Journal of reconstructive microsurgery最新文献

Access to female mentorship in microsurgery is limited. The American Society for Reconstructive Microsurgery Women's Microsurgery Group (WMG) established a mentorship program in 2014. This study evaluates recent participant demographics and mentee priorities.Data from the 2023 to 25 WMG mentorship cohorts were analyzed to assess demographics, mentor practice patterns, and mentee priorities using standard statistical methods.The recent cohort includes 51 mentors and 55 mentees. Mentees were primarily medical students. Mentors were primarily junior attendings. Mentees represented 48 institutions; 12.5% lacked female plastic surgery faculty and 39.6% lacked a female microsurgeon. Among medical student mentees, 32.1% were from schools without an integrated residency and 25% had no home plastic surgery program. Mentee priorities varied significantly by training level (p = 0.006), with earlier trainees valuing career advancement and later trainees prioritizing transition to practice. Significant discordance existed between mentee preferences and mentor backgrounds in both practice type (p < 0.001) and setting (p = 0.006). While 55.8% of mentees expressed interest in blended practices and 36.5% favored hospital-based or private practice settings, most mentors had purely reconstructive (86.3%) academic practices (86.3%).The WMG mentorship program effectively connects mentees-many from institutions lacking female microsurgeons or plastic surgery programs-with female mentors. The majority of mentors are junior faculty and a substantial number of mentees are "orphan applicant" medical students, underscoring the need for broader mentorship initiatives and efforts to reduce mentor fatigue. Findings also highlight the importance of expanding mentor recruitment to better reflect the evolving interests and goals of mentees.

Radiation therapy following axillary lymph node dissection (ALND) is a key risk factor for lymphedema, with regional nodal irradiation (RNI) posing a higher risk. Immediate lymphatic reconstruction (ILR) with microsurgical lymphovenous anastomosis performed concurrently with ALND aims to prevent lymphedema, but its efficacy in the setting of RNI is unclear. This study compares lymphedema incidence, complications, and LYMPH-Q patient-reported outcomes (PROs) after ILR based on receipt of RNI.We retrospectively studied consecutive patients who underwent mastectomy and ALND with ILR between 2017 and 2024 at our institution. Patients receiving radiotherapy were categorized based on receipt of RNI, and outcomes were compared using multivariable regression, adjusting for patient and treatment factors.We identified 119 patients with a mean follow-up time of 25.0 ± 15.5 months, of whom 68.9% (n = 82) received RNI. Radiotherapy characteristics were comparable between the RNI and non-RNI cohorts, including 3D Conformal Radiotherapy use (95.1% vs. 88.2%, p = 0.945), mean chest wall radiation dose (5,006 ± 238 cGy vs. 5,054 ± 593 cGy, p = 0.656), and receipt of chest wall scar boosts (32.9% vs. 27.0%; p = 0.520). In adjusted analyses, RNI was not associated with higher odds of lymphedema (OR, 0.30; p = 0.429), surgical complications (OR: 1.94; p = 0.540), reoperation (OR: 1.11; p = 0.844) or worse LYMPH-Q symptoms (p = 0.823), function (p = 0.353), appearance (p = 0.362), or psychological well-being (p = 0.174) scales.RNI in the setting of ILR was not associated with increased surgical morbidity, lymphedema rates, or adverse patient-reported outcomes. While ILR may mitigate the expected morbidity of RNI, prospective studies are needed to establish its definitive value in this high-risk population.

