Journal of reconstructive microsurgery最新文献

While the need for reconstructive microsurgical procedures has increased across the developing world, several constraints in low- and middle-income settings prevent its consistent performance. Our study aimed to understand the impact of microsurgery training on local capacity in a low-income setting, and to understand limitations that may affect long-term build-up of microsurgical capacity.Cross-sectional study evaluating survey responses of trainees and surgeons who participated in a Flap Transfer and Microsurgery course held in Ibadan, Nigeria. The survey consisted of a pre- and postcourse questionnaire, and a 2-year posttraining survey. The questionnaire sought to assess training impact on microsurgical capacity and limitations at each participants institution. Fourteen surgeons completed all questionnaires and were included in the study.Thirteen (92.3%) participants had encountered at least one defect requiring microvascular surgery within 2 years of the training, and 9 (69.2%) reported having performed at least one surgery. Most surgeons indicated having performed less procedures than needed across all defect anatomical site/etiology. The most common limitation reported by participants consisted of man-power shortage (78.6%), followed by expense of each procedure, difficulty procuring materials, and trainers with limited experience.There is a significant need for microsurgical reconstruction in sub-Saharan Africa, with varied local challenges preventing consistent delivery of microsurgical care. The analysis complements previous literature on microsurgical care in developing countries and highlights significant constraints preventing widespread adoption and the role of local training opportunities that help in building long-term local capacity.

Head and neck squamous cell carcinoma accounts for 4.5% of all new cancers diagnosed. A fibula free flap is often performed after tumor resection. Preoperative acknowledgment of the branching patterns of the popliteal artery is important to avoid flap failure or leg ischemia after flap harvest. We performed this extensive study using a modified classification to help thoroughly recognize variations.The subjects were Taiwanese patients who received radiologic examinations of their lower limbs at a single medical center from May 2006 to December 2022. Only digital subtraction angiography, computed tomography angiography, and magnetic resonance angiography, which reveal the vasculature of the lower limbs, were included. All images were viewed by the same plastic surgeon on the same computer screen. Statistical analysis was subsequently performed on the data.In total, 1,244 right legs and 1,198 left legs (2,442 legs in total) from 1,485 Taiwanese patients were included in this study. In addition to normal branching, type IA, other branching patterns as variations occurred in 4.1% (n = 100) of the included legs. The second and third common patterns were type IIIA (1.06%, n = 26) and IB (0.98%, n = 24), respectively. Forty-seven patients presented with variation and had both legs evaluated, and 29.8% of them presented with bilateral variations.A preoperative vascular examination is strongly recommended before harvesting a free fibular flap because some patients might have a blood supply to the foot and lower leg, mainly from the planned-to-be-harvested peroneal artery (PR), or might not have a workable PR. Using fibular vessels as a flap pedicle might not be able to be performed in up to 1.84% of legs.

Postoperative anticoagulation is widely used in microsurgical flap reconstruction to reduce the risk of thrombosis and flap complications. However, their effectiveness and safety in relation to flap outcomes remain uncertain. This systematic review and meta-analysis evaluate the existing evidence on postoperative anticoagulant use in microsurgical flap reconstruction.A literature search was performed in the PubMed database for studies published from 1995 until January 2025 that compared flap outcomes with postoperative prophylactic anticoagulation regimens in microsurgical flap procedures. Outcomes of interest included hematoma, complete flap failure, and reoperation. Relevant data were extracted and analyzed using meta-analytic techniques.In total, 11 studies were included in the final review and meta-analysis. Seven studies comparing patients who received postoperative anticoagulation with those who did not demonstrated a significantly higher rate of hematoma in the anticoagulated group (5.0% vs. 3.0%; p = 0.03). However, there were no significant differences in flap failure or reoperation rates. In subgroup analyses, only studies using unfractionated heparin showed increased hematoma risk, whereas low-molecular-weight heparin (LMWH) showed no significant effect. Four studies compared patients receiving postoperative anticoagulation plus aspirin with those receiving anticoagulation alone and found a higher reoperation rate when aspirin was added (17.5% vs. 10.0%; p < 0.01), with no significant differences in flap failure rates.Postoperative heparin increases the risk of hematoma without improving flap survival. Additionally, combining aspirin with LMWH may increase reoperation rates. These results suggest that routine anticoagulation may not benefit all patients and support a risk-based approach to postoperative management in microsurgical reconstruction.

