Scientific Abstract Presentations: Reconstruction Session 7 Saturday, October 17 Sat, Oct 17 5:00-6:00 p.m. CDT

Background Groin and genital defects often arise from oncologic resections, inflammatory processes, or infections. Reconstruction here is particularly challenging due to constant moisture, a high bacterial load, significant pressure and shear forces. These wound qualities require durable, well-vascularized soft-tissue coverage. The gracilis flap is traditionally considered the workhorse thigh-based option of this region, but it has a short pedicle with an unreliable distal third pedicle and expected loss of muscle bulk over time. The profunda artery perforator (PAP) flap is a muscle-sparing alternative based on consistent posterior medial thigh perforators offering adequate volume, reliable pedicle length, and minimal donor-site morbidity. We present a case series of 8 patients undergoing PAP flap reconstruction for perineal defects to better define its role, technical considerations, and outcomes in this complex population.

Methods This was a retrospective review of 8 patients who underwent pedicled PAP flap reconstruction for perineal defects at our institution from November 2024 to February 2026 (10 flaps total). Demographics, comorbidities, wound information, complications, and hospital course data were collected. Flap details included flap size, number of perforators, perforator location, pedicle length, and pedicle location.

Results The median age at surgery was 56 years and 50% of patients were female. One patient (13%) required coverage for Fournier's Gangrene, five patients (63%) required reconstruction after oncologic resection (n=1 sarcoma, n=2 colorectal cancer, n=1 cervical cancer, n=1 perianal squamous cell carcinoma), and two patients (25%) required coverage after hidradenitis suppurativa resection. Two patients required bilateral PAP reconstruction. Preoperative CT angiogram was obtained in all patients. All flaps were designed longitudinally along the thigh. Average flap length was 17.3 cm, and width was 6.2 cm (total area 107 cm2). Half of the flaps (50%) were tunneled to the defect. An average of 2 perforators were used per flap, with the A perforator being the most common. The average distance from the most proximal perforator to the most proximal edge of the flap was 8 cm, and from the most distal perforator to the most distal edge of the flap was 7.3 cm. The average pedicle length was 11.3 cm. The average distance of the entry of the PAP pedicle into the profunda (pivot point) was 7.7cm from the groin crease. There were no instances of partial or total flap loss or OR takebacks.

Conclusion The pedicled PAP is a reliable choice for perineal reconstruction. It provides long-lasting bulk to obliterate dead space, its perforators are highly predictable, and the skin paddle is highly reliable. The flap's long pedicle and generous arc of rotation allow a wide reach with minimal donor site morbidity. We recommend taking a single perforator when possible to maximize pedicle length and considering the entry point of the pedicle into the profunda artery to allow sufficient reach.

Background Severe burn injuries require highly specialized, multidisciplinary care delivered through regionalized systems, with 143 centers currently listed by the American Burn Association (ABA) across 51 states. Although verified centers are associated with improved outcomes, the national composition and training backgrounds of physicians staffing these centers have not been systematically characterized, limiting workforce planning.

Methods A cross-sectional analysis of surgeons practicing at ABA-listed burn centers was conducted. All 51 states and jurisdictions listed by the ABA were reviewed. Physicians were identified using publicly available institutional websites for each center. Recorded variables included degree type, gender, residency training background, fellowship type and completion year, and completion of dedicated burn fellowship. Residency and fellowship graduation years were compiled to assess workforce age distribution and projected retirement risk. Physicians who completed training prior to 2005 were considered at highest likelihood of retirement within the next decade. Projected workforce entry was estimated using the number of surgeons who entered the workforce between 2021 and 2025 as a proxy for future workforce growth.

