Journal of reconstructive microsurgery最新文献

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.

Background:  The treatment approach for soft tissue sarcomas (STS) of the lower extremity has shifted toward the use of neoadjuvant radiation combined with limb-sparing surgery (LSS). The resulting defects often require reconstruction with free tissue transfer for adequate outcomes. Data have demonstrated a potentially increased risk of microvascular complications for free flaps performed using irradiated recipient vessels. Similarly, certain anatomic areas of the lower extremity have a high proportion of unnamed perforators that are available as recipient vessels, increasing the technical difficulty. We aimed to determine if the characteristics of recipient vessels that were used for the reconstruction of STS defects influenced rates of microvascular complications in our patients.

Methods:  A retrospective chart review of all patients who underwent reconstruction of lower extremity STS defects with free tissue transfer from 2009 to 2020 was conducted. Data regarding recipient vessel type (axial vessel vs. unnamed perforator), radiation status of the recipient vessels (irradiated vs. non-irradiated), and microvascular complications were compared across groups.

Results:  A total of 204 free flaps were included. The overall microvascular complication rate was 13.7% (28 cases). Most microvascular complications were detected postoperatively (82.1%) rather than intraoperatively, with the majority involving venous congestion/thrombosis (20 cases, 71.4%). While there was a trend toward increased microvascular complications with the use of irradiated recipient vessels (27 cases, 96.4%), this did not reach statistical significance (OR = 1.98, p = 0.52). The use of perforating branches as recipient vessels did not confer an increased risk of microvascular complications (OR = 0.87, p = 0.75).

Conclusion:  The reconstruction of irradiated lower-extremity STS defects represents a particularly challenging issue. This analysis demonstrates that free tissue transfer can be safely performed using irradiated vessels without a significantly increased risk of microvascular complications. Furthermore, unnamed perforating branches can be successfully used for reconstruction in anatomically challenging areas of the lower extremity.

Background: Hybrid deep inferior epigastric perforator (DIEP) flap and simultaneous silicone implant breast reconstruction procedures ("DIEP+I") have many conceptual advantages compared to either reconstruction method alone, but the outcomes of DIEP+I reconstruction have not yet been well studied. Therefore, the purpose of this study was to compare the outcomes of DIEP+I with implant-only and DIEP-only reconstruction.

Methods: A retrospective review was conducted of patients undergoing DIEP+I, implant-only, and DIEP-only breast reconstruction from 2019-2023 at a single institution. Demographics and complication rates were compared between groups.

Results: A total of 145 patients were included in the DIEP+I (N = 26), implant-only (N = 59), and DIEP-only (N = 60) groups. The DIEP+I group had a lower overall complication rate than implant-only reconstruction (18.4% vs 41.1%, P = 0.014), which was primarily due to the lower incidence of infections in the DIEP+I group (2.6% vs 22.2%, P = 0.006). Accordingly, DIEP+I reconstruction decreased the odds of infection by 90% (OR = 0.095, P = 0.024) compared to implant-only reconstruction. The DIEP+I group had similar rates of wound healing and implant-related complications compared to the implant-only and DIEP-only groups, and no patients in the DIEP+I group experienced flap loss.

Conclusion: DIEP+I breast reconstruction had a lower rate of infectious complications than implant-only reconstruction, and no higher rate of flap compromise or wound healing complications. This technique could be considered as a means of minimizing infection risk in patients with other risk factors who are seeking implant-based reconstruction, and of enhancing breast projection in patients who are seeking DIEP flap reconstruction.

Background Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction. Methods A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007-October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis. Results In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf-) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf+). Overall flap survival rates were similar across both cohorts (Tf+: 92.9% vs Tf-: 96.6%, p=0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9% vs. 2.0.%, p<0.001), amputation (6.0% vs 0.7%, p=0.015), and postoperative hardware infection (10.6% vs 2.7%, p=0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis (p=0.033). Conclusion Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.

Background: Patients with head and neck tumours undergoing free flap reconstructions are at high risk of postoperative venous thromboembolism (VTE). To date, no specific guidelines are available regarding venous thromboembolism prophylaxis in this patient group. This study aims to contribute to this scarcity of information by reviewing the literature regarding anticoagulation regimens in this patient group and evaluating the efficacy and safety of postoperative subcutaneous heparin dosed at 5000 units every 8 hours routinely utilised at our institution.