Fibula free flap (FFF) surgery complications can arise from vascular disease within the donor peroneal artery. Computed tomography angiography (CTA) has become standard for preoperative evaluation. However, current methods rely on qualitative assessments to determine surgical eligibility. This study aims to improve preoperative risk evaluation by implementing two quantitative scoring systems, the Bollinger score and the lower limb arterial calcification score (LLACS), assessing distinct vascular health components. The Bollinger score quantifies intraluminal stenosis caused by atherosclerotic plaques, while the LLACS quantifies arteriosclerosis by evaluating calcification within the arterial walls.A retrospective review was conducted on all head and neck microvascular FFF procedures performed at a university-affiliated tertiary care center between August 2021 and March 2023. Data collected included patient demographics, medical history, operative details, and postoperative complications (infection, hematoma, seroma, fistula, dehiscence, or flap failure) within 90 days. Peroneal artery Bollinger scores and crural segment LLACSs from the donor lower extremity were calculated from preoperative CTAs.A total of 117 patients were included. Increasing Bollinger scores were significantly associated with an increased risk of complications and longer hospital stays, even after controlling for potential confounders. Combining both scores improved risk stratification, with high-risk patients experiencing an 8.36-fold higher risk of complications.Our findings suggest that quantitative preoperative peroneal vessel assessment improves risk stratification for patients undergoing FFF surgery. These scoring systems may enhance patient selection and guide strategies to minimize postoperative complications. Integrating multiple scoring systems is key to the comprehensive assessment of vascular health.

In this study, we explored the transition from implant-based to autologous breast reconstruction, focusing on the factors prompting conversion, patient outcomes, and the role of emerging flap types such as profunda artery perforator (PAP) and lumbar artery perforator (LAP) in reconstruction choices. Historically, implant-based methods dominated breast reconstruction, but limitations and complications have led a subset of patients to prefer autologous reconstruction, especially after radiation therapy. This research aimed to elucidate the decision-making process behind switching to autologous methods, examining a broad range of patient demographics and conversion factors.A retrospective review was conducted using REDCap database information from January 2012 to August 2023, including 119 patients who converted from implant-based to autologous reconstruction and 1,329 who underwent primary autologous reconstruction. Data analysis covered demographics, comorbidities, reasons for conversion, types of surgeries performed, and BREAST-Q responses to assess satisfaction and quality of life.Indications for conversion included capsular contracture, dissatisfaction, and complications from previous treatments. Patients undergoing autologous conversion typically experienced more revision surgeries compared with those with primary autologous reconstruction. Notably, emerging flap options like PAP and LAP were more frequently utilized in conversions. BREAST-Q scores showed no significant preoperative differences, but postoperative satisfaction varied, highlighting the nuanced outcomes of reconstruction choices.In conclusion, converting to autologous breast reconstruction offers a patient-centered alternative for those facing implant-based reconstruction failures, underscoring the need for individualized surgical approaches. This study contributes valuable insights into optimizing reconstructive outcomes by understanding patient preferences and advancements in flap techniques.

While obesity is a known risk factor for developing breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND), its impact on outcomes of immediate lymphatic reconstruction (ILR) is yet to be elucidated. The purpose of this study is to assess the influence of obesity on BCRL incidence and patient-reported outcomes following ILR.We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 across a university hospital system. BCRL prevalence and condition-specific (LYMPH-Q) quality-of-life performance were compared and correlated via multivariable regression.We identified 172 patients (mean body mass index [BMI]: 29.5 ± 6.9 kg/m²) with 72 patients (41.9%) categorized as obese (BMI ≥ 30). BCRL incidence was 7.0% with no significant difference between groups (obese, 8.3% vs. nonobese, 6.0%; p = 0.553). In adjusted models, obesity was not associated with higher risk of BCRL (OR, 0.90; 95% CI, 0.23-3.47; p = 0.875), surgical complications (OR, 1.18; 95% CI, 0.50-2.74, p = 0.708) or unplanned reoperation (OR, 0.72; 95% CI, 0.29-1.80, p = 0.479). However, obese patients showed significantly lower mean scores in the LYMPH-Q symptom scale (66.7 ± 27.7 vs. 84.7 ± 16.8, p = 0.004) when compared with nonobese patients. In adjusted models, obesity was associated with independently lower LYMPH-Q symptom scores (-13.8; 95% CI, -26.7 to -0.81; p = 0.038).ILR mitigated the risk of BCRL associated with obesity following ALND. However, obesity remained associated with significantly worse patient-reported lymphedema symptom burden following ILR. These findings highlight a dissociation between objective risk reduction and subjective symptom burden, underscoring the need for integrated assessment and targeted symptom management protocols.

