Scientific Abstract Presentations: Research & Technology Session 4 Saturday, October 17 Sat, Oct 17 8:00-9:30 a.m. CDT

Background Successful deep inferior epigastric perforator (DIEP) flap breast reconstruction depends on accurate identification of optimal perforators and their intramuscular course. Conventional preoperative planning relies on axial CT angiography (CTA) images and radiology reports, which may limit three-dimensional spatial understanding. Three-dimensional volume-rendered technique (3D VRT) reconstruction of CTA allows direct visualization of perforator origin, intramuscular trajectory, and fascial exit, potentially improving operative efficiency and safety. This study compares operative outcomes before and after routine implementation of surgeon-reviewed 3D VRT imaging for DIEP flap planning. Methods A retrospective comparative study was performed including 48 consecutive DIEP flap breast reconstructions. In the control group (n=28), perforator selection was based on conventional 2D CTA images and radiology reports alone. In the 3D VRT group (n=20), operating surgeons reviewed reconstructed 3D VRT CTA images preoperatively to assess perforator size, course, and intramuscular anatomy. Primary outcomes included intramuscular perforator dissection time, flap harvest time, and total operative time. Secondary outcomes included intraoperative perforator injury and return to theatre. Continuous variables were compared using Student's t-test, and categorical variables using Fisher's exact test, with significance set at p<0.05. Results Use of 3D VRT was associated with a significant reduction in operative times. Mean intramuscular perforator dissection time was significantly shorter in the 3D VRT group compared to the conventional group (mean 25.5 ± 5.2 vs 36.8 ± 6.3 minutes, p<0.001). Mean flap harvest time was reduced from 1.55 ± 0.27 hours to 1.04 ± 0.23 hours (p<0.001). Total operative time was also significantly lower in the 3D VRT group (3.4 ± 0.3 vs 4.0 ± 0.4 hours, p<0.01). Intraoperative perforator injury occurred in 2 cases in the conventional group and in none of the 3D VRT cases. One return to theatre for venous augmentation occurred in the conventional group. No flap losses were observed in either cohort. Conclusions Surgeon-directed preoperative planning using 3D volume-rendered CTA significantly improves visualization of DIEP perforator anatomy and intramuscular course. This enhanced anatomical understanding translates into reduced intramuscular dissection time, shorter flap harvest duration, and decreased overall operative time, with fewer perforator-related complications. Routine use of 3D VRT represents a valuable adjunct in DIEP flap surgery, improving operative efficiency and precision across varying levels of surgical experience.

Introduction: Intramuscular fat grafting is increasingly used in aesthetic and reconstructive surgery for muscle volumization and contour enhancement. Its rationale is partly based on the regenerative potential of adipose-derived stem cells (ADSCs) (1-3). However, evidence supporting structural or functional benefits of adipose tissue or ADSC injection into healthy skeletal muscle remains lacking, and data in injured muscle are inconclusive. Given the growing clinical use of intramuscular lipografting, its biological effects on non-injured muscle require systematic investigation. This study evaluated the histological and molecular effects of intramuscular injection of adipose tissue and its derivatives in healthy skeletal muscle.

Methods: Adipose tissue harvested from healthy female donors undergoing elective liposuction was processed into macrofat, microfat, stromal vascular fraction (SVF), and ADSCs. Sixty-four female Wistar rats were randomized into four groups (n = 8 per group), each receiving 0.5 mL of one preparation injected into the quadriceps muscle. After eight weeks, muscles were harvested for analysis of muscle weight, histology, and gene expression. Hematoxylin and eosin–stained sections were evaluated in 10 random fields at 20× and 40× magnification to assess cyst formation, fibrosis, inflammatory infiltration, and vascular density.

Results: No significant differences were observed among groups in cyst formation (p = 0.0539), fibrosis (p = 0.353), macrophage infiltration (p = 0.783), or polymorphonuclear leukocyte infiltration (p = 0.267). However, vascular density differed significantly (Kruskal–Wallis, p = 0.00357). Dunn's post hoc analysis demonstrated higher vascular density in the microfat group compared with the ADSC group (14.39 vs. 8.03; p = 0.0118) and the nanofat group (14.39 vs. 6.33; p = 0.0410). No other significant pairwise differences were detected.