Results Of 143 ABA-listed burn centers, 130 (90.9%) had publicly available physician data, identifying 394 unique surgeons; 91.8% (n = 362) held an MD degree and 75.1% (n = 296) were male. General surgery was the most common residency background (60.9%, n = 240), followed by plastic surgery (26.1%, n = 103). Training cohort analysis showed that 11.2% (n = 44) completed residency before 1995 and 17.5% (n = 69) between 1996 and 2005, indicating that 28.7% of the workforce is approaching late-career status. By 2030, the burn surgeon workforce is projected to experience a net loss of 9 surgeons, driven by a total decrease of 44 surgeons that is only partially offset by 35 new entrants. By 2035, the workforce is projected to experience a net loss of 43 surgeons, driven by a total decrease of 113 surgeons (those who trained before 2005) that is only partially offset by 70 new entrants. Burn fellowship training was concentrated at select institutions, most commonly the Regional Burn Center at Harborview (University of Washington) and Shriners Hospital for Children.

Conclusion This study provides the first comprehensive national characterization of physicians staffing ABA-listed burn centers. Most providers are general surgery–trained MDs, and fewer than half have completed dedicated burn fellowship training, highlighting variability in formal burn-specific preparation across centers. While many surgeons completed fellowship after 2005-suggesting recent growth and sustained interest in the field-a meaningful proportion are nearing retirement, raising concerns about future attrition. These findings underscore the importance of strengthening standardized training pathways, recruitment efforts, and pipeline development to ensure adequate national coverage.

Purpose: Achieving tension-free repair in large complex abdominal wall defects remains challenging. Prior studies demonstrated preoperative Botulinum Toxin (BTX) administration to the lateral abdominal wall musculature significantly increased fascial closure rates during abdominal wall reconstruction (AWR) due to increased laxity and degree of motion (1). This study aimed to compare the outcomes of patients undergoing complex AWR with and without preoperative BTX.

Methods: A single center retrospective study of patients undergoing AWR with preoperative BTX (BTX+) versus without (BTX-) between July 2016 and December 2023 was completed. Patients with multiple mesh placements and bridging meshes were excluded. A 1:1 propensity score match was performed based on age (calipers ± 8 years), BMI (± 6 kg/m2), and defect size (± 100cm2) as measured manually on abdominopelvic computed tomography scans obtained within one year before surgery. Intraoperative factors and postoperative outcomes within 90 days were compared.

Results: A total of 1,239 patients underwent AWR (BTX+ 74, BTX- 1165). Fifty-nine pairs of patients were analyzed. Average age (64.35 vs 64.92 years; p=0.774), BMI (31.82 vs 32.23 kg/m2; p=0.746), and defect size (259.20 vs 251.60 cm2; p =0.675) were comparable. Sex, smoking status, diabetes, and ventral hernia working group were comparable. The majority of patients in both groups were closed with a bilateral component separation technique (CST) (78.0%, 66.1%; p=0.190) followed by a unilateral CST (6.8%, 10.2%; p=1.000), with bilateral external oblique release being used more in the BTX+ group (82.6% vs 59%; p=0.013). Biosynthetic mesh was most commonly used (84.7%, 86.4%; p=1.000) and placed in the onlay position (74.6%, 62.7%; p=0.234). The rate of acute kidney injury (AKI) was higher in the BTX- group (10.2% vs 28.8%; p=0.020). The incidence of surgical site infection (13.6%, 11.9%; p=1.000), seroma (11.9%, 10.2%; p=1.000), hematoma (6.8%, 6.8 %; p=1.000), delayed wound healing (27.1%, 28.8%; p=1.000), and total length of stay (6, 6 days; p=0.663) were comparable. The number of reoperations was also comparable between the groups (22%, 18.6%; p=0.833), although the BTX- group had reoperations for surgical site occurrences more often than the BTX+ group. Median follow-up duration was greater in the BTX- group (688, 1109 days; p=0.001). Hernia recurrence was comparable between groups (25.4%, 23.7%; p=1.000). There was no significant difference in hernia recurrence-free survival between the two groups (p=0.34).

Conclusions: Patients who received preoperative BTX were more commonly closed with a bilateral external oblique release with biosynthetic mesh in the onlay position, and exhibited lower rates of AKI with similar postoperative outcomes and recurrence-free survival compared to matched controls. The addition of preoperative BTX allows us to achieve outcomes similar to matched controls in large, challenging defects. This study provides insight about potential operative modifiers and their consequences regarding postoperative outcomes, and sets a framework for future larger studies to expound on long-term associations of preoperative BTX use for AWR.

