Journal of reconstructive microsurgery最新文献

Background:  Foot drop is the common endpoint for a diverse set of nerve injuries, affecting over 128,000 in the United States each year. The level of injury, finite pace of regeneration, and/ exponential decay in the percentage of motor end-plates reinnervated over time may explain the limited success with natural recovery. Past nerve techniques have also been met with limited success.

Methods:  This narrative review explores why past nerve techniques have failed to correct foot drop.

Results:  Previously described nerve transfer techniques suffer from incompletely balancing the foot and ankle, poor donor-target nerve synergy, and/or not effectively bypassing the wide and oftentimes underappreciated zone of injury. For maximal stability, one should look to balance the foot in both dorsiflexion and eversion. Detailed descriptions and illustrations of the branching anatomy for the peroneal and tibial nerves are provided, with specific application to nerve transfer reconstruction.

Conclusion:  Based on an understanding of why past nerve techniques have failed to correct foot drop, a set of surgical principles can be codified to optimize functional outcomes. A surgical technique should be versatile enough to address foot drop from any of the three common pathways of injury (lumbar spine, sciatic nerve, and common peroneal nerve). With increasing familiarity using this once poorly understood anatomical region, limitations with past nerve transfer techniques may be overcome.

Background:  The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap.

Methods:  CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap.

Results:  A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm³ (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm³ (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm³ (SD = 62.40).

Conclusion:  The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Background:  Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers.

Methods:  Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes.

Results:  There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients.

Conclusion:  Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.

Background:  Fasciocutaneous free deltoid flaps are used to reconstruct hand, foot, and maxillofacial defects. Although anatomical studies of this flap pedicle have been performed on cadavers, there are no reports on the use of 320-detector row computed tomography angiography (CTA-320) to investigate the deltoid flap pedicle in living humans. This study aimed to investigate the arterial characteristics of the deltoid flap pedicle using the CTA-320 system in living humans.

Methods:  Twenty-seven adult Vietnamese patients with 54 healthy deltoid regions underwent CTA-320 to investigate arterial blood supply before clinical free-flap transfer. Two- and three-dimensional reconstruction images of the arterial pedicle were visualized, and clinical reconstruction results were evaluated.

Results:  The cutaneous vessel branches of the deltoid flap were separated from the posterior circumflex humeral artery (PCHA) and originated from the axillary (77.78%), subscapular (12.96%), and brachial (9.26%) arteries. The PCHA penetrated the quadrangular space in 90.74% of patients. The cutaneous arterial branch was present in the deltoid-triceps groove in 100% of patients. The average diameter and length of the PCHA were 3.38 ± 0.58 and 43.08 ± 6.60 mm, respectively. The average diameter and length of the flap cutaneous branch were 1.49 ± 0.28 and 44.57 ± 4.83 mm, respectively. The findings of CTA-320 were aligned with the intraoperative clinical findings well. All deltoid flaps were successfully free-transferred with good outcomes.

Conclusion:  The CTA-320 is a practical and effective method for investigating deltoid flap pedicles. It enables accurate flap design and harvesting of flaps, thereby enhancing the clinical success of free-flap transfer.

Background: Microsurgery is a highly specialized field requiring years of dedicated training and proper support to sustain a practice. We sought to describe career paths of young microsurgeons and investigate factors associated with switching jobs.

Methods: Public data on surgeons who completed a microsurgery fellowship between 2016 and 2020 were collected. Analysis on job switching was determined using the Kaplan-Meier method.

Results: One hundred sixty-seven graduates were analyzed. Most initially practiced microsurgery (92.2%) and 61.7% went into academics. Fifty-two (31.4%) have switched jobs and Kaplan-Meier estimates 36.0% will switch by 5 years into practice. Over half (58%) changed practice setting type, 19% left academics, and 12% stopped performing microsurgery. Gender, residency training type, taking a job where they trained, and presence of a microsurgery fellowship had no effect on job switching. (p=0.74, 0.95, 0.71, 0.26). Surgeons in academics were significantly more likely to change jobs (p=0.04). Gender, residency training type, or taking a job where they trained had no effect on leaving academics (p=0.89, 0.42, 0.37). Taking a first job where a microsurgery fellowship was present was significantly associated with staying in academics (p=0.04) Conclusion: Most microsurgery fellows take jobs performing microsurgery. Thirty-six percent will switch jobs by 5 years, more than half will change practice setting type, and about 20% will leave academics. A minority stop performing microsurgery. Surgeons in academics are more likely to switch jobs. Taking a job where there is a microsurgery fellowship is significantly associated with staying in academics during the switch.