Microsurgery is an important discipline with a steep learning curve. The gold standard for training is on traditional operative-level microscopes (TM), although they are expensive, large, and immobile. Smartphones as microscope simulators (SMS) pose a promising alternative due to their ubiquity, affordability, and portability, yet existing studies are limited.Students and surgical residents were recruited and randomized to three groups: Test-Only (no interval training), SMS (remote training on smartphone), or TM (training on hospital TM). Participants completed identical initial and final suture tests 1-week apart on the TM that were filmed, then blindly evaluated by two microsurgery fellowship-trained plastic surgeons. During the week in between, SMS and TM participants had four training sessions. One and five suture completion, suture quality (using the Stanford Microsurgery and Resident Training [SMART] Score), speed, self-confidence, and training completion rate were evaluated. Paired t-tests and multivariate analysis of variance were performed in R Studio.A total of 58 participants completed the study. Compared with no training, SMS (n = 20) significantly improved single suture and five suture completion (p = 0.004), SMART Score (p = 0.0002), and self-confidence (p = 0.001). Test-Only (n = 20) had significant improvement for self-confidence (p = 0.039) but not suturing. TM (n = 18) had higher SMART Scores (p = 0.006) and training completion rate compared with SMS (89 vs. 45%, respectively [p = 0.012]). Between SMS and TM, there was no difference in five suture completion (p = 0.178), speed (p = 0.289), or self-confidence (p = 0.632). Students after SMS training had similar SMART Scores as residents at baseline (p = 0.260).SMS is an effective training modality for achieving basic suture competency, speed, and self-confidence, whereas TM remains superior for suturing quality. SMS may be particularly well suited for acquisition of basic microsurgical skills in training situations with limited TM access, or as an adjunct to TM in early training to establish basic skills, instrument familiarity, and increase repetitions.

Objective: Health literacy is closely linked to health outcomes, underscoring the importance of accessible patient education, particularly for patients undergoing complex surgical procedures. Despite this, there is limited research examining the influence of health literacy on outcomes in autologous breast reconstruction.

Methods: We performed a retrospective review of autologous breast reconstruction patients between 2017 and 2022 at our institution. Baseline demographic and clinical data were collected. Health literacy (HL) scores were assessed using the validated Set of Brief Screening Questions (SBSQ), with increasing value equating lower health literacy. Patients were categorized by Charlson Comorbidity Index (CCI) into groups representing mild, moderate, and severe comorbidity burden. Logistic and linear regression analyses were performed.

Results: The study included 264 patients, of whom 175 had mild, 49 moderate, and 40 severe comorbidity burden. Within the severe CCI group, worse HL was associated with increased odds of recipient site wound (OR 1.85, p = 0.0472), post-operative emergency department visits within 30 days (OR 2.56, p = 0.0489), and increased post-operative phone utilization (β = 0.52, p = 0.0461). No significant association was found between HLS and rate of surgical site infections, donor site wounds, or post-operative hernia.

Conclusion: In this study lower health literacy was significantly associated with increased health system utilization and wound complications in patients with severe comorbidity burden. This highlights the complex relationship between health literacy and outcomes, and importance of patient education and shared decision making in autologous breast reconstruction.

Management of patients with limb-threatening pathology represents a clinical challenge. Orthoplastic limb salvage centers have been developed to streamline care and improve patient outcomes for complex extremity pathology. However, no formal criteria exist for the establishment of orthoplastic limb salvage centers. We conducted a survey of orthoplastic limb salvage centers to assess current practice patterns and establish consensus-based criteria for the development of such centers.The American Society of Reconstructive Microsurgery membership was used to survey self-identified members of orthoplastic limb salvage centers in the United States. We evaluated current practices and recommended characteristics for team service structure, outcome tracking, quality systems, and barriers to standard implementation. Consensus rates (%) were calculated for current and recommended practice patterns, demonstrating implementation gaps.Strong consensus exists for four criteria: orthoplastic multidisciplinary teams (100%), high case volume (96%), 24/7 service availability (87%), and standardized outcome tracking (83%). Specialist integration demonstrated strong agreement for vascular surgery, infectious disease, and physiatrists (83% each). Gaps in implementation were identified, including dedicated operation room (OR) time (48% current vs. 65% recommended) and standardized outcome measurement (52% current vs. 65% recommended). Primary barriers to development included lack of standardized outcome reporting (83%), insufficient institutional support (70%), and financial constraints (61%).This study provides a consensus-based framework for the development of orthoplastic limb salvage centers (of excellence). National survey results identify comprehensive multidisciplinary care, outcome metrics tracking, and quality systems as priority areas for standardization. Barriers to collaborative quality initiative development include the lack of universal standards, institutional support, and financial constraints.