Conclusion: Intramuscular injection of adipose tissue and its derivatives into healthy skeletal muscle did not increase inflammation, fibrosis, or cyst formation. Microfat, however, was associated with increased vascular density compared with selected cell-based derivatives, suggesting a localized angiogenic effect without adverse remodeling. In non-injured muscle, adipose-derived preparations do not promote overt structural regeneration, although microfat may enhance vascularization. Further studies are warranted to determine the functional and clinical relevance of these findings.

References: 1- Takegaki J, Sase K, Kono Y, Nakano D, Fujita T, Konishi S, Fujita S. Intramuscular injection of mesenchymal stem cells activates anabolic and catabolic systems in mouse skeletal muscle. Sci Rep. 2021 Oct 27;11(1):21224. doi: 10.1038/s41598-021-00627-6. PMID: 34707171; PMCID: PMC8551189. 2- Schilling BK, Baker JS, Komatsu C, Turer DM, Bengur FB, Nerone WV, Qin F, Cottrill AR, Kokai LE, Rubin JP, Marra KG. Intramuscular Nanofat Injection Promotes Inflammation-Induced Gastrocnemius Regeneration in a Syngeneic Rat Sciatic Nerve Injury Model. Plast Reconstr Surg. 2023 Jun 1;151(6):947e-958e. doi: 10.1097/PRS.0000000000010115. Epub 2022 Dec 26. PMID: 36728782. 3- Peçanha R, Bagno LL, Ribeiro MB, Robottom Ferreira AB, Moraes MO, Zapata-Sudo G, Kasai-Brunswick TH, Campos-de-Carvalho AC, Goldenberg RC, Saar Werneck-de-Castro JP. Adipose-derived stem-cell treatment of skeletal muscle injury. J Bone Joint Surg Am. 2012 Apr 4;94(7):609-17. doi: 10.2106/JBJS.K.00351. PMID: 22488617.

Background: Patients requiring plastic surgery consultation are frequently evaluated by surgery residents without immediate access to specialty-trained attendings. This model can delay expert involvement, potentially affecting patient confidence, care experience, and real-time clinical decision-making for complex wounds, soft tissue injuries, and reconstructive needs. Augmented reality (AR) glasses offer a novel solution by allowing remote plastic surgeons to participate in bedside encounters through live, first-person visualization and direct interaction. This approach enables attending-level assessment without physical presence, creating a new model for timely specialty care. While AR applications in surgical education have expanded, the patient perspective on AR-assisted care remains poorly defined. This study evaluates patient satisfaction with AR-assisted plastic surgery encounters, focusing on comfort with the technology, trust in the care delivered, and perceptions of timely access to attending-level evaluation. Methods: Surgery residents on the plastic surgery service wore AR glasses during inpatient consultations, wound evaluations, dressing changes, and minor bedside procedures. The device transmitted a secure, HIPAA-compliant live video feed to attending plastic surgeons, who joined remotely via desktop or mobile interface. Attendings provided real-time audio guidance and projected digital annotations into the resident's visual field, enabling active participation throughout the encounter. Patients were informed of the technology and provided consent prior to use. After each visit, patients completed a structured satisfaction survey using validated Likert-scale measures assessing: (1) comfort with AR-assisted care, (2) trust and confidence in care quality, and (3) satisfaction with the timeliness and directness of attending involvement. Open-ended responses were collected to further characterize patient perceptions. Results: Overall patient satisfaction with AR-assisted care was high. Most patients reported that the technology was comfortable and nonintrusive. Patients expressed strong confidence that they were receiving attending-level evaluation despite the attending's physical absence, with many citing reassurance from knowing a plastic surgeon was directly involved in real time. Satisfaction with the speed of specialty input was consistently high, and AR-facilitated encounters were commonly perceived as providing faster access to expert assessment than traditional consultation workflows. The immediacy of attending participation during the encounter, rather than after a delay, emerged as a central theme. Qualitative feedback highlighted appreciation for clear communication about the technology and for direct attending engagement. No patients declined participation due to discomfort with AR use. Conclusion: AR-enabled remote supervision at the bedside was well tolerated and associated with high patient satisfaction, strong confidence in care quality, and improved perceived access to timely specialty evaluation. Patients valued the ability to receive real-time expert input during their encounter, an experience that compared favorably with traditional consultation models. These findings support the feasibility of virtual attending presence as a patient-centered care delivery model in plastic surgery. Larger prospective studies are needed to confirm these results and define best practices for integrating AR into clinical workflows.

