Scientific Abstract Presentations: Reconstruction Session 5 Saturday, October 17 Sat, Oct 17 10:30 a.m.-12:30 p.m. CDT

Introduction: Tendinopathy, ranging from tendinitis to complete tendon rupture, is considered one of the most feared side effects of fluoroquinolones. This devastating consequence is thought mechanistically to arise from collagen disruption, extracellular matrix degradation, and fibroblast toxicity, which evidence suggests may not reverse rapidly with cessation of treatment. Thus, the question of safety of fluoroquinolones is prompted in patients who require antibiotic therapy within the preoperative window. To investigate this potential risk, a multicenter retrospective cohort study was conducted in the setting of autologous breast reconstruction (ABR).

Methods: Eligible patients were identified on the US Research Network of TriNetX. Those who underwent ABR and treated with fluoroquinolones within 30 days before surgery qualified for the exposure cohort; those treated with alternative classes of antibiotics qualified for the control cohort. Patients were propensity score-matched 1:1 for demographic variables, comorbidities, medications, procedures, and body mass index classifications. Short-term complication rates of wound dehiscence, infection, bleeding, seroma, pain, emergency department visits, and hospitalizations were assessed at postoperative days 30, 60, and 90. Long-term complication rate of significant revisions was assessed at postoperative year 2.

Results: Matched cohorts comprised 488 patients each. At postoperative day 90, patients with preoperative fluoroquinolone exposure were at significantly higher risks of wound dehiscence (risk ratio [RR] 1.909, P-value [P] 0.0097), infection (RR 1.966, P 0.0016), ED visits (RR 1.656, P 0.0171), and hospitalizations (RR 1.421, P < 0.0001). These short-term complication risks were largely preserved at the earlier timepoints. At postoperative year 2, there was no significant difference in the rate of revisions (RR 1.103, P- 0.1760).

Conclusions: Despite widespread knowledge of the side effects of fluoroquinolones, the implications of prescribing this class of antibiotic in the preoperative setting had not been investigated in the plastic and reconstructive surgery literature. This multicenter propensity score-matched study may offer the first set of clinical evidence against fluoroquinolones that may help to set patients who require antibiotic therapy shortly before ABR on a more favorable postoperative course.

Background: Lipedema is classically defined as an adipose disorder with symmetric fat accumulation, often presumed to spare the lymphatic system until late-stages. However, mounting evidence from lymphoscintigraphy and ICGL suggests that lymphatic dysfunction may be intrinsic to lipedema. Subclinical lymphatic impairment has been reported even in early stages, challenging the historical separation between lipedema and primary lymphedema. Methods: From March 2022 to September 2024, 78 consecutive patients with clinically diagnosed lipedema were prospectively enrolled. Diagnoses were confirmed using standardized criteria by both vascular specialists and our team. All patients underwent four-limb indocyanine green lymphography to assess lymphatic architecture and flow dynamics. Results: All 78 patients (100%) demonstrated definitive lymphatic dysfunction in all four limbs on ICGL, regardless of lipedema stage or symptom burden. Only 11 patients (14.1%) reported overt leg swelling (7 unilateral, 4 bilateral), suggesting widespread subclinical lymphedema masked by the adipose phenotype. No patient exhibited normal lymphatic architecture in any limb, indicating systemic lymphatic involvement even in clinically "unaffected" arms and legs. Conclusion: Our findings support a paradigm shift: lipedema is not merely a fat disorder but a systemic, four-limb lymphatic disorder in all cases. These results suggest that primary lymphedema is universally present in lipedema patients, often subclinical, and detectable only through advanced imaging. Recognizing this lymphatic component may help explain the poor response to adipose-focused therapies and reframe lipedema as a disorder on the lymphatic disease spectrum.

Background: Lymph node-to-vein anastomosis (LNVA) is an emerging physiologic treatment for fluid-predominant lymphedema that combines the efficacy of lymphatic bypass with reduced technical complexity. Despite its advantages, LNVA is limited by challenges in identifying suitable lymph nodes and recipient veins. This study evaluated whether three-dimensional stereolithography (SLA) could improve surgical planning, intraoperative navigation, and efficiency in robotic LNVA.

Methods: A retrospective comparative study was conducted of 29 patients who underwent robotic inguinal LNVA between November 2024 and September 2025. Thirteen procedures were performed using standard robotic LNVA (control group), and sixteen were performed with the addition of SLA-assisted planning and navigation (study group). Patient-specific SLA models were created from contrast-enhanced CT data, segmented into lymph nodes, veins, arteries, and bony landmarks, and printed at 1:1 scale for incision planning and real-time intraoperative reference. Outcome measures included operative time, time to identification of target structures (TITS), surgeon-perceived operative difficulty (SPOD), and early patient-reported outcomes.

Results: Mean operative time was similar between groups (171 vs. 161 minutes), but TITS was significantly shorter with SLA (36 vs. 27 minutes; p = 0.021). Double LNVA was achieved in 69% of SLA cases compared with 8% of controls, without prolonging operative duration. SPOD was significantly lower in the SLA group (p < 0.001). All anastomoses were patent intraoperatively, and all patients reported symptom relief at one month. Model fabrication required approximately eight hours and averaged $270 per case.

Conclusions: Stereolithography enhances robotic LNVA by providing a tangible three-dimensional roadmap that improves intraoperative orientation, reduces identification time, and enables multiple anastomoses without added operative burden. With modest cost and rapid production, SLA makes LNVA more precise, reproducible, and scalable, facilitating wider adoption and serving as a foundation for future outcome-based research.

Purpose: The Deep Inferior Epigastric Perforator (DIEP) flap is the the gold standard for autologous breast reconstruction, providing reliable soft-tissue replacement while preserving abdominal wall musculature.(1) Donor-site hernia and abdominal wall bulge remain clinically significant sources of morbidity. Retrorectus mesh reinforcement has been proposed to mitigate abdominal wall weakness; however, routine prophylactic use remains controversial due to concerns regarding infection risk, and uncertain outcomes. (2)(3) We aimed to quantify abdominal bulge incidence and evaluate whether routine retrorectus mesh (RRM) placement reduces donor-site morbidity.

