings suggest a potentially stronger antifibrotic role for GLP-1-mediated signaling in human skin. Future studies will refine this model and use quantitative analyses to further characterize the observed antibiotic effects.

References: 1. Soare A, Györfi HA, Matei AE, Dees C, Rauber S, Wohlfahrt T, Chen CW, Ludolph I, Horch RE, Bäuerle T, von Hörsten S, Mihai C, Distler O, Ramming A, Schett G, Distler JHW. Dipeptidylpeptidase 4 as a Marker of Activated Fibroblasts and a Potential Target for the Treatment of Fibrosis in Systemic Sclerosis. Arthritis Rheumatol. 2020 Jan;72(1):137-149. doi: 10.1002/art.41058. PMID: 31350829. 2. Fandiño J, Toba L, González-Matías LC, Diz-Chaves Y, Mallo F. GLP-1 receptor agonist ameliorates experimental lung fibrosis. Sci Rep. 2020 Oct 22;10(1):18091. doi: 10.1038/s41598-020-74912-1. PMID: 33093510; PMCID: PMC7581713.

Background: Microsurgical reconstruction is a cornerstone of modern plastic, orthopedic, and oncologic surgery, yet it remains limited by skill, time, and high-cost equipment. Microsurgical anastomosis, or reconnection of small-caliber arteries and veins, is particularly error-prone, with complications like backwalling (inadvertently piercing the opposite vessel wall) contributing to free flap failure rates of up to 10%. Expensive visualization tools and long learning curves further limit access to high-quality outcomes.

Methods: We developed the Equidistant Anastomosis Suture Instrument (EASI), a novel intraluminal guide designed to standardize and simplify microsurgical anastomosis. EASI features a cylindrical core with guiding divots for equidistant suturing, an anti-rotation stabilizing rod, and compatibility with Acland clamps (Figure 1). The device enables precise, tactile-only anastomosis in vessels as small as 1-5 mm, without the need for high-magnification microscopes or extensive microsurgical training.

Results: In an ex vivo chicken thigh vessel model, EASI eliminated backwalling, reduced anastomosis time by up to 60%, and improved user confidence from a 3 to a 10. It is effective in both arteries and veins, unlike the venous coupler, which is vein-specific and costs $400 per use (Table 1). EASI offers dual-vessel compatibility at a projected price of $200, representing an initial $40 million market opportunity with significant downstream cost savings: $45,000 per avoided flap salvage procedure and $88/minute saved in the OR. Beyond microsurgery, EASI has potential applications other surgical subspecialties where small tubular structures are anastomosed. Upcoming milestones include in vivo testing in a rat carotid artery model to assess surgical timing, perfusion, and safety, followed by licensing negotiations, sterilization and biocompatibility testing, clinical trials, and regulatory submission.

Conclusion: With strong interest from academic surgeons, EASI has received $270,000 in non-dilutive funding. With a clear clinical need, robust preliminary data, and a defined regulatory pathway, EASI has the potential to democratize microsurgery by making it safer, more efficient, and accessible across a wider range of surgical settings. Our device will serve both a clinical tool and a powerful adjunct to surgical education worldwide.

Introduction: Fat graft retention remains unpredictable, partly due to variability in harvesting, processing, and especially cryopreservation protocols (1,2). Freezing and thawing can significantly reduce adipocyte and stromal vascular fraction viability, compromising proliferative potential and long-term graft survival (3-5) . Despite growing clinical use of cryopreserved fat, standardized preservation methods are lacking. This study evaluates the impact of different extraction and cryopreservation protocols on adipose tissue cellular viability and proliferative capacity.

Methods: Lipoaspirate samples were obtained from three healthy female donors. The harvested fat was cryopreserved at −80°C for periods of three, six, and twelve months. After thawing, samples were analyzed for cellular viability and proliferative capacity according to the preservation protocol applied.

Results: After three months of cryopreservation, the DMSO group demonstrated higher cell viability compared to the DMEM and trehalose groups. The DMSO + trehalose group showed comparable results. At six months, the highest viability rates were observed in the DMSO and DMSO + trehalose groups. After twelve months of cryopreservation, all groups exhibited an approximate 50% reduction in cell viability compared to fresh fat samples. Nevertheless, the DMSO + trehalose combination yielded results comparable to those obtained with DMSO or trehalose alone. Cell-block histological analysis demonstrated preservation of cellular architecture particularly in the DMSO + trehalose group.

Conclusion: This study demonstrates a reduction in cellular viability across all cryopreserved samples compared to fresh adipose tissue at all evaluated time points. Among the tested conditions, DMSO alone and DMSO combined with trehalose produced the most favorable viability outcomes. Further controlled studies are necessary to establish proof of concept and to validate these findings.