References: 1. Timmer, A.S., et al., A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction. Hernia, 2021. 25(6): p. 1413-1425.

Purpose Cefazolin-based prophylaxis represents the gold standard for surgical site infection (SSI) prevention. However, in the setting of a reported penicillin allergy, providers routinely opt for inferior alternatives, often unnecessarily, despite well-established evidence that true cross-reactivity between penicillin and cephalosporins is exceedingly rare (~1%) (1). Ventral hernia repair (VHR) is among the most frequently performed abdominal procedures in the United States, with over 350,000 repairs performed annually (2). This volume combined with meaningful baseline infection risk, makes prophylactic antibiotic selection particularly consequential. Despite this, the real-world impact of Penicillin Allergy (PA)-driven antibiotic substitution on postoperative outcomes in VHR remains poorly characterized. This study examines cefazolin utilization and 90-day surgical outcomes in PA versus non-allergic patients undergoing VHR using a large global database.

Methods The TriNetX database was accessed to identify two cohorts of patients undergoing VHR between from 2010-2025: those with documented PA (n=3,785) and those without (n=48,814). Details on antibiotic utilization were collected. A 1:1 propensity score match was performed for these cohorts including age, sex, BMI, tobacco use, diabetes, and concomitant mesh placement. Primary outcomes included 90-day rates of SSI, abscess formation, sepsis, and reoperation.

Results Prior to matching, PA vs non-PA patients demonstrated older mean age (57.4 vs. 51.7 years), significantly greater comorbidity burden including diabetes (30.3% vs. 19.1%), and higher rates of tobacco use (8.8% vs. 3.5%); all p<0.001. After matching (3,779 pairs), PA patients were noted to receive cefazolin significantly less frequently (26.7% vs. 37.2%, p<0.001) and were more often administered clindamycin (40.0% vs. 12.1%) or vancomycin (40.5% vs. 19.1%); both p<0.001. PA patients experienced significantly worse 90-day outcomes across all measured infection endpoints: SSI (5.9% vs. 4.6%, p=0.008), sepsis (3.0% vs. 1.9%, p=0.002), abscess formation (3.9% vs. 2.8%, p=0.006), and deep SSI (1.3% vs. 0.8%, p=0.034). Reoperation rates were not significantly different, and anaphylaxis events were too infrequent for analysis.

Conclusion Documented PA is independently associated with significantly increased 90-day infectious morbidity following VHR, including deep SSI, abscess, and sepsis, a risk that tracks closely with deviation from cefazolin-based prophylaxis. These findings make a compelling case for systematic antibiotic stewardship programs. Collaborative multidisciplinary actions that prioritize PA confirmation and allergy re-evaluation can ultimately ensure that optimal surgical prophylaxis is not compromised by frequently inaccurate, outdated, or unverified allergy labels. In hernia surgery, the label "penicillin-allergy" has become a modifiable driver for preventable surgical harm and may carry more risk than the allergy itself.

References

1. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med. 2012;42(5):612-620. doi: 10.1016/j.jemermedd.2011.05.035

2. Bhardwaj P, Huayllani MT, Olson MA, Janis JE. Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors. JAMA Surg. 2024;159(6):651-658. doi:10.1001/jamasurg.2024.0233

Background Lower extremity amputations (LEA) are associated with high wound complication rates, painful neuromas, phantom-limb syndrome, significant health-care utilization, and 30-day mortality as high as 20% (1-3). Plastic and reconstructive surgery (PRS) involvement can potentially reduce wound complications and postoperative pain. Access to advanced limb salvage techniques at a county hospital with limited resources and access to care can pose challenges. This study evaluated the association between PRS involvement in postoperative wound complications and emergency department (ED) utilization following major LEA. Secondarily, we evaluated the association between targeted muscle innervation (TMR) and/or regenerative peripheral nerve interface (RPNI) and rates of stump pain and phantom limb pain (PLP).

