Scientific Abstract Presentations: Reconstruction Session 8 Sunday, October 18 Sun, Oct 18 8:00-9:30 a.m. CDT

Purpose: Biofilm formation on breast silicone implants contributes to surgical site infection, chronic inflammation, and capsular contracture, often requiring revision surgery. Current preventive strategies, such as antimicrobial coatings, provide incomplete protection and may introduce toxicity or antimicrobial resistance. Biosurfactants demonstrate antibiofilm activity in vitro but lack clinical validation. Pulmonary surfactant (PS) proteins are endogenous molecules used clinically to treat neonatal respiratory distress syndrome and possess surface-active, antimicrobial, and immunomodulatory properties with an established safety profile. This study evaluates biosurfactant precoating of silicone surfaces and examines pulmonary surfactant as a biocompatible alternative for preventing implant-associated biofilm formation.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided systematic search of PubMed, Embase, Scopus, ScienceDirect, and the Cochrane Library was performed from inception to May 13th, 2025. Studies evaluating biosurfactant precoating of silicone materials with outcomes related to microbial adhesion or biofilm formation were included. Data on compound type, pathogens, experimental models, efficacy, and cytotoxicity were extracted and synthesized narratively due to methodological heterogeneity.

Results: Twenty-two in vitro studies met the inclusion criteria. Precoating silicone surfaces consistently reduced bacterial and fungal adhesion, supporting the translational potential of this strategy for silicone breast implants. Microbial biosurfactants, including rhamnolipids, sophorolipids, lipopeptides, and glycolipids, demonstrated substantial antibiofilm activity. Rhamnolipids achieved greater than 90% inhibition of Staphylococcus aureus, Staphylococcus epidermidis, and Candida albicans within 24–72 hours, organisms commonly implicated in implant infection and capsular contracture. Several biosurfactants exhibited dose-dependent cytotoxicity toward mammalian cells, limiting clinical applicability. Pulmonary surfactant proteins, which are endogenous and clinically validated, offer a safer alternative while retaining surface-modifying and antimicrobial properties.

Conclusions: Biologically derived surfactant coatings show strong potential for preventing biofilm formation on silicone implants. Although microbial biosurfactants demonstrate in vitro efficacy, pulmonary surfactant proteins represent a highly translational candidate due to proven safe clinical use. This review provides a theoretical proof of concept that clinically approved biosurfactants could be repurposed as biocompatible antibiofilm coatings for silicone implants. Further in vivo and clinical studies are needed to determine whether this approach can reduce infection and capsular contracture in reconstructive and aesthetic breast surgery.

Background: Direct in vivo visualization of normal human superficial collecting lymphatic vessels is rarely feasible, limiting evidence on how their nutrient microcirculation contributes to lymphatic integrity. Using intraoperative video-capillaroscopy (VC), we directly observed the vasa vasorum of superficial collecting lymphatic vessels (VCL) in non-lymphedematous, untreated tissue and compared findings with lower-extremity lymphedema (LEL) to characterize physiologic VCL perfusion patterns and determine whether progressive morphologic deterioration reflects lymphosclerosis and endothelial injury.

Methods: One-minute real-time VC recordings (175×/620×) were retrospectively analyzed. The LEL cohort included 32 patients (48 limbs; 104 vessels) undergoing lymphaticovenular anastomosis between June 2022 and May 2023. The non-lymphedematous comparator cohort included 12 cancer patients (53 vessels) undergoing head-and-neck reconstruction with VC performed at untreated donor-site subcutaneous tissue between April 2022 and August 2024. Patients with trauma, inflammatory conditions, chemotherapy exposure, or prior lymphatic surgery were excluded. VCL stage (0–5) was assigned based on morphology. Main and branch diameters and red-blood-cell (RBC) velocity were measured. VCL perfusion pattern in non-lymphedematous vessels was classified as pressure-driven or peristalsis-driven. D2-40 immunostaining was scored (0–2). Statistical significance was set at p<0.05. Clinical observation period for outcome correlation ranged from intraoperative assessment to 12 months postoperatively.

Results: In non-lymphedematous tissue, pressure-driven vessels showed higher RBC velocity than peristalsis-driven vessels (main: 220±159.2 vs 42.6±32.9 μm/s; branch: 102.8±88.8 vs 26±26.7 μm/s; p<0.05), despite similar diameters. Overall mean main diameter and velocity were 0.038±0.031 mm and 185±160.5 μm/s. In LEL, VCL staging distribution was stage 0: 3.8%, stage 1: 15.4%, stage 2: 17.3%, stage 3: 34.6%, stage 4: 19.2%, stage 5: 9.6%. Higher VCL stage correlated with more advanced lymphosclerosis (p=0.002) and higher indocyanine green lymphography stage (p=0.007). RBC movement declined significantly with increasing VCL stage (p<0.001), accompanied by progressive reductions in vessel diameter (ANOVA p<0.001). Worsening VCL stage was strongly associated with reduced D2-40 positivity (p<0.001).