Results: 1- Cucchiani R, Corrales L. The Effects of Fat Harvesting and Preparation, Air Exposure, Obesity, and Stem Cell Enrichment on Adipocyte Viability Prior to Graft Transplantation. Aesthet Surg J. 2016 Nov;36(10):1164-1173. doi: 10.1093/asj/sjw106. Epub 2016 Jul 29. PMID: 27474770. 2- Streit L, Jaros J, Sedlakova V, Sedlackova M, Drazan L, Svoboda M, Pospisil J, Vyska T, Vesely J, Hampl A. A Comprehensive In Vitro Comparison of Preparation Techniques for Fat Grafting. Plast Reconstr Surg. 2017 Mar;139(3):670e-682e. doi: 10.1097/PRS.0000000000003124. PMID: 28234835. 3- Zanata F, Bowles A, Frazier T, Curley JL, Bunnell BA, Wu X, Wade J, Devireddy R, Gimble JM, Ferreira LM. Effect of Cryopreservation on Human Adipose Tissue and Isolated Stromal Vascular Fraction Cells: In Vitro and In Vivo Analyses. Plast Reconstr Surg. 2018 Feb;141(2):232e-243e. doi: 10.1097/PRS.0000000000004030. PMID: 29369990. 4- Mashiko T, Wu SH, Kanayama K, Asahi R, Shirado T, Mori M, Sunaga A, Sarukawa S, Uda H, Yoshimura K. Biological Properties and Therapeutic Value of Cryopreserved Fat Tissue. Plast Reconstr Surg. 2018 Jan;141(1):104-115. doi: 10.1097/PRS.0000000000003952. PMID: 28922324. 5- Chaput B, Orio J, Garrido I, De Bonnecaze G, Espagnolle N, Gadelorge M, Chavoin JP, Grolleau-Raoux JL, Casteilla L, Planat V, Bourin P. A clinical scalable cryopreservation method of adipose tissue for reconstructive surgery assessed by stromal vascular fraction and mice studies. Plast Reconstr Surg. 2014 Apr;133(4):815-826. doi: 10.1097/PRS.0000000000000051. PMID: 24675187.

Purpose A large subset of patients with headache disorders (HD) suffer from nerve pain, such as occipital neuralgia. These patients are often misdiagnosed, resulting in delayed treatment (on average 20 years) and risk of developing chronic pain. Early diagnosis at the initial point-of-care (IPOC) (primary care, non-specialty providers) is challenging due to a lack of diagnostic expertise, resulting in inadequate referrals for specialty consultation. Patient-generated pain drawings have been demonstrated to be an effective screening tool to detect nerve pain, as nerve pain typically follows a pathognomonic pattern in the nerve's distribution. However, clinical expertise is currently required to evaluate pain drawings, significantly limiting access to care for patients. To bridge this gap, our team developed NerveAI, a web-based, AI-driven screening tool for automated nerve pain detection using pain drawings at the IPOC. Using a retrospective training dataset, we demonstrated that NerveAI can accurately identify nerve pain using pattern recognition (AUROC 0.879) with a multilayer perceptron model. This study prospectively evaluates NerveAI to identify the optimal algorithm for nerve pain detection.

Methods This prospective, multi-institutional study recruited subjects with head and neck pain. Subjects reported their prior headache diagnoses from IPOC providers and drew their pain on a web-based 3D head model. Each drawing was evaluated by (a) a physician blinded to clinical information with expertise in neuralgia (neurologist/headache specialist or headache surgery-trained surgeon) and (b) NerveAI. The NerveAI algorithm encoded pain drawings into feature vectors capturing pain pathway frequency and directionality, applying machine learning classifiers for nerve pain detection. Subjects then underwent comprehensive clinical evaluation and were given a formal diagnosis using ICHD-3 criteria, which served as the gold standard. The diagnostic accuracy of the blinded experts' evaluations of the drawings, NerveAI, and the subjects' prior diagnoses was compared with the gold standard.

Results Forty-five subjects were enrolled from five centers (71% female; mean age 48 years). Of these, 28 (68%) had been diagnosed with neuralgia by IPOC providers. After comprehensive clinical evaluation, 39 (87%) were diagnosed with neuralgia. Blinded expert assessment of pain drawings achieved an accuracy of 98%, with a sensitivity of 100% and a specificity of 83% (Cohen's κ = 0.90). Region-specific performance of the blinded expert assessment was highest for the occipital and frontal regions (accuracy 98%; Cohen's κ = 0.95 and 0.90, respectively), while performance was lower for the temporal region (accuracy 89%; Cohen's κ = 0.67). NerveAI demonstrated strong region-specific diagnostic performance: occipital (AUROC 0.933), temporal (AUROC 0.875), and frontal (AUROC 0.880).