Background: Medical tourism involves individuals traveling abroad for elective medical procedures, driven by factors such as cost savings, shorter waiting periods, and the unavailability of certain treatments at home. A major concern occurs during the return trip, especially when most patients fly shortly after their procedures. While this travel can lower hospitalization costs, it also increases the risk of thromboembolic events. Furthermore, the flight exposes patients to several hours in a relatively hypobaric and hypoxic environment, since commercial aircraft can be pressurized to levels as low as 0.75 atmospheres absolute (ATA). This hypoxic environment is known to cause skin flap failure, raise the risk of surgical site infection, and lead to cell-mediated free radical damage. Methods: Twenty rats underwent a modified McFarlan flap-a dorsal random flap-with skin excised to simulate tension during closure (PiZA flap). Ten rats were exposed to a hypobaric environment to simulate flight, whereas the other ten were not. All rats were monitored and sacrificed after two weeks to examine the scars histologically. Results: Rats in the hypobaric exposure group experienced more wound complications than those in the control group (10/10 vs. 3/10, respectively, p<0.001). When adjusted for total complication scores, the hypobaric group had a higher score (1.24±1.75 vs. 0.15±0.23, p=0.042). Complications in this group included one catastrophic flap necrosis, two major flap dehiscences, and minor wound healing issues. Conclusions: The environment immediately following surgery significantly influences flap survival and postoperative complications. Exposure to such conditions during flight-though harmless for unoperated individuals-can cause severe complications if it occurs after an operation. Our findings provide evidence for this and suggest the need for further research into flights following various procedures.

Purpose: Burn surgery requires rapid, evidence-based decision-making across acute resuscitation, operative management, and reconstruction. Despite increasing interest in artificial intelligence (AI) for clinical decision support, no burn-specific system currently exists that provides transparent, citation-traceable guidance suitable for time-critical surgical care.

Methods: We developed BurnRAG, a burn surgery–specific retrieval-augmented generation (RAG) clinical decision support system using a hierarchical RAPTOR architecture and a curated corpus of 4,683 peer-reviewed burn surgery articles (2000–2025). Ten expert-designed clinical scenarios spanning acute management, operative decision-making, reconstruction, rehabilitation, and mass casualty triage were evaluated. Performance was characterized using semantic similarity (SEM-eval), maximum and mean similarity scores, a holistic G Score assessing response completeness, content coverage analysis, and manual citation verification.

Results: BurnRAG demonstrated consistently high evidence-alignment performance across scenarios, with mean semantic similarity of 0.94±0.02 and mean G Score of 0.97±0.06. The system synthesized an average of 6.8 peer-reviewed sources per query, with 100% citation accuracy on manual review. Highest performance was observed in acute surgical decision-making scenarios, including escharotomy planning, fluid resuscitation with inhalation injury, and early excision timing. Reconstructive and rehabilitation scenarios also demonstrated robust multi-source synthesis.

Conclusions: BurnRAG is the first burn-specific, citation-traceable AI system demonstrating high-fidelity evidence synthesis across the burn care continuum. By providing transparent, source-attributed guidance for emergency triage, operative planning, and reconstruction, BurnRAG addresses fundamental limitations in clinical decision support for burn care.

Background High-fidelity human skin models are central to plastic surgery research in applications of wound healing, scarring, infection control, and evaluation of cutaneous drug effects. Conventional 2D cultures and animal models often fail to replicate the layered architecture, cell-matrix interactions, and diffusion barriers that govern scar formation and topical drug responses in human tissue. 3D-bilayered skin constructs that incorporate a dermal fibroblast compartment and a stratified keratinocyte layer offer a translational platform to model fibrosis and evaluate clinically relevant therapies, including emerging injectable collagen formulations and topical agents used in infection prevention and cutaneous oncology.

Purpose This project aimed to develop and validate a high-fidelity 3D bioprinted bilayered human skin construct for modelling scarring in a controlled in vitro environment and, assessing cutaneous drug interactions, including injectable nano-collagen and topical antimicrobials and field-directed skin cancer therapies such as 5-fluorouracil and imiquimod.