Methods: We conducted a retrospective cohort study of patients who underwent unilateral or bilateral DIEP flap breast reconstruction at a single academic institution between January 2017 and July 2025. All procedures were performed by two microsurgeons using a standardized operative technique. Patients were stratified according to abdominal wall reinforcement strategy into retrorectus mesh (RRM) and no-mesh (NM) cohorts. The primary outcome was clinically or radiographically diagnosed donor-site hernia or abdominal wall bulge. Secondary outcomes included patient demographics, and postoperative complications, including donor-site infection and systemic medical morbidity. Minimum follow-up time was 6 months.

Results: A total of 402 patients were included (RRM: 268; Nm:134). Mean age at the time of surgery was 54 years, and BMI was 29 kg/m². Donor-site hernia or abdominal wall bulge occurred in 3/268 (1.1%) patients in the RRM group versus 27/134 (20.1%) in the NM group (RR 0.06, 95% CI, 0.02–0.18; p < 0.001). The absolute risk reduction was 19.0%, corresponding to a number needed to treat (NNT) of 6 to prevent one donor-site hernia or bulge. Overall medical complications occurred in 15.3% of patients, including pulmonary embolism (1.6%), venous thromboembolism (3.2%), cellulitis (7.3%), and pneumonia (0.8%). Return to the operating room occurred in 3% of patients, most commonly for abdominal wound debridement, evacuation of hematoma, or flap-related complications. Three flap failures were observed. Donor-site infection rates were similar between groups (2.9% vs 2.6%, p > 0.05).

Conclusion: Routine retrorectus mesh placement during DIEP flap reconstructions was associated with a statistically significant reduction in donor-site hernia and abdominal wall bulge without an increase in donor-site infection or overall medical complications. With a NNT of 6, retrorectus reinforcement is demonstrably a safe and highly effective strategy to mitigate donor-site complications. Surgeons should consider its routine use, particularly in patients at elevated risk for abdominal wall weakness, to enhance reconstructive durability and optimize patient-centered outcomes.

References 1. Nelson JA, Fischer JP, Wink JD, et al. Enhanced recovery pathways in microsurgical breast reconstruction: a systematic review and meta-analysis. Plast Reconstr Surg. 2023;151(4):789-799. doi:10.1097/PRS.0000000000012846 2. Liu DZ, Mathes DW, Neligan PC. Antibiotic prophylaxis in plastic surgery: from evidence to practice. Ann Plast Surg. 2022;89(3):e1-e7. doi:10.1097/SAP.0000000000004650 3. Neligan PC. Perioperative care in microsurgical breast reconstruction: enhanced recovery pathways. Plast Reconstr Surg. 2017;139(5):1056e-1063e. doi:10.1097/PRS.0000000000003768

Background: Lymphovenous bypass (LVB) is an established microsurgical treatment for lymphedema, yet selection criteria vary widely across institutions. Appropriate patient selection is critical, as LVB depends on the presence of functional lymphatic vessels and favorable tissue characteristics. We performed a systematic review to characterize contemporary protocols for LVB candidate selection, including imaging modalities, physiologic requirements, disease stage, and clinical criteria. Methods: A systematic review was conducted of studies reporting explicit protocols or criteria for LVB selection with over 24 months of follow-up. Extracted variables included imaging modalities used for lymphatic mapping, disease stage inclusion criteria, requirement for conservative therapy failure, physiologic and tissue characteristics, and use of disease duration in selection. Results: Twenty-one studies published between 2004 and 2025 met inclusion criteria, encompassing 1,258 patients evaluated for LVB. Study designs included 12 prospective studies, 8 retrospective studies, and 1 randomized controlled trial. 5 studies evaluated upper-extremity lymphedema, 10 studies evaluated lower-extremity lymphedema, 5 studies included both upper- and lower-extremity disease, and 1 study evaluated head and neck lymphedema. Indocyanine green (ICG) lymphography was the most frequently used imaging modality for candidate selection, reported in 10 of 21 studies (48%), followed by lymphoscintigraphy in 5 studies (24%), ultrasound in 4 studies (19%), and MR lymphangiography in 1 study (5%). Several studies used multiple imaging modalities in combination. The presence of patent lymphatic vessels was explicitly required for surgical candidacy in 8 studies (38%). Disease stage was a major determinant of patient selection. Seven studies (33%) restricted inclusion to early-stage disease (ISL stage I–II). An additional eight studies included later-stage disease but still predominantly treated early-stage patients, resulting in 15 of 21 studies (71%) primarily operating in early-stage disease. Failure of conservative therapy prior to surgery was required in 10 studies (48%), typically following a defined course of compression therapy or complex decongestive therapy. Notably, disease duration was used as a selection criterion in only 5% of studies, indicating that physiologic lymphatic function rather than chronicity determines candidacy. Conclusion: Modern LVB selection protocols prioritize physiologic lymphatic function and clinical disease stage over disease duration. The typical candidate is a patient with early-stage (ISL I–II) lymphedema, demonstrable patent lymphatic vessels on ICG lymphography, and persistent symptoms despite conservative therapy. ICG lymphography has emerged as the dominant global selection modality. These findings support a physiology-driven selection paradigm and help define consensus criteria for optimal LVB candidacy, which may improve surgical outcomes and standardize patient selection across centers.

Background: Lower extremity free flap reconstruction (LE FFR) is a complex limb salvage intervention associated with considerable direct and indirect costs. Yet, the personal financial impact on patients remains poorly characterized. This study evaluates financial toxicity experienced by patients following LE FFR and identifies associated risk factors.

Methods: A cross-sectional survey of 146 patients who underwent LE FFR at two Level I trauma centers between 2002 and 2025 assessed financial burden (composite score 0-6) and financial worry (5-point Likert scale). Multivariable negative binomial and ordinal logistic regression models identified factors associated with financial burden and worry scores. Outcomes were stratified by defect etiology and anatomic location.