Introduction: At our breast reconstruction center we have over time developed a focused program to increase access to care for low resource patients. This program includes outreach clinics, physician extenders, care coordinators, and telehealth utilization.

Methods: A retrospective review of all free flap breast reconstruction patients between 2017 and 2022 at our center was performed. Specific criteria including insurance carrier, educational attainment and zip code median household income, language barriers, and distance to hospital were used to create favorably-resourced (FR) and unfavorably-resourced (UR) cohorts. Propensity score matching was then used to control for clinical factors and comorbidities.

Results: 49 and 52 patients met inclusion criteria for FR and UR cohorts, respectively, producing 33 matched pairs. FR was associated with a greater average number of donor site revisions (0.73 vs. 0.45, p=0.05). Other statistically significant differences included average zip code household income ($109,477 FR vs. $71,996 UR, p<0.01), bachelor's degree education level (26% FR vs. 16% UR, p<0.01), and average distance to hospital (25 miles FR vs. 82 miles UR, p< 0.01). No significant differences were detected between groups regarding mastectomy skin flap necrosis, recipient site infection, recipient site wound, breast revisions, donor site infection, donor site wound, seroma, fat necrosis, hernia/bulge, length of follow-up, or drain removal time.

Conclusion: This study shows that through the utilization of access to care programs equivalent results can be achieved in autologous breast reconstruction in both favorably and unfavorably resourced patients.

Dysfunction of the lymphatic system causes lymphedema, a chronic disease that can lead to cellulitis. However, the optimal treatment modality for preventing cellulitis has not yet been established. This cohort study investigated the outcomes of cellulitis by treatment modality in lymphedema of the extremities. A meta-analysis was conducted to evaluate the change in frequency of cellulitis episodes according to the surgical procedure.This single-center retrospective cohort study included patients with extremity lymphedema who were treated at our department. We performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from 2000 to March 2025 with a primary outcome of change in the frequency of cellulitis episodes before and after treatment. The meta-analysis was conducted using a random-effects model.Our cohort study included 183 patients (nonsurgical treatment: 91; surgical treatment: 92). The change rate in frequency of cellulitis episodes before and after treatment increased by 27.0% in the nonsurgical group but decreased by 85.4% in the surgical group. Thirty-five studies, comprising 2,241 patients, were included in the meta-analysis. The mean reduction rates of cellulitis episodes per year before and after surgery were 84.8, 78.2, 80.6, and 87.6% for lymphaticovenous anastomosis, vascularized lymph node transfer (VLNT), liposuction, and combined surgery, respectively. Compared to before surgery, the number of cellulitis episodes per year was significantly reduced after lymphaticovenous anastomosis, VLNT, liposuction, and combined surgery, with standard mean differences of 0.91 (I ² = 87%), 1.78 (I ² = 94%), 0.68 (heterogeneity not calculable), and 1.66 (I ² = 88%), respectively.The findings of this cohort study showed that surgical treatment was superior to nonsurgical treatment in preventing the development of cellulitis in extremity lymphedema. The meta-analysis results demonstrated that surgical procedures tailored to the severity of lymphedema can significantly reduce the development of cellulitis.