Introduction Defects of the lower extremity often require free tissue transfer to provide adequate soft tissue reconstruction. Patients typically undergo a postoperative dangle protocol to condition the flap to withstand the increase in venous pressure. The purpose of this study was to evaluate the safety and postoperative length of stay after early initiation of dangle. Methods A retrospective review of patients undergoing lower extremity free tissue transfer reconstruction at Grady Memorial Hospital from 2012-2022 was conducted. Patient demographics, surgical characteristics, and outcomes were analyzed. Patients were categorized into two groups: early (within 5 days after surgery) and late dangle (day 6 or greater). Univariate and multivariate statistical analysis were performed, with significance determined to be p<0.05. Results 83 of 99 available patients met inclusion criteria; 22 patients underwent early and 61 late dangle. Free flap survival was 90.9% in the early and 90.2% in the late group. The mean post-operative length of stay in the early and late groups were 12.3 and 18.8 days, respectively (p=0.0018). There was no difference in the number of patients who had wound healing complications, flap failure, and a need for amputation in each group. Conclusion Our results demonstrate that initiation of an early dangle protocol does not affect surgical outcome and leads to a reduction in postoperative length of stay. These results can be used to inform evidence-based recommendations for flap management in lower extremity reconstruction.

Background: High-level median or ulnar nerve injuries and repairs typically result in suboptimal re-innervation of distal muscles. Functioning Free Muscle Transplantation (FFMT) is increasingly recognized as an effective method to restore function in chronic muscle denervation cases. This study investigates the efficacy of using an additional FFMT, neurotized by lateral sprouting axons from a repaired high-level mixed nerve in the upper limb, to enhance distal hand function.

Methods: Thirty-five Sprague-Dawley rats were divided into four groups to evaluate the proposed FFMT technique. The infraclavicular median nerve (MN) was transected and repaired in each animal. The nearby musculocutaneous nerve (MCN) was transected, and the terminal nerve after the biceps muscle was divided and embedded into the biceps muscle, creating an FFMT model. The distal stump of the MCN was anchored to the MN, 1.5 mm distal to the MN repair site. Assessments of nerve and muscle function were conducted four months postoperatively.

Results: Behavioral analysis, along with measurements of biceps muscle weight and tetanic contraction force, indicated significant recovery in the biceps muscle. Histological staining confirmed re-innervation of the MCN from the repaired MN. Additionally, functional examination of the flexor digitorum superficialis muscle revealed no deterioration associated with the repaired MN.

Conclusion: The study demonstrates the potentiality of utilizing lateral sprouting axons from a repaired high-level median nerve to reinnervate an additional FFMT to enhance flexor digitorum superficialis function. The surgical strategy promises recovery of distal muscle function and implies for diverse clinical applications.

Background: As surgical interventions for lymphedema become increasingly available, it is important to understand characteristics of patients that undergo lymphedema surgery. The goal of this study was to define clinical variables of patients evaluated at a medical center who underwent lymphedema surgery to better inform which referred patients are surgical candidates.

Methods: A cross-sectional observational study was performed on patients referred to plastic surgery for lymphedema between January 2016 and June 2023. The operative group included patients who underwent lymphedema surgery, including physiologic surgery (PS) and excisional surgery (ES). The non-operative group consisted of patients referred for lymphedema who did not undergo lymphatic surgery. Patient records were collected, and between-group comparisons were performed.

Results: 285 total patients were identified (n=66 operative, n=219 non-operative). The operative cohort had higher body mass index (BMI) than the control (33.5 versus 31.2 kg/m2, p<0.035) and was more likely to have undergone physical therapy/occupational therapy (68.2% versus 53.4%, p=0.005). Within the operative cohort (PS=37, ES=29), PS patients were more likely to be white (91.9% versus 69.0%, p=0.043) and have lower BMI (32 versus 42.7 kg/m2, p=0.007). PS patients were diagnosed for a longer period (8 versus 3 years, p=0.03) before seeing a plastic surgeon, more commonly had upper extremity lymphedema (43.2% versus 13.8%, p=0.016) and presented at an earlier lymphedema stage (stage 1 64.9% versus 27.6%, p=0.002). PS patients were more likely to have prior radiation (56.8% versus 20.7%, p=0.005), previous surgery (75.5% versus 48.3%, p=0.038), and prior lymphatic intervention (67.6% versus 17.2%, p<0.001) near the affected area.