Conclusion This preliminary analysis demonstrated that blinded expert physicians achieve high diagnostic accuracy when assessing pain drawings, while IPOC providers underdiagnose neuralgia. NerveAI showed promising results to bridge this diagnostic gap, serving as a screening tool with strong region-specific discriminative performance. Validation in a larger population is needed.

Two-point discrimination (2PD) testing is widely used in plastic surgery, hand surgery, and neurology to assess peripheral nerve injury and sensory recovery by determining the minimum distance at which a patient can distinguish two separate points applied to the skin (1). However, commercially available tools are often expensive and inaccessible, particularly in resource-limited settings, leading clinicians to rely on improvised tools with nonstandardized spacing (2). Advances in open-source design and desktop 3D printing provide an opportunity to improve accessibility while preserving clinical precision (3). We developed an open-source, parametric, 3D-printed 2PD device designed to provide a low-cost, customizable, and locally manufacturable alternative while maintaining clinically appropriate precision. The device was designed using OpenSCAD as a fully parametric model allowing user-defined testing distances. Iterative design–print cycles were performed using fused deposition modeling (FDM) and stereolithography (SLA) printers. Prototypes were evaluated for print reliability, durability, prong geometry, and ergonomic usability. Material consumption and printing costs were calculated and compared with commercially available 2PD devices. A companion website was developed to host preset STL files and enable automated generation of customized device configurations. Though SLA printing provided higher resolution, the device printed reliably across both FDM and SLA platforms, producing accurate testing distances and consistent prong geometry suitable for clinical use. Material manufacturing cost was approximately $0.20 using PLA-based FDM printing and $0.40 using SLA resin, corresponding to 0.15% and 0.30% of the cost of commercially available Dellon–MacKinnon Disk-Criminator devices ($135 per pair), respectively. Relative to commonly available online alternative 2PD devices ($18–50 per pair), manufacturing costs represented approximately 0.40–1.11% (PLA) and 0.80–2.22% (SLA) of device cost. The web-based interface successfully generated customizable STL files across tested distance ranges, enabling rapid local fabrication using widely available desktop 3D printers. This open-source, 3D-printed 2PD device provides a low-cost, locally manufacturable alternative to commercial tools, broadening access to standardized sensory testing in diverse clinical settings. Furthermore, this work demonstrates the feasibility of clinician-driven medical device development using open-source software and 3D printing technology.

References: 1. Moberg E. Two-point discrimination test. A valuable part of hand surgical rehabilitation, e.g. in tetraplegia. Scand J Rehabil Med. 1990;22(3):127-134. 2. Crosby PM, Dellon AL. Comparison of two-point discrimination testing devices. Microsurgery. 1989;10(2):134-137. doi:10.1002/micr.1920100214 3. Ventola CL. Medical Applications for 3D Printing: Current and Projected Uses. P T. 2014;39(10):704-711.

