Journal of reconstructive microsurgery最新文献

Background:  Microsurgical training should be implemented with consideration of operative difficulties that occur in actual clinical situations. We evaluated the effectiveness of a novel clinical scenario simulator for step-by-step microsurgical training that progressed from conventional training to escalated training with additional obstacles.

Methods:  A training device was designed according to multiple and intricate clinical microsurgery scenarios. Twenty surgical residents with no experience in microsurgery were randomly assigned to either the control group (conventional training curricula, n = 10) or the experimental group (step-by-step training courses, n = 10). After 4 weeks of laboratory practice, the participants were scheduled to perform their first microvascular anastomoses on patients in an operating room. The Global Rating Scale (GRS) scores and operative duration were used to compare microsurgical skills between the two groups.

Results:  There were no significant differences in the participants' baseline characteristics before microsurgical training between the groups with respect to age, sex, postgraduate year, surgical specialty, or mean GRS score (p < 0.05). There were also no significant differences in recipient sites between the two groups (p = 0.735). After training, the GRS scores in both groups were significantly improved (p = 0.000). However, in the actual microsurgical situations, the GRS scores were significantly higher in the experimental than control group (p < 0.05). There was no significant difference in the operative duration between the two groups (p < 0.13).

Conclusion:  Compared with a traditional training program, this step-by-step microsurgical curriculum based on our clinical scenario simulator results in significant improvement in acquisition of microsurgical skills.

Background:  With the success of free autologous breast reconstruction, the abdominal donor site is now an important consideration, especially in patients of childbearing age. In our institution, there are increasing patients who have successfully undergone the deep inferior epigastric artery perforator (DIEP) flap despite previous pregnancy. This study aims to answer questions on the effect of the donor site on pregnancy and vice versa.

Methods:  A retrospective cohort study was conducted to identify breast cancer patients who received a free DIEP flap for breast reconstruction from January 2018 to August 2020. Patients were allocated to two groups according to whether they had prior pregnancies with successful deliveries. Demographics, flap-related parameters, surgical outcomes on breast and abdomen, and patient-reported outcome (Breast-Q questionnaire) were analyzed. Patients were excluded if follow-up time was less than 1 year, or if there was incomplete medical records or Breast-Q replies.

Results:  Ninety-nine of 116 patients had had successful pregnancies with delivery, 17 of them remained nulliparous. No statistically significant differences existed between groups regarding demographic data, flap-related parameters, surgical outcomes on breast and abdomen. Nulliparous patients exhibited significantly lower score in physical well-being in the abdomen domain compared with delivery-experienced patients (62.1 vs. 73.4, p = 0.025). Significantly, nulliparous patients felt more tightness and pulling of the abdominal wall than the delivery-experienced patients (2.9 vs. 3.7; p = 0.05 and 3.5 vs. 4.0; p = 0.04).

Conclusion:  Free DIEP flap can be transferred safely in nulliparous patients despite a slight increase in abdominal tightness and abdominal pulling. Precise flap design and surgical approaches may help to minimize the abdominal discomfort especially on young, normal body mass index, and nonchildbearing patients.

Background: The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72 hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction.

Methods: The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays.

Results: One-thousand and thirty patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours-10 days, 18% from 10-30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared to those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications.

Conclusions: Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion.

Introduction: Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exists regarding the early post-operative pain course for patients who undergo either Primary (<14 days since amputation) or Secondary (≥14 days) TMR. This study aims to outline the post-operative pain course for Primary and Secondary TMR during the first six post-operative months, to aid in patient education and expectation management.

Methods: Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effect models were utilized to visualize and compare pain courses between Primary and Secondary TMR patients.

Results: A total of 203 amputees were included, with 40.9% being Primary and 59.1% being Secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month post-operative trajectory (p<0.001) compared to Secondary TMR patients, with a difference of Δ-1.0 at day of TMR (Primary=4.5, Secondary=5.5), and a difference of Δ-1.4 at the 6-month mark (Primary=3.6, Secondary=5.0). Primary TMR patients also reported significantly lower Pain Interference (p<0.001) and Pain Intensity scores (p<0.001) over the complete trajectory of their care.

Conclusion: Primary TMR patients report lower pain during the first six months post-operatively compared to secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the post-operative pain course and in managing patient expectations following TMR.

Introduction: Scalp reconstruction in plastic and reconstructive surgery often necessitates the transfer of soft tissue flaps to restore form and function. The critical decision lies in choosing between muscle-containing (MC) and fasciocutaneous (FC) flaps for scalp reconstruction, and while both variants have their merits, flap composition remains a subject of ongoing debate. This scientific discussion aims to explore this contentious issue through a comprehensive meta-analysis, shedding light on the rationale behind the choice of these flaps and the potential impact on clinical outcomes.

Methods: A comprehensive systematic review was conducted following PRISMA-P guidelines, encompassing six prominent databases up to the year 2023. Data were collected from studies assessing outcomes of MC and FC flaps for scalp reconstruction. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool. Statistical analysis included descriptive statistics, meta-analysis, sensitivity analysis, and assessment of bias using STATA software.

Results: The meta-analysis included 28 non-randomized studies, totaling 594 flaps (380 MC, 214 FC). MC flaps were significantly larger than FC flaps. There were no significant differences in flap loss, flap necrosis, or wound dehiscence between the two flap types. However, the incidence of venous congestion was significantly higher in FC flaps. Sensitivity analysis confirmed the robustness of results, and publication bias assessment showed no significant evidence of bias.