Results: Substantial financial hardship was prevalent despite patients residing in areas with low neighborhood deprivation (median ADI 21) and 97.3% insurance coverage; 51.4% of patients reported financial burden, and 28.8% experienced high financial worry. Employment-related variables were the only significantly associated factors with financial toxicity. Patients retired before surgery had 89.4% lower financial burden (IRR=0.106, p<0.001) and 97% lower financial worry (OR=0.03, p<0.001) compared to those previously employed, while patients with other employment status (student/disabled) had 77% lower financial worry (OR=0.23, p=0.022). Delayed return to work was strongly associated with both outcomes: patients returning at approximately 12 months had 5.57-fold higher odds of worry (p=0.008) and 4.39-fold higher burden (p<0.001). By 12 months, 68% were able to return to work. Strikingly, one in six employed patients (15.5%) was never able to return to work. Patients with high worry demonstrated significantly delayed return to work beyond 12 months (66.7% vs 13.4%; p<0.001). Clinical factors including defect etiology, anatomic location, complications, and number of surgeries showed no significant association with financial outcomes in multivariable analysis.

Conclusions: Patients undergoing LE FFR face substantial financial hardship despite a high prevalence of insurance coverage. Financial toxicity appears to be primarily driven by employment disruption rather than clinical factors. The persistence of substantial financial burden and worry, even in the context of relatively favorable socioeconomic conditions, highlights the importance of addressing and further studying financial distress in patient populations with less access to care and higher neighborhood deprivation. Targeted financial counseling programs that emphasize rehabilitation and early return-to-work interventions may help direct resources more effectively to mitigate financial hardship and improve outcomes.

Purpose: Abdominal wall laxity and pelvic floor disorders like pelvic organ prolapse (POP) and stress urinary incontinence (SUI) rank among the most common indications for elective surgery among adult women. However, the approach to surgical repair remains largely siloed within plastic surgery and urogynecology, respectively. Although these conditions share common risk factors (age, multiparity, obesity), the relationship between body-contour operations and PFDs is poorly understood. Some surgeons posit that abdominal contour procedures improve PFDs by decreasing abdominal wall pull/restoring core support via rectus plication, while others believe they worsen PFDs by increasing intraabdominal pressure (IAP), thus loading the pelvic floor. Given these potentially conflicting impacts, plastic surgeons need more robust data to better guide their patients.

Aims: The primary aim of this study was to define the incidence of surgery for POP and SUI following panniculectomy and abdominoplasty among women. Our secondary aim was to examine the impact of abdominal contour operations on the rates of other IAP-associated conditions: gastroesophageal reflux (GERD), inguinal hernia, and anterior abdominal wall hernia.

Methods: Women who underwent panniculectomy or abdominoplasty from 1995 to 2021 were identified from Truven Health MarketScan database and age-matched to controls who did not undergo abdominal contour surgery. To avoid survival bias, all controls were assigned a 'pseudo surgery' date to correspond with the follow-up of their matched case. Women in any group who had surgery for POP or SUI prior to the abdominal contour surgery (or 'pseudo surgery' for controls) were excluded. Primary outcomes included surgery for POP or SUI. Secondary outcomes included GERD, inguinal hernia, and abdominal wall hernia diagnoses. After controlling for age, presence of obesity, and surgery type, we ran multivariable Cox proportional hazard models on time from initial abdominal contour surgery to each primary and secondary outcome.

Results: This study included 33,071 adult women [age: 47 (range 39-55); BMI 32.3 kg/m2 (range 27.6-37.5), 80.5% urban residents]. Compared to controls, abdominal contour operations significantly elevated the incidence of surgery for both POP [panniculectomy: HR 3.6 (CI 2.5-5.1, p<0.001); abdominoplasty: HR 4.8 (CI 3.4-6.9, p<0.001)] and SUI [panniculectomy: HR 2.6 (CI 1.8-3.6, p<0.001); abdominoplasty: HR 4.0 (CI 2.9-5.5, p<0.001)]. Relative to abdominoplasty, patients undergoing panniculectomy alone, had a modest, but significantly lower progression rate to surgery for POP (HR 0.74, p=0.014) and SUI (HR 0.64 p<0.001). Abdominal contour operations also substantially increased progression to IAP-related diagnoses: GERD HR 1.5 (CI 1.4-1.6 p<0.001), inguinal hernia HR 5.1 (CI 3.0-9.2 p <0.001), and anterior abdominal wall hernia [panniculectomy: HR 12.7 (CI 10.9-14.7, p<0.001); abdominoplasty: 12.3 (CI 10.6-14.3, p<0.001)].

Conclusions: Abdominal contour operations significantly increased the risk of surgery for POP and SUI, with abdominoplasty having a greater impact than panniculectomy alone. Given similar trends among other IAP-related diagnoses, our findings indicate that abdominal wall tightening-likely through its increase on IAP-worsens or precipitates PFDs. We propose that plastic surgeons should screen for PFDs before and after abdominal surgery, counsel patient on the risks of precipitating PFDs, and situate these risks within their patient's holistic goals before offering contour operations.

Background: Traditional lymphedema progression describes gradual transition from fluid-dominant to fat-dominant disease. However, some early-stage patients present with severe fat accumulation despite minimal lymphatic dysfunction on lymphoscintigraphy. This study identifies risk factors for severe early fat accumulation (SEFA) to guide appropriate treatment selection.

Methods: A retrospective review of 187 extremity lymphedema patients at National Taiwan University Hospital Yunlin Branch (2017-2024) was conducted. Fat accumulation severity was assessed using International Society of Lymphology staging, while lymphatic dysfunction was evaluated by Taiwan Lymphoscintigraphy Staging. SEFA was defined as early lymphoscintigraphy staging (P1 or P2) with clinical classification as ISL stage 3. Logistic regression and Fisher's exact test identified associated factors.

Results: Mean age was 58.7±13.3 years with 79.1% female predominance. BMI, lymphedema duration, and lymphoscintigraphy staging correlated with progressive fat accumulation. Multivariate analysis revealed younger age (OR=0.86, p=0.045) and higher BMI (OR=1.37, p=0.02) as significant SEFA predictors. Male gender (p=0.004) and infection-related etiology (p<0.001) were additional risk factors, with 80% of infection-caused cases developing SEFA versus 5.3% of non-infectious cases.

Conclusions: Younger age, higher BMI, male gender, and infection-related etiology significantly predict severe early fat accumulation in lymphedema. Recognition of these factors enables appropriate treatment planning, indicating debulking procedures rather than physiological procedures alone for optimal outcomes in fat-dominant disease, even with early-stage lymphoscintigraphy findings.