Method A reproducible 3D-printed bilayer construct was engineered comprising a collagen-based dermal matrix seeded with human dermal fibroblasts and an epidermal layer formed by human keratinocytes. Print geometry, dermal stiffness, and culture conditions were iteratively optimized to improve structural fidelity, reduce contraction, and promote epidermal continuity. A pro-fibrotic scarring phenotype was induced using a defined cytokine environment and mechanical constraint, with fibrosis assessed by construct contraction, histology, and molecular markers of myofibroblast activation and extracellular matrix deposition. The established model was then used to evaluate: intradermal injection of nanocollagen formulations, and topical exposure to representative antimicrobials and skin cancer agents (5-fluorouracil and imiquimod). Outcomes included cell viability, barrier integrity surrogates, fibroblast activation signatures, and ECM/collagen production within the dermal compartment.

Findings Iterative fabrication produced a stable, high-fidelity bilayer construct with reproducible dermal architecture and epidermal coverage suitable for longitudinal testing. Scar induction generated a measurable fibrotic phenotype characterized by increased contraction, enhanced myofibroblast-associated markers, and increased dermal ECM deposition relative to baseline constructs. Within this scarring context, injectable nano-collagen demonstrated early evidence suggestive of upregulated endogenous fibroblast activity, with increased collagen-associated markers. Topical antimicrobial exposure demonstrated dose-dependent decolonisation rates. Topical 5-fluorouracil and imiquimod produced a limited response, indicating limitations on the model's ability to reproduce immunogenic properties of skin

Conclusion A 3D-printed bilayered human skin construct can provide a robust and clinically relevant platform for modelling scarring and evaluating cutaneous drug interactions, albeit with some ongoing limitations. This approach enables controlled assessment of fibroblast-driven fibrosis and epidermal responses, supporting preclinical screening of injectable biomaterials such as nano-collagen and evaluating established topical therapeutics including antimicrobials and field-directed skin cancer agents. The model offers a scalable foundation for future mechanistic studies and optimization of therapies aimed at modulating scar formation and improving reconstructive outcomes.

The Successful Use of a Minimally Invasive Temperature-Controlled Radio Frequency (RF) Device to Treat Recalcitrant Symptomatic Hemangiomas in Children Background: Infantile hemangiomas (IHs) are common benign vascular tumors of childhood. While many regress without intervention, a subset remains symptomatic, disfiguring, or refractory to standard therapies such as propranolol, corticosteroids, or laser treatment. For these complex cases, we evaluated the use of a minimally invasive, temperature-controlled radio frequency (RF) device as a novel therapeutic approach. Methods: A retrospective review of 22 pediatric patients with symptomatic or treatment-resistant hemangiomas treated with a Radio Frequency (RF) device delivering targeted thermal energy. Patient ages ranged from 11 months to 17 years (mean: 4.6 years) When appropriate pre-operative ultrasound was obtained. A non-conductive tumescent solution (lactated Ringer's with epinephrine at 1:400,000 dilution) was used for vasoconstriction and thermal insulation. RF energy was applied with the probe placed within the lesion (internal mode) or externally on the surface (external mode) according to device specifications. Internal tissue temperature approached 60°C and was monitored in real time. Surface temperature was monitored using infrared thermography. Follow-up occurred at 2, 6, and 12 weeks, with ultrasound performed at 12 weeks to assess volume involution and vascular changes. Clinical outcomes were documented via imaging, photographs, and physician assessments. Results: Of the 22 patients (12 female, 10 male), two patients received both internal and external RF treatments. Twelve patients underwent multiple RF procedures (avg 2.4) Over 85% demonstrated marked improvement, including reduced lesion volume, improved skin contour, and decreased vascularity. No significant complications were reported. Ultrasound and photographic data confirmed substantial tissue remodeling, especially in patients previously unresponsive to therapies such as propranolol and pulsed dye laser. Conclusion: Temperature-controlled RF treatment is a safe, minimally invasive option for recalcitrant pediatric hemangiomas. Ultrasound guidance, precise thermal control, and a standardized protocol support its clinical utility. This approach offers a promising alternative for complex vascular anomalies in children and merits further validation in prospective studies.

Liposuction is traditionally regarded as a body contouring procedure, with limited recognized impact on systemic metabolic regulation. However, growing recognition of adipose tissue as an active endocrine organ has renewed interest in the physiologic implications of subcutaneous fat reduction (1,2). Contemporary clinical data evaluating metabolic trends following high-volume ultrasound-assisted liposuction (UAL) remain limited and controversial. This study evaluates longitudinal metabolic and body composition trends following high-volume UAL in a clinical practice setting.

