Scientific Abstract Presentations: Reconstruction Session 6 Saturday, October 17 Sat, Oct 17 2:00-3:30 p.m. CDT

Background: The ideal timeframe for tissue expander to implant exchange following postmastectomy radiotherapy (PMRT) is not well defined. This study aimed to identify the optimal time to undergo exchange after PMRT therapy to minimize postoperative complications.

Methods: A multicenter retrospective cohort study was conducted on patients who underwent two-stage breast reconstruction with PMRT to the tissue expander between 2016-2025. The primary outcome was 90-day complication rate after permanent implant placement. Patients were excluded if they received neoadjuvant radiation therapy, PMRT to permanent implants, or did not complete the second stage of breast reconstruction.

Results: Final sample included 298 patients with an average age of 46.2 ± 10.2 years and BMI of 25.5 ± 5.0 kg/m². The mean interval between PMRT completion and implant exchange was 8.2 ± 5.4 months. ROC analysis identified >6.87 months as the optimal interval delay (AUC: 0.558). Patients who underwent earlier exchange (<6.87 months) experienced an increased overall complication rate after second stage reconstruction (14.8% vs. 6.7%, p=0.025), primarily greater rates of major infection (8.7% vs. 2.7%, p=0.025) and wound dehiscence (9.4% vs. 3.4%, p=0.033). When adjusting for covariates on multivariable logistic regression, earlier exchange (<6.87 months) remained independently associated with an increased risk of complication (OR: 2.255, 95% CI: 1.015-5.008, p=0.046).

Conclusion: This study found that delaying second stage reconstruction until at least 6.87 months after PMRT was associated with the lowest risk of 90-day complications. Incorporating this timeframe into surgical decision-making may help optimize patient outcomes and improve preoperative risk counseling.

Background: Precise localization and visualization of inguinal lymph nodes is critical in lymphatic surgery (lymph node-to-vein astomosis (LNVA)). While (newer) techniques such as 3D-printed anatomical models have improved surgical planning by offering tangible representations of patient anatomy, they are time-consuming to produce and add significant cost. Augmented reality (AR) offers a rapid, cost-effective alternative for intraoperative visualization of patient-specific structures. Methods: Using patient CT scans, we generated 3D reconstructions of lymphatic anatomy in the femoral and inguinal regions. These models were overlaid directly onto the patient using the Meta Quest 3 AR headset. Fiduciary skin markers were applied during imaging to enable manual alignment of the CT-derived models to the patient's body. We evaluated the accuracy of AR overlays, surgeon usability, and intraoperative integration across six OR cases. Additionally, we are developing software for automated registration to streamline workflow and improve precision. Results: The AR overlays demonstrated high anatomical fidelity, with accuracy constrained primarily by CT resolution and segmentation precision. Compared to traditional 3D printing workflows, AR implementation reduced preparation time from several days to under an hour. Surgeons reported improved spatial orientation and efficiency without increased cost or disruption to surgical flow. Conclusion: AR-based lymphatic localization using Meta Quest 3 is a promising, low-cost, real-time alternative to physical 3D models. Early operative use indicates strong potential to enhance surgical planning and intraoperative decision-making. Continued software refinement aims to achieve fully automated, markerless alignment, enabling broader clinical adoption.

Background: Head and neck microvascular free flap reconstruction is frequently challenged by compromised vessel conditions due to tumor extension, radiation therapy, and surgical scarring. Microvascular couplers effectively promote intima-to-intima contact, reducing thrombosis risk, but have limitations in vessel size compatibility and cost. We developed the Evert Style Vessel Anastomosis (ESVA) technique to achieve similar intimal apposition benefits without couplers and evaluated its efficacy and safety.

Materials and Methods: We retrospectively analyzed 32 patients who underwent head and neck microvascular free flap reconstruction between 2020 and 2024. Vessel conditions were classified as Type 1 (easily evertible), Type 2 (evertible with atherosclerosis/inflammation), Type 3 (technically difficult eversion), or Type 4 (non-evertible). Anastomoses were performed using either nylon or ACRI+Asflex sutures. The ESVA technique involved 90-degree needle insertion with external vessel wall eversion. Outcome measures included anastomosis time, vascular complications, and flap survival rates. Only end-to-end arterial and venous anastomoses were included in the present analyses.