Conclusions: Intraoperative VC enables direct comparison of non-lymphedematous and lymphedematous human lymphatic vessels, demonstrating that normal VCL perfusion may be pressure-driven or peristalsis-driven and that VCL morphology can be staged along a continuum tightly linked to impaired perfusion, lymphosclerosis, and endothelial loss. VC-based VCL staging may serve as a practical intraoperative biomarker to stratify lymphatic viability and guide early intervention and regenerative strategies targeting lymphatic microcirculation.

Purpose: Split-thickness skin grafting (STSG) is widely used in reconstructive surgery but creates an iatrogenic donor-site wound with clinically meaningful morbidity, including delayed re-epithelialization and pain. Autologous platelet concentrates (APCs), including platelet-rich plasma (PRP) and platelet-rich fibrin (PRF), are increasingly used to accelerate donor-site healing, yet comparative evidence remains limited. (1) We evaluated whether topical APCs improve STSG donor-site outcomes compared with standard dressing care.

Methods and Materials: We conducted a PRISMA 2020–informed systematic review and meta-analysis. PubMed, Embase, and CENTRAL were searched from inception to December 21, 2025. Comparative adult studies evaluating topical APCs applied to STSG donor sites versus standard care were included. The primary endpoint was time to complete donor-site re-epithelialization (days). Secondary endpoints were percentage epithelialization at postoperative days 8 and 14 and pain at postoperative day 8 (VAS/NRS). Random-effects models (REML) pooled mean differences (MDs) with 95% confidence intervals (CIs). Heterogeneity was quantified with I², and prediction intervals were calculated.

Experience: Ten comparative studies (309 adult patients) were included. Most patients underwent STSG for burns or mixed complex wounds (trauma and ulcers). Donor sites were predominantly the thigh. Mean ages ranged from the early 30s to the late 60s. APC protocols varied substantially, including blood volumes from 8.5 to 120 mL, single- versus double-spin processing, and a single automated system. Most studies used a single APC application delivered by spray, syringe, or gel, while comparator dressings varied from commonly petrolatum/paraffin-based gauze to a hydrocolloid. Analgesic regimens were inconsistently reported.

Results: APCs shortened time to complete donor-site re-epithelialization versus controls (MD −4.23 days; 95% CI −6.29 to −2.17; I²=82.2%; prediction interval −10.51 to 2.06). In the RCT-only analysis (4 trials), APCs reduced healing time (MD −4.25 days; 95% CI −6.72 to −1.79; P<0.01; I²=89.5%). In split-body RCTs, the effect remained significant (MD −3.12 days; 95% CI −5.39 to −0.86; P<0.01). Epithelialization did not differ at day 8 (2 split-body RCTs; MD 6.16%; 95% CI −18.76 to 31.08) but was higher at day 14 (2 studies; MD 10.77%; 95% CI 8.93 to 12.62). Pain at day 8 was associated with a reduction overall (4 studies; MD −1.06; 95% CI −2.14 to 0.02) with substantial heterogeneity.

Conclusions: Topical APCs are associated with faster STSG donor-site re-epithelialization; however, substantial heterogeneity and prediction intervals that cross the null suggest that effects may vary by APC preparation/application, comparator dressings, and clinical context. (3) Given persistent donor-site morbidity and variation in dressing practices, adequately powered RCTs with standardized donor-site endpoints and prespecified analgesic protocols are needed.

(1) Braza ME, Marietta M, Fahrenkopf MP. Split-Thickness Skin Grafts. [Updated 2025 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551561/ (2) Page MJ, Mckenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(Suppl 1):n71. doi:10.1136/bmj.n71 (3) Asuku M, Yu TC, Yan Q, et al. Split-thickness skin graft donor-site morbidity: A systematic literature review. Burns : journal of the International Society for Burn Injuries. Published online February 25, 2021. doi:10.1016/j.burns.2021.02.014

Background: Lymphedema is a chronic, debilitating disease affecting approximately 120 million people worldwide. The lack of curative treatments highlights the gaps in our understanding of its underlying pathophysiology. Although the general features and progression of lymphedema are well-characterized, the mechanistic relationship between lymphatic dysfunction and adipose tissue formation remains unclear. This study aimed to elucidate how lymphatic injury contributes to adipose tissue deposition by histologically characterizing the skin and adipose tissue of patients with secondary lymphedema compared to healthy controls.