A retrospective observational analysis was performed on patients undergoing UAL between October 2009 and January 2024. Patients with documented preoperative and postoperative body mass index (BMI) measurements and available metabolic laboratory data were included. Assessed variables included BMI, waist circumference, fasting glucose, triglycerides, total cholesterol, and blood pressure where available. Patients undergoing bariatric surgery were excluded. All procedures were performed within established safety guidelines, with a maximum aspirate volume of 5 liters per session. Only final documented follow-up values were analyzed to assess durable physiologic trends rather than immediate postoperative fluctuations.

High-volume UAL was associated with consistent reductions in waist circumference and modest but sustained decreases in BMI relative to aspirate volume. In patients with elevated baseline triglycerides, reductions in total triglyceride levels were observed at follow-up. Downward trends in total cholesterol were noted in select patients with borderline dyslipidemia. Improvements in fasting glucose values and laboratory patterns suggestive of insulin resistance were observed in individuals with preoperative metabolic dysregulation. Stabilization or reduction in blood pressure was seen in select hypertensive patients. Patients with normal baseline metabolic markers demonstrated minimal laboratory change, suggesting that observed trends may preferentially occur in dysregulated phenotypes. No adverse metabolic deterioration was identified.

Subcutaneous adipose tissue plays a recognized role in adipokine signaling, inflammatory mediation, and insulin sensitivity (2,3). Selective adipocyte emulsification achieved with ultrasound-assisted technology may influence local tissue remodeling and downstream metabolic signaling pathways (4). While causality cannot be established in this observational design, the directional consistency of metabolic trends in selected patients supports further investigation into the physiologic effects of targeted adipose reduction. Durability of observed trends appeared closely associated with postoperative lifestyle stability, reinforcing the importance of comprehensive patient counseling.

High-volume UAL should not be considered a primary treatment for metabolic disease; however, its potential association with favorable metabolic trends in selected patients, when performed within established safety parameters, warrants prospective study to clarify mechanisms, quantify magnitude of effect, and define appropriate patient selection criteria (5).

References

1. Klein S, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350(25):2549-2557.

2. Frühbeck G, et al. Adipose tissue as an endocrine organ. Nat Rev Endocrinol. 2019;15(9):507-524.

3. Karczewski J, et al. The role of adipose tissue in metabolic regulation. J Physiol Pharmacol. 2021;72(4):479-494.

4. Chia CT, Neinstein RM, Theodorou SJ. Evidence-based medicine: Liposuction. Plast Reconstr Surg. 2017;139(1):267e-274e.

5. Mohammed BS, et al. Long-term effects of large-volume liposuction on metabolic risk factors for coronary heart disease. Obesity (Silver Spring). 2008;16(12):2648-2651.

PURPOSE: Robotic microsurgical systems' enhanced precision, control and reachability have enabled novel microsurgeries. They also offer enhanced motion scaling, tremor reduction, and improved visualization for sub-millimeter tasks. We conducted the first formal study of the Symani Surgical System (MMI Inc.) in the U.S and analyzed its impact on surgical efficiency and efficacy.

METHODS: We present a retrospective study of anastomoses utilizing Symani and conventional techniques at a single academic hospital in Spring 2025. Data collection primarily includes surgical videos, which were analyzed using Adobe Premiere Pro.

RESULTS: The primary benefit of the Symani Surgical System is ensuring vessel integrity. With Symani, one arterial anastomosis incurred minor vessel damage: the needle retracted once after insertion. In comparison, all arterial anastomoses utilizing conventional techniques incurred vessel damage: one was major as the vessel was cut and required re-anastomosis; three had needle retractions, among which, two had multiple retractions. Both arterial and lymphatic anastomoses with Symani had a fewer number of insertion pairs but the arterial anastomosis had more ties per knot. Arterial anastomosis time with Symani was 15% greater than conventional techniques and the time required per knot was 38% greater. Lymphatic anastomosis time was comparable but the time per knot with Symani was 54% greater.

CONCLUSIONS: Our series demonstrates that anastomosis time with Symani Surgical System is longer than the conventional techniques in our cohort of plastic surgeons, however vessel damage is significantly reduced. This suggests that once surgeons become proficient with Symani, robotic microsurgical systems may lead to better surgical outcomes for patients.