Results: A total of 30 arterial and 31 venous anastomoses were performed using the ESVA technique. Three anastomoses involving Type 4 (non-evertible) vessels required conventional anastomosis without eversion. Among vessels suitable for ESVA, Type 2 vessels were most common, followed by Type 3 and Type 1. The mean arterial anastomosis time was significantly shorter with ACRI+Asflex sutures (20.8 ± 2.4 minutes) compared with nylon (23.4 ± 2.8 minutes; p = 0.007). Similarly, venous anastomosis time was reduced from 21.4 ± 2.7 minutes with nylon to 19.2 ± 1.2 minutes with ACRI+Asflex sutures (p = 0.007). In ESVA cases involving Type 1 and/or Type 2 vessels, ACRI+Asflex sutures significantly reduced arterial (20.8 vs. 23.4 minutes; p = 0.014) and venous (18.7 vs. 20.2 minutes; p = 0.04) anastomosis times. Even in anastomoses involving Type 3 vessels (either donor, recipient, or both), significant time reduction was observed for both arteries (23.0 vs. 25.6 minutes; p = 0.008) and veins (19.5 vs. 24.8 minutes; p <0.001). No macroscopic intimal damage was observed under operative microscopy, and no vascular complications or flap failures occurred.

Conclusion: The ESVA technique safely and effectively achieves intima-to-intima contact in head and neck microvascular reconstruction without coupler-related limitations. The use of ACRI+Asflex sutures enhances procedural efficiency across all vessel types while maintaining excellent flap survival rates.

Background: Existing literature on long-term patient-reported outcome measures (PROMs) after lower extremity free flap reconstruction (LE FFR) is limited and lacks standardization. This study assessed PROMs at long-term follow-up and examined associations between defect etiology and patient-reported outcomes at two Level I trauma centers.

Methods: A cross-sectional survey of 94 patients who underwent LE FFR between 2002 and 2020 was conducted at two Level I trauma centers to assess PROMs. Minimum follow-up was 5.4 years, with a median of 10 years (range: 5.4-23.2 years). Measures included PROMIS Depression, Anxiety, Pain Interference, and Physical Function T-scores; Visual Analog Scale (VAS) pain intensity; and EQ-5D Visual Analog Scale (EQ-VAS) quality of life scores. Patients were stratified by defect etiology into three groups: infectious/vascular/diabetic (n=19, 20%), oncologic (n=28, 30%), and traumatic (n=47, 50%). Multivariable linear regression models using log-transformed PROM outcomes identified factors independently associated with patient-reported results.

Results: At a median 10-year follow-up (range: 5.4-23.2 years), patients demonstrated psychological well-being, pain, and physical function scores that were comparable to or better than established population norms. Most patients had less psychological distress and pain compared to population norms (mean = 50 ± 10): 75% scored ≤46.0 for anxiety, 75% scored ≤46.4 for depression, and 75% scored ≤52.4 for pain interference. Physical function scores approached population norms, with 75% achieving scores ≥39.4. While most patients reported minimal pain on VAS scales (median 3/10), the upper quartile experienced ongoing moderate pain (75th percentile = 7/10, with 10% scoring ≥8/10). Quality of life scores ranged from 6 to 100 (median 78.5). Wound etiology demonstrated significant associations with PROMs across multiple domains. Oncologic patients achieved the best outcomes, with significantly lower depression scores (β = -0.106, p = 0.005) and reduced pain interference (β= -0.098, p=0.016) compared to infectious/vascular/diabetic patients. In contrast, traumatic patients had outcomes similar to the infectious/vascular/diabetic group, showing no significant advantages in depression (β = -0.050, p = 0.229) or pain interference (β = 0.0004, p = 0.993). Post-hoc analysis confirmed oncologic patients had significantly better pain outcomes than traumatic patients (p = 0.007), establishing infectious/vascular/diabetic and traumatic patients as equally high-risk groups.