Methods: PubMed and Embase databases were searched from inception until November 2023. Data was collected and levels of evidence were evaluated according to the Oxford Centre for Evidence Based Medicine guidelines. Additionally, a retrospective review of all patients with head and neck tumours undergoing free tissue transfer at our institution between 2015 and 2021 was performed. Patients were restricted to those receiving 5000 units of subcutaneous heparin every 8 hours postoperatively. Key outcomes included rates of VTE and surgical site haematoma.

Results: This systematic review found 15 studies eligible for inclusion ranging from 1998 to 2023. Anticoagulation regimens were markedly heterogenous. Among the literature, VTE rates reported ranged from 0% to 9.6% and bleeding rates ranged between 3.5% to 29%. Our six-year institutional analysis revealed 393 total patients. Overall, three episodes of venous thromboembolism were identified (0.76%) consisting of one deep vein thrombosis and two pulmonary emboli. The overall rate of haematoma was 9.4% with a higher rate of haematoma at the recipient site (8.1%) than the donor site (1.3%).

Conclusion: When compared to the existing literature this study found a low rate of venous thromboembolism and a comparable incidence postoperative haematoma. This suggests that 5000 units of subcutaneous heparin given every 8 hours may be a safe and effective postoperative anticoagulation regimen for these patients.

Background:  Persistent disparities in breast reconstruction access have been widely documented, yet a significant research gap remains in understanding the impact of social determinants of health (SDOH) on postoperative outcomes and complications.

Methods:  A retrospective chart review was performed on all patients who underwent abdominal-based free-flap breast reconstruction between August 2018 and December 2022 at a racially, ethnically, and socioeconomically diverse urban academic institute with a historically underserved patient population. Patients were stratified by the public (Medicare and Medicaid) versus private insurance as a proxy for SDOH. Patient demographics, length of stay (LOS), timing in progression through postoperative recovery milestones, and complications were compared.

Results:  A total of 162 patients were included, and 57% of patients had public insurance, with this group more likely to be Hispanic (odds ratio [OR] 2.7; p = 0.003) and Spanish-speaking (OR 3.4; p = 0.003). Privately insured patients were more likely to be non-Hispanic Black (OR 2.7; p = 0.006). Patients with public insurance had a higher rate of unplanned return to the operating room within 90 days and a higher incidence of complications, though not statistically significant. They also experienced a significantly longer LOS than privately insured patients (3.6 ± 1.0 vs. 3.0 ± 0.7 days; p < 0.0001). Logistic regression identified an LOS exceeding 3 days as independently associated with public insurance status (OR 3.0; p = 0.03), bilateral procedure (OR 5.6; p = 0.0007), preoperative functional-dependent status (OR 7.0; p = 0.04), and higher body mass index (BMI; OR 1.1; p = 0.03). Patients with public insurance were more likely to encounter delays in achieving recovery milestones.

Conclusion:  Public insurance status, serving as a proxy for a disadvantage in SDOH, is predictive of extended LOS and postoperative recovery delays following microsurgical breast reconstruction. This underscores the need for future quality improvement efforts to address and mitigate these disparities.

Background:  In patients with a low body mass index (BMI), the options for autologous breast reconstruction are limited. With the hypothesis that adipose tissue deposition favors the lumbar region over the abdominal wall, this study sought to investigate the lumbar artery perforator (LAP) flap as an alternative reconstructive option in patients with deficient autologous donor sites consequent to a low BMI.

Methods:  A retrospective cohort analysis was performed, from a prospectively maintained database, of all consecutive deep inferior epigastric artery perforator flap breast reconstructions performed in our unit. A randomized selection of 100 patients with low BMI < 22, normal BMI 22 to 24, and high BMI > 30 was performed. Patient computerized tomography scans were analyzed to measure abdominal wall and lumbar tissue thickness and to define anatomical landmark relations of the LAP.

Results:  A statistically significant difference was identified between the ratio of lumbar-to-abdominal wall thickness between BMI groups, highlighting preservation of the lumbar thickness in patients with low BMI. The mean distance at which the fourth lumbar perforator entered the subcutaneous tissues was 7.7 cm lateral to the spinous process (range 6.4-9.5 cm), with no significant difference between BMI groups, highlighting this consistent anatomical position.

Conclusion:  This study confirms a greater lumbar-to-abdominal wall thickness, therefore volume, in low BMI patients, with consistent lumbar perforator anatomy of 6.4 to 9.5 cm lateral to the spinous process. The LAP flap should therefore be strongly considered for autologous breast reconstruction in this patient cohort.