Purpose Lipomas are the most common benign adipocytic tumors, affecting approximately 1%-2% of adults (1). While traditionally regarded as incidental findings of cosmetic significance, their frequent occurrence in adults with metabolic risk factors suggests they may reflect systemic metabolic dysfunction rather than isolated adipose overgrowth. This multicenter study evaluated whether adults with lipomas exhibit a higher prevalence of metabolic syndrome (MetS) components (2), specifically obesity, dyslipidemia, hypertension, and type 2 diabetes mellitus (T2DM), compared to population benchmarks. Methods and Materials We conducted a retrospective, multicenter, cross-sectional analysis of electronic health records from three Israeli hospitals between January 2000 and December 2022. Data were harmonized using the Observational Medical Outcomes Partnership (OMOP) Common Data Model via the Lynx platform. Prevalence of metabolic traits was compared against age- and sex-specific benchmarks from the 2023 national Knowledge, Attitudes, and Practices survey using Z-tests and exact binomial tests. Experience The final analytic cohort included 7,868 adults diagnosed with lipomas (mean age 53.0 years; 53.6% women). Cases were identified through diagnostic coding from hospital inpatient and outpatient records. As a registry-based analysis of routinely collected health records, all participants contributed data to at least one metabolic trait analysis, though no longitudinal follow-up was required for this cross-sectional study. Results Lipoma patients demonstrated a significantly higher prevalence of all four metabolic traits compared to population benchmarks (p<0.001). Dyslipidemia was the most overrepresented trait, with prevalence rising to 88.7% in men aged 65 years and older versus 50.1% in the general population. Hypertension prevalence was markedly elevated, reaching 89.3% in older men and 85.4% in older women. Notably, T2DM showed a uniform excess across all age and sex subgroups. Clustering of three or more metabolic traits, consistent with MetS (2), was significantly more prevalent in the lipoma cohort after age 35. Conclusions Adults with lipomas exhibit a substantially higher burden of metabolic syndrome components compared with population norms. These findings align with recent evidence characterizing specific lipomatosis as a manifestation of systemic metabolic syndrome (3). Recognizing lipomas as visible clinical indicators of cardiometabolic risk could improve the early identification of individuals at risk for endocrine diseases. Plastic surgeons should consider incorporating basic metabolic screening into the clinical evaluation of patients presenting with these tumors. References 1. Singh Sarla G. Epidemiology of subcutaneous lipomas. Online Türk Sağlık Bilim Derg. 2019;4(3):350-359. 2. Alberti KGMM, Zimmet P, Shaw J. Metabolic syndrome-a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006;23(5):469-480. 3. Ishihara S, Fujita N, Azuma K, et al. Spinal epidural lipomatosis is a previously unrecognized manifestation of metabolic syndrome. Spine J. 2019;19(3):493-500.

Purpose: Techniques aimed at improving outcomes in wound re-epithelization and healing have evolved in recent years (1). ReCell (Avita Medical, Valencia, CA, USA) is an autologous skin cell harvesting system in which epithelial cells are enzymatically isolated and aerosolized onto a wound bed or skin graft to promote rapid wound healing (2,3). There are limited clinical data regarding use of this technology in settings outside of burn reconstruction, such as in "complex" wound reconstruction, defined as a full or partial-thickness defect with impaired intrinsic healing capacity. This study aims to describe a single institution experience, outcomes, and techniques utilizing the ReCell system to enhance reconstructions in complex wounds.

Methods: A retrospective chart review was completed upon identifying patients >18 years of age who were treated with ReCell technology from January 2025 to February 2026. Patients were included if ReCell technology was utilized in conjunction with a skin graft and had explicit documentation of specific surgical techniques and follow-up greater than 90 days. Evaluation of outcomes and descriptive statistics were performed.

Results: Under the inclusion criteria, 9 patients with 11 wounds were identified (6 males, 3 females) with an average age of 52.8 +/- 20.4 and BMI of 24.5 +/- 8.3. Wound etiology included wound complications in immunosuppressed patients (n=4) (Figure 1), injury to extremity with chronic venous insufficiency (n=2), hidradenitis suppurativa (n=2), and genital reconstruction (n=1). At time of intervention, wounds had been present for a mean 4.9 +/- 5.7 months, and the majority of wounds (78%) underwent debridement prior to the use of ReCell. At most recent follow-up, 7 of 9 patients (77.8%) achieved complete wound healing, with an average time to healing of 8.3 weeks. Wounds demonstrated acceptable cosmesis and pliability.