Purpose- Glucagon-like peptide 1-receptor agonists (GLPra) are increasingly prescribed for weight loss and type 2 diabetes. Given the limited literature on this subject, the aim of this study was to analyze the association between prior GLPra use and postoperative wound outcomes in reconstructive procedures and whether the timing of discontinuation modified this risk.
Methods- A retrospective cohort study was performed using the TriNetX database. The database was queried to identify patients undergoing panniculectomy, abdominoplasty, and breast reduction. Patients with prior GLPra exposure within one year of surgery were compared with GLPra negative controls undergoing the same procedure. GLPra patients were secondarily stratified by timing of discontinuation before surgery (6-12 months, 3-6 months, 1 month, or perioperative use). Propensity score matching was performed for age, sex, race, body mass index (<19.9, 20-29, 30-39, >40), diabetes status, hemoglobin A1c level (<7%, >7%), smoking status, coagulopathies, cancer, and bariatric surgery history. The rates of surgical wound infections, dehiscence, hematoma, and seroma, were assessed 90 days postoperatively. Statistical analysis was performed on the TriNetX platform. Results- In the panniculectomy group, wound dehiscence occurred in 15.7% of 362 patients discontinuing GLPra 6-12 months preoperatively [odds ratio (OR):2.00, 95% confidence interval (CI):1.26-3.18; p=0.003] and 14% of 328 patients discontinuing 1-3 months preoperatively (OR:1.67, 95%CI:1.02-2.73; p=0.041) compared to a control of 21,069 patients with no GLPra exposure. Of 340 patients discontinuing 3-6 months preoperatively and 435 perioperative users, 11.8% and 11.5% of patients had wound dehiscence, respectively, which was not significant compared to the matched control cohort. After adjusting for age, sex, BMI greater than 40, bariatric surgery status, and race, the patients who discontinued 3-6 months preoperatively had an increased risk of wound dehiscence (hazard ratio:1.341, 95% CI:1.016-1.771, p=0.0381). In abdominoplasty, wound dehiscence occurred in 16.7% of 144 patients discontinuing GLPra 1-3 months preoperatively (OR:2.25, 95%CI:1.08-4.69; p=0.028) compared to a control of 10,327 patients with no GLPra exposure. Other exposure intervals (6-12 months:17.1% of 152 patients and 8.9% of 144 perioperative users) did not have a significant association. There was an insufficient sample size for the patients who stopped 3-6 months preoperatively. In breast reduction, wound dehiscence occurred in 9.2% of 349 patients discontinuing GLPra 6-12 months preoperatively (OR:3.45, 95%CI:1.61-6.46, p=0.0004), compared to a control of 62,134 patients with no GLPra exposure. Other exposure intervals (3-6 months:6.6% of 301 patients, 1-3 months:7.3% of 358 patients, and 5.7% of 438 perioperative users) did not have a significant association. In the panniculectomy group, hematoma or seroma occurred in 10.4% of 374 patients who discontinued GLPra therapy 6-12 months preoperatively (OR:2.08, 95%CI:1.19-3.65, p=0.009), with no significant differences in other intervals and procedures. No significant associations with wound infection were observed. Conclusions- The risk of surgical site wound healing complications in patients was higher in those with GLPra exposure who underwent panniculectomy, abdominoplasty, and breast reduction. The absence of a timing-dependent effect suggests that GLPra exposure may not represent a modifiable perioperative medication effect and that the discontinuation of GLPra alone may not mitigate the risk of wound healing complications.

Purpose: An option for medical students who do not match into Plastic and Reconstructive Surgery (PRS) residencies is a Non-Designated Preliminary Surgical Residency (NDPSR) position. These positions allow unmatched students the potential to continue pursuing PRS residency. The purpose of this study is to 1) determine the NDPSR year re-applicant match rate in the following cycle, and 2) determine what characteristics are associated with increased match success.

Methods: A retrospective cohort study was conducted from 2020-2025 using Integrated PRS applications from multiple academic institutions. Applicants currently completing a preliminary NDPSR position at the time of reapplication were included. Demographics and academic factors were collected and analyzed for each applicant using independent samples T- tests, Chi Square, Fisher's Exact Tests, Univariate and Multivariate Logistic Regressions.

Results: A total of 106 applicants who were NDPSR at the time of application met inclusion criteria. Successful match rate was 43.4%. The median Step 2 Score was 254(20) for matched applicants and 239(20) for unmatched. 28.3% of matched applicants were AOA and 45.70% achieved Honors in their surgical clerkship, in contrast to 10% and 46.67% for unmatched. 32.6% of matched applicants completed a research year prior to graduation and 95.7% received two or more (2+) letters of recommendation (LOR) from PRS faculty; 23.33% of unsuccessful applicants completed a research year and 75% received 2+ LOR. 93.5% of applicants who matched had an Integrated PRS program at their NDPSR institution, in contrast to 73.33% of unmatched. The mean number of first author publications for matched applicants was 4.24(±5.634), total publications was 9.96(±10.918), and total presentations was 16.02(±14.262). The mean number of first author publications for unmatched applicants was 2.25(±3.487), total publications was 5.53(±7.464)(p=0.017), and total presentations was 12.22(±11.669).

Chi Square and Fisher's Exact test revealed statistically significant associations between matching and male gender (p=0.043), PRS program at preliminary institution (p=0.01), AOA (p=0.021), and having 2+ LOR from PRS faculty (p=0.006). Furthermore, several statistically significant associations were determined between matching and applicant number of first author publications(p=0.029), total number of publications (p=0.045), and average standardized LOR (SLOR) score (p=0.003).

Multivariate regression was performed using NDPSR Integrated PRS program affiliation, Step 2 scores, AOA, 2+ PRS LOR, total and first author publication number. It was revealed that each point increase in Step 2 scores (p=0.004, (Exp(β)=1.054, 95%CI:1.017-1.092) and having a PRS program at NDPSR institution (p=0.045, (Exp(β)=4.469, 95%CI:1.032-19.351) are the strongest predictors for successful match.