The latissimus dorsi (LD) is a common workhorse flap used in reconstructive surgery to cover large wound defects. Estimating the area of possible coverage is necessary for preoperative planning and surgical success. The aim of this study is to investigate the relationship between patient factors and the measurable dimensions of the LD flap in order to inform more personalized preoperative planning and evidence-based flap selection.This is a retrospective study of individuals who underwent computed tomography (CT) angiography of the chest and abdomen. Patient demographics - height, age, sex, and body mass index (BMI) were collected. The primary outcome was the dimensions of the LD muscle edges and length of the thoracodorsal pedicle measured on CT. Multivariable linear regression was performed to determine the independent effects of patient demographics on the dimensions of the LD muscle.A total of 50 patients were included in this study. Patient demographics were significantly associated with all LD muscle dimensions. The length of the vascular pedicle was 9.502 ± 1.281 cm and was significantly associated with height (p < 0.001). Patient demographics had a strong correlation (r = 0.957) with this length. The average wound defect area the LD can cover was 209.99 cm² (range: 114.24-312.40 cm²). This area increases or decreases by 1.498 cm² per centimeter change in a patient's height (p = 0.011).An understanding of how patient factors are associated with LD muscle dimensions is critical for preoperative planning and surgical success. Our study found that height, BMI, age, and sex all have associations with the dimensions of the LD muscle. As well, height is strongly correlated with the length of the thoracodorsal vascular pedicle, influencing the possible rotation arc of the flap.

No consensus exists regarding the utilization of the lower extremity superficial venous system compared with the deep veins in free flap procedures for limb salvage. This study analyzed the risks of venous complications associated with superficial and deep venous anastomoses for lower extremity reconstruction.A retrospective review was performed on patients who required free flap reconstruction of the lower extremity between 2016 and 2024. The recipient veins were characterized as deep (venae comitantes) or superficial (saphenous veins). Flaps with two venous anastomoses were further classified as deep, superficial, or combined venous drainage. The primary study outcome was composite venous complications, which included venous congestion, flap hematoma, and partial and total flap necrosis during index hospitalization.A total of 333 patients underwent free flap reconstruction of the lower extremity. Of these patients, 31 (9.3%) experienced the primary outcome. Free flaps with superficial-only drainage had a significantly higher rate of venous complications (27.8%) than those with deep (8.6%) or combined (4.3%) drainage systems. Multivariate analysis showed that flaps anastomosed to superficial veins had significantly higher odds of venous complications (OR = 4.11, CI: 1.24-11.9, p = 0.049) than those utilizing a deep drainage system.This study showed higher rates of venous complications with the use of superficial venous drainage in lower-extremity free flaps. Although efforts should be made to incorporate a deep venous recipient, superficial veins may be used as an adjunct in certain situations with good reconstructive outcomes.

The anterolateral thigh (ALT) flap is a very popular perforator flap, but variations in design and in harvest techniques result in a broad spectrum of approaches that considerably differ from literature descriptions. We therefore designed this study to assess the differences in surgical techniques and practice preferences toward this flap across world regions.The study was conducted via an online questionnaire covering demographic data, surgical techniques, and preferences in 21 questions. The participants were divided into six geographical regions that were compared. Two questions that are the subject of debate amongst microsurgeons (limitation of vasopressor use and anticoagulation before flap division) were further analyzed using a logistic regression to identify predicting variables.There were 263 respondents worldwide with notable differences in demographics, experience, level, and technique across different world regions. The main differences were noted in intraoperative evaluation of perforators, in the primary instrument for dissection, and in the use of loupe magnification. Microsurgeons in North America with limited experience were more likely to limit vasopressor use during flap harvest. There were also discrepancies regarding the use of systemic anticoagulation prior to flap division, but not of the same magnitude.This study is the first attempt to offer a clinical reference to apprehend differences in surgical preferences regarding ALT flap harvest techniques. Vasopressor use is notably limited by microsurgeons in North America, as well as by less experienced microsurgeons, despite available clinical evidence.