Methods A retrospective cohort study of patients over 18 years of age who underwent below or above knee amputations with formalization at a large county institution was performed between 2018 to 2024. Categorical variables including demographic information and comorbidities were compared using Fisher's exact tests or Chi-squared tests. Multivariable logistic regression evaluated the association of PRS involvement with wound infection, wound dehiscence, and ED visits. A secondary analysis assessed the association of TMR/RPNI and postoperative stump pain and PLP.

Results Out of 116 patients, PRS was involved in 35 cases (30%). The median age at time of surgery was 55 years (interquartile range 48-61). The main indication for LEA was infection (90%). The PRS group demonstrated a higher prevalence of diabetes (94% vs. 86.4%, p=0.3) and a greater rate of tobacco use (62.9% vs. 46.9%, p=0.2) compared with the non-PRS group. Postoperative wound infection occurred in approximately 25% of patients and did not vary with PRS involvement (p = 0.8). Wound dehiscence rates were comparable between PRS and non-PRS groups (77.1% vs 77.5%, p > 0.9). On multivariate analysis, PRS involvement was not independently associated with decreased rates of wound infection (OR 1.46, 95% CI 0.61–3.35, p = 0.4), wound dehiscence (OR 1.96, 95% CI 0.74–4.98, p = 0.2), or ED visits (OR 0.77, 95% CI 0.33–1.71, p = 0.5). PRS formalizations implementing TMR/RPNI were not independently associated with lower rates of PLP (OR 2.10, 95% CI 0.23-1.83, p = 0.5). However, there is a trend towards lower reported pain at the stump site (OR 0.37, 95% CI 0.11-1.03, p = 0.072).

Conclusions Although PRS involvement was not associated with lower rates of postoperative wound complications or ED utilization, the PRS cohort had greater comorbidity burden, suggesting involvement in more complex patients. These findings highlight the multifactorial drivers of clinical outcomes in this high-risk population.

1. Morisaki K, Yamaoka T, Iwasa K. Risk factors for wound complications and 30-day mortality after major lower limb amputations in patients with peripheral arterial disease. Vascular. 2018 Feb;26(1):12- 17.
2. Jensen TS, Krebs B, Nielsen J et al. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain. 1983 Nov;17(3):243-56.
3. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil. 2005 Mar;86(3):480-6.

Purpose Limited data exist on the impact of immunotherapy on postoperative outcomes in patients with melanoma undergoing wide local excision (WLE) and subsequent reconstructive surgery. Compared to historical complication rates of 5-10%, we sought to evaluate the effect of immunotherapy on postoperative outcomes in this burgeoning patient population.

Methods A retrospective review of patients with stage I-III melanoma (AJCC 8th edition) who received immunotherapy and underwent WLE with reconstruction at a quaternary-referral center between 2015-2019 were included. Primary outcome was delayed wound healing.

Results Among 239 patients with melanoma who underwent WLE and reconstruction, 173 (72%) patients received immunotherapy. Reconstruction included complex closure (31%), rotational/advancement flaps (31%), split- or full-thickness skin grafts (23%), and dermal substitutes (15%). The most common operative site was the head/neck (58%). Median melanoma thickness was 1.8mm (IQR 1.0-3.3). The overall postoperative complication rate was 18%. Median follow-up was 39 months.

Receipt of neoadjuvant immunotherapy was associated with delayed wound healing (OR 7.75, 95% CI 0.89-55.72, p<0.05). Interestingly, receipt of perioperative or adjuvant immunotherapy was not associated with delayed wound healing.

Conclusions Patients with melanoma who undergo WLE with reconstruction who receive neoadjuvant immunotherapy may have almost an eight-fold increased risk of delayed wound healing as compared to those not receiving immunotherapy. Given immunotherapy may impair wound healing, careful patient selection, preoperative counseling, and timing of multimodality therapy is critical to minimize postoperative complications.

