Journal of reconstructive microsurgery最新文献

Formal dangling protocols are often used after lower extremity free flap reconstruction to acclimate flaps to gravitational stress. However, their clinical benefit remains uncertain. This study evaluates how the inclusion or omission of structured inpatient dangling affects flap outcomes.A retrospective review was conducted of 82 patients who underwent lower extremity free flap reconstruction at a single institution (2015-2024). Patients were grouped based on use of a formal dangling protocol (≥3 consecutive supervised sessions beginning after postoperative day 5) versus no protocol (ad libitum dangling beginning day 3). Outcomes included flap survival, complications, 30-day unplanned reoperation, time to ambulation, and length of stay. Statistical analysis included chi-squared, t-tests, and multivariable regression models.Fifty-three patients adhered to a dangle protocol; 29 did not follow a protocol. Demographics, comorbidities, flap type, and defect characteristics were similar between groups. Flap survival (96.2% vs. 96.6%, p = 0.94), partial necrosis (9.4% vs. 10.3%, p = 0.89), and reoperation rates (3.4% vs. 7.5%, p = 0.46) were comparable. On multivariable analysis, dangle protocol use was not associated with reduced complication risk (OR = 0.95, p = 0.93) but was associated with a 3.0-day longer median hospital stay (p < 0.01).The application of a formal dangling protocol did not affect flap survival but was independently associated with prolonged hospitalization. These findings challenge the necessity of structured regimens and support more patient-tailored postoperative strategies that may accelerate recovery without compromising surgical outcomes.

In total brachial plexus injury (BPI), there are inadequate donor nerves to adequately reinnervate the limb to regain full upper limb function. Free vascularized ulnar nerve grafts have been used to connect root stumps to the distal median nerve (MN) for hand neurotization. Axonal regeneration arrives by presenting with a sensate hand, but unpredictable motor reinnervation of the target muscles renders a paralyzed hand without extrinsic finger flexion. Thus, we describe the strategy of recycling the motor branches from the MN and replacing the forearm muscles with free functioning muscle transplantations (FFMTs).Between 1998 and 2017, a total of 34 patients received gracilis-FFMT for finger flexion, using previously reinnervated MN motor branches as the motor neurotizer. The muscle power of finger flexion [Medical Research Council (MRC)] and the satisfactory rate (≥M2) were recorded. The patient-reported outcomes, including the shortened version of the Disability of Arm, Shoulder and Hand (QuickDASH) and the Michigan Hand Outcomes Questionnaire (MHQ), were obtained.About 67.7% of the patients achieved finger flexion of M2 or greater after FFMT. The average postoperative QuickDASH score significantly decreased from 76.3 ± 13.8 to 65 ± 15.8 (p = 0.042). The overall MHQ score showed significant improvement in the domains of overall hand function and work.FFMT neurotized by previously reinnervated MN branches can serve as a salvage or adjunctive strategy to augment finger flexion. The surgical strategy of recycling previously innervated MN to an FFMT helps with efficient planning of donor nerves in reconstruction for total BPI.

Autologous breast reconstruction (ABR) is a reliable option for reconstruction after mastectomy. In cases where single donor sites do not offer adequate tissue, the use of "stacked" flaps, or multiple free flaps, can be brought together to provide optimal breast volume. This large-scale study aims to compare clinical outcomes, resource utilization, and readmission rates between single and stacked flaps.The National Readmission Database was used to retrospectively identify adult female patients who underwent ABR with free flaps between 2016 and 2020. In this study, free flaps were restricted to nonpedicled types, with latissimus dorsi (LD) and pedicled transverse rectus abdominis myocutaneous flaps (TRAM) excluded. Patients were categorized based on flap type (single vs. stacked) using relevant International Classification of Diseases, Tenth Edition (ICD-10) procedure codes. Patient demographics, hospital factors, complication rates, and readmission data were analyzed. The primary outcome was the difference in postoperative flap complication rates between single and stacked flaps.A total of 52,180 adult females were included for analysis. Of these, 51,140 (n = 98.5%) had single flaps and 783 patients (n = 1.5%) had stacked flaps. Use of stacked flaps was not statistically associated with higher odds of any flap complication (adjusted odds ratios: 1.16, p = 0.46) compared to single flaps. Stacked flaps were associated with longer length of stay and higher hospitalization costs, but there was no significant difference in 30-day readmission compared to the single flap cohort.Our study found similar rates of overall flap complications between the cohorts. Thus, in cases where more tissue is needed or desired, the use of stacked flaps appears to be a safe and feasible option to ABR.

Diabetic foot ulcer (DFU) care represents a significant challenge in plastic and reconstructive surgery. Oftentimes, patients encounter complex articles and websites to answer questions about their surgeries, including anterolateral thigh (ALT) flaps. Artificial intelligence (AI) represents a new and simplified resource for DFU patients seeking information regarding their care. To assess ChatGPT's utility as a patient resource, we evaluated the accuracy, comprehensiveness, and safety of AI-generated responses to frequently asked questions (FAQs) related to ALT flap surgery for DFU.Ten DFU and ALT flap care FAQs were posed to ChatGPT Model 3.5 in June 2024. Four plastic surgeons evaluated responses using a 10-point Likert scale for accuracy, comprehensiveness, and danger of ChatGPT's answers. Surgeons also provided qualitative feedback. Response readability was assessed using 10 readability indexes, averaged to produce a reading grade level for each response.Overall, ChatGPT answered patient questions with a mean accuracy of 9.1 ± 1.2, comprehensiveness of 8.2 ± 1.5, and danger of 2.0