Background The ability to predict how much tissue beyond the midline will be perfused by a single perforator remains a key challenge in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction. Overestimation of the amount of flap that can be perfused beyond midline can lead to risk of fat necrosis and flap compromise, while underestimation may lead to unnecessary bipedicle harvest. Computed tomography angiography (CTA) accurately maps perforator anatomy and enables volumetric planning (1); however, its role in predicting perfusion territory remains underexplored. The perforasome theory suggests that the distance between perforators has an effect on the volume of tissue perfused (2). Therefore we planned a study which will evaluate whether CTA-derived inter-perforator distance can serve as a preoperative surrogate marker for cross-midline perfusion and safe flap harvest. Methods A prospective observational study was conducted in 43 women undergoing DIEP flap breast reconstruction. Preoperative CTA identified dominant perforators and measured inter-perforator distance. Intraoperatively, perfusion beyond the midline was assessed using the scratch test, and harvested flap volume was recorded. CTA volumetry was used to compare hemiabdominal and contralateral breast volumes. Spearman correlation analysis evaluated relationships between inter-perforator distance, perfusion distance, and flap volume. Results Mean inter-perforator distance was 6.83 cm. Inter-perforator distance demonstrated a strong negative correlation with perfusion beyond the midline (ρ = −0.709, p < 0.00001), indicating that closer perforators were associated with greater cross-midline perfusion. A moderate negative correlation was observed between inter-perforator distance and harvestable flap volume (ρ = −0.484, p = 0.009). Patients with shorter inter-perforator distances demonstrated improved perfusion efficiency, allowing larger flaps to be safely harvested on a single perforator. Using this data in our cohort of patients we were also able to identify patients likely to require bipedicle flaps. Complication rates were low and flap safety was maintained when planning incorporated these parameters. Conclusions CTA-derived inter-perforator distance provides a practical imaging surrogate for predicting perfusion beyond the midline and estimating the volume of tissue that can be safely harvested on a single perforator. Incorporating this parameter into DIEP flap planning may reduce intraoperative uncertainty and improve flap safety. Clinical Relevance Inter-perforator distance transforms CTA from a perforator-mapping tool into a predictive planning instrument, enabling surgeons to anticipate perfusion territory and make evidence-based decisions regarding single- versus dual-pedicle DIEP flap harvest.

References 1. Eder M, Raith S, Jalali R, Mittermayr R, Papp C, Kopp J, et al. Three-dimensional prediction of free-flap volume in autologous breast reconstruction by CT angiography imaging. Plast Reconstr Surg. 2013;131(2):339-48. 2. Saint-Cyr M, Schaverien M, Arbique G, Hatef D, Brown SA, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(5):1529-44.

Background - Scalp defects from trauma, burns, infection, tumor excision or surgical interventions pose unique reconstructive challenges requiring a delicate balance between restoring both aesthetics and function. Traditional reconstructive methods often involve subjective decision-making, with variable outcomes based on surgeon experience and patient factors. A more structured, evidence-based approach is needed to standardize decision-making and improve results.

Objectives - This study aims to introduce an algorithmic approach to scalp defect reconstruction that standardizes decision-making, ensuring optimal cosmetic and functional outcomes. By considering patient-specific factors and defect characteristics, the algorithm provides a stepwise guide for selecting the most appropriate reconstructive techniques.

Methods - A retrospective three-year analysis of scalp defect reconstruction techniques was conducted. Defects were evaluated based on etiology, size, location, depth, and surrounding tissue availability. Reconstructive modalities included split-thickness skin grafting (STSG), local flaps (rotation, transposition), and microvascular free tissue transfer. Scalp defects amenable to primary closure or healing by secondary intention were excluded. Primary endpoints were wound healing and complication rates. Secondary endpoints included functional recovery, cosmetic outcome (assessed via Likert scale), and patient satisfaction (Patient Satisfaction Index). Based on this analysis, an algorithmic approach to select the appropriate reconstruction technique was proposed.

Results - The study included one-hundred-six patients (mean age: 39.6 years; male-to-female ratio 4:1). Trauma (51%) was the most common etiology. Combined-region defects (39.6%) were the most frequent location, and bone exposure was present in 88% of cases. Scalp reconstruction techniques included skin grafting, loco-regional flaps, and free flaps. Rotation flaps were the most frequently performed procedure (36.8%), followed by transposition flaps (29.7%), free flaps (20.7%), and skin grafting (12.8%). Specifically, 92% of patients treated with rotation flaps demonstrated statistically superior outcomes compared to other modalities, and achieved 'Good' functional recovery, and 77% achieved 'Good' cosmesis. Conversely, STSG was associated with intermediate functional results and poor cosmesis in 100% of cases. The overall complication rate was 8.5% (n=9), including partial graft loss (n=5), partial necrosis of local flaps (n=3), and one free latissimus dorsi flap failure.

Conclusions - Locoregional tissue rearrangement-particularly rotation flaps-remains the reconstructive modality of choice for moderate-sized scalp defects, demonstrating statistically significant superiority in both functional and cosmetic outcomes. compared to skin grafting. While free tissue transfer is essential for massive composite defects, local flaps should be maximized whenever the surrounding scalp tissue is viable. The proposed algorithmic approach to scalp defect reconstruction provides a standardized, evidence-based framework that optimizes cosmetic and functional outcomes. It enhances surgical precision, minimizes complications, and improves overall patient satisfaction.

References: 1. Sandhir RK. Learn to climb the simple reconstructive ladder properly for optimum results. Indian J Plast Surg. 2018;51(3):331-2. 2. Steiner D, Horch RE, Eyüpoglu I, Buchfelder M, Arkudas A, Schmitz M, et al. Reconstruction of composite defects of the scalp and neurocranium-a treatment algorithm from local flaps to combined AV loop free flap reconstruction. World J Surg Oncol. 2018;16(1):217. 3. Krishna D, Khan MM, Dubepuria R, Chaturvedi G, Cheruvu VPR. Reconstruction of Scalp and Forehead Defects: Options and Strategies. Cureus. 2023;15(7): e41479.

Background: Restoring dynamic facial movement in incomplete Moebius syndrome remains a significant reconstructive challenge. These patients often present asymmetrically, retaining partial facial movement, which complicates surgical planning. Traditional dynamic facial reanimation, including free functional muscle transfer (FFMT), has relied on single nerve inputs, potentially delaying spontaneous, emotionally-driven movement. Dual-innervated FFMT using both the ipsilateral masseteric nerve and a cross-facial nerve graft (CFNG) has emerged as a promising strategy to achieve early movement while promoting cortical integration for a spontaneous smile. The masseteric nerve provides strong immediate contraction, whereas the CFNG supports long-term, coordinated activation through the contralateral facial nerve. This technique represents an innovative, standardized approach addressing the unique challenges of incomplete Möbius syndrome.