Introduction: Brachioplasty and thighplasty are increasingly performed following massive weight loss to improve function, cosmesis and quality of life. However, these procedures traverse regions rich in superficial lymphatic networks, raising concern for postoperative lymphatic complications, including lymphedema. Despite this, lymphatic outcomes are inconsistently reported and poorly characterized in the body-contouring literature. Objectives: To systematically review the incidence of postoperative lymphedema after brachioplasty and thighplasty and to evaluate secondary outcomes including lymphedema characterization, assessment methods, and the influence of adjunctive liposuction on lymphatic outcomes. Methods: Results: Eight non-randomized studies involving 408 patients met the inclusion criteria. Reported postoperative lymphedema was uncommon, with incidence ranging from 0% to 22.7%, varying by procedure type and surgical technique. Higher rates were observed in excision-only brachioplasty and extended vertical thighplasty, while liposuction-assisted and lymph-sparing techniques reported few or no cases. Adjunctive liposuction was not consistently associated with increased lymphedema risk. Diagnostic approaches were heterogeneous and largely subjective; only two studies incorporated objective lymphatic imaging. Conclusions: Although clinically reported lymphedema following brachioplasty and thighplasty appears infrequent, the true incidence is difficult to determine and likely underestimated. Patients may instead develop prolonged postoperative extremity "edema" that goes unrecognized, or they may seek specialized lymphedema assessment outside the surgical setting, limiting detection and reporting. Nonetheless, lymphedema remains a relevant and often underdiagnosed risk that, if progressive, can substantially impair function and quality of life. Awareness and appropriate preoperative counseling should be provided to all patients undergoing these procedures. Future studies should incorporate longer-term follow-up with standardized assessments (ideally including objective lymphatic imaging) to better define incidence and identify patients at highest risk; population-based observational studies examining chronic extremity edema among patients with a history of extremity body contouring may also be informative.

Background: The Reverse Sural Artery Flap (RSAF) supplied by distal peroneal perforators is a versatile local flap option for distal limb coverage. We describe perforator distribution in cadaveric dissections, and our clinical experience with four novel modifications (perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, proximal peroneal artery ligation) to allow greater reach for the RSAF.

Methods: 38 cadaveric legs were dissected to study the peroneal perforators. In addition, 12 patients from 5-73 years-old underwent RSAF and the proposed modifications for a variety of defects, including the medial foot and distal forefoot.

Results: From the cadaveric study, terminal peroneal perforator was at a mean distance of 10.96±3.67 cm above the malleolus. Only 10.6% of distal-most perforators were within the last 20% of the fibular length, or 6.76 cm from the malleolus. Clinical series findings were comparable, with adult distances of 9.31±1.80 cm. However, the pivot point was lower, at 6.67±1.59 cm, owing to perforator skeletonization and dissection off the Achilles in all cases, tunneling under the Achilles in four, and proximal peroneal artery ligation in one. Two had subsequent <10% distal tip necrosis and one 50% superficial epidermolysis, which healed with local care.

Conclusions: The terminal peroneal perforator may lie higher than the 5 cm pivot point generally recommended for the RSAF. For these cases, perforator skeletonization, dissection off and/or tunneling under the Achilles tendon, and even proximal peroneal artery ligation can allow further reach of the RSAF to reliably cover distal defects including the medial foot and forefoot.

