Journal of reconstructive microsurgery最新文献

Neuroma complicates lower extremity (LE) amputations causing significant morbidity. This study examines the relationship between access to plastic surgery and the likelihood of receiving a neuroma-preventing nerve procedure with LE amputation in the United States.Using the National Inpatient Sample, 2016 to 2021, ICD-10 codes identified encounters undergoing above- or below-knee LE amputation with or without concurrent nerve procedures (targeted muscle reinnervation and regenerative peripheral nerve interface). Plastic surgery volume was determined using ICD-10-PCS codes. Outcomes included population-adjusted LE amputation incidence, odds of concurrent nerve procedures, and their incidence relative to facility plastic surgery volume. Statistical analysis included univariate analysis and multivariate Poisson and logistic regression models.A total of 245,170 weighted encounters underwent LE amputation, of which only 1,525 (0.6%) included concurrent nerve procedures. Population-adjusted LE amputation incidence remained stable throughout the study period (p = 0.159). Higher LE amputation incidence was associated with higher comorbidity burden and Black and Native American race (p ≤ 0.036). Odds of nerve procedures increased with more recent surgery year, younger age, higher income, and Black race (p ≤ 0.044). Nerve procedure incidence at facilities in the highest quartile of plastic surgery volume was significantly higher than that of facilities in the lowest quartile (incidence rate ratio: 21.949; 95% confidence interval: 16.493-29.211; p < 0.001).Amidst stable population LE amputation incidence, Black and Native American race increased LE amputation incidence. Higher income and Black race elevated odds of concurrent nerve procedures. Increasing facility plastic surgery volume was associated with increased concurrent nerve procedure incidence in LE amputation.

Accurate preoperative mapping of skin-paddle perforators is vital for osteocutaneous fibula free flap (FFF) success. While handheld Doppler (HHD) is widely used due to its convenience, its performance compared with color Doppler ultrasound (CDU) in FFF planning remains uncertain.In this prospective study, 50 consecutive patients undergoing FFF reconstruction after head and neck cancer resection were evaluated. Each patient underwent HHD and CDU mapping on the day before surgery. Perforator skin surface location, anatomical type (septocutaneous vs. musculoseptocutaneous), peak systolic velocity, and source vessel (peroneal vs. posterior tibial) were recorded. Mapping marks were concealed between examinations.A total of 185 perforators were confirmed intraoperatively (mean 3.7 per limb). CDU identified 179 candidates, yielding 95% sensitivity, 92% specificity, and 94% accuracy. HHD detected 155 sites, achieving 59% sensitivity, 6% specificity, and 48% accuracy, with significantly more false positives and negatives (p < 0.001). Both overall and dominant perforators clustered in the fourth decile of the lower leg (counting from lateral malleolus to fibular head). Distal regions were dominated by septocutaneous vessels, while musculoseptocutaneous types were more common in proximal regions. Anatomical variants-perforators draining into the posterior tibial instead of the peroneal vessels-occurred in 8% of cases and were identified exclusively by CDU.CDU outperforms HHD for preoperative perforator mapping in osteocutaneous FFF, combining high spatial precision with reliable hemodynamic assessment and variant detection. Incorporation of CDU into routine surgical planning promises to enhance flap design accuracy and minimize intraoperative uncertainty.

Abdominally based breast free flap reconstruction exposes patients to potential significant donor site morbidity. Utilization of postoperative Incisional Negative Pressure Wound Therapy (iNPWT) has been proposed to minimize incision site complications. This study aims to assess if iNPWT reduces rates of donor site complications after DIEP and TRAM flap harvest.This single-center, retrospective study included patients who underwent Deep Inferior Epigastric Artery (DIEP) or Transverse Rectus Abdominis Muscle (TRAM) flap reconstruction from 2022 to 2024. Patients' abdominal donor sites received either standard wound care or iNPWT at the time of reconstruction.A total of 362 patients were identified with a median age of 51.3 (IQR: 43.3-59.6) years. Rates of delayed healing at the donor site were lower in the iNPWT cohort compared to standard of care (13.4% vs. 35.3%, p < 0.001). Controlling for tobacco exposure, diabetes, hypertension, and laterality, there was a lower likelihood of delayed healing in the iNPWT cohort (OR: 0.249 [0.14-0.43], p < 0.001). This finding persisted in current and former smokers (OR: 0.269 [0.16-0.46], p < 0.001) and patients with comorbid hypertension (OR: 0.257 [0.15-0.44], p < 0.001).These results suggest iNPWT usage is associated with lower rates of donor site delayed healing after DIEP and TRAM procedures in the general patient population and should be considered in those with two or more vascular risk factors. Further investigation is required to stratify the risk of delayed healing for patients with concomitant hypertension, tobacco exposure, diabetes, and/or obesity.

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.

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.