Methods: Ten consecutive patients underwent single-stage gracilis FFMT with dual innervation. Surgical technique included: (1) harvest of a CFNG from the sural nerve coapted to the contralateral facial nerve (typically the branch to zygomaticus major) and (2) ipsilateral masseteric nerve coaptation. End-to-End coaptation was performed to the masseteric nerve, and end-to-side coaptation to the CFNG using microsurgical techniques under microscopic magnification (Kinevo, Carl Zeiss). Demographics, laterality, operative time, intraoperative considerations, and early functional outcomes were recorded. Donor site morbidity was minimal.

Results: The cohort was predominantly pediatric (mean age 11.8 years,range 5–25), with equal distribution of unilateral and bilateral paralysis. Mean operative time was ~7 hours. All flaps were successfully transferred without intraoperative complications or flap failures. Early return of movement (within 4–6 months) was primarily masseteric driven, providing immediate dynamic function. Most patients demonstrated spontaneous smile activation within the first year, suggesting successful cortical integration via the CFNG. The dual-innervated technique proved feasible, reproducible, and adaptable across variable anatomy, while preserving residual native facial function.

Conclusions: Dual-innervated gracilis FFMT is a safe, reproducible, and standardized technique for incomplete Möbius syndrome. By combining immediate masseteric-driven movement with potential for spontaneous smile via CFNG, this approach balances early functional restoration with long-term cortical integration. Its reliability across patients and operative settings provides a practical framework for standardized care in this challenging population.

Purpose: Single-stage reconstruction of full-thickness cutaneous defects with meshed split-thickness skin graft (mSTSG) supplemented by autologous skin cell suspension (SCSA) has demonstrated reliable epithelialization (1); however, contour stability and pliability remain limitations. The addition of bovine dermal collagen matrix (BDCM) (2) may provide structural support and improve long-term soft tissue quality. We evaluated outcomes of single-stage oncologic reconstruction using SCSA-enhanced mSTSG with BDCM. Methods: A retrospective review was conducted on patients undergoing reconstruction of defects that resulted from excision of squamous cell carcinoma, basal cell carcinoma, and other complex lesions involving the scalp, nose, forehead donor site, forearm, and upper back. All patients received SCSA-enhanced fenestrated sheet graft or 1.5:1 meshed split-thickness skin grafts (0.016 inch). A subset of this group also had the placement of BDCM under the grafts. Outcomes assessed included graft take, complications, graft contracture size, contour depth. Experience: Fourteen consecutive patients (age 32–82 years) undergoing single-stage reconstruction using split-thickness skin graft (mSTSG) supplemented by autologous skin cell suspension (SCSA) following oncologic excision between December 2023 and January 2025 were reviewed. Six of these patients underwent adjunctive placement of BDCM at the time of reconstruction. Results: All fourteen patients with autologous skin cell suspension and STSG achieved successful reconstruction without need for staged procedures. The BDCM cohort with single-stage reconstruction demonstrated 100% graft take, including in wounds with bacterial colonization. Mean skin graft contracture for BDCM progressed at 3–4 mm per week through 11 weeks postoperatively. Qualitative assessment revealed improved pliability and texture in the BDCM cohort. Two complications occurred (one hematoma in an anticoagulated patient and one localized infection), neither resulting in graft loss. Patients undergoing BDCM-assisted reconstruction required fewer secondary procedures and fewer postoperative clinic visits. The patient shown in Figure 1 underwent successful reconstruction of the basosquamous cell carcinoma defect with a posteriorly based rotation scalp flap and anteriorly with a fenestrated skin graft with underlying BDCM. Conclusions: Incorporation of BDCM into SCSA-enhanced mSTSG reconstruction was associated with reliable graft take, improved contour stability, increased skin pliability, reduced concavity, and decreased need for revision compared with SCSA-enhanced grafting alone. The addition of a dermal scaffold may improve graft outcomes while preserving the advantages of single-stage reconstruction. This approach offers a structurally reinforced, resource-conscious option for complex oncologic defects.

References:

1. Henry, S., et al., Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting. J Trauma Acute Care Surg, 2024. 96(1): p. 85-93.
2. Bush, K.A., et al., Bovine Dermal Collagen Matrix Promotes Vascularized Tissue Generation Supporting Early Definitive Closure in Full-Thickness Wounds: A Pre-clinical Study. Cureus, 2025. 17(3): p. e81517.

Purpose: To compare peri-operative and postoperative outcomes in pediatric patients with non-idiopathic scoliosis undergoing posterior spinal fusion with and without prophylactic muscle flap closure.

Methods: A retrospective review was performed of pediatric patients with non-idiopathic scoliosis who underwent posterior spinal fusion at a single institution from 2018 to 2025. Ninety patients were included in the study; 35 underwent prophylactic muscle flap closure and 52 underwent standard closure. Outcomes assessed included hospital length of stay, emergency department visits, readmissions, re-operations, and postoperative complications, including infection.

Results: Patients receiving prophylactic muscle flap closure had significantly larger preoperative Cobb angles (mean 91.9° vs 74.8°, p = 0.012). A greater pre-operative kyphosis angle and degree of pelvic obliquity was observed in the prophylactic flap group (mean 47.5° vs 40.6°, p = 0.274 and mean 23.7° and 19.1°, p = 0.237 respectively). Pelvic instrumentation was more common in the muscle flap cohort (80.0% vs 69.2%), though not statistically significant (p = 0.258). Operative times were longer in the muscle flap group (p < 0.001). Estimated blood loss and transfusion requirements were similar. No significant differences were observed in length of stay, emergency department visits, readmissions, re-operations, or overall complication rates. Despite greater surgical complexity, the muscle flap cohort demonstrated a lower postoperative infection rate compared with standard closure (2.9% vs 9.6%), corresponding to a 70% risk reduction, though not statistically significant (relative risk 0.297, p = 0.395). Additionally, as the number of flap procedures performed for a given patient increased, there was a trend towards fewer observed complications (p = 0.094).

