Journal of reconstructive microsurgery最新文献

Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use has been shown to have unfortunate adverse effects. With increasing awareness and diagnostic capabilities for neuroma formation, this study evaluates whether upper extremity neuroma excision may reduce opioid use and if adjunctive nerve procedures further reduce opioid use.The PearlDiver database was queried for patients undergoing upper extremity neuroma excision surgery from 2010 to 2020. Patients with opioid prescription fill records preoperatively were extracted and stratified by an operative technique involving either (1) excision alone, (2) nerve implantation into bone or muscle, or (3) nerve reconstruction. Records were then assessed at 1, 3, and 6 months postoperatively to assess for opioid use. Prescription fill rates at 1, 3, and 6 months postoperatively were then assessed across techniques.Of the 14,330 patients that underwent upper extremity neuroma excision, 4,156 filled opioids preoperatively. Excision led to significant reductions in opioid prescription fill rates postoperatively, decreasing to 67.4% at 1 month and to 57.5% by 6 months (p < 0.001). Excision alone resulted in lower opioid use compared with excision with implantation at all postoperative time points (p < 0.05). At 6 months, opioid use was also significantly less following excision with nerve reconstruction compared with implantation (56.4% vs. 65.6%, p = 0.0096). There were no differences between excision alone and excision with nerve reconstruction.Neuroma excision significantly reduces opioid use in patients with preoperative opioid use while adjunctive operative techniques did not potentiate opioid reduction. This highlights the importance of understanding patient complaints, neuroma localization, and candidacy for excision as an effective measure for addressing opioid use in patients with preoperative opioid dependence.

Ischemic myopathy in the upper limb may develop progressively in cases of peripheral arterial disease or acutely following traumatic vascular injuries. Prolonged ischemia can lead to catastrophic damage to distal muscles, with a significant risk of irreversible motor function loss. It is hypothesized that the neuromuscular junction (NMJ) sustains substantial damage beyond a critical threshold of arterial ischemia. Furthermore, concomitant upstream nerve injuries may exacerbate NMJ degeneration, potentially resulting in permanent dysfunction. This study aims to evaluate the NMJ-level changes in target muscles and investigate the impact of nerve injury and repair, with a particular focus on the potential benefits of the supercharge end-to-side (SETS) nerve transfer technique.A mouse forelimb ischemia model was created by clamping the brachial artery and ablating collateral vessels. The first aim assessed NMJ changes with increasing ischemia time. The second investigated the impact of ischemia on muscle reinnervation after transection and repair of the median nerve. Lastly, the ulnar nerve was used for SETS to the distal median nerve following nerve repair to evaluate its effect on muscle recovery. Functional grip tests, electrophysiological assessments, and immunohistochemical analyses were performed.Prolonged ischemia significantly decreased CMAP and grip strength, with markedly declined after 8 hours of prolonged arterial ischemia. When the upstream median nerve was cut and repaired, NMJ innervation of the target muscle dropped significantly at 12 hours, with fully innervated NMJs reduced to 27 to 39% compared with 67 to 72% at 4 to 8 hours (control = 81%). SETS transfers significantly improved CMAP, grip strength, and NMJ innervation, particularly in the 12-hour ischemia group.Prolonged ischemia leads to severe NMJ degeneration within the target muscle, with 8 hours being the critical time point at limb ischemia, and 12 hours being the time point after ischemia and nerve injury. As an alternative to limb amputation or muscle loss, SETS nerve transfer to augment the innervating median nerve can initiate partial NMJ innervation within the remaining target muscles to attempt to restore functional capacity.

Paralytic lagophthalmos, a common consequence of facial nerve palsy, leads to corneal exposure and ophthalmic complications. The postseptal upper eyelid weight technique was first described in 2013 to address complications associated with the traditional pretarsal approach including weight visibility, extrusion, migration, eyelid ptosis, entropion, and astigmatism. This follow-up study assesses the long-term efficacy of the postseptal technique.Patients treated with postseptal upper eyelid weight implantation from 2008 to 2023 were included. Outcome measures included the presence of complications and degree of eye closure, assessed through videographic and photographic review.One hundred twenty-three patients were included. The mean follow-up time was 46 months, ranging from 12 to 143 months. The overall complication rate was 16%, with 9% experiencing extrusion. The adjusted extrusion rate in the present study was 2.3 extrusions per 100 person-years while the mean adjusted extrusion rate was 2.9 extrusions per 100 person-years for the evaluated studies in the literature (p = 0.005). No entropion or astigmatism was observed. Complete or near-complete eye closure was achieved by 98% of patients. A history of previous upper eyelid blepharoplasty was associated with more complications (p = 0.024).The postseptal technique is safe, reproducible, and effective for primary and secondary lid weight implantation, even in high-risk cases. Complication rates for the postseptal approach are similar to or lower than those reported in the literature for the pretarsal approach, with similar functional outcomes, and improved aesthetics. Upper eyelid skin resection prior to lid weight insertion was associated with increased complications.

