Journal of reconstructive microsurgery最新文献

Introduction: Free tissue transfer (FTT) is determined by a multitude of patient and surgeon factors. However, no tool exists to quantify patient risk for complications following FTT. This study developed the Microsurgical Index for Complication Risk and Outcomes (MICRO) to address this.

Methods: Patients were queried from the 2007-2015 MarketScan Databases with CPT codes for FTT requiring microsurgical anastomosis. ICD-9 codes were used to query comorbidity and 90-day postoperative complication data for each patient. The Charlson and Elixhauser Comorbidity Indexes were constructed for each patient. The MICRO was then constructed with a forward stepwise selection from Elixhauser comorbidities and domain expert input. Indexes were used as covariates in multivariate logistic regression models with patient age, sex, and flap tissue type to predict complications following FTT. The area under the receiver operating characteristic curve and five-fold cross-validation classification accuracy was determined.

Results: A total of 5,595 patients were included. The final MICRO consists of seven variables (Charlson - 19; Elixhauser - 30). It had the highest area under the receiver operating characteristic curve (0.60) and accuracy (60.4%) of all indexes when predicting complications.

Conclusion: The MICRO outperforms available patient comorbidity indexes at predicting complications following FTT with far fewer variables. Future studies could augment the MICRO with more granular or institutional data consisting of surgeon, donor-site, and recipient-site data to create a sharper risk-stratification tool for the plastic surgeon.

Background: Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use has been shown to have unfortunate adverse effects. With increasing awareness and diagnostic capabilities for neuroma formation, this study evaluates whether upper extremity neuroma excision may reduce opioid use and if adjunctive nerve procedures further reduce opioid use.

Methods: The PearlDiver database was queried for patients undergoing upper extremity neuroma excision surgery from 2010-2020. Patients with opioid prescription fill records preoperatively were extracted and stratified by operative technique involving either 1) excision alone, 2) nerve implantation into bone or muscle, or 3) nerve reconstruction. Records were then assessed at 1, 3, and 6 months postoperatively to assess for opioid use. Prescription fill rates at one, three, and six months postoperatively were then assessed across techniques.

Results: Of the 14,330 patients that underwent upper extremity neuroma excision, 4,156 filled opioids preoperatively. Excision led to significant reductions in opioid prescription fill rates postoperatively, decreasing to 67.4% at 1 month and to 57.5% by 6 months (p<0.001). Excision alone resulted in lower opioid use compared to excision with implantation at all postoperative time points (p<0.05). At 6 months, opioid use was also significantly less following excision with nerve reconstruction compared to implantation (56.4% vs. 65.6%, p = 0.0096). There were no differences between excision alone and excision with nerve reconstruction.

Conclusion: Neuroma excision significantly reduces opioid use in patients with preoperative opioid use while adjunctive operative techniques did not potentiate opioid reduction. This highlights the importance of understanding patient complaints, neuroma localization, and candidacy for excision as an effective measure for addressing opioid use in patients with preoperative opioid dependence.

Abdominal wall bulges and hernias are not uncommon complications following deep inferior epigastric perforator (DIEP) flap harvest. Abdominal wall reinforcement using synthetic meshes has been found to decrease bulges by up to 70%; however, such meshes can be associated with other issues such as seromas and infections. Reinforced tissue matrix (RTM) mesh can be used for abdominal wall reinforcement due to its ability to recruit fibroblasts and provide a scaffold for cellular proliferation. There is no literature on the use of OviTex mesh for abdominal wall reinforcement following DIEP flap harvest. Therefore, this study aimed to evaluate the efficacy and safety of its use in this setting.A retrospective review was performed on patients undergoing DIEP flap harvest between January 2020 and June 2023. Patients who had completed at least 12 months of follow-up visits were included. Descriptive, univariate, and multiple logistic regression analyses were completed.A total of 199 patients were included. The mean age at the time of surgery was 51.1 ± 10.0 years and the mean body mass index (BMI) was 30.2 ± 5.9 kg/m². Abdominal wall reinforcement was completed in 85 (42.7%) patients. Patients who had OviTex placed developed fewer bulges compared to the non-mesh cohort (0% vs. 5.3%, p = 0.04). Furthermore, OviTex mesh did not increase adverse events and was not significantly different in seroma/hematoma rates when compared to the non-mesh cohort (10.6% vs. 5.3%, p = 0.26).This study demonstrates that OviTex mesh is safe and efficacious in reducing the rate of bulges following DIEP flap harvest without increasing other complications.