Conclusion: Prophylactic muscle flap closure in pediatric non-idiopathic scoliosis patients undergoing posterior spinal fusion was associated with comparable outcomes despite increased surgical complexity. Although not statistically significant, the observed 70% infection risk reduction may be clinically meaningful when considering morbidity and resource utilization. These findings support prophylactic muscle flaps as a valuable strategy in high-risk pediatric spine surgery.

The purpose of this study is to utilize a large-scale national database to identify specific risk factors predicting adverse outcomes following traumatic upper extremity (UE) soft tissue reconstruction in a primarily civilian setting.

A retrospective cohort review was conducted using the Trauma Quality Improvement Program/National Trauma Databank from January 2019 to December 2023. Patients who underwent UE reconstruction were identified using ICD-10 procedure codes. The primary outcomes evaluated were surgical site infection (SSI), secondary amputation, hospital length of stay (LOS), need for free flap reconstruction, and discharge disposition. Multivariable logistic regression models were developed to identify independent predictors of these outcomes. The study cohort comprised 10,543 unique patient admissions who underwent a total of 12,281 reconstructive procedures.

The median patient age was 38 years, and the majority were male (78.1%). Most injuries were the result of blunt trauma (73.5%). The median time to initial reconstruction was 21.9 hours, and 38.9% of all flap reconstructions performed were free flaps. The overall cohort SSI rate was 1.3%, the median LOS was 4 days, and the secondary amputation rate following reconstruction was 4.0%. Multivariable regression analysis demonstrated that free flap reconstruction independently predicted SSI (OR 2.15), secondary amputation (OR 2.30), and prolonged LOS >4 days (OR 19.32). The odds of secondary amputation were also strongly predicted by an ipsilateral vascular intervention prior to reconstruction (OR 2.79) and a mangled UE diagnosis (OR 2.84). Additionally, pre-existing diabetes mellitus significantly increased the risk of secondary amputation (OR 2.23). A prolonged LOS was most strongly driven by the presence of an SSI (OR 49.90).

This study provides the largest nationally-based analysis of outcomes following upper extremity reconstruction to date. While limb salvage is successfully achieved in the vast majority of UE trauma patients, the requirement for free tissue transfer, pre-reconstruction vascular interventions, a mangled extremity diagnosis, SSI, and diabetes are powerful independent predictors of secondary amputation and prolonged hospitalization. These national-level predictors provide a critical framework to facilitate realistic preoperative patient counseling and comprehensive risk stratification for complex reconstructive efforts.

Purpose: Trochanteric pressure ulcers in patients with chronic immobility remain a reconstructive challenge due to high rates of osteomyelitis, recurrence, and wound breakdown. The tensor fascia lata V-Y hatchet myocutaneous flap combines reliable vascularity with enhanced advancement capability and tension-free donor-site closure. This study evaluates long-term outcomes of the hatchet V-Y tensor fascia lata flap for trochanteric pressure ulcer reconstruction over a 20-year single-center experience.

Methods: A retrospective cohort study was conducted including all consecutive adult patients who underwent trochanteric pressure ulcer reconstruction using the tensor fascia lata V-Y hatchet flap between January 2004 and December 2024. Demographics, comorbidities, smoking status, ulcer characteristics, operative parameters, complications, healing outcomes, recurrence, donor-site morbidity, and patient satisfaction were analyzed. Associations between clinical variables and postoperative outcomes were assessed using appropriate statistical tests, with significance set at p < 0.05.

Results: Twenty-five patients were included. The majority were male (76 percent), with spinal cord injury as the universal etiology of immobility. Stage IV ulcers predominated (80 percent), and osteomyelitis was present in 88 percent. Mean ulcer duration prior to surgery was 20.0 months.

Mean operative time was 123 minutes and mean blood loss was 172 mL. Flap survival was achieved in 92 percent of patients. Complete healing occurred in 92 percent at a mean of 4.3 weeks. Recurrence was observed in 8 percent during a mean follow-up of 22 months. No patient required reoperation.

Overall complications occurred in 64 percent, largely minor and managed conservatively. The most common complications were flap-edge necrosis and seroma (24 percent each). Donor-site morbidity occurred in 36 percent, most commonly hypertrophic scarring and wound dehiscence.

Smoking was significantly associated with postoperative complications (p = 0.027) and donor-site morbidity (p = 0.041). Flap viability was strongly associated with healing outcome (p < 0.001) and morbidity (p = 0.049). Higher intraoperative blood loss was associated with donor-site morbidity (p = 0.022). Patient satisfaction was favorable, with 88 percent reporting very good or excellent outcomes.

Conclusions: The tensor fascia lata V-Y hatchet flap is a reliable option for reconstruction of advanced trochanteric pressure ulcers, demonstrating high flap survival, excellent healing rates, and low recurrence over long-term follow-up. Smoking is a significant modifiable risk factor associated with complications and donor-site morbidity. Careful patient optimization and meticulous surgical technique are critical to achieving durable outcomes in this high-risk population.