Conclusions: While both MC and FC flaps offer viable options for scalp reconstruction, the choice should be tailored to individual patient characteristics and defect size. FC flaps may provide advantages such as shorter operative times and reduced morbidity, whereas MC flaps could be preferred for addressing larger defects. Future research should focus on prospective studies and strategies to mitigate venous congestion in FC flaps, enhancing their safety and efficacy in scalp reconstruction.

Background Tissue engineering based on whole-organ perfusion decellularization has successfully generated small-animal organs, including the heart and limbs. Herein, we aimed to use angiosome-guided perfusion decellularization to generate an acellular fasciocutaneous flap matrix with an intact vascular network. Method Abdominal flaps of rats were harvested, and the vascular pedicle (iliac artery and vein) was dissected and injected with methylene blue to identify the angiosome region and determine the flap dimension for harvesting. To decellularize flaps, the iliac artery was perfused sequentially with 1% sodium dodecyl sulfate, deionized water, and 1% Triton-X100. Gross morphology, histology, and DNA quantity of flaps were then obtained. Flaps were also subjected to glycosaminoglycan and hydroxyproline content assays, as well as computer tomography angiography. Results Histological assessment indicated that cellular content was completely removed in all flap layers following 10-h perfusion in sodium dodecyl sulfate. DNA quantification confirmed 81% DNA removal. Based on biochemical assays, decellularized flaps had hydroxyproline content comparable with that of native flaps, although significantly fewer glycosaminoglycans (p = 0.0019). Histology and computed tomography angiography illustrated the integrity and perfusability of the vascular system. Conclusion The proposed angiosome-guided perfusion decellularization protocol could effectively remove cellular content from rat fasciocutaneous flaps and preserve the integrity of innate vascular networks.

Background: Free flap (FF) reconstruction is frequently required for soft tissue coverage after significant orthopedic trauma of the lower extremity (LE). While usually the final step in limb salvage, re-elevation of the previously inset FF may be necessary to restore a functional limb. In this study, we present our algorithm for LE FF re-elevation and review our experience to identify factors associated with successful limb salvage and return to ambulation.

Methods: A retrospective, single-institution review was conducted of adult patients with LE wounds who required FF reconstruction from 2016-2021. From this cohort, patients that required re-elevation of their LE FF were identified. Successful FF re-elevation was defined by limb salvage and return to ambulation.

Results: During the study period, 412 patients with LE wounds required flap reconstruction. Of these patients, 205 (49.8%) underwent free tissue transfer, and 39 (9.5%) met our inclusion criteria. From this cohort, 34 had successful FF re-elevations, while 1 was non-weight bearing and 4 elected for amputation due to chronic complications unrelated to their FF. Univariate analysis revealed the total number of FF re-elevations (p < 0.001), the frequency of re-elevation indicated for orthopedic access (p < 0.001), and infections necessitating return to the operating room (p = 0.001) were each negatively associated with limb salvage and return to ambulation.

Conclusion: The described algorithm highlights the preoperative planning and meticulous flap preservation necessary for the successful coverage of critical structures following FF re-elevation. Our data demonstrates that LE FFs can be safely re-elevated for hardware access or flap revision. In these complex cases of LE trauma, management by a multidisciplinary team is essential for successful limb salvage.

Background: Microsurgical free tissue transfer has become an essential method for reconstruction of complex surgical defects, making the level of training an important factor to consider. There is little published regarding the impact of training level on microsurgical outcomes. This study investigates microsurgical free tissue transfer ischemia time and post-operative complications based on resident and attending surgeon experience level.

Methods: A retrospective review of all free flaps at a single institution from 1/1/2013 to 12/31/2021 was performed. Linear regression was performed analyzing ischemia time of 497 free flaps and attending surgeon experience defined by years in practice and resident level defined as post graduate year (PGY). Logistic regression model was used to analyze complications based on attending experience and resident level.

Results: The average resident PGY was 3.5 +/- 0.8; the average attending has been practicing 6.4 +/- 5.1 years. There was no statistically significant difference in ischemia time or complication rates based on resident PGY or attending surgeon experience level.

Conclusion: Lower PGY residents were not found to increase ischemia time or increase complication rates. Lower attending surgeon year was not found to increase ischemia time or increase complication rates compared to surgeons who had been practicing for longer. Microsurgical free tissue transfer is considered a safe procedure in residency training and trainee involvement should be encouraged to improve resident education and enhance technical skills.

Purpose: Breast anesthesia and hypoesthesia occur commonly after mastectomy and negatively impact quality of life. Neurotization during deep inferior epigastric perforator (DIEP) breast reconstruction offers enhanced sensory recovery. However, access to neurotization for DIEP reconstruction patients has not been evaluated.

Methods: This retrospective study included patients who underwent DIEP breast reconstruction between January 2021 and July 2022 at a tertiary-care, academic institution. Demographics, outcomes, insurance type, and Area Deprivation Index (ADI)were compared using two-sample t-test or Chi-square analysis.

Results: Of the 124 patients who met criteria, 41% had neurotization of their DIEP flaps. There was no difference in history of tobacco use (29% vs 33%), diabetes (14% vs 9.6%), operative time (9.43 hr vs 9.73 hr), length of hospital stay (3 d vs 3 d), hospital readmission (9.8% vs 6.8%), or reoperation (12% vs 12%) between to patients with and without neurotization. However, access to neurotization differed significantly by patient health insurance type. Patients who received neurotization had a lower median ADI percentile of 40.0 indicating higher socioeconomic advantage compared to patients who did not receive neurotization at 59.0 (p=0.01).

Conclusions: Access to neurotization differed significantly by patient health insurance and by ADI percentile. Expanding insurance coverage to cover neurotization is needed to increase equitable access and enhance quality of life for patients who come from disadvantaged communities. Our institution's process for pre-authorization is outlined to enhance likelihood of insurance approval for neurotization.