Faculty Bibliography

Segmental peripheral nerve injuries, particularly those involving long nerve gaps, pose a significant challenge in reconstructive surgery. Conventional strategies, such as nerve autografts or processed allografts, are often limited by inadequate length or poor regenerative outcomes, especially in traumatized wound beds. Nerve flaps offer the theoretical advantage of enhanced axonal regeneration through improved perfusion and support of Schwann cell viability but are rarely used due to technical complexity and limited donor options. We present a unique case of a free sural nerve flap used to reconstruct a 7-cm segmental defect of the tibial nerve following blast trauma in a 23-year-old man. A composite flap consisting of the sural nerve and lesser saphenous vein was harvested with preservation of the bridging adipofascial tissue to maintain perfusion to the nerve. The lesser saphenous vein was anastomosed to the retrograde peroneal artery distally and ligated proximally, whereas the sural nerve was divided and used as a double-barrel cable graft across the defect. Intraoperative Doppler and SPY angiography confirmed perfusion of the nerve through the preserved adipofascial connections. The patient was recently seen in our clinic at 17 weeks postoperation. He demonstrated undetectable 2-point discrimination in all nerve distributions of his foot but is ambulatory. This case demonstrates the feasibility and potential utility of a free vascularized sural nerve flap for reconstructing extensive peripheral nerve defects, particularly in cases where standard techniques are inadequate.

PURPOSE/OBJECTIVE:Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects. METHODS:We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review. RESULTS:(±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases. CONCLUSIONS:Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.

OBJECTIVE:To describes our institutional experience of a case series using a novel multi-segment, chimeric free ileal flap for posterior urethral reconstruction, focusing on surgical technique, perioperative management, and functional outcomes. Complex posterior urethral defects, particularly those resulting from radiation pose a significant reconstructive challenge that is not easily approachable with standard reconstructive techniques. In this case series, we present a novel approach for this complex problem. METHODS:We retrospectively reviewed consecutive patients who underwent posterior urethral reconstruction with a chimeric free ileal flap at our institution. Data were collected via chart review. RESULTS:Six male patients (median age: 61 years range: 59-77) with radiation-associated posterior urethral stenosis and bladder neck pathology underwent reconstruction. One was an active smoker; three had prior failed reconstructions. A 20-cm ileal segment was harvested and designed into a chimeric construct in all cases. The left deep inferior epigastric vessels were used for flap anastomosis. Median operative time was 717 minutes, and median hospital stay was 9 days. Two patients experienced early postoperative complications; none had flap loss. At median follow-up of 204 days, four patients had successful functional outcomes. One had persistent leak, and one required cystectomy for newly diagnosed squamous cell carcinoma found at the bladder neck on final pathology. CONCLUSIONS:Chimeric free ileal flap reconstruction is a novel management option for radiation-associated posterior urethral defects, offering well-vascularized, versatile tissue in patients unsuitable for traditional approaches. However, this approach is complex that requires multidisciplinary collaboration and extensive surgical planning.

BACKGROUND:The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, though its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures. METHODS:A retrospective review was conducted on 769 free flaps performed between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage. RESULTS:No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared to the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%. CONCLUSION/CONCLUSIONS:We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.

BACKGROUND/UNASSIGNED:A seroma following prepectoral tissue expander (TE) reconstruction often begets other complications, which may compromise the reconstruction. This study investigated the association between seroma and subsequent complications. METHODS/UNASSIGNED:All consecutive prepectoral TE reconstructions performed between March 2017 and December 2022 at a single center were reviewed. Demographics, operative characteristics, and complications data were extracted for all patients and analyzed. RESULTS/UNASSIGNED:< 0.01). CONCLUSIONS/UNASSIGNED:Although causality cannot be determined, our data suggests that seroma may be the "kiss of death" in prepectoral TE reconstruction because half of all breasts with a seroma went on to develop other complications.

INTRODUCTION/UNASSIGNED:Ventral hernia repair (VHR) is a common procedure complicated by high hernia recurrence rates exceeding 30 % over ten years. The T-Line® Hernia Mesh is a synthetic, polypropylene mesh featuring mesh extensions designed to prevent anchor point failure by evenly distributing tension to reduce ventral hernia recurrences. This study evaluates the outcomes of the T-Line® mesh in VHR with 1-3 year follow-up. METHODS/UNASSIGNED:This study is a multi-institutional retrospective cohort study on patients who underwent VHR with T-Line® mesh between October 2020 and December 2022. Patient demographics, surgical details, and postoperative outcomes were collected. Patient-reported outcomes were assessed using HerQLes and ACHQC surveys. RESULTS/UNASSIGNED:= 7, 12.3 %). Of the five patients that reported feeling a slight bulge at their previous hernia site, upon clinical evaluation two patients had a recurrence (one recurrence was caused by the suture tearing through the underlying laparotomy repair while the mesh remained anchored intact above the repair, and the second recurrence was caused by inadequate mesh fixation at the caudal border of the mesh), while no patients reported using pain medication for abdominal wall discomfort. CONCLUSIONS/UNASSIGNED:The T-Line® Hernia Mesh demonstrated safety and effectiveness in ventral hernia repair, with low recurrences and postoperative complications rates over a 1-3-year period, suggesting it is a valuable tool for complex hernia repairs.