Conclusions: This study presents long-term follow-up of PROMs following LE FFR, showing that most patients achieve psychological well-being, pain control, and physical function comparable to population norms at 10-year follow-up. However, defect etiology significantly influenced long-term patient-reported outcomes, with oncologic patients experiencing consistently superior outcomes in depression and pain interference compared to infectious/vascular/diabetic patients and traumatic patients. These findings suggest infectious/vascular/diabetic and traumatic patients represent the high-risk groups for poor psychological and pain-related outcomes. Etiology-specific outcome patterns should inform preoperative discussions to set appropriate expectations and help identify patients who may benefit from additional multidisciplinary support to optimize long-term, patient-centered outcomes.

Background: Despite advancements in reconstructive techniques, lower limb amputations remain a common outcome of lower limb trauma. The primary aim of amputation is to create a functional, sensate, and pain-free stump whilst preserving maximal limb length possible. The foot is a valuable source of tissue that is otherwise discarded in traditional amputations. It offers robust, vascularised coverage for amputation stumps. Key options include the fillet-of-sole flap, which consists of the durable glabrous skin, plantar muscles, and fascia, and the complementary dorsal foot flap, made of soft tissue from the dorsal foot. To date, no established treatment algorithm exists for these flaps in the context of leg amputation. We present our experience with the 'spare-parts' concept in lower limb reconstruction through an illustrative case series and propose an algorithm aimed at optimising residual limb length and sensibility.

Method: A retrospective, multi-centre review was conducted on patients who underwent lower limb amputation stump reconstruction using salvaged tissue from 2022 to 2024.

Results: Three male patients, aged 20–27, were included: one with an above-knee amputation and two with below-knee amputations due to motor-related trauma. One free and three pedicled fillet-of-sole flap reconstructions were performed. All flaps remained healthy and sensate throughout the follow-up period. Based on these cases, a pragmatic decision-making algorithm was developed to guide management in future presentations.

Conclusion: Foot flaps are a viable option for reconstructing traumatic lower limb amputations. Developing a protocol based on vascular integrity and zone of trauma can improve outcomes by tailoring techniques to specific clinical situations.

Background: Immediate lymphatic reconstruction (ILR) with lymphovenous bypass (pLVB) is known to reduce breast cancer–related lymphedema, but optimal intraoperative lymphatic mapping strategies remain unclear. We evaluated whether combined proximal chromatic and distal fluorescent mapping improves lymphatic identification compared with proximal mapping alone.

Methods: A retrospective cohort study was conducted of patients undergoing ILR. Mapping strategies were categorized as proximal blue dye alone or combined proximal blue dye with distal fluorescent dye. Outcomes included the number of lymphatic channels identified and the number of lymphovenous anastomoses performed. Multivariable linear regression was used to identify independent predictors of lymphatic channel count.

Results: A total of 160 ILR procedures were analyzed, including 107 proximal mapping (67%) and 53 combined proximal and distal mapping (33%) cases, with no differences in baseline demographic, oncologic, or operative characteristics between groups. Proximal blue dye identified a similar number of channels in both cohorts. Combined proximal and distal mapping identified more total lymphatic channels (median 4 [IQR 3–6] vs. 3 [IQR 2–4], p = 0.002) and enabled more lymphovenous anastomoses (median 4 [IQR 3–5] vs. 3 [IQR 2–4], p = 0.005). On multivariable analysis, combined proximal and distal mapping was independently associated with increased lymphatic channel identification (β = 1.07, 95% CI 0.52 to 1.62; p < 0.001), while higher body mass index was associated with fewer channels (β = −0.06 per kg/m²; p = 0.004).

Conclusions: Proximal chromatic plus distal fluorescent lymphatic mapping improves lymphatic identification and anastomotic yield during axillary ILR, supporting multimodal mapping as an optimized strategy for lymphedema prevention surgery.