Methods: Skin and adipose tissue samples were collected from female patients diagnosed with secondary lymphedema (N=11), and healthy controls without lymphedema (N=11). Histological sections were stained with hematoxylin and eosin for assessment of epidermal thickness and adipocyte morphology. Immunohistochemical staining for Podoplanin was used to identify lymphatic vessels, while CD34 staining was used to assess vascularity. Quantitative morphological analyses were performed to compare structural differences between groups, with statistical significance determined using t-tests (p < 0.05).

Results: Skin samples from lymphedema patients demonstrated a significant increase in epidermal thickness compared to controls (p = 0.031). Analysis of skin lymphatic vessels showed no significant difference in density (count/region of interest) between groups (p>0.05), however, both the mean lymphatic vessel area and the total lymphatic vessel area coverage were significantly increased in lymphedema patients (p = 0.015 and p = 0.014, respectively). Assessment of skin vasculature demonstrated a significant increase in CD34-postive vessel density, mean vessel area, and total vascular area coverage in the lymphedema group, compared to controls (p = 0.011, p = 0.023, p = 0.019, respectively). In adipose tissue, the fat globule density was comparable between groups (p>0.05), but lymphedema samples demonstrated a significant increase in mean fat globule area (p = 0.023). In adipose tissue, a trend toward greater lymphatic channel density, mean lymphatic vessel area, and overall lymphatic coverage was noted, however, this did not reach statistical significance (p>0.05). Adipose vasculature analysis showed increased density in controls relative to lymphedema samples. In contrast, lymphedema samples exhibited significantly larger mean vessel area and greater vascular coverage (p = 0.038, p = 0.028, and p = 0.012, respectively).

Conclusions: This study identifies distinct histological changes in the skin and adipose tissue of patients with secondary lymphedema, emphasizing the complex interplay between lymphatic dysfunction, tissue fibrosis, vascular remodeling, and adipocyte hypertrophy. The findings suggest that chronic lymphatic stasis leads to altered tissue remodeling, contributing to epidermal thickening, lymphatic and vascular changes, and adipose tissue hypertrophy. These alterations may impair the regenerative capacity of affected tissues, thereby promoting disease progression. Future work will further elucidate the molecular and immunological mechanisms driving these changes to identify potential therapeutic targets for lymphedema management.

Background: Free tissue transfer (FTT) plays a critical role in limb salvage for complex lower extremity (LE) wounds, particularly in patients with diabetes, peripheral vascular disease, and infection. Although flap success rates are high, a subset of patients still progress to early limb loss. Identifying predictors of early amputation may improve patient selection, perioperative optimization, and shared decision-making. This study evaluated risk factors for early amputation following FTT and explored whether cumulative risk better predicts limb loss than individual variables. Methods: A retrospective review was performed of patients undergoing LE FTT for limb salvage at a single tertiary center between July 2011 and July 2025. Patients were stratified into two groups based on presence of early amputation (≤6 months after FTT). Demographics, comorbidities, vascular characteristics (including medial arterial calcification [MAC] score), wound characteristics, and postoperative outcomes were compared. Firth logistic regression was used to identify independent predictors of early amputation. Results: A total of 409 limbs underwent FTT. Early amputation occurred in 22 (5.9% ) of cases. Patients progressing to amputation more frequently had chronic steroid use (18.2% vs 5.7%, p = 0.043), midfoot wounds (36.4% vs 17.3%, p = 0.025), and medial or lateral leg involvement (p = 0.041 and p =0.018 respectively). They also experienced higher postoperative complication rates (77.3% vs 28.7%, p < 0.001), infection (59.1% vs 13.2%, p < 0.001), and reduced ambulatory status (40.9% vs 81.9%, p < 0.001) at median final follow-up duration of 17 months. On univariate Firth regression, significant predictors of early amputation included low albumin (p=0.001), diabetes (p=0.007), peripheral neuropathy (p=0.014), higher MAC score (p<0.001), elevated hemoglobin A1c (p=0.010), larger wound area (p=0.040), osteomyelitis (p=0.043), and calcified vessels (p=0.046). In multivariable regression, low albumin (OR=0.35 per g/dL increase, p=0.006) and higher MAC score (OR=1.31 per point, p=0.021) remained independent predictors. A composite high-risk cluster of all significant predictors on univariate analysis demonstrated increased odds of early amputation (OR 6.1), though statistical significance was not achieved (p=0.208), likely due to the low event count. Conclusions: Early amputation following FTT is uncommon but remains clinically significant. Nutritional status and overall vascular disease burden are key independent predictors of early limb loss. A cumulative risk profile may help identify vulnerable patients and allow for preoperative risk stratification to guide limb salvage decision-making.