Conclusion: Defining patient characteristics associated with surgical intervention for lymphedema can aid surgeons to increase the proportion of patients seen in clinic who are surgical candidates. Factors relating to oncologic and surgical history in the affected area may suggest a patient is more likely to undergo PS.

Background:  Multidisciplinary care with vascular surgery and plastic surgery is essential for lower extremity free flap (LEFF) success in the chronic wound population with diabetes and peripheral vascular disease. There is a lack of understanding on performing targeted direct endovascular reperfusion on a vessel that will be used as the flap recipient. Our study compares outcomes of patients who received targeted revascularization (TR) to the recipient vessel for LEFF anastomosis versus nontargeted revascularization (NR) of arterial recipients prior to LEFF.

Methods:  LEFF patients who underwent preoperative endovascular revascularization (ER) from July 2011 to January 2023 were reviewed. Location of ER, demographics, perioperative details, and outcomes were collected. TR was performed on the same vessel as the flap recipient and NR was located on a different vessel than the flap recipient.

Results:  A total of 55 LEFF patients were identified. Overall, 50.91% (n = 28) received TR and 49.1% (n = 27) received NR. Average age was 60.3 ± 10.9 years and average Charlson Comorbidity Index was 5.3 ± 1.9. On preoperative angiogram, the TR group had significantly lower rates of ER above the knee (3.6 vs. 33.3%, p < 0.001). Immediate flap success rate was 98.2%, with no differences between groups (p = 1.000). No significant differences were found in rates of any postoperative flap complications (p = 0.898), takeback (p = 0.352), partial flap necrosis (p = 0.648), or dehiscence (p = 0.729). Both TR and NR groups had similar rates of a postoperative angiogram (42.9 vs. 48.2%, p = 0.694) and reintervention (35.7 vs. 40.7% p = 0.701). Amputation rates were similar between TR and NR (17.9 vs. 14.8%, p = 1.000).

Conclusion:  Close follow-up with vascular and plastic surgery is required for patients who undergo ER prior to LEFF, as nearly half of our cohort required additional endovascular procedures. Overall, we observed no significant differences in complication rates for the TR and NR groups, informing revascularization strategies for free tissue transfer in a highly comorbid chronic wound population.

Background:  There is a lack of literature regarding the effects of language barriers, socioeconomic status, racial disparities, and travel distance to the hospital on the outcomes of lower extremity (LE) flap reconstruction. Consequently, this study assesses the potential influence of these factors on ambulation within this specific patient demographic.

Methods:  A retrospective review was performed between 2007 and 2022 of patients who underwent LE reconstruction with tissue flap placement at a single institution. The primary outcome was ambulation status, with cohorts compared between those who were ambulatory versus nonambulatory. Covariates included race, age, gender, primary language, distance from patient home to hospital, socioeconomic status (determined using area deprivation index [ADI]), and flap characteristics. Outcomes were assessed with multivariable logistic regression.

Results:  A total of 242 patients who underwent LE flap reconstruction during the study period. The average time to final ambulatory status was 7.0 months (standard deviation: 11.0), with 51.7% requiring either a wheelchair or assistance device and 48.4% being fully ambulatory at final follow-up. The average state ADI for the cohort was 5.8, with Hispanic patients having significantly higher deprivation indexes (6.3 vs. 5.6, p < 0.001). Multiple logistic regression demonstrated that when controlling for numerous covariates, patients in the highest 15th percentile of deprivation were significantly less likely to be fully ambulatory at final follow-up (odds ratio: 0.22, 95% confidence interval: 0.061-0.806, p = 0.022).

Conclusion:  The current study emphasizes the substantial impact of socioeconomic disparities on postoperative outcomes in LE flap reconstruction. The finding that patients in the highest 15th percentile of deprivation were less likely to achieve full ambulation underscores the need to prioritize socioeconomic factors in clinical consideration and highlights a crucial avenue for future research.