Introduction: Pelvic exenteration is an extensive surgical extirpation for locally advanced or recurrent pelvic malignancies, often resulting in large pelvic and perineal defects. Reconstruction can mitigate wound healing complications. Flap reconstruction is advantageous over primary closure because of radiation-induced tissue damage, high-tension skin closure, and tendency for fluid collections that can progress to abscesses or fistulae (1,2). Multiple studies report that primary closure is associated with a two- to three-fold higher rate of major wound complications when compared with flap-based reconstruction (2). Traditionally, abdominal-based flaps such as the vertical (VRAM) and oblique (ORAM) rectus abdominis myocutaneous flaps have served as the mainstay of reconstruction due to their reliable vascularity, robust tissue volume for pelvic deadspace, and ability to utilize the existing midline incision from the oncologic procedure. However, abdominal-based flaps sacrifice the rectus muscle and are associated with significant donor site morbidity, including abdominal wall dehiscence, hernia, bulge, and infection, with reported rates ranging from 6–20% (3). Additionally, the frequent need for multiple ostomies in these patients can further complicate the use of these flaps. In recent years, there has been growing interest in alternative reconstructive strategies given the increasing frequency of minimally invasive oncologic approaches. This study aims to directly compare abdominal- and thigh-based flaps for reconstruction of pelvic exenteration defects to evaluate postoperative outcomes.

Methods: A retrospective cohort study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010–2022. Patients undergoing pelvic exenteration for malignancy were identified and stratified by flap type: abdominal-based (CPT 15734) or thigh-based (CPT 15738). Outcome variables included superficial surgical site infection (SSI), deep SSI, organ-space SSI, wound dehiscence, 30-day readmission, and unplanned return to the operating room. Composite endpoints were created for wound complications and major medical complications. Inverse probability of treatment weighting (IPTW) was applied to compare outcomes between abdominal and thigh-based flap reconstructions.

Results: In the ACS-NSQIP database from 2010–2022, 6,093 patients underwent pelvic exenteration for malignancy, including 974 who also were coded as undergoing abdominal- or thigh-based flaps. The final cohort was comprised of 843 abdominal flaps (86.5%) and 131 (13.5%) thigh-based flaps. On univariate analysis, a greater proportion of patients receiving abdominal flaps were female (69.8% vs 52.7%, p<0.01). No other demographic differences were statistically significant. Wound healing complications were similar between groups (26.0% thigh vs. 21.0% abdominal, p = 0.21). IPTW reduced all standardized mean differences to below 0.1, indicating balanced weighted comparisons. Weighted logistic regression showed no significant differences in the odds of complications between thigh- and abdominal-based flaps. There was no difference in wound complications in crude analyses (OR 1.32; p=0.201) or weight-adjusted analyses (OR 1.29; p=0.266). There were also no statistically significant differences in surgical site infections, medical complications, readmission, unplanned return to the operating room, or length of stay.

Conclusion: This 974-patient cohort represents one of the largest reported series directly comparing outcomes of thigh- and abdominal-based flaps for pelvic exenteration reconstruction. Both abdominal- and thigh-based flaps offer similar short-term postoperative outcomes for reconstruction following pelvic exenteration. Flap selection should be individualized, considering factors such as prior abdominal surgery, the presence of multiple ostomies, radiation history, donor-site characteristics, and the planned oncologic approach.

References: 1) Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. Jan 2009;123(1):175-183. doi:10.1097/PRS.0b013e3181904df7 2) Devulapalli C, Jia Wei AT, DiBiagio JR, et al. Primary versus Flap Closure of Perineal Defects following Oncologic Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. May 2016;137(5):1602-1613. doi:10.1097/prs.0000000000002107 3) Radwan RW, Tang AM, Harries RL, Davies EG, Drew P, Evans MD. Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: A systematic review. J Plast Reconstr Aesthet Surg. Mar 2021;74(3):523-529. doi:10.1016/j.bjps.2020.10.100

Purpose: Sternal wound complications (SWC) following open cardiac surgery frequently require reconstructive management due to their association with prolonged recovery and high resource utilization. Existing literature has largely focused on the incidence of deep sternal wound infection in small-series cohorts, with limited national analyses evaluating their burden and interaction with baseline physiologic vulnerability.

Methods and Materials: A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from January 2012 to December 2024. Adult patients undergoing inpatient open cardiac surgery were identified using Current Procedural Terminology (CPT) codes. Patients were stratified by the presence of SWC within 30 days. Baseline demographics, comorbidities, laboratory values, and operative characteristics were compared. Multivariable logistic and Poisson regressions were used to identify independent predictors and evaluate effect modification across subgroups.

Experience: The study evaluated a total of 48,837 inpatient open cardiac surgery patients. All patients had a standard 30-day postoperative follow-up.