Background: Robotic microsurgery offers submillimetric precision through tremor filtering and motion scaling, enabling enhanced dexterity for delicate reconstructive procedures. Although prior case series have demonstrated the feasibility of microsurgical robots in specific applications, comparative clinical data remain limited. To our knowledge, this study represents the largest cohort analysis to date comparing robotic-assisted and conventional manual microsurgical reconstruction across multiple reconstructive indications, including free flap, immediate lymphatic reconstruction (ILR), and lymphovenous bypass (LVB).

Methods: A single-center retrospective cohort study was conducted from September 2024 to September 2025. Patients undergoing free flap breast reconstruction, ILR, or LVB for the treatment of lymphedema were included. The robotic-assisted cohort comprised patients in whom the Symani Surgical System was used for microvascular anastomosis, while the manual cohort included those who underwent comparable procedures performed using standard microsurgical instruments under an operating microscope. Perioperative outcomes, complications, and procedure length were compared were compared using nonparametric and Fisher's exact tests. Predictors of operative time were identified by multivariable linear regression.

Results: Among 118 cases (36 robotic, 82 manual), robotic assistance was most frequently used for ILR (52.8%), followed by free flap reconstruction (33.3%) and LVB (13.9%; all robotic). Demographics, comorbidities, and treatment histories were comparable between robotic and manual groups. Robotic utilization varied by surgeon by procedure types (p<0.05). For free flaps, operative time trended longer with robotics (median 570.5 vs 537.0 minutes, p=0.07), while revision rates were higher but not significant (18.2% vs 5.5%, p=0.06). In ILR without concurrent procedures, robotic cases were longer (92.4 ± 23.6 vs 49.4 ± 18.1 minutes, p<0.01). Across ILR and LVB, postoperative outcomes were comparable, with no significant differences in flap or anastomotic complications. On multivariable analysis, manual approach (β = –42.1 min, p = 0.01) and absence of concurrent procedures (β = –39.1 min, p = 0.02) independently predicted shorter operative times. Anastomosis time declined significantly with experience (slope = –2.36 min/case, p = 0.01).

Conclusion: Robotic-assisted microsurgery using the Symani system offers comparable clinical outcomes to conventional techniques across free flap and lymphatic reconstruction. Although operative times were initially longer, they decreased rapidly with experience, reflecting a favorable learning curve. These findings suggest that robotic microsurgery can be successfully integrated into reconstructive practice, with future efforts focused on workflow optimization, long-term outcomes, and cost-effectiveness analysis.

Purpose: Complex abdominal wall reconstruction (AWR) using an anterolateral thigh (ALT) flap requires precise preoperative assessment of flap reach, pedicle length, muscle volume, and recipient vessel suitability. Conventional computed tomography angiography (CTA) provides static anatomic information but may not reliably predict dynamic flap behavior or the feasibility of pedicled versus microsurgical reconstruction. We describe a standardized protocol for integrating virtual surgical planning (VSP) into ALT flap–based AWR and demonstrate its application in complex cases.

Methods: Between January 2015 and December 2024, 16 ALT flaps incorporating vastus lateralis muscle were performed for complex AWR at a single tertiary center, including 11 pedicled and 5 microsurgical flaps. VSP was selectively employed in two patients with anticipated reconstructive complexity. High-resolution CTA datasets were segmented using three-dimensional modeling software to reconstruct skin, subcutaneous tissue, musculature, perforators, and vascular pedicles. Perforators were traced from the lateral circumflex femoral artery to their subcutaneous termini. Pedicle length, flap reach, and muscle volume were digitally measured. Multidisciplinary planning sessions were conducted approximately one week prior to surgery to simulate flap positioning relative to defect geometry and determine feasibility of pedicled versus free flap reconstruction.

Results: In the first patient, VSP estimated a pedicled flap reach of 10.3 cm from the distal vastus lateralis to the superior abdominal incision; intraoperative measurement was 13 cm. The pedicled ALT flap provided adequate coverage and abdominal closure. In the second patient, VSP demonstrated that the left-sided pedicle originated more cranially than the right, providing 4.4 cm greater predicted reach. Despite this advantage, modeling predicted insufficient overall coverage, prompting preoperative planning for microsurgical transfer. Intraoperative findings confirmed inadequate pedicled reach, and a free flap was performed as anticipated.

Conclusions: In selected complex cases, VSP provided dynamic, patient-specific assessment beyond static CTA, enabling improved prediction of flap reach, pedicle orientation, and need for microsurgical conversion in ALT flap–based AWR. Incorporation of VSP may enhance surgical preparedness and reduce intraoperative uncertainty in patients with significant loss of domain.

Background:
Acellular dermal matrix (ADM) is widely used in implant-based breast reconstruction to support soft tissue, improve lower pole control, and optimize cosmetic outcomes. Previous data show that, compared with non-ADM expander reconstruction, ADM does not significantly change major complications, infections, reconstructive failure, or patient reported outcomes [1]. Human cadaveric ADMs (HADMs) such as AlloDerm, DermACELL, FlexHD, and SurgiMend are effective but costly, prompting interest in ovine reinforced meshes (ORM) as more economical alternatives [2-4]. This review aims to compare the outcomes of HADM vs ORM.