PURPOSE/OBJECTIVE:Although many factors in prepectoral breast reconstruction such as mastectomy weight and flap quality are out of the plastic surgeon's control, some elements such as intraoperative tissue expander (TE) fill can be optimized. This study assesses the impact of intraoperative TE fill on postoperative complications in prepectoral breast reconstruction and posits the optimal fill. METHODS:All consecutive, prepectoral TE reconstructions performed between March 2017 and December 2022 at a single center were reviewed. A "fill ratio" or ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify deadspace in the breast pocket, with values closer to 1 signifying less deadspace. Major complications include those requiring readmission or reoperation and minor complications include those that could be treated as an outpatient. A P < 0.05 was considered statistically significant. RESULTS:A total of 200 patients (318 breasts) with average follow-up of 22 months were included. Patients were, on average, 53 years old, were nonsmoker (98%), were nondiabetic (91%), and had a body mass index of 26 kg/m2. Only immediate reconstructions were included and were performed following prophylactic mastectomies in 34% and therapeutic mastectomies in 66% of cases. Seventy-six (24%) breasts were radiated, and 93 (47%) patients received chemotherapy. Mean mastectomy weight was 546 g, median intraoperative TE fill was 175 ± 250 cc, and median final TE fill was 390 ± 220 cc.Major complications occurred in 64 (20%) breasts and were associated with less deadspace (0.49 vs 0.36, P < 0.05). In multivariable models, a higher fill ratio was associated with 2.4 times higher odds of major complications (95% CI, 1.2-4.7; P = 0.01). Optimal intraoperative TE fill for avoiding major complications was 80 cc, and optimal fill ratio was 0.09.Explantation occurred in 44 (14%) breasts and was associated with less deadspace (0.51 vs 0.35, P < 0.05); the optimal fill for avoiding explantation was 80 cc, and optimal ratio was 0.12. CONCLUSIONS:Higher intraoperative TE fill and less deadspace were associated with postoperative complications. Filling a TE to 80 cc or approximately a tenth of mastectomy weight may reduce complications.

BACKGROUND:The National Comprehensive Cancer Network guidelines consider pancreatic cancer with celiac axis (CA), proper hepatic artery (PHA), and superior mesenteric artery (SMA) involvement unresectable. Thus, technical reports and video illustrations of these operations are rare. We report the stepwise management of multivascular reconstruction for Mayo Clinic class IIIb CA resections at New York University Langone Health, a dedicated center of excellence in pancreatic surgery. METHODS:We illustrated the management of a 56-year-old patient with biopsy-confirmed pancreatic ductal adenocarcinoma arising from the pancreatic body and involving the CA, PHA, SMA, and mesentericoportal venous axis. PERIOPERATIVE MANAGEMENT/UNASSIGNED:The preoperative stepwise considerations include: 1) mandatory patient selection; 2) planning vascular reconstructability; 3) tailoring risk assessment while carefully considering the need for total pancreatectomy, total gastrectomy, and mesenteric/hepatic revascularization; and 4) 3D-reconstruction for arterial evaluation. The key intraoperative considerations include: 1) selective and sequential clamping for vascular reconstruction in a "domino" fashion, to minimize warm ischemic time 2) a combined multi-surgeon approach to comprehensively tackle vascular reconstructions; 3) a low threshold for total pancreatectomy to avoid pancreatic leak; and 4) two-stage surgery to reassess the blood supply to the liver and stomach for on-demand gastric preservation instead of a theoretically advised total gastrectomy. CONCLUSION/CONCLUSIONS:Liver, stomach, and bowel vascularization present life-threatening risks that require an extensive preoperative evaluation and a multidisciplinary approach. Our stepwise management for these extensive operations includes total pancreatectomy, "domino" vascular reconstruction, and two-stage surgery.

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory skin disease characterized by keratinized epithelial tunnels that grow deeply into the dermis. Here, we examined the immune microenvironment within human HS lesions. Multi-omics profiling and multiplexed imaging identified tertiary lymphoid structures (TLSs) near HS tunnels. These TLSs were enriched with proliferative T cells, including follicular helper (Tfh), regulatory (Treg), and pathogenic T cells (IL17A+ and IFNG+), alongside extensive clonal expansion of plasma cells producing antibodies reactive to keratinocytes. HS fibroblasts express CXCL13 or CCL19 in response to immune cytokines. Using a microfluidic system to mimic TLS on a chip, we found that HS fibroblasts critically orchestrated lymphocyte aggregation via tumor necrosis factor alpha (TNF-α)-CXCL13 and TNF-α-CCL19 feedback loops with B and T cells, respectively; early TNF-α blockade suppressed aggregate initiation. Our findings provide insights into TLS formation in the skin, suggest therapeutic avenues for HS, and reveal mechanisms that may apply to other autoimmune settings, including Crohn's disease.