Results: Among the cohort, 2,460 patients (5.0%) developed a SWC. Patients with wound complications demonstrated greater physiologic vulnerability, including higher BMI (median 30.23 vs 28.69 kg/m2; p<0.0001), increased insulin-dependent diabetes (21.8% vs 13.4%; p<0.0001), active smoking (21.8% vs 19.3%; p=0.003), higher frailty burden (mFI-5 of 2/3 more frequent; p<0.0001), and lower preoperative albumin (median 3.8 vs 3.9 g/dL; p<0.0001). Within the 30-day registry window, management most frequently involved lower-complexity interventions, including debridement (4.5%) and simple closure (2.3%), while flap reconstruction was rare (0.5%). While early mortality was predominantly driven by massive baseline systemic deficits rather than the wound event itself, SWC were powerful catalysts for systemic morbidity. They were associated with substantially higher rates of reoperation (25.7% vs 5.6%; p<0.0001), readmission (25.0% vs 7.7%; p<0.0001), medical complications (29.1% vs 16.0%; p<0.0001), transfusion (53.2% vs 48.4%; p<0.0001), and longer hospital stay (median 11 vs 8 days; p<0.0001). Effect modification analyses demonstrated that SWC were consistently associated with an amplified risk of medical complications and reoperation across subgroups, with a greater relative impact among patients with higher baseline physiologic vulnerability.

Conclusions: In this large cohort, SWC occurred in 5% of open cardiac surgery patients and emerged not merely as localized technical failures, but as profound amplifiers of physiologic vulnerability. By altering the recovery trajectory, SWC drive compounded downstream morbidity, reoperation, and resource utilization. For the reconstructive surgeon, these findings underscore the critical importance of preoperative optimization, proactive risk stratification, and early multidisciplinary management to mitigate the systemic consequences of local tissue failure in high-risk populations.

Background: Hormone replacement therapy (HRT) is widely used in breast cancer patients. Concerns exist about its effects on coagulation, vascular perfusion, and wound healing, which could influence microvascular free flap outcomes. Evidence on perioperative safety remains limited. This systematic review aimed to evaluate the impact of hormone replacement therapy on microvascular free flap complications in patients undergoing breast reconstruction.

Materials and Methods: A systematic review was conducted in accordance with PRISMA guidelines. A total of 10,836 articles were initially identified; after screening and applying inclusion criteria, 21 full-text articles were assessed, of which 6 studies met eligibility for inclusion. Extracted variables included patient demographics, comorbidities, cancer stage, preoperative chemo/radiotherapy, type of hormone therapy, reconstruction timing (immediate vs. delayed), flap type (DIEP, SIEA, TRAM, TMG), operative time, and postoperative complications including flap loss, mastectomy skin necrosis, fat necrosis, umbilical necrosis, hematoma, seroma, surgical site infection, unplanned reoperation, hospital readmission, DVT, and PE. Results were summarized descriptively due to heterogeneity in reporting.

Results: The six included studies included a total of 3,549 patients undergoing over 4,000 free flap reconstructions. Patient age ranged 46–52 years, BMI 25–29 kg/m². Comorbidities were slightly lower in HRT groups; hypertension 14–26% vs. 17–25%, diabetes 2–5% vs. 3–12%, coronary artery disease 0–1% vs. 0.5–1.8%, and smoking 8–13% vs. 11–14%. Flap types were predominantly DIEP (57–98%), followed by SIEA, TRAM, and TMG. Immediate reconstruction was performed in 17–87% of HRT patients, delayed in 28–92%, and bilateral reconstructions ranged 41–58%. Operative time ranged 5.5–9.8 hours, and flap weight 330–727 grams. Complication rates were low. Total flap loss occurred in 0.5–3.5% of HRT patients versus 1–1% in non-HRT patients; partial flap loss 0.5–5.5% vs. 2–2.2%. Mastectomy skin necrosis affected 2–15% vs. 5–12%, fat necrosis 7–15% vs. 9–16%, umbilical necrosis 0.5–10% vs. 0–4.4%, hematoma 1.5–15% vs. 3–15%, seroma 3–15% vs. 4–15%, and surgical site infection 1–8% vs. 4–10%. Thromboembolic events were rare: DVT 0–1%, PE 0–0.5%, without significant increase in HRT patients. Unplanned reoperation and hospital readmission were <5%. Across studies, HRT did not significantly increase flap or wound complications.