Midface reconstruction should address both functional and cosmetic aspects. The vascularized fibular osteomyocutaneous flap (VFOF) is a promising first choice because of its numerous advantages in this type of reconstruction.This study aimed to investigate the causes of VFOF failure during midface reconstruction. We retrospectively reviewed patients who underwent midface defect reconstruction using VFOF from August 2011 to May 2022 at a single center. The primary outcome variable was VFOF loss within 30 days, and secondary outcomes included late complications related to VFOF occurring at least 6 months postoperatively.A total of 62 patients underwent VFOF reconstruction for midface defects. The VFOF technique was primarily used in 56 (90.3%) patients for initial reconstruction. according to the Brown and Shaw classification, most reconstructions were performed for Class III (77.4%) and Class b (83.6%) defects. Skin paddles of the VFOF were used in 51 (82.3%) patients, and a double flap technique utilizing the fibular was employed in 24 (38.7%) patients. VFOF failure occurred in 10 (16.1%) patients. Prognostic factors associated with VFOF failure included sex (p = 0.01) and maxillary Brown and Shaw classification (horizontal; p = 0.01). Long-term follow-up of 47 patients revealed late complications in 11 (23.4%) patients, and diabetes mellitus was identified as a significant risk factor (p < 0.01).The VFOF is suitable for midface defect reconstruction; however, proper placement of the fibular bone, avoiding pedicle vessel kinking, ensuring tension-free vascular anastomosis during surgery, considering the use of an additional flap in addition to the fibula flap for large defects, and diligent postoperative nasal care are essential.

Reconstructive microsurgery remains a demanding field, requiring technical expertise and long operating hours. This places microsurgeons at increased risk of dissatisfaction and burnout. The co-surgeon model has been developed to mitigate these challenges. This study was designed to evaluate microsurgeon perspectives on the characteristics and impact of the co-surgeon model for microsurgical free flaps.An electronic anonymous survey was distributed via email to attending microsurgeon members of the American Society of Reconstructive Microsurgeons. The survey collected various demographic and practice-related information including Likert scale questions to assess microsurgeon perspectives on the utility of the co-surgeon model.A total of 862 microsurgeons received the survey, with 102 responses available for analysis. The average age of respondents was 46.6 (± 9.7) years. Most of the microsurgeons were male (71%) practicing in the United States (93%), with 74.5% of respondents utilizing a co-surgeon model in their practice. Bilateral breast flaps were the most common microsurgical procedure performed using a co-surgeon (85%), followed by head and neck free flaps (60%), with immediate lymphatic reconstruction being the least common (3.1%). On the day of the co-surgery case, the co-surgeon was more likely than the primary surgeon to have additional cases (68.4 and 36.4%, respectively), with the additional cases being rarely free flaps. More than 80% of microsurgeons stated that the co-surgeon model improves "very much" or "quite a bit" operative efficiency and duration, as well as surgeon well-being and career longevity.This study provides new insight into the utility of using a co-surgeon for free flap reconstruction by demonstrating that approximately 80% of microsurgeons have a positive perception of the model's impact on procedure efficiency, operative time, surgeon well-being, and career longevity. Therefore, adopting a co-surgeon model for microsurgical free flap reconstruction may be useful in reducing burnout and promoting well-being among microsurgeons.

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Background:  Deep inferior epigastric perforator (DIEP) flap is a common autologous breast reconstruction option. DIEP flap may be performed immediately on the day of mastectomy (immediate DIEP) or at a later date typically following placement of a tissue expander during mastectomy (delayed-immediate DIEP). Preparing internal mammary vessels during microsurgical anastomoses involves prolonged retraction of the breast skin flaps, which can increase tension on acutely ischemic mastectomy skin. The purpose of this study is to investigate whether DIEP flap timing has an effect on mastectomy skin necrosis.

Methods:  A single-center study was performed of patients who underwent immediate or delayed DIEP flap reconstruction over a 3-year period. Patients were divided into two groups: Group I (immediate DIEP flap) and Group II (delayed-immediate DIEP with flap staged separately from mastectomy). The outcomes assessed were breast skin flap necrosis and management of skin flap necrosis.

Results:  The study included 106 patients (173 flaps) in Group I (49 patients, 80 flaps) and Group II (57 patients, 93 flaps). Mastectomy skin flap necrosis rates were 11.3% (9/80) for Group I compared to 2.2% (2/93) of Group II patients (p = 0.025). Skin necrosis necessitating operative debridement was 7.5% (6/80) in Group I and 1.1% (1/93) in Group II (p = 0.0499).