Background:  Modern trends in reconstructive surgery involve the use of free perforator flaps to reduce the donor site morbidity. The course of perforator vessels has a great anatomic variability and demands detailed knowledge of the anatomical relationships and the variability of the course of the perforators. The numerous modifications to perforator nomenclature proposed by various authors resulted in confusion rather than simplification. In our study, we focused on the hypothesis that a septocutaneous perforator traverses from the given source vessel to the deep fascia adherent to but not to within the septum itself.

Methods:  Sixty-nine septocutaneous perforators from three different limb donor sites (lateral arm flap, anterolateral thigh flap, and radial forearm free flap) were collected from the gross pathology specimens of 14 fresh cadavers. The gross picture and the cross-sections with the histological cross-sections on different levels were examined to determine the position of the vessel to the septal tissue.

Results:  Of the observed 69 septal perforators, 61 (88.5%) perforators were adherent to but not within the septum. The remaining eight (12.5%) perforators passed through the septum. All these eight perforators were found in multiple different cross-section levels (2 of 19 in lateral arm flap, 3 of 27 in anterolateral thigh flap, and 3 of 23 in radial forearm free flap).

Conclusion:  Although septocutaneous vessels appear identical macroscopically, microscopically two types of vessels with paraseptal and intraseptal pathways are observed. The majority of these vessels are merely adherent to the septum having a paraseptal pathway, while a minority are within the septum and are "true" septocutaneous perforators. It is advisable to dissect with a piece of the septum in order to avoid damage or injury to the perforator.

Introduction This research aims to validate the proficiency and accuracy of the robotic microsurgery platform using rat femoral vessel model. Materials and Methods Total of 256 rat femoral vessels were performed, half using robotic and the other by manual microanastomosis by 8 microsurgeons with less than 5 years of experience given 8 trials (rats) each. Vessel demographics, proficiency (duration of suture and Structured Assessment of Robotic Microsurgical Skills (SARMS)) and accuracy (patency and Scanning Electron Microscopic (SEM)) was analyzed between the two groups. Results Using the robot, an average of 4 trials was needed to reach a plateau in total anastomosis time and patency. Significant more time was required for each vessel anastomosis (34.33 versus 21.63 minutes on the 8th trial, p<0.001) one factor being higher number of sutures compared to the hand-sewn group (artery: 7.86±0.51 versus 5.86±0.67, p=0.035, vein: 12.63±0.49 versus 9.57±0.99, p=0.055). The SARMS scores became nonsignificant between the two group on the 4th trial. The SEM showed higher tendency of unevenly spaced sutures, infolding, tears in the vessel wall for the hand-sewn group. Conclusion Using the robot, similar patency, accuracy, and proficiency can be reached through fast but steep learning process within 4 trials (anastomosis of 8 vessels) as the hand-sewn group. The robotic anastomosis may take longer time, but this is due to the increased number of sutures reflecting higher precision and accuracy. Further insight of precision and accuracy was found through the SEM demonstrating the possibility of the robot to prevent unexpected and unwanted complications.

Purpose: To assess the burden of post-discharge healthcare utilization given by readmissions beyond 30-days following immediate breast reconstruction (IBR) nationwide.

Methods: Women with breast cancer who underwent mastectomy and concurrent IBR (autologous and implant-based) were identified within the 2010-2019 Nationwide Readmission Database. Cox proportional hazards and generalized linear regression controlling for patient- and hospital-level confounders were used to determine factors associated with 180-day unplanned readmissions and incremental hospital costs, respectively.

Results: Within 180 days 10.7% of 100,942 women were readmitted following IBR.. Readmissions tended to be publicly insured (30.8% vs. 21.7%, P<0.001), and multimorbid (Elixhauser comorbidity index >2 31.6% vs. 19.6%, P<0.001) compared to non-readmitted patients. There were no differences in readmission rates amongst types of IBR (tissue expander 11.2%, implant 10.7%, autologous 10.8%; P>0.69). Of all readmissions, 40% occurred within 30 days and 21.7% in a different hospital, and 40% required a major procedure in the operating room. Infection was the leading cause of readmissions (29.8%). In risk-adjusted analyses, patients with carcinoma in situ, publicly insured, low socioeconomic status, and higher comorbidity burden were associated with increased readmissions (all P<0.05). Readmissions resulted in additional $8,971.78 (95% CI: $8,537.72-9,405.84, P<0.001) in hospital costs which accounted for 15% of the total cost of immediate breast reconstruction nationwide.

Conclusion: The majority of inpatient healthcare utilization given by readmissions following mastectomy and IBR occurs beyond the 30-day benchmark. There is evidence of fragmentation of care as a quarter of readmissions occur in a different hospital and over one-third require major procedures. Mitigating postoperative infectious complications could result in the highest reduction of readmissions.