Journal of reconstructive microsurgery最新文献

Background: Enhanced Recovery After Surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.

Methods: A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), ICU utilization, opioid usage, cost, and flap outcomes were analyzed in patients with BMI greater than 35 before and after ERAS implementation.

Results: 35 morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral vs bilateral or immediate vs delayed reconstruction. LOS decreased with ERAS (3.43 vs 2.06 days, p< 0.0000001). ICU utilization decreased with ERAS (0.94 vs 0.0 days, p< 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs 17.9 MME, p< 0.0001; 190.5 vs 54.7 MME, p< 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs $25,079, p = 0.0002) and increased cost margin ($4,458 vs -$8,306, p= 0.004). There were no differences in donor or recipient site outcomes including flap loss, DVT/PE, hernia/bulge, delayed wound healing, revisions, and blood loss.

Conclusion: ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased length of stay, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Background:  Clinically, there has been increasing employment of the lateral femoral condyle flap. The objective of this study was to explore the vascular anatomy of the lateral femoral condyle in pigs and to explore the feasibility of using pigs as an animal model of the lateral femoral condyle flap.

Methods:  A total of 20 fresh cadaveric hindlimbs of 4-week-old hybrid pigs were used in this study. The origination, course, and branches of the nourishing vessels of the lateral femoral condyle were observed in 15 specimens. The primary parameters included the variability in the anatomy of the vessels and the length and outer diameter of the vessels. Surgical procedures for the lateral femoral condyle flap were conducted on five specimens.

Results:  The primary nourishing arteries of the lateral femoral condyle in pigs were the first superolateral geniculate artery, which was observed in all 15 specimens and had a diameter and length of 1.99 ± 0.44 mm and 2.27 ± 0.46 cm, respectively, as measured at their origination. The operation was performed in the lateral position. A 10-cm skin incision was made from the lower edge of the patella to the posterior lateral side of the distal femur. After blunt dissection of the intermuscular septum between the biceps femoris and vastus lateralis, the whole course of the first superolateral geniculate artery was exposed.

Conclusion:  The vascular anatomy of the lateral femoral condyle in pigs and that of humans exhibited great similarities. The harvesting of the lateral femoral condyle flap in pigs was as easy as that in humans. Pigs could serve as a suitable animal model for the lateral femoral condyle flap.

Background:  Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear.

Methods:  We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study.

Results:  Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3, 21.9, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). A total of 58.9% of the population received postoperative antithrombotic agents. The rate of flap revision surgery was similar (11.6 and 10.0%, respectively), with and without antithrombotic treatment (p > 0.05). There were no major bleeding complications or deep vein thrombosis.

Conclusion:  The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.

Background:  Breast reconstruction with sensory restoration is gaining recognition as an important goal. Successful reinnervation has been shown in autologous reconstruction but not widely studied in implant-based reconstruction (IBR). This article describes our technique for nipple-areola complex (NAC) neurotization to predict maximal nerve length. We also propose a novel equation that can be utilized preoperatively to estimate the total nerve length required for NAC neurotization.

Methods:  This is a retrospective study of patients who underwent nerve reconstruction with IBR between April 2021 and May 2022. An equation based on the arc length of a circle was utilized to predict the total nerve length required. Postoperative assessment of sensation was performed at 3, 6, and 12 months using Semmes-Weinstein monofilament testing in all four breast quadrants and the NAC. Patients completed the Breast-Q Sensation Module preoperatively and at 3, 6, and 12 months.

Results:  NAC neurotization was performed in 58 patients undergoing IBR. The average length of intercostal nerve (ICN) harvested was 5.3 cm for staged reconstructions and 5.6 cm for direct-to-implant reconstruction. The average total nerve length (allograft + mobilized ICN) was 12.3 cm. On average, 6.9 cm of nerve allograft was used. The mean difference between total nerve length and predicted nerve length was 0.47 cm (range -3.5 to 4.6 cm). There was a significant improvement in sensory monofilament values measured in all four breast quadrants and the NAC between 3 to 6 and 6 to 12 months postoperatively.

Conclusion:  A thorough understanding of sensory anatomy and precise surgical techniques are essential to perform NAC neurotization successfully. Our early results suggest the positive impact of breast sensation on patient quality of life.

Background: Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-days post-operative complications between these two techniques.

Methods: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications.

Results: A cohort of 8,403 breast cancer patients was analyzed. 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p<0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p<0.001), exhibited a higher BMI (31.73 vs. 26.93, p<0.001), had a greater prevalence of diabetes mellitus (11.0% vs. 5.0%, p<0.001). They also had a higher ASA classification (2.33 vs. 2.15, p<0.001), shorter operative time (173.39 vs. 216.20 min, p<0.001), and a higher proportion of outpatient procedures (83.7% vs 39.5%, p<0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients, (4.2% vs. 10.9%, p<0.001), including lower rates of surgical complications (2.2% vs 8.0%, p<0.001) and wound complications (1.9% vs. 4.8%, p=0.005) compared to MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications.