The selection of recipient vessels is critical for the success of free flap transfer in lower extremity reconstruction following trauma. We hypothesized that variations in soft tissue, vascular, and bone injuries across different injury levels influence recipient vessel selection. This study aimed to investigate the injury patterns and recipient vessel selection at different injury levels.A retrospective analysis was performed on patients with acute open tibial fractures (Gustilo IIIB/C) and mangled foot injuries treated at a single trauma center between 2013 and 2022. Injury levels were classified as proximal tibia (P/3), middle tibia (M/3), distal tibia (D/3), and foot injuries. We analyzed injury patterns by level and defined recipient vessel selection as the primary outcome.A total of 91 limbs from 88 patients were analyzed (P/3: 10, M/3: 39, D/3: 18, foot: 24). M/3 injuries were the most severe, with extensive compartment involvement (p < 0.01) and bone loss in 49% of cases, whereas P/3 injuries were the least severe. The distal posterior tibial artery was predominantly used in P/3 injuries, the proximal posterior tibial artery was most frequently used in M/3 and D/3 injuries, and the anterior tibial artery was used primarily for foot injuries (p < 0.01). Vein grafts were required exclusively in M/3 cases, with intraoperative vascular disturbances occurring in 33%. Postoperative vascular complications ranged from 6 to 20%, with an overall flap survival and limb salvage rate of 95%.Among the findings of this study, key findings were that M/3 injuries were the most severe, and P/3 injuries had favorable outcomes with distal posterior tibial artery anastomosis. Injury patterns and recipient vessel selection show distinct, level-specific differences in severe open fractures of the tibia and foot.

Free flap reconstruction for lower extremity (LE) trauma has a higher failure rate than free flaps in other anatomic regions. Postoperative anticoagulation and antiplatelet therapy may influence LE free flap outcomes, but an optimal regimen has not been established. This study aims to evaluate complication rates associated with different anticoagulation and antiplatelet protocols in LE free flap reconstruction.Adult patients (≥18 years of age) with LE trauma requiring free flap reconstruction at our level 1 trauma center from 2016 to 2021 were included for retrospective chart review. Complications requiring reoperation were grouped into a composite variable named major complications (i.e., hematoma, flap thrombosis, flap necrosis >10%, infection requiring reoperation). Nonrandomized patients were categorized into three groups based on postoperative anticoagulation or antiplatelet regimen (aspirin only, heparin only, and aspirin + heparin), with heparin being a subtherapeutic fixed-dose heparin infusion at 500 to 800 units/hour. Complication rates were compared across groups, and both univariate and multivariate analyses were conducted to identify associations with major complications. p-Values were set at p < 0.05.Of 191 patients, 37 (19.4%) received aspirin only, 76 (39.8%) received heparin only, and 78 (40.8%) received aspirin + heparin. Demographics were similar between the groups. On univariate analysis, the heparin group had a significantly lower rate of major complications (5.26%) compared with aspirin only (18.92%) and aspirin + heparin (20.51%; p = 0.016); however, on multivariate analysis, when accounting for additional perioperative factors, no association between anticoagulation group and major complications was found.Our study found that neither aspirin alone, heparin alone, or aspirin + heparin demonstrated a more favorable association with LE free flap outcomes. To reduce bias from the study's retrospective design and the surgeon's discretion in choosing anticoagulation protocols, future research should randomize patients to standardized postoperative regimens to assess differences in complications.

The Symani surgical system (Symani) is the first robotic system specifically designed for microsurgical purposes and attracted substantial interest in recent times. Despite some initial investigations, no independent analysis of the histopathological/biomechanical properties and anastomoses quality of Symani-sutured anastomoses have been conducted so far. This study aims to compare in-depth robotic-assisted microsurgical anastomoses using the Symani versus conventional anastomoses regarding anastomosis quality, biomechanical, and histopathological properties.We compared 12 microsurgical end-to-end anastomoses sewn by the Symani versus 12 by the conventional technique in a preclinical artery chicken-thigh-model regarding time until completion of the anastomosis, anastomosis quality (modified MARS10-rating and anastamosis lapse index (ALI)) and diameter. Additionally, histopathological analysis of the thread hole diameter, and knot firmness as well as biomechanical tests for intraluminal resistance and tensile strength of the anastomoses were conducted.Anastomosis quality was comparable between both techniques. The Symani-assisted anastomosis took a significantly longer time to perform than conventional anastomosis. Histopathological analysis revealed similar vessel wall damage while showing greater variability in knot spacing and bite width in the robotic anastomoses. No significant differences were observed in the tensile strength test or intraluminal resistance. However, the knot firmness of Symani-assisted anastomosis was significantly less than conventionally performed knots.This study demonstrates that the Symani performs on par with conventional anastomosis techniques regarding anastomosis quality, vessel wall damage, intraluminal resistance, and tensile strength. Long-term continuous training and/or further innovations of the Symani system may lower the time required to perform the anastomosis and improve knot firmness.