Conclusion: ReCell technology is emerging as a promising and practical tool in carefully selected patients. This case series demonstrates its potential in enhancing wound healing in complex reconstructive cases. In this setting, traditional approaches may be limited due to higher risk for complications. These findings warrant further investigation into the role of ReCell in customized, patient specific, complex reconstructive algorithms.

References: 1. Neriamparambil AJ, Sawhney R, Wong WL. Evidence-Based Management of Burns: A Narrative Review of Evolving Practices. Eur Burn J. 2025 Nov 10;6(4):59. PMID: 41283468 2. Holmes Iv JH, Molnar JA, Carter JE, Hwang J, Cairns BA, King BT, Smith DJ, Cruse CW, Foster KN, Peck MD, Sood R, Feldman MJ, Jordan MH, Mozingo DW, Greenhalgh DG, Palmieri TL, Griswold JA, Dissanaike S, Hickerson WL. A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries. J Burn Care Res. 2018 Aug 17;39(5):694-702. PMID: 29800234 3. Z -C Hu, D Chen, D Guo, Y -Y Liang, J Zhang, J -Y Zhu, B Tang, Randomized clinical trial of autologous skin cell suspension combined with skin grafting for chronic wounds, British Journal of Surgery, Volume 102, Issue 2, January 2015, Pages e117–e123

Purpose: Robotic surgery is expanding in plastic and reconstructive surgery (PRS), yet its adoption carries higher operative costs and longer case durations. Whether these factors translate into measurable patient benefits, or at minimum, equivalent safety profiles, remains unanswered at a national scale. Following the introduction of the dedicated robotic variable to the ACS-NSQIP, a national assessment of robotic-assisted approaches became possible. We sought to determine whether robotic use in PRS procedures was associated with differences in perioperative morbidity compared to matched conventional approaches.

Methods and Materials: A retrospective cohort study was conducted using the ACS-NSQIP database from January 2022 to December 2024. Adults (18 years old) undergoing breast surgery performed with robotic assistance were identified using CPT codes. Propensity score matching (PSM) was performed using nearest neighbor matching on the logit scale with a 1:5 ratio, a caliper of 0.2, no replacement, and exact matching on the primary CPT code. A dedicated subgroup analysis was performed for CPT 19364 (free flap breast reconstruction), which comprised 73.6% of the patient cohort. Primary outcomes were 30-day mortality, operative time, length of stay (LOS), return to the operating room, and composite surgical and medical complication rates.

Experience: The study evaluated a total of 420 cases, consisting of 70 robotic cases and 350 matched conventional cases. All patients had a standard 30-day postoperative follow-up.

Results: Thirty-day mortality was zero in both cohorts. Robotic cases were associated with significantly longer operative time across all procedures (542 vs. 389 min; p<0.001) and within the free flap subgroup (654 vs. 443 min; p<0.001). Despite this, robotic surgery was not associated with any increase in composite surgical complications (15.7% vs. 15.9%; p=1.000), return to the operating room (8.6% vs. 9.8%; p=1.000), medical complications (7.1% vs. 2.9%; p=0.149), or LOS (3 vs. 3 days; p=0.240). Individual endpoints, including wound infection, dehiscence, transfusion, and venous thromboembolism, were equivalent between groups. The sole significant morbidity difference was postoperative pneumonia, which was higher in the robotic cohort (4.3% vs. 0.3%; p=0.016), a finding that may reflect prolonged anesthetic exposure during early institutional adoption.

Conclusions: In this propensity-matched national analysis, robotic surgery in PRS was associated with significantly longer operative times but no increase in 30-day mortality, surgical complications, or hospital LOS compared to conventional approaches. These findings support the short-term safety of robotic integration in PRS. However, the operative time burden, increased anesthesia timing, and its downstream resource implications warrant prospective evaluation. Future studies capturing surgeon volume, learning curve thresholds, flap-specific outcomes, and cost are essential to define the conditions under which robotic adoption is clinically and economically justified.

Introduction Lymphedema is chronic swelling from lymphatic dysfunction. The murine hindlimb model is used to study lymphedema and employs hindlimb radiation. The vascular delay phenomenon is used in flap physiology to increase flap viability. The approach employs a staged selective partial disruption of flap blood supply to increase flap vascular robustness followed by interval flap transfer 7-10 days later. While vascular delay phenomenon has been studied, a similar corollary for lymphatics remains unknown. The purpose of this study was to evaluate whether lymphatic preconditioning with staged disruption of lymphatics in the murine hindlimb lymphedema model can be protective against lymphedema.