Methods:
We reviewed randomized trials, prospective cohorts, retrospective studies, reporting outcomes of implant-based breast reconstruction using HADMs or ORMs. Three studies evaluating OviTex (hybrid ORM) were identified, encompassing 305 patients and 457 breasts, reporting clinical endpoints including complications, capsular contracture, reoperation, reconstructive failure, and cost.

Results:
In a single surgeon retrospective series of 127 patients (234 breasts), OviTex (ORM) showed no significant differences in total complications (18.4% vs. 21.1%; P = 0.34), major complications requiring return to the operating room (8.1% vs. 14.8%; P = 0.31), drain removal times (p = 0.42), or reconstructive success rates (p = 0.066). While material cost was approximately 24–38% lower [2].

A case series examined 79 patients (134 breasts) undergoing alloplastic reconstruction with OviTex. Reconstructions were direct-to-implant (65%) and prepectoral (72%). Overall reoperation rate was 22%, with exposure (20%) and infection (10%). Reoperation was significantly more likely in direct-to-implant compared to tissue expander-based reconstruction (79% vs. 21%; P < 0.001) and on the cancer side compared to the prophylactic side (90% vs. 10%; P < 0.001)[3].

In advanced capsular contracture, a retrospective comparison of ovine mesh with porcine ADM (STRATTICE) in 89 breasts showed significantly greater reduction in Baker grade with ovine mesh (96.6% vs 73.3% achieving Grade I, p<0.05) and lower material cost. The average cost was $27.37/cm2 for STRATTICE vs $22.28/cm2 for OviTex PRS [4]. Preclinical non-human primate work showed earlier host cell infiltration, neovascularization, and collagen deposition with ovine reinforced constructs than with HADM, with more complete remodeling by 12 weeks [5].

Conclusion:
Across all three studies, OviTex demonstrated complication profiles comparable to established biological matrices, with evidence of superior capsular contracture outcomes relative to porcine ADM and a favorable cost profile.

ORMs therefore appear to function as reasonable substitutes for HADMs in early series, without increased complication risk, while potentially offering cost advantages and improved capsular contracture outcomes. However, current ovine data remain limited by retrospective design, modest sample sizes, and short follow-up periods.

Larger prospective comparative studies with standardized complication reporting, long-term patient-reported outcomes, and formal cost analyses are needed to define the longitudinal safety, aesthetic outcomes, and overall value of ovine meshes versus HADMs in implant-based breast reconstruction.

References 1. Sorkin M et al. Plast Reconstr Surg. 2017;140:1091–1100. 2. Sweitzer K et al. Ann Plast Surg. 2024;93:664–667. 3. Paliwoda ED et al. Ann Plast Surg. 2026; Ahead of print. 4. Harfouche CJ et al. Aesthet Surg J Open Forum. 2024;6:ojae068. 5. Overbeck N et al. Eplasty. 2022;22:e43.

Purpose: Fat necrosis is a common complication following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Technical factors such as perforator number and flap weight are frequently implicated, though existing evidence is inconsistent. This study evaluated technical, patient, and operative factors associated with fat necrosis in a large, single-institution cohort of DIEP flaps.

Methods: A retrospective cohort study was conducted of patients who underwent DIEP flap reconstruction between 2016 and 2025 at a single academic institution. Each flap was analyzed individually. Fat necrosis was defined as documentation of clinically diagnosed fat necrosis in postoperative clinic notes. Demographic, technical (perforator number, flap weight, weight-per-perforator), and operative variables were collected. Continuous variables were analyzed using Wilcoxon rank-sum tests and categorical variables using Fisher's exact tests. Multivariable logistic regression was performed to evaluate independent associations between reconstruction timing, DIEP laterality, and fat necrosis after adjustment for age and BMI.

Results: A total of 332 DIEP flaps were included, of which 107 (32.2%) developed fat necrosis. Fat necrosis rates were 30.3% in single-perforator flaps, 29.3% in two-perforator flaps, and 37.7% in flaps with ≥ 3 perforators (p = 0.308). Patient age, BMI, operative time, flap weight, and weight-per-perforator ratio were not associated with fat necrosis on univariate analysis. Bilateral reconstruction was associated with significantly higher rates of fat necrosis compared to unilateral reconstruction (36.6% vs. 22.6%, p = 0.020). Delayed reconstruction was also associated with higher rates of fat necrosis compared to immediate reconstruction (40.7% vs. 26.8%, p = 0.011). In multivariable logistic regression including both reconstruction timing and laterality, bilateral reconstruction remained independently associated with increased odds of fat necrosis (OR 2.17, 95% CI 1.23–3.95, p = 0.009). Delayed reconstruction also remained independently associated with increased odds of fat necrosis (OR 2.04, 95% CI 1.26–3.36, p = 0.004).