Conclusion: Perioperative HRT does not appear to increase microvascular free flap complications, wound healing problems, or thromboembolic events. These findings support the safe continuation of HRT in the perioperative period when clinically indicated. Prospective studies are warranted to confirm these observations and guide optimal perioperative management strategies.

Purpose

Autologous breast reconstruction (ABR) has experienced a resurgence in recent years, with national trends demonstrating increased utilization (63.4% in 2020 from 58.8% in 2016), as patients seek natural, long-lasting reconstructive outcomes following mastectomy (1,2). However, abdominal donor-site bulge represents a significant source of patient dissatisfaction and reoperation following abdominally based ABR (ABABR), with reported rates as high as 32% (3). While prophylactic mesh reinforcement has been proposed to reduce bulge formation, optimal patient selection and comparative effectiveness data remain limited. This study evaluates the impact of retrorectus prophylactic mesh placement on donor-site morbidity in one of the largest single-institution ABR cohorts reported to date.

Methods

A retrospective analysis of patients undergoing ABABR from January 2014 to December 2024 was performed. Demographic data, comorbidities, and surgical characteristics were analyzed using descriptive statistics. Abdominal closure techniques were stratified into primary fascial closure versus retrorectus mesh reinforcement. Primary outcomes included bulge, seroma, hematoma, surgical site infection (SSI), and delayed healing. Multivariate logistic regression models adjusted for age, BMI, smoking status, diabetes, and flap type. Stratified analyses by obesity class were performed separately, with severe obesity defined as BMI ≥40 kg/m².

Results

A total of 936 patients (1,507 donor sites) were analyzed. Mean age was 53 years (SD 10) and mean BMI was 29.8 kg/m² (SD 5.8). Primary fascial closure was performed in 520 donor sites (34.5%) and retrorectus mesh reinforcement in 987 donor sites (65.5%). Overall bulge rate was 1.7%. No significant differences were observed between groups for seroma, hematoma, SSI, or delayed healing (p>0.05). The retrorectus mesh group demonstrated significantly lower bulge rates compared to primary closure (1.0% vs. 2.9%, p=0.013), representing a 66% relative risk reduction. Multivariate regression revealed a pronounced protective effect in severely obese patients, with an 89% reduction in bulge odds (OR 0.11, p=0.016). Mesh material comparison showed biosynthetic mesh was associated with increased delayed healing compared to synthetic mesh (OR 0.46, p=0.034).

Conclusion

This large single-institution analysis demonstrates that retrorectus prophylactic mesh reinforcement significantly reduces donor-site bulge rates following ABABR without increasing wound complications. With a 66% relative risk reduction in bulge formation and particularly robust protection in severely obese patients, these findings support selective use of prophylactic mesh in ABR donor-site closure. These data provide evidence-based guidance for surgical decision-making and inform the development of risk-stratified protocols for abdominal wall closure in ABR.

References

1. Shah J, Amakiri U, Cevallos P, et al. Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016–2019. Annals of Plastic Surgery. 2024; 92 (4): e1-e13. doi: 10.1097/SAP.0000000000003764.

2. Esparham, A., Shoar, S., Whittington, J. et al. National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Ann Surg Oncol 32, 985–992 (2025). https://doi.org/10.1245/s10434-024-16255-z

3. Elmorsi R, Camacho L, Rogan D, et al. Retrorectus Polyglactin Mesh Reduces the Risk of Bulge in DIEP Flap Donor Sites: A Propensity Score–Matched Study with Hernia Risk Modeling. Plastic and Reconstructive Surgery. 9900; Publish Ahead of Print doi: 10.1097/PRS.0000000000012814.

Introduction

Perineal wounds after abdominoperineal resection (APR) remain a major challenge, particularly because of the radiated surgical site. Flap reconstruction reduces perineal complications.(1) Historically, these have been managed with abdominal-based flaps (i.e., vertical rectus abdominus myocutaneous [VRAM]). (2,3) Thigh-based flaps (e.g., gracilis, anterolateral thigh [ALT]) are increasingly used to avoid additional abdominal wall morbidity (4) especially following minimally invasive (MIS) APR. However, data comparing outcomes between flap types after MIS APR remains limited. The objectives of this study were to evaluate trends in the use of abdominal- versus thigh-based flaps for perineal reconstruction after MIS APR and compare short-term outcomes between flap types.

Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2016–2021) was reviewed to identify adults undergoing MIS APR (Current Procedural Terminology [CPT] code 45395) with abdominal- (CPT 15734) or thigh-based (CPT 15738) flaps. Patients with primary closure or unplanned conversion to open were excluded. Baseline characteristics were compared using univariate analyses. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. Categorical outcomes were evaluated using logistic regression, with crude and weighted-adjusted odds ratios.

Results A total of 278 patients met the inclusion criteria; 174 (62.6%) received abdominal- and 104 (37.4%) received thigh-based flaps. Baseline demographics did not differ significantly between groups. Flap selection differed by operative year, with increasing use of thigh-based flaps over time (p < 0.01); of which 37% were performed in 2021. In the final year, 50.1% of all flaps were thigh-based, compared with 25% in 2016. Complications did not differ on univariate analysis. Logistic regression demonstrated that thigh-based flaps were associated with lower adjusted odds of any complication (0.05, aOR 95% CI 0.26-0.95, p = 0.035) and wound dehiscence (0.21, aOR 95% CI 0.06-0.77, p = 0.019). There were no differences in wound infections, readmission, or reoperation.

Conclusion Thigh-based flaps are increasingly used for perineal reconstruction after MIS APR and demonstrate noninferior short-term outcomes. These findings suggest thigh-based flaps may be a reliable first-line option for perineal reconstruction after MIS APR, as they avoid abdominal donor site morbidity.

References 1. Yang XY, Wei MT, Yang XT, et al. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis. Feb 2019;21(2):138–155. doi:10.1111/codi.14471 2. Lefevre JH, Parc Y, Kerneis S, et al. Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneous flap on survival, recurrence, morbidity, and wound healing. Ann Surg. Nov 2009;250(5):707–11. doi:10.1097/SLA.0b013e3181bce334 3. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. Jan 2009;123(1):175–183. doi:10.1097/PRS.0b013e3181904df7 4. Tang AM, Spencer N, Parkins K, et al. Radiological incidence of donor-site incisional hernia and parastomal hernia after vertical rectus abdominus myocutaneous flap-based reconstruction following colorectal surgery. Colorectal Dis. Apr 2023;25(4):738–746. doi:10.1111/codi.16400

Introduction: In a healthcare environment increasingly focused on cost containment, length of hospital stay (LOS) has become an important performance metric. Patients undergoing lower extremity free tissue transfer (LE FTT) represent a medically complex population that frequently requires prolonged hospitalization. We sought to define LOS in this population, distinguish medically necessary inpatient care from discharge-related delays, and characterize drivers of extended hospitalization. Methods: A retrospective review of the most recent 101 LE FTT procedures performed at a single tertiary center from 2023–2025 was conducted. Prolonged LOS was defined as LOS ≥ the 75th percentile. Patients with prolonged LOS were compared with those with non-prolonged LOS. Initial physical therapy (PT) evaluation after final surgery was used as a proxy for medical stability to differentiate time attributable to medical versus discharge care. Logistic regression assessed predictors of prolonged LOS. Results: Median LOS was 27 days [IQR 21], including 20 days [IQR 18] attributable to medical care and 8 days [IQR 7] related to discharge processes. Prolonged LOS was defined as ≥41 days and was associated with larger wound area (90 [155.5] vs 56 [70.0] cm², p=0.010), higher rates of diabetes (84% vs 47%, p<0.001), chronic kidney disease (44% vs 11.8%, p<0.001), dialysis dependence (28% vs 3.9%, p<0.001), and higher Charlson Comorbidity Index scores (6 [4] vs 4 [4], p=0.017). Social vulnerability index and insurance type were similar between groups (p>0.4). A majority of prolonged LOS patients were discharged to acute rehabilitation (52.5%), whereas most non-prolonged LOS patients were discharged home (59.2%, p=0.003). Each 1 cm² increase in wound size increased odds of prolonged LOS by 0.8% (OR 1.008, p<0.05). Dialysis dependence was strongly associated with prolonged LOS (OR 13.1, p=0.050). Flap success, postoperative ipsilateral amputation, and ambulation at final follow-up were similar between groups (p>0.4). Medical care demonstrated substantially stronger model fit for prolonged LOS (Nagelkerke R² = 0.847) compared with discharge care (Nagelkerke R² = 0.295). Conclusions: Extended hospitalization after LE FTT is primarily driven by medical complexity. Despite greater comorbidity burden, flap success, functional outcomes, and ambulation were similar between prolonged and non-prolonged LOS groups. As hospitals and payors increasingly use LOS as a performance metric, recognition of clinically justified prolonged hospitalization is essential for accurate reimbursement and realistic benchmarking of complex reconstructive surgery.