Introduction Patients with Gustilo-Anderson type III lower extremity fractures were traditionally recommended to have soft tissue reconstruction within 72 hours. However, contemporary evidence and guidelines support definitive coverage within 7 days (1-3). Factors contributing to delays beyond this window remain poorly characterized. Our objectives were to describe national trends in soft-tissue coverage timing, identify factors associated with delayed coverage, and evaluate the association between coverage timing and infectious complications. Methods and Materials The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) database was reviewed (2017-2024) for Gustilo-Anderson type III lower extremity fractures requiring soft-tissue coverage. Delayed coverage was defined as >7 days according to ACS guidelines (3) and >10 days according to literature proposed cutoffs (1). Separate multivariable logistic regression models were fit for the occurrence of coverage >7 and >10 days with covariates including patient, injury, hospital, and treatment factors. To assess the association between delayed coverage with infectious complications, multivariable logistic regression models were fit to estimate the odds of any wound infection, deep surgical site infection (dSSI), and osteomyelitis. Separately, time to definitive coverage was also modeled as a single categorical covariate (<7 days, 7–10 days, and >10 days) comparing timeframes. Results From 2017 to 2024, 5,255 patients sustained Gustilo–Anderson type III lower extremity fractures requiring soft-tissue reconstruction. Definitive coverage occurred within 72 hours cumulatively in 337 (6.4%) patients, within 7 days in 1,830 (34.8%), and within 10 days in 2,680 patients (50.9%). In adjusted models, older age, obesity, ICU admission, higher summed-abbreviated injury severity (AIS) score, and >3 fixation procedures were independently associated with higher odds of coverage after both >7 and >10 days. The use of pedicle flaps was associated with lower odds of delayed coverage. Coverage >7 and >10 days were associated with higher odds of wound infection (> 7 days aOR 2.93, 95% CI 2.00-4.44;> 10 days aOR 3.63, 95% CI 2.60-5.15), dSSI (>7 days aOR 2.89, 95% CI 1.82-4.83;>10 days aOR 3.67, 2.45-5.66), and osteomyelitis (>7 days aOR 6.83, 95% CI 3.02-19.60;>10 days aOR 4.75, 95% CI 2.68-9.12). Coverage within 7–10 days was not associated with increased infectious complications compared with <7 days, whereas coverage >10 days was associated with higher odds of any wound infection, deep SSI, and osteomyelitis within 30 days after controlling for other factors. Conclusion Multiple factors are associated with delayed coverage beyond currently recommended timeframes, increasing the risk of infectious complications. Targeted system-quality improvement initiatives to build capacity, resources, and access could improve time to coverage and outcomes.   References 1. Habarth-Morales TE, Davis HD, Ríos-Díaz AJ, et al. The Godina Principle in the 21st Century: Free Flap Timing after Isolated Lower Extremity Trauma in a Retrospective National Cohort. J Reconstr Microsurg. Jul 2025;41(6):469–477. doi:10.1055/a-2404-7634 2. Lee ZH, Stranix JT, Rifkin WJ, et al. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm. Plast Reconstr Surg. Sep 2019;144(3):759–767. doi:10.1097/PRS.0000000000005955 3. American College of Surgeons. ACS TQIP Best Practices in the Management of Orthopaedic Trauma. Accessed 1/15/2026, 2026. https://www.facs.org/media/mkbnhqtw/ortho_guidelines.pdf

Fitness-To-Flap (F2F) Score: A Novel Algorithmic Framework for Pre-Flap Patient Optimization

Introduction: Flap reconstruction for pressure injuries and complex soft tissue defects carries reported complication rates of 20–40% and recurrence rates of 20–30% (1–3). Although numerous risk factors have been identified, determination of "fitness for flap" remains largely subjective, and existing surgical risk scores inadequately address complex wound reconstruction. We developed the Fitness-To-Flap (F2F) Score as an AI-assisted, evidence-grounded conceptual framework to standardize pre-flap patient optimization.

Methods: We performed a targeted review of six published retrospective flap reconstruction cohorts, supplemented by a mechanistic biomarker study on wound healing (1-5). Independent multivariable regression models associated with complications and recurrence were extracted using AI-assisted software, followed by two rounds of human verification. Pooled relative risks and effect sizes were synthesized in structured spreadsheets. A machine learning model weighted variables proportionally to their independent association with adverse flap outcomes.

Results: Analysis of six flap cohorts (n=723) identified independent predictors of complications and recurrence, including hypoalbuminemia, active infection, osteomyelitis, prior flap failure at same site, uncontrolled diabetes, active smoking, severe peripheral vascular disease, previous radiotherapy, poor functional status, and inadequate offloading and social support (1-4). Laboratory markers such as elevated procalcitonin, C-reactive protein, and leukocyte count, were incorporated as proxy indicators of a persistent inflammatory state impairing wound healing (5). Effect sizes guided score weighting across four domains: biomarkers and nutrition, local wound factors, systemic comorbidities, and functional status with social support. The resulting 0-30 points score stratifies patients into four tiers: low risk (0-5 pts), immediate reconstruction with standard preoperative measures; moderate risk (6-12 pts), prompting 1-2 week of targeted optimization; high risk (13-19 pts), delayed reconstruction after 2-4 week of aggressive optimization; and not ideal candidate (≥20 pts), favoring non-operative and palliative strategies. Patients may be reassessed and down-staged following optimization.

Conclusions: The F2F Score offers a novel and practical tool to standardize preoperative evaluation for flap reconstruction. By organizing known risk factors into a four-domain scoring system, it reduces subjectivity in candidacy decisions and emphasizes concrete optimization strategies. Ongoing prospective validation will determine its predictive performance and clinical impact. For now, it provides a useful framework for clinical discussion, patient counseling, and deliberate preoperative planning.

References 1. Bamba R, Madden JJ, Hoffman AN, et al. Flap reconstruction for pressure ulcers: an outcomes analysis. Plast Reconstr Surg Glob Open. 2017;5(1):e1187. 2. Keys KA, Daniali LN, Warner KJ, Mathes DW. Multivariate predictors of failure after flap coverage of pressure ulcers. Plast Reconstr Surg. 2010;125(6):1725-1734. 3. Kierney PC, Engrav LH, Isik FF, et al. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg. 1998;102(3):765-772. 4. Larson DL, Hudak KA, Waring WP, Orr MR, Simonelic K. Protocol management of late-stage pressure ulcers: a 5-year retrospective study of 101 consecutive patients with 179 ulcers. Plast Reconstr Surg. 2012;129(4):897-904. 5. Hahm G, Glaser JJ, Elster EA. Biomarkers to predict wound healing: the future of complex war wound management. Plast Reconstr Surg. 2011;127 Suppl 1:21S-26S.