Conclusion: Fat necrosis following DIEP reconstruction was independently associated with delayed and bilateral reconstruction, whereas perforator number and flap weight were not associated. These results suggest that the reconstructive approach may exert greater influence on fat necrosis risk than perforator characteristics. Recognition of delayed and bilateral reconstruction as higher-risk settings may inform surgical planning and patient counseling, although prospective studies are warranted to validate these findings.

Introduction: Microsurgical treatment for lymphedema attempts to restore physiologic function and is well accepted in the extremities. Surgical modalities include lymphovenous anastomoses (LVA), vascularized lymph node transfers (VLNT), and vascularized lymph vessel transplants (VLVT). The microsurgical management of head, neck, breast, trunk, and genital lymphedema is, however, underreported. The objective of this systematic review was to assess microsurgical outcomes for non-extremity lymphedema to identify evidence gaps and evaluate efficacy and safety.

Methods: A database search of PubMed, Web of Science, and Embase was conducted for randomized controlled trials, cohort studies, case-control studies, and case series. Inclusion criteria consisted of English-language articles published after 2000, patients over 18 years of age, primary or secondary lymphedema, and n ≥ 2 patients. Studies reporting outcomes for non-microsurgical procedures were excluded unless performed concurrently with microsurgery. The primary outcome was edema reduction, and secondary outcomes included complications, recurrence of cellulitis, and patient-reported outcome measures (PROMs).

Results: Fifteen studies met inclusion criteria, consisting of 2 retrospective cohort studies and 13 case series, totaling 101 patients. For male genital lymphedema (n=72), 38.9% were treated with LVA and 61.1% with VLNT. Microsurgical studies for female genital lymphedema were not found. All head/neck lymphedema studies utilized LVA (n=13). For truncal lymphedema (n=13), 61.5% were treated with LVA, and 38.5% with LVA and VLNT. Breast lymphedema patients (n=3) were treated with LVA (66.7%) or VLNT (33.3%). Edema reduction was quantified with tape measuring in 33.3% of studies (3 genital, 2 head/neck), with marked edema reduction observed. For genital lymphedema, 22.2% (4/18) of LVA-treated patients and 0% (0/34) of VLNT-treated patients had recurrence of cellulitis in the follow-up period. The Genital Lymphedema Score and Lymphedema Symptom Intensity and Distress Surveys-Head and Neck tool were the most utilized to assess patient-reported outcomes. Statistically significant improvements in patient quality of life were observed for VLNT-treated genital lymphedema patients and LVA-treated head/neck lymphedema patients.

Conclusion: Though non-extremity lymphedema is rare, the burden of care is substantial. Microsurgery can be safely implemented for non-extremity lymphedema and may greatly improve patient quality of life through reduction in edema and skin infection recurrence. The current evidence base is limited by small observational studies and heterogeneity in edema outcome reporting. Future prospective studies are needed using validated objective and patient-reported outcome measures to establish evidence-based treatment algorithms for non-extremity lymphedema.

Background: Free tissue transfer (FTT) is a reconstructive option for highly comorbid patients with chronic non-healing lower extremity (LE) wounds. Understanding survival outcomes and early mortality risk factors is critical for patient counseling and perioperative care. This study characterizes overall mortality following LE FTT and identifies predictors of early death within one year.

Methods: A total of 396 patients undergoing LE FTT with median follow-up of 16.6 [IQR: 27.2] months were retrospectively reviewed. Survival time was calculated from the date of FTT to death or last follow-up. Kaplan-Meier analysis estimated survival probability. Early death was defined as mortality within one year following FTT. Due to low event counts (21 deaths), firth logistic regression was used to evaluate the association of patient characteristics, vascular history, and surgical factors with early death. Results: Kaplan-Meier analysis demonstrated a 1-year survival of approximately 70%, with a median survival time of 1.5 years. In the adjusted Firth logistic regression, female sex (OR 5.73; 95% CI 1.43–22.98; p=0.014) and higher Charlson Comorbidity Index (OR 1.41 per point; 95% CI 1.01–1.97; p=0.045) were independent predictors of early death. Diabetes (OR 6.44; 95% CI 0.50–83.44; p=0.193) showed non-significant trends toward increased risk. Age, body mass index, smoking status, end-stage renal disease, immunosuppression, wound area, tibial vessel runoff, and flap type were not significantly associated with early mortality. The overall model's penalized likelihood ratio test indicates overall significance (p=0.0015). Conclusion: Female sex was independently associated with early mortality after LE FTT, echoing vascular literature that describes worse perioperative outcomes in women undergoing limb salvage (1-3). These disparities may reflect delayed presentation, higher disease burden, or treatment differences. These findings highlight the need for sex-specific risk stratification and highlight gaps in representation and outcomes data for female patients in microsurgical reconstruction.