Purpose: In 2022, we found that insurance coverage for lymphedema-specific imaging and surgery was low in the United States. Since that time, new evidence in microsurgery and the implementation of the Lymphedema Treatment Act (2024) have prompted us to reexamine national insurance coverage to see if there have been any improvements. This study examines how U.S. insurers' coverage policies have changed over the past five years. Methods: We analyzed recent lymphedema coverage policies from 57 major U.S. insurers using web searches and compared them to our 2021 baseline study. We recorded the existence of a policy, the specifics of coverage, and the associated criteria. Two-proportion z-tests were used to find significant changes. Results: In this five-year update, we reviewed 57 insurance plans and found that 81% (n=46) have policies for imaging and/or surgical lymphedema treatments. Coverage for one or more lymphedema imaging techniques fell from 65.5% to 42.9% (p=0.019), while bioimpedance spectroscopy coverage increased dramatically from 2.6% to 41.4% (p<0.001). Coverage for lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT) rose significantly, from 3.7% to 40.0% (p=0.001) and 6.9% to 34.5% (p=0.010), respectively. Liposuction coverage also increased from 30.4% to 53.8% (p=0.098). Among the covered plans, failed conservative treatment measures was a common criterion, and functional impairment (hindered ADLs) became a universal criterion for liposuction (100% vs. 66.7%; p=0.028). Conclusions: Over the past five years, there has been significant growth in coverage for physiologic lymphedema surgery, such as LVB and VLNT, as well as for bioimpedance spectroscopy. Although coverage for excisional procedures like liposuction has been relatively higher, strict criteria might hinder access to care if conservative treatments are not covered. Most novel imaging techniques, such as acoustic radiation force impulse elastography (ARFIE), indocyanine green (ICG) lymphography, and lymphoscintigraphy (LS), still have inconsistent coverage. This challenge limits their effectiveness in comprehensive lymphedema care. These issues emphasize the need for evidence-based practices and establishing standardized national policies.

Introduction: Postoperative pain management in open ventral hernia repair (VHR) is critical to facilitate early ambulation, reduce complications, and align with Enhanced Recovery After Surgery (ERAS) protocols. Although multimodal analgesia (MMA) is standard, the relative efficacy of specific components in complex abdominal wall reconstruction (AWR) remains unclear.

Methods: A retrospective review was conducted of 155 patients undergoing elective open VHR over a ten-year period. Patients were stratified by postoperative analgesic regimen: intravenous opioids alone (Group A), or MMA strategies incorporating combinations oral medications (acetaminophen, celecoxib, gabapentin), epidural, intrathecal morphine (ITM), and/or liposomal bupivacaine transversus abdominis plane block (LB-TAP). Primary outcomes were change in patient-reported pain score (0–10) from postoperative day (POD) 0 to POD5. Secondary outcomes included inpatient opioid use (oral morphine equivalents/day, OME/day) and length of stay (LOS).

Results: All regimens achieved significant pain reduction by POD5. Group A had the steepest numerical decrease (–2.06 points), however, Group A also started with the highest baseline pain and opioid use. MMA groups using LB-TAP or ITM with oral medications (Groups D and E) demonstrated significantly lower OME/day (63% and 64% reductions, respectively; p < 0.05) compared to Group A. Final pain scores by POD5 and LOS did not differ significantly between groups.

Conclusions: Although opioid-heavy regimens may achieve faster pain reduction, regional anesthesia techniques layered with non-opioid oral medications provide yield comparable analgesia by POD5 while minimizing opioid exposure. These findings support broader adoption of opioid-sparing, layered pain management protocols in open VHR within enhanced recovery frameworks.