Background: Beyond its physical and emotional toll, lymphedema imposes a substantial economic burden on survivors, with healthcare costs for affected patients often nearly double those of unaffected individuals (1). Vascularized lymph node transfer (VLNT) has traditionally been performed in the inpatient setting due to concerns regarding microsurgical monitoring and postoperative safety. This study presents one of the first reported U.S. outpatient VLNT cohorts and evaluates early safety outcomes and institutional cost implications compared with traditional inpatient management. Methods: A retrospective chart review was performed of 10 consecutive patients undergoing upper extremity VLNT who were discharged ≤23 hours from admission. Clinical outcomes were evaluated at 30 and 90 days postoperatively. Financial performance of the outpatient cohort was compared to 19 recent, clinically similar inpatient VLNT cases. To account for differing cohort sizes, financial metrics were normalized to a 10-case equivalent cohort for direct comparison. Outcomes assessed included total cost, direct cost, technical charges, net revenue, and contribution margin Results: The mean patient age was 66.5 years (range 54.3–73.0) with a mean BMI of 26.0 kg/m² (range 19.5–30.9). Donor sites included laparoscopically harvested omentum (n=7) and supraclavicular lymph nodes (n=3). Nine patients (90%) underwent concurrent procedures, including lymphovenous anastomosis, liposuction, and/or nanofibrillar collagen scaffold placement. Four patients were discharged on the same calendar day without an overnight stay; the remainder were discharged within 23 hours. All patients underwent their first post-discharge evaluation at a pre-scheduled clinic visit on postoperative day (POD) 2 or 3. There were no 30- or 90-day complications. Specifically, no patients experienced flap loss, donor-site morbidity, wound complications, cellulitis, hematoma, reoperation, or hospital readmission. When financial outcomes were normalized to a 10-case cohort, implementation of an outpatient pathway resulted in a total cost reduction of $300,830 and direct cost reduction of $128,990, largely attributable to elimination of postoperative inpatient hospitalization. Although modeled net revenue was lower under outpatient reimbursement structures, the outpatient pathway maintained a positive contribution margin of $137,530 overall ($13,753 per case). Transitioning VLNT to the outpatient setting also avoided an estimated 39 inpatient bed-days based on the 3.9-day mean length of stay observed in inpatient controls. This creates capacity for backfilled admissions and approximately $155,259 in potential technical contribution margin opportunity ($3,981 per day), if reallocated to other revenue-generating inpatient cases. Conclusions: Outpatient VLNT is a safe and financially sustainable alternative to traditional inpatient management. In one of the first reported outpatient VLNT cohorts, transition to a same-day discharge pathway substantially reduced hospital expenditures while maintaining positive procedural margin and excellent short-term clinical outcomes. By eliminating routine hospitalization and conserving inpatient bed capacity, outpatient VLNT represents an operationally efficient and scalable model aligned with value-based surgical care delivery.

1. Shih YC, Xu Y, Cormier JN, et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol. 2009;27(12):2007-2014. doi:10.1200/JCO.2008.18.3517

Background: Vascular anomalies can share oncogenic signaling pathways with malignant tumors. These masses often mimic one another clinically and radiographically. As a result, malignant lesions may initially mimic benign vascular processes. We present a case series of pediatric patients referred to our Vascular Anomalies Clinic whose presumed vascular anomalies were ultimately found to be malignant. Methods: This was a retrospective review of four pediatric patients referred to our Vascular Anomalies Clinic between 2022 and 2025 for evaluation of presumed vascular anomalies. Preoperative imaging revealed solid masses with vascular characteristics, raising concern for underlying malignancy. Definitive diagnoses were established through incisional or excisional biopsy with histopathologic confirmation, accompanied by genetic testing to aid clinical management. Results: Four pediatric patients (ranging from infant to adolescent) were referred for presumed vascular anomalies based on clinical and radiographic findings. Initial diagnoses included lymphatic malformation, venolymphatic malformation, hemangioma, and venous malformation. Two patients underwent vascular-directed therapy prior to definitive diagnosis. Definitive tissue diagnosis ultimately revealed malignant or neoplastic pathology in all patients, including nodular lymphocyte-predominant Hodgkin lymphoma, infantile fibrosarcoma, giant cell angioblastoma, and spindle cell neoplasm. Concurrent genetic testing identified mutations in all cases (HRAS p.Q61L, ETV6::NTRK3 fusion, and SEPTIN7::BRAF fusion), and patients transitioned to targeted oncologic therapy. Discussion: This case series underscores the significant diagnostic overlap between vascular lesions and malignancy. Several patients initially presumed to have benign vascular anomalies were ultimately found to have cancer. These findings emphasize the importance of maintaining a high index of suspicion for malignancy when assessing vascular masses. Additionally, they demonstrate the benefit of obtaining genetic testing at the time of biopsy, which can expedite diagnosis and guide therapy, particularly when the initial pathology is inconclusive.