(1) Vouyouka AG, Egorova NN, Salloum A, Kleinman L, Marin M, Faries PL, Moscowitz A. Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease. J Vasc Surg. 2010 Nov;52(5):1196-202. doi: 10.1016/j.jvs.2010.05.106. Epub 2010 Jul 31. PMID: 20674247. (2)Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M, Chaikof EL, Schermerhorn ML. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg. 2014 Feb;59(2):409-418.e3. doi: 10.1016/j.jvs.2013.07.114. Epub 2013 Sep 29. PMID: 24080134; PMCID: PMC3946884. (3) Farag N, Pham BL, Aldilli L, Bourque ML, Zigui M, Nauche B, Ades M, Drudi LM. A Systematic Review and Meta-Analysis on Sex-Based Disparities in Patients with Chronic Limb Threatening Ischemia Undergoing Revascularization. Ann Vasc Surg. 2023 Sep;95:317-329. doi: 10.1016/j.avsg.2023.03.007. Epub 2023 Apr 17. PMID: 37075836.

Background: Immediate lymphatic reconstruction (ILR) performed at the time of axillary surgery aims to reduce LE risk, but its impact on patient-reported fear and lymphedema-specific quality of life (QoL), particularly when ILR is aborted intraoperatively, is not well characterized. This study compared longitudinal Lymphedema Life Impact Scale (LLIS) trajectories and fear-related domains among patients scheduled for ILR who either completed ILR or did not receive ILR.

Methods: We performed a single-surgeon retrospective cohort study of adults patients with breast cancer referred for ILR. The decision to undergo ILR was made intraoperatively, if patients underwent axillary lymph node dissection (ILR group) or was not performed if patients only required sentinel node biopsy (noILR group). Demographic, oncologic, and treatment variables were extracted from the medical record. Primary outcome included QoL and fear of lymphedema was assessed using LLIS surveys at baseline, 1-month, 3, 6, and 12 months postoperatively. Secondary endpoints: cumulative BCRL incidence by bioimpedance spectroscopy (BIS; ≥10 L-Dex units) or patient reported symptoms, and compression use/complications.

Results: Seventy patients were referred to plastic surgery for possible ILR from January 2020 to August 2025; 50 underwent ILR and 20 did not. Baseline LLIS scores were low and similar between cohorts (mean 7.49 vs 1.68; p = 0.19). Postoperatively, ILR patients reported lower overall LLIS scores than noILR patients (mean 6.51 vs 15.99; mean difference −9.49 points; 95% CI −22.43 to 3.45; p = 0.13). Among 31 patients with ≥1-year data (26 ILR, 5 noILR), ILR patients improved on average (mean ΔLLIS −6.11), whereas noILR patients worsened (mean ΔLLIS +15.00). The between-group difference in change (−21.11 points; 95% CI −44.96 to 2.74) showed a large effect size and reached significance (p = 0.038). Item-level analyses suggested the greatest ILR-associated benefits in movement, reliance on others, pain, skin tightness, and sleep. Cumulative incidence of BCRL was 9.5% in the ILR group and 32% in the noILR group (p=0.014).

Conclusions: In this cohort of patients referred for ILR, longitudinal LLIS scores favored those who underwent ILR, despite their higher surgical risk profile. Even when ILR is not performed in patients deemed lower risk, lymphedema-related impact and fear of lymphedema remains clinically relevant and worsened over time, underscoring the need for expectation-setting, targeted survivorship education, and integration of psychosocial care alongside surgical pathways.

PURPOSE: Clinicians currently lack objective tools to predict when a wound will heal or whether healing is progressing appropriately, forcing reactive management that delays intervention and wastes critical treatment windows. Existing AI wound assessment technologies trained on image color features show reduced accuracy on darker skin tones (1), particularly because underserved populations bear a disproportionate chronic wound burden. We developed an AI-driven platform that predicts wound healing day from objective biomechanical data using digital image speckle correlation (DISC), with a detection pipeline that operates independently of skin pigmentation.

METHODS: DISC measures mechanical force propagation through healing tissue by tracking displacement of natural skin features under controlled point loading via video (2). We automated wound boundary detection using two zero-shot AI foundation models (Grounding DINO, SAM) that rely on gradient-based intensity patterns rather than learned color features, enabling detection across all skin tones without wound-specific training data. Using a 28-day porcine burn model (six treatment groups, two application timepoints), we trained eight machine learning architectures on five features: wound closure percentage, DISC-derived force propagation ratio, applied force, treatment type, and application timing (n=614, days 7 to 28, 10 repeated 80/20 train-test splits).