Conclusions: For reapplicants, having an Integrated PRS Program at the NDPSR institution increases the matching likelihood four times over. Step 2 scores remain important, with a 1.054 increase in likelihood in matching per point score increase. These findings may help applicants navigate the challenging Integrated PRS match.

PURPOSE: Secondary lymphedema, particularly following breast cancer treatment, results in progressive lymphatic dysfunction and early skin changes. While dermal backflow on indocyanine green (ICG) lymphography is a hallmark of early disease, its biological relevance and association with skin pathology remain unclear. The purpose of this study was to analyze structural and functional skin alterations in early-stage secondary lymphedema and evaluate their correlation with ICG lymphography findings and patient-reported symptoms.

METHODS: In this prognostic study, 31 patients with unilateral early-stage breast cancer-related lymphedema (BCRL) underwent ICG lymphography to identify dermal backflow regions between January 2022 and June 2023. Backflow intensity was quantified using image analysis. Non-invasive skin assessments measured transepidermal water loss (TEWL), skin stiffness (tonometry), and percentage water content (PWC) in the unaffected arm, affected areas with dermal backflow, and affected areas without backflow. Full-thickness skin biopsies from matched sites were obtained in a subset of 8 patients for histologic and immunofluorescent analysis. Correlations between dermal backflow intensity, skin metrics, and symptom scores were evaluated.

RESULTS: Dermal backflow intensity correlated with TEWL (r = 0.42, p = 0.002) and PWC (r = 0.77, p < 0.0001). Patients accurately localized dermal backflow areas based on symptoms, which correlated with backflow intensity (r = 0.79, p < 0.0001), PWC (r = 0.63, p < 0.0001), and TEWL (r = 0.39, p = 0.0006). Histologic analysis revealed that dermal backflow regions exhibited increased epidermal thickness (p = 0.03), upregulation of keratinocyte differentiation markers KRT10 (p = 0.01) and KRT14 (p = 0.03), and elevated expression of thymic stromal lymphopoietin (TSLP; p = 0.03). These regions also demonstrated increased infiltration of CD45+ immune cells (p = 0.02) and lymphatic remodeling, including vessel dilation and tortuosity, compared with non-backflow and contralateral control skin.

CONCLUSION: Dermal backflow regions in early-stage BCRL are characterized by localized skin barrier dysfunction, fluid accumulation, and Th2-mediated inflammation. These areas are biologically distinct, clinically symptomatic, and detectable with non-invasive assessments, supporting their relevance as early indicators of disease activity and potential targets for early intervention.

Background: Academic leadership in plastic surgery is thought to reflect scholarly productivity and advanced training; however, the relative contributions of academic output, gender, and fellowship training remain unclear. This study evaluates factors associated with leadership positions among U.S. plastic surgery faculty.

Methods: A cross-sectional analysis of all U.S. plastic surgery residency programs was performed. Faculty were identified through program websites. Data collected included h-index, gender, fellowship training, and leadership position (program director, chair, division chief, or equivalent). Mann-Whitney and Kruskal-Wallis tests were used to compare differences in h-indices between groups. Univariate logistic regression was used to evaluate associations between individual predictors and leadership. Model discrimination was assessed using area under the receiver operating characteristic curve (AUC). Regression results are reported as odds ratios (OR) with 95% confidence intervals (CI).

Results: A total of 1,100 faculty were included; 25.6% were female and 86.3% completed fellowship training. The mean h-index was 15.8. Overall, 31.4% held leadership positions. Male faculty demonstrated significantly higher h-indices compared to female faculty (13.0 vs 9.0, p < 0.0001). Faculty in leadership roles had higher h-indices compared to non-leadership faculty (17.0 vs 10.0, p < 0.0001). There was no significant difference in h-index between fellowship-trained and non-fellowship-trained faculty (p=0.12), nor among subspecialty fellowship categories. On logistic regression, increasing h-index was associated with leadership position (OR 1.03 per point increase [1.02-1.04], p< 0.0001, AUC=0.62). Female gender was independently associated with lower odds of leadership (OR 0.70 [0.52-0.95], p=0.02). Fellowship training was not associated with leadership (OR 1.17 [0.80-1.73], p=0.41). Model discrimination was modest.

Conclusions: Among U.S. plastic surgery faculty, academic productivity as measured by h-index was independently associated with leadership attainment. Female faculty demonstrated lower odds of leadership and fellowship training was not associated with leadership. These findings suggest that scholarly output remains a key driver of academic advancement in plastic surgery while persistent gender disparities in leadership warrant further investigation.