Microsurgery is an essential component of plastic surgery, yet its technical demands and steep learning curve pose challenges for trainees. The Fundamentals of Microsurgery (FMS) curriculum is a structured, competency-based simulation training program with five increasingly difficult noncadaveric tasks testing microsurgical dexterity outside the operating room (OR). This study evaluates the impact of FMS simulation on microsurgical efficiency and technical skills in plastic surgery trainees, translated into outcomes in the OR.A retrospective review of 28 total integrated and independent plastic surgery residents who participated in the FMS curriculum from 2019 to 2024 at a single-institution was conducted, analyzing 168 individual arterial anastomoses amongst 104 unique free flap breast reconstructions in the OR. Patient predictive variables, including body mass index (BMI) and prior radiation where analyzed. Outcomes included arterial anastomosis times, intraoperative technical imperfections, and total operative times. Statistical analyses were performed to assess independent predictors of surgical efficiency, with p < 0.05.Completion of the FMS curriculum was significantly associated with shorter intraoperative arterial anastomosis times (22.45 minutes vs. 33.65 minutes; p < 0.001) and fewer intraoperative technical imperfections, even in more difficult cases such as patients with higher BMI and those with prior radiation.The FMS curriculum enhances microsurgical technical skills and operative efficiency in plastic surgery trainees, even in difficult cases. These findings underline the necessity for standardized microsurgical training curricula to improve operative efficiency and technical precision. FMS or similar models should be integrated into all plastic surgery training programs to optimize patient outcomes and trainee competency.

Background: The Fat-Augmented Latissimus Dorsi (FALD) flap is an autologous flap that combines Latissimus Dorsi (LD) flap with intraoperative autologous fat transfer (AFT) in order to improve breast reconstruction (BR) volume. In recent years, our team has described the ergonomic FALD flap, an evolution of this technique which helps to achieve a complete BR in a single surgical step. In this case-control study, we analyze the long-term morphological variations of the breast after ergonomic FALD flap reconstruction compared to the traditional FALD flap technique.

Methods: Between December 2020 and April 2023 we prospectively enroll patients undergoing BR using FALD flap into 2 groups: group A included ergonomic FALD flap, while group B included traditional FALD flap. The primary endpoint was to compare the two groups in terms of breast projection (BP), breast width (BW) and breast height (BH), while the second endpoint concerned the analysis of the aesthetic outcomes.

Results: 42 FALD flaps (31 patients) were performed for the group-A and 37 FALD flaps (29 patients) for group-B. The two groups were homogeneous regarding demographic variables. Using a propensity score weighting analysis, group-A showed a significantly higher breast projection compared to group-B (6.78 vs 5.75; p<0.0001), after 12 months of follow-up. Final aesthetic analyses showed to be superior in group-A concerning breast shape (p=0.003) and global score evaluation (p=0.023).

Conclusion: The ergonomic FALD flap showed us a better long-term aesthetic outcome for autologous BR with higher breast projection compared to the traditional transverse FALD flap.

Background The descending genicular artery (DGA) axis can provide a versatile reconstruction that includes several tissue components including bone, skin, muscle, tendon and nerve. We present a novel CT angiography study to define the branches of the DGA axis as they relate to flap design for composite bone and soft tissue defect reconstruction. Methods Lower limb CT angiography studies performed at a major microsurgery unit between 2019-2021 were evaluated by two independent clinicians. Vascular anatomy of the DGA, saphenous artery (SA) and branches to regional structures were evaluated and measured. Results An initial 98 studies were identified with 64 studies included for final analysis. The DGA was seen in 56 (87.5%) cases. Cutaneous supply via the DGA axis was possible in 40 cases (70%). Cutaneous supply was seen via direct perforators in 18 (32.1%) cases and the SA in 34 (53.1%) cases. Branches to the vastus medialis were frequent (51.6%). A novel four-tier classification system of the cutaneous supply was developed to assist in chimeric flap design based on these findings. Based on this classification, cutaneous paddle design was possible via the SA in 60% of cases and a further 10% of cases via a direct DGA perforator (skin perforator arising from the DGA proper). Conclusion The DGA axis provides separate and consistent soft tissue and bone pedicles, enabling reliable chimeric flap design. Preoperative CT angiographic imaging ensures a simple, versatile flap with long pedicle and minimal donor morbidity.