RESULTS: All eight models outperformed a baseline predictor (MAE 5.55 days). Performance was consistent across linear, tree-based, kernel, and ensemble methods, and within-7-day accuracy ranged from 85% to 91%, confirming that the predictive signal in DISC-derived features is model-agnostic. The best-performing model (KNN) achieved MAE of 3.39±0.25 days, R-squared of 0.549±0.051, and within-7-day accuracy of 90.6±2.6%. Accuracy at tighter prediction windows reached 47.5% within 3 days and 75.9% within 5 days. Feature importance analysis using iterative Random Forest (3) with stability analysis identified wound closure (48.4%) and force propagation ratio (17.6%) as the two dominant predictors, followed by treatment type (15.2%) and applied force (14.9%). Ablation confirmed that removing wound closure degraded MAE by 0.94 days, and that force propagation ratio adds predictive value beyond visual closure alone. Per-day prediction errors ranged from 2.4 days (day 21) to 4.6 days (day 28), with no systematic bias toward overprediction or underprediction.

CONCLUSIONS: This AI-driven predictive platform demonstrates that DISC biomechanical data contain sufficient information to predict healing day with approximately 90% accuracy within one week. Because the system detects tissue boundaries through mechanical displacement rather than color, it avoids known bias in medical imaging AI and provides equitable assessment across skin tones. These results support DISC as a clinical platform with applications in remote wound monitoring via telemedicine, burn zone prediction for surgical triage, debridement timing, and standardized assessment by non-specialist clinicians.

References: 1. Daneshjou R, Vodrahalli K, Novoa RA, et al. Disparities in dermatology AI performance on a diverse clinical image set. Sci Adv. 2022;8(31):eabq6147. 2. Verma R, Klein G, Xu Y, et al. Digital image speckle correlation to optimize botulinum toxin type A injection. Plast Reconstr Surg. 2019;143(6):1614-1618. 3. Basu S, Kumbier K, Brown JB, Yu B. Iterative random forests to discover predictive and stable interactions. Proc Natl Acad Sci U S A. 2018;115(8):1943-1948.

Background: Breast reconstruction after mastectomy can restore body image and improve quality of life (1). Implant-based reconstruction (IBR) offers shorter operative times without donor-site morbidity, while deep inferior epigastric perforator (DIEP) flaps may provide more natural outcomes (2,3). This systematic review compared outcomes of DIEP flaps and IBR.

Methods: A systematic search of MEDLINE, CENTRAL, and Google Scholar was performed in June 2025 (PROSPERO ID: CRD420251081966) for studies comparing DIEP and IBR after mastectomy. Studies reported BREAST-Q scores and/or complications, reconstruction failures, and revision surgeries. Risk of bias was assessed using Cochrane RoB 2.0 for randomized trials and ROBINS-I for non-randomized studies, with evidence graded using GRADE (4,5). Pooled mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated.

Results: Twenty studies including 3,106 patients (1,068 DIEP and 2,038 IBR) were analyzed. DIEP flap group showed higher overall BREAST-Q scores (MD +9.28; p = 0.008), with improvements in breast satisfaction, psychosocial well-being, and sexual well-being. Nipple satisfaction and chest physical well-being showed no significant differences. Infection, hematoma, and seroma rates were comparable. DIEP flap had lower reconstruction failure rate (odds ratio [OR] 0.15; p = 0.019), though donor-site morbidity and revision rates were higher. Anxiety and depression outcomes showed no significant differences.

Conclusions: DIEP flap reconstruction offers better patient satisfaction and lower failure rates than IBR, without increased complications. These benefits must be weighed against operative complexity and resource demands. High-quality multicenter trials with standardized outcome reporting are needed for patient-centered decisions.

1. Roy N, Downes MH, Ibelli T, et al. The psychological impacts of post-mastectomy breast reconstruction: a systematic review. Annals of Breast Surgery. 2024;8. doi:10.21037/ABS-23-33/COIF)
2. Malekpour M, Malekpour F, Wang HTH. Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome. World J Clin Cases. 2023;11(10):2201-2212. doi:10.12998/WJCC.V11.I10.2201,
3. Busic V, Das-Gupta R, Mesic H, Begic A. The deep inferior epigastric perforator flap for breast reconstruction, the learning curve explored. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2006;59(6):580-584. doi:10.1016/j.bjps.2005.04.061
4. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: A tool for assessing risk of bias in non-randomised studies of interventions. BMJ (Online). 2016;355. doi:10.1136/BMJ.I4919,
5. Sterne JAC, Savović J, Page MJ, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. The BMJ. 2019;366. doi:10.1136/BMJ.L4898,