Background: Preoperative imaging for vascular mapping of superficial circumflex iliac perforator (SCIP) flaps has traditionally relied on angiography. Recently, duplex ultrasonography (US) has emerged as a less invasive, more accessible alternative, yet its effectiveness compared to conventional imaging methods remains understudied. This study evaluates the use of preoperative imaging, particularly duplex US, in planning SCIP flap reconstruction. Methods: A retrospective cohort study was conducted at a tertiary academic institution, including all patients who underwent lower extremity (LE) SCIP flap reconstruction between 2015 and 2024. Demographic variables, injury characteristics, preoperative imaging methods, flap details, and postoperative complications were reviewed. The primary outcomes included flap revision rates, flap survival, infection, flap necrosis, and osteomyelitis. Statistical analyses utilized chi-squared and logistic regression models, adjusting for covariates. Results: Thirty-six SCIP flaps were performed during the study period. Eighteen (50%) had preoperative vascular imaging: 15 (83.3%) were for routine preoperative planning, and 3 (16.7%) were due to suspected arterial injury. Imaging modalities included duplex US (n=6, 33.3%), CT angiography (n=5, 27.8%), and formal angiography (n=7, 38.9%). There were no significant differences in flap survival, infection rates, flap necrosis, or osteomyelitis between patients who received imaging and those who did not. However, flap revision was significantly less likely in the imaging group compared to the non-imaging group (0% vs. 22%; p=0.034) after adjusting for covariates. Among those who received preoperative imaging, there were no significant differences in flap outcomes when controlling for covariates. Conclusion: Our findings support duplex ultrasonography as an effective and minimally invasive modality for preoperative vascular planning in SCIP flap reconstruction. The significant reduction in flap revision rates with preoperative imaging emphasizes its potential clinical advantage. Duplex US provides rapid, accurate visualization of perforator vessels without the invasiveness or radiation exposure associated with traditional angiographic techniques. Future prospective studies should focus on further validating duplex US efficacy, optimizing protocols for imaging, and evaluating patient outcomes over longer follow-up periods to solidify its routine use in reconstructive microsurgery.

• Purpose Traumatic limb amputation imposes unique patient demographics, anatomical involvement, and disease severity. The successful adoption of durable prostheses substantially reduces physical, psychological, and social burdens, thereby improving overall quality of life. This study retrospectively analyzed the clinical characteristics of patients with traumatic major limb amputations and identified prognostic factors associated with successful prosthesis adoption one year after the event.

• Material and methods A retrospective review of traumatic major limb amputations performed at a tertiary medical center from January 2013 to July 2025. Inclusion criteria were patients who underwent major upper- or lower-limb amputation due to trauma. Exclusion criteria included non-traumatic indications and insufficient follow-up. Collected variables included patient demographics, trauma mechanism, injury severity score(ISS), anatomical region (e.g., amputation level), comorbidities, and interval time to amputation. Primary outcome was prosthesis adaption at one year. Secondary outcomes include mortality, overall complications, stump-related complications, or stump-related hospitalization. Associations between categorical variables and prosthesis use were assessed with Chi-square or Fisher's exact tests as appropriate. Binary logistic regression analysis was performed to determine factors independently increased the odds ratio (OR) for specific events.

• Results A total of 57 patients met the inclusion criteria (mean age 53.46±19.03 years; 72% male). Most injuries resulted from traffic accidents (42/57, 72%), and 36 patients (63%) had ISS ≥16. The overall mortality rate was 7%. Functional prosthesis use reached 70% at the 1-year follow-up. Univariate analyses demonstrated significant associations between prosthesis adoption and age ≤40 years (p = 0.044) and undergoing stump revision surgery (p = 0.024). Revision surgery was associated with an increased likelihood of durable prosthesis use (OR 3.81, 95% CI 1.15–12.58; p = 0.028), whereas diabetes mellitus and the presence of post-operative complications other than stump‑related issues were associated with lower odds of prosthesis adoption. Discontinuation of prosthesis use was significantly associated with comorbid diabetes (p = 0.031) and with complications other than stump‑related issues (p = 0.015).

• Conclusions Traumatic major limb amputation in younger patients-particularly those under 40 years of age and without concomitant diabetes-should prompt clinicians to adopt a more aggressive strategy for managing postoperative complications beyond stump-related issues, and to use a lower threshold for revision surgery to optimize residual-limb geometry and tissue quality for durable prosthetic fitting, thereby conferring a critical advantage for improving long-term quality of life.

Purpose Whole-eye transplantation (WET) represents a novel form of vascularized composite allotransplantation (VCA), yet noninvasive methods for local immune surveillance remain undefined. Tear proteomics has emerged in dry eye disease and autoimmune ocular disorders as a sensitive indicator of epithelial barrier disruption and innate immune activation. We longitudinally characterized tear proteomic changes in a WET recipient during a corneal abrasion and subsequent epithelial recovery.

Methods Schirmer strip tears were collected from the transplant and contralateral native eyes and from age- and sex-matched controls without ocular disease. Samples underwent mass spectrometry–based bottom-up proteomics with data-independent acquisition. Differential expression across baseline, abrasion, and recovery phases were assessed by fold-change analysis. Ingenuity Pathway Analysis (IPA) evaluated enriched immune pathways.

Results Proteomic profiling yielded >5,000 proteins per group. At baseline, the transplant eye demonstrated a distinct immune milieu compared with the native eye, characterized by enrichment of neutrophil-associated and innate immune proteins, including DEFA3, with relative depletion of lacrimal epithelial secretory proteins (PRR4, CST4, LCN1). Transition from pre-abrasion to abrasion was associated with suppression of tear-film epithelial proteins (PRR4 −2.44; CST4 −2.38; LCN1 −2.29) and enrichment of extracellular matrix and plasma-associated proteins (KERA +4.19; FGB +3.10; SERPINA1 +3.67; LPA +3.18), consistent with inflammatory barrier disruption and increased vascular/epithelial permeability. The abrasion phase represented peak innate immune activation, with marked enrichment of acute-phase and neutrophil-associated proteins (SAA1 +6.48; S100A12 +3.81; DEFA3 +4.17), followed by decline with clinical resolution. Post-abrasion samples demonstrated only partial restoration of tear-film homeostasis (PRR4 +3.87; CST4 +3.97; LCN1 +3.54). IPA demonstrated activation of innate immune, complement, Fc receptor–mediated phagocytosis, and B-cell signaling pathways in transplant versus control tears.

Conclusion Proteins upregulated during abrasion phase were consistent with inflammatory barrier disruption and increased vascular/epithelial permeability, and only partial restoration of tear-film homeostasis proteins were evidenced post-abrasion. WET patient's corneal abrasion improved with tacrolimus eyedrops and antibiotic ointment despite negative systemic rejection markers. The tear signature overlapped with non-transplant patterns reported in dry eye and autoimmune ocular disease - specifically innate inflammatory (S100-associated) signaling and tear-film homeostasis disruption - while uniquely exhibiting prominent complement activation in the transplant setting. Tear proteomics may provide a noninvasive platform for localized immune surveillance in WET.