Detailed knowledge of venous valves and valve-like structures is essential in reconstructive surgery, as these structures may contribute to postoperative venous congestion following flap transfer. However, their presence in the superficial temporal veins (STVs), which are frequently utilized in craniofacial reconstruction, remains unclear. The authors performed morphological and morphometrical examinations of venous valves and valve-like structures in the STVs through cadaver dissection.This study involved the longitudinal dissection of 24 STVs from 12 cadavers. The veins were then examined under a stereomicroscope to determine the presence of venous valves or valve-like structures, and their quantity and location were recorded.The STVs contain both venous valves and valve-like structures known as venous cristae. All observed venous valves were bicuspid, whereas venous cristae were characterized by ridge-like protrusions of venous wall into the lumen. A total of 5 venous valves and 69 cristae were identified across 24 STVs. Venous valves were exclusively located in the main trunks of the STVs, whereas venous cristae were classified into five types based on their locations, with venous bifurcations being the most common sites. Most main trunks (22/24)contained either one venous valve or one crista, and the average distances from these structures to the superior margin of the zygomatic arch were 8.42 ± 0.80 and 9.03 ± 0.86 mm, respectively.A comprehensive understanding of the characteristics, quantity, and distribution of venous valves and cristae in the STVs could provide valuable insights for surgeons in preventing postoperative venous congestion.

This study aims to compare demographic, risk, and complication profiles of pediatric and adult patients who underwent supercharged pedicled jejunal interposition for esophageal reconstruction.A systematic review and meta-analysis were performed, which included patients who underwent esophageal reconstruction with supercharged jejunum from 23 published studies. Patients were divided into two groups: pediatric/young adults (≤18 years), and adults (>18 years). The primary outcome was postoperative complications. Python 3.11 with pandas was used for data management, scikit-learn for Ridge regression and imputation of missing values, and SciPy for statistical analysis. Ridge regression analysis was utilized with regularization (α = 0.1), while examining the relationship between demographic factors and overall complication rates in adult patients to account for limited sample sizes.A total of 254 manuscripts were reviewed, and 23 studies met inclusion criteria. Of 477 included patients, 415 were adults (87%) and 62 were pediatric patients (13%). Adult patients had significantly higher odds of developing an anastomotic leak (OR 8.63, p < 0.01) and dysphagia (5.99, p < 0.02) following surgery. Preoperative radiation was positively associated with postoperative dumping symptoms (β = 0.56), stricture formation (β = 0.27), poor wound healing (β = 0.27), and need for reoperation (β = 0.27). A history of cancer was most positively associated with anastomotic leak (β = 0.22) following surgery. Preoperative radiation was positively associated with anastomotic leak (β = 0.12). Smoking demonstrated a strong inverse association with the need for reoperation (β = - 0.66), and a weaker inverse association with leakage (β = - 0.25).Adult patients have a significantly greater likelihood of experiencing postoperative anastomotic leakage and dysphagia compared with pediatric patients. Preoperative radiation was associated with dumping symptoms, stricture, need for reoperation, poor wound healing, and pulmonary complications. Smoking was associated with decreased need for reoperation and anastomotic leakage.

Deep inferior epigastric perforator (DIEP) flap is a common autologous breast reconstruction option. DIEP flap may be performed immediately on the day of mastectomy (immediate DIEP) or at a later date typically following placement of a tissue expander during mastectomy (delayed-immediate DIEP). Preparing internal mammary vessels during microsurgical anastomoses involves prolonged retraction of the breast skin flaps, which can increase tension on acutely ischemic mastectomy skin. The purpose of this study is to investigate whether DIEP flap timing has an effect on mastectomy skin necrosis.A single-center study was performed of patients who underwent immediate or delayed DIEP flap reconstruction over a 3-year period. Patients were divided into two groups: Group I (immediate DIEP flap) and Group II (delayed-immediate DIEP with flap staged separately from mastectomy). The outcomes assessed were breast skin flap necrosis and management of skin flap necrosis.The study included 106 patients (173 flaps) in Group I (49 patients, 80 flaps) and Group II (57 patients, 93 flaps). Mastectomy skin flap necrosis rates were 11.3% (9/80) for Group I compared to 2.2% (2/93) of Group II patients (p = 0.025). Skin necrosis necessitating operative debridement was 7.5% (6/80) in Group I and 1.1% (1/93) in Group II (p = 0.0499).Immediate DIEP flaps performed on the day of mastectomy have a significantly higher risk of mastectomy skin necrosis. Patients may be counseled that another advantage of performing a DIEP flap on a different day than a mastectomy is to decrease the risk of mastectomy skin necrosis.