Conclusion: OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared to MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.

Introduction: There is a lack of literature regarding the effects of language barriers, socioeconomic status, racial disparities, and travel distance to the hospital on the outcomes of lower extremity (LE) flap reconstruction. Consequently, this study assesses the potential influence of these factors on ambulation within this specific patient demographic.

Methods: A retrospective review was performed between 2007-2022 of patients who underwent LE reconstruction with tissue flap placement at a single institution. The primary outcome was ambulation status, with cohorts compared between those who were ambulatory vs. non-ambulatory. Covariates included race, age, gender, primary language, distance from patient home to hospital, socioeconomic status (determined using area deprivation index (ADI)), and flap characteristics. Outcomes were assessed with multivariable logistic regression.

Results: 242 patients who underwent LE flap reconstruction during the study period. The average time to final ambulatory status was 7.0 months (SD: 11.0), with 51.7% requiring either a wheelchair or assistance device and 48.4% being fully ambulatory at final follow-up. The average state ADI for the cohort was 5.8, with Hispanic patients having significantly higher deprivation indexes (6.3 vs. 5.6, p<.001). Multiple logistic regression demonstrated that when controlling for numerous covariates, patients in the highest 15th percentile of deprivation were significantly less likely to be fully ambulatory at final follow-up (OR: 0.22, 95% CI .061-.806, p=.022).

Conclusion: The current study emphasizes the substantial impact of socioeconomic disparities on postoperative outcomes in LE flap reconstruction. The finding that patients in the highest 15th percentile of deprivation were less likely to achieve full ambulation underscores the need to prioritize socioeconomic factors in clinical consideration and highlights a crucial avenue for future research.

Background: Primary closure of donor sites following large flap harvest may not be feasible. The use of perforator propeller flap (PPF) in this setting is gaining popularity, successfully resurfacing the wound and lessening potential donor site morbidity. In this study, we aimed to review our experience and outcomes using PPFs in donor site coverage throughout the body.

Methods: A retrospective chart review was performed of all patients who underwent one or more PPFs surgery for donor site resurfacing between February 2009 and December 2021. Flap and defect characteristics were summarized. Postoperative complications and perioperative factors were analyzed.

Results: Fifty-five patients underwent donor site reconstruction using 68 PPFs. Of the 55 primary donor sites, 44 were covered with a single PPF, nine with two PPFs, and two with three PPFs. One flap experienced complete necrosis and four flaps experienced distal flap necrosis, leading to an overall complication rate of 9.1%. No risk factors were found to be statistically significantly associated with the complication. All secondary PPF donor sites were closed primarily. During the average follow-up period of 15.1 months, none of the patients developed contour deformities or functional impairments.

Conclusions: The PPF technique can be safely and effectively used for donor site closure with minimal complications. It greatly frees surgeons to harvest a large workhorse flap for demanding soft-tissue defect reconstruction.

Background:  Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures.

Methods:  A retrospective study was done using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0-5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories.

Results:  Of 2,305 patients, the mean age and body mass index (BMI) were 53.13 years and 28.53 kg/m², respectively. The 5-mFI ≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant.

Conclusion:  5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI ≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions.

Background: The field of microsurgery continues to grow, yet barriers to practice still exist. This qualitative study aims to elucidate factors both strengthening and threatening this subspecialty through structured interviews with fellowship-trained microsurgeons.

Methods: An interview guide was designed, and structured interviews were conducted with practicing fellowship-trained microsurgeon members of the American Society of Reconstructive Microsurgeons between August 2021 and May 2022. Interviews were transcribed, content-coded, and thematically analyzed by three independent reviewers. Themes and subthemes were discussed and finalized.

Results: Twenty-one practicing microsurgeons were interviewed, hailing from all four Census geographical regions of the United States. The most common practice model was academic (43%, n=9). Five overarching themes emerged: a passion for microsurgery, training and mentorship, practical considerations, team support, and hope for the future. Microsurgeons reported early exposure to microsurgery as catalyzing their passion, while a strong training foundation and lifelong mentors sustained it. Practical challenges arose when establishing and maintaining a microsurgery practice, such as poor reimbursement and unfavorable referral patterns. Team support from staff and from other microsurgeons (e.g., a co-surgeon model) was crucial to success. Finally, microsurgeons hoped that future advances would expand access to microsurgerical reconstruction for patients and plastic surgeons alike.

Conclusions: This unique, qualitative description of the current landscape of microsurgery revealed that though practical barriers exist, team-based models can alleviate some difficulties. Future advances that increase accessibility may further strengthen this unique and versatile field.