Methods: C57BL/6 mice underwent 20-Gy hindlimb irradiation. Group 1 (immediate lymphatic disruption) underwent a circumferential skin incision, complete lymphatic disruption, and popliteal lymph node excision in a single stage operation. Group 2 (delayed lymphatic disruption) underwent a two-stage approach including a 1) semi-circumferential skin incision along the inguinal crease, dominant lymphatic transection and a 2) circumferential skin incision, complete lymphatic transection, and popliteal lymphadenectomy occurring 7 days later. Paw thickness was measured weekly following complete lymphatic disruption. Near-infrared laser lymphangiography and immunohistochemistry of the hindlimb was performed on D35.

Results The study included 12 mice. Group 1 had 6 mice and Group 2 had 6 mice. Average paw thickness in Group 1 was 3.5±0.3 cm compared to 2.9±0.2 cm in Group 2 on D14 (p=0.0003) Paw thickness on D35 was 3.2±0.2 cm in Group 1 compared to 2.6±0.1 cm in Group 2 (p=0.0008). Near-infrared laser lymphangiography signal intensity at 24-hours postinjection was 102.4±33.4 AU in Group 1 compared to 9.4±3.3 AU in Group 2 on D35 (p=0.0035). Immunohistochemistry at D35 exhibited abundance of lymphatic endothelial-specific marker podoplanin in Group 2 compared to Group 1 at D35 (p=0.03). Picrosirius red (collagen deposition marker) was less intense in Group 2 compared to Group 1 at D35 (p=0.004).

Conclusion Mice that underwent lymphatic preconditioning with partial lymphatic injury followed by staged completion of lymphatic disruption 7 days later exhibited less paw swelling. This study demonstrates evidence for a novel concept of a lymphatic delay phenomenon parallel to the well-known vascular delay phenomenon. Lymphatic preconditioning has potential translational clinical applications for protective effects to minimize lymphatic dysfunction.

Background: Recent advances in ambient artificial intelligence (AI) technologies, including DAX Copilot, offer real-time transcription and note generation by passively listening to clinical encounters. These systems promise to reduce physician documentation burden while allowing for more direct, face-to-face interaction with patients. High-quality evidence evaluating the impact of ambient AI on documentation efficiency in surgical outpatient clinics is limited.

Purpose: The purpose of this study is to characterize the effect of an ambient AI-powered clinical tool (DAX Copilot) on physician documentation and clinic workflow.

Methods: Outpatient clinic documentation by a single pediatric plastic surgeon was retrospectively analyzed between January and August 2025. Time to visit closure, same-day chart closure, note character count, time spent with notes open, visit type (established, new, peri-op, virtual visit), and documentation composition (Voice Recognition, Template, SmartPhrase, SmartLink, Manual, Copy Previous/Forward, Ambient Listening) were compared before and after DAX implementation. Analyses were performed using R v4.5.0 (April 2025). Continuous variables were assessed with Student's t-test or the Wilcoxon rank-sum test, as appropriate, and categorical variables with chi-square or Fisher's exact test. Multivariable logistic regression adjusted for potential confounders. Statistical significance was defined as a two-sided p-value <0.05.

Results: A total of 226 notes without ambient listening and 113 notes with ambient listening were analyzed. Ambient listening was associated with higher same-day chart closure rates (63.7% vs 50.4%, p = 0.028) and 73% greater odds of same-day closure (OR 1.73, p = 0.021). Notes generated with ambient listening were shorter (989.32 vs 1624.69 characters, p < 0.001) and demonstrated reduced use of the copy-forward function (p = 1.63 × 10⁻⁶). There were no other significant differences in documentation composition strategies (Voice Recognition, Template, SmartPhrase, SmartList, SmartLink, SmartBlock, Manual) between groups. Time spent creating clinic notes was significantly reduced with ambient listening across established (p = 0.02), new (p = 0.02), perioperative (p = 0.02), and telehealth visits (p = 0.005).

Conclusion: Ambient AI-powered scribe technology is associated with improved documentation efficiency and increased same-day chart closure in a plastic surgery outpatient clinic across all visit types. Additionally, ambient listening can produce shorter, potentially more focused documentation that is less reliant on copying prior notes, thereby improving note redundancy.