Conclusion:  Immediate DIEP flaps performed on the day of mastectomy have a significantly higher risk of mastectomy skin necrosis. Patients may be counseled that another advantage of performing a DIEP flap on a different day than a mastectomy is to decrease the risk of mastectomy skin necrosis.

Background:  The thoracodorsal artery perforator (TDAP) flap is a versatile pedicled and free flap with low donor site morbidity and a relatively thin skin paddle. Physical patient characteristics may influence interindividual differences in perforator characteristics and, therefore, help to estimate the safety of the TDAP flap.

Methods:  Dynamic infrared thermography and color duplex ultrasound were applied to assess the TDAP diameter, peak systolic velocity (PSV), end-diastolic velocity, resistance index, and thickness of the latissimus dorsi muscle and the subcutaneous tissue bilaterally in 25 subjects. The effect of handedness on the symmetry of perforator characteristics was investigated.

Results:  Perforator properties were not significantly altered by sex or body mass index. The mean latissimus dorsi muscle thickness correlated positively with both the perforator diameter (Pearson's r = 0.25, p = 0.0048, n = 124) and the PSV (r = 0.29, p = 0.0012, n = 124). In contrast, a negative correlation was observed between subcutaneous tissue thickness and PSV (r = -0.31, p = 0.0003, n = 124). A comparison of the perforator diameter and the PSV in the dominant and nondominant sides showed no statistically significant difference.

Conclusion:  The findings of the study indicate that perfusion of the thoracodorsal artery flap is enhanced by the presence of a thicker latissimus dorsi muscle, a thinner subcutaneous tissue, and a reduced quantity of TDAPs.

Background:  There is a growing emphasis on minimally invasive techniques as an alternative to surgical delay to promote vessel reorganization and prevent partial and total flap loss. This systematic review evaluates existing literature on these minimally invasive techniques, focusing on their potential applications in preventing ischemia-related complications.

Methods:  A systematic review was conducted in July 2024 using PubMed, MEDLINE, and Web of Science following preferred reporting items for systematic reviews and meta-analysis guidelines. Inclusion criteria were studies that included patients undergoing any flap-based reconstruction treated with minimally invasive delay. Exclusion criteria were non-English papers, other systematic reviews, nonhuman patients, and pediatric patients.

Results:  Six studies were included (angiographic delay n = 143, heat preconditioning n = 191, ischemic preconditioning n = 60) which examined minimally invasive methods for perfusion optimization. Aggregated data from the three studies on angiographic delay demonstrated a 13% (18/143) combined skin or fat flap necrosis rate, which was lower than that of non-delayed flaps and comparable to more invasive traditional surgical ligation. Ischemic preconditioning showed no significant differences (p = 1.0) g compared with controls, whereas heat preconditioning led to reductions (26% vs. 35%) in flap necrosis and necrosis requiring surgical intervention (11% vs. 17%).

Conclusion:  Angiographic embolization presents a promising alternative to invasive surgical delay, effectively reducing flap necrosis risk. Heat and ischemic preconditioning also show potential for increasing flap survival, although current studies are limited by small sample sizes. Further research is essential to explore preoperative conditioning interventions to improve surgical outcomes for patients who require less invasive delay techniques.

Background: Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer (FTT). However, there is a significant lack of FTT literature in this patient population. Thus, this study presents our 12-year experience with LE FTT in patients with PAV.

Method: Patients receiving LE FTT reconstruction from July 2011 to March 2024 were reviewed. Preoperative angiograms were reviewed by a single vascular surgeon, and the presence of PAV was identified and classified as IIIA, IIIB, or IIIC. Primary outcomes were flap success and limb salvage.

Results: A total of 339 LE FTT were performed in 331 patients. 32 patients (9.4%) had PAV, accounting for a total of 34 LE FTT. Class III-A was the most common category (n=20, 58.8%) followed by III-B (n=8, 23.5%) and III-C (n=6, 11.7%). Median age and BMI were 63.5 (IQR: 22.5) years and 27.4 (IQR: 10.3) kg/m2. The median Charlson Comorbidity Index was 5 (IQR: 2.5), with prevalent rates of diabetes (n=18/32, 56.3%) and peripheral artery disease (n=16/32, 50.0%). Median wound area was 71.0 (IQR: 80.0) cm2. Flap success rate was 100% (n=34/34). At a median follow-up of 12.8 (IQR: 22.6) months, limb salvage was 97.1% (n=33/34) and mortality was 6.3% (n=2/32).

Conclusion: In this large population of LE FTT, PAV occurs in almost one out of ten patients. Essential to flap success and limb salvage is appropriate preoperative vascular imaging with arteriography, as the presence of PAV changes microsurgical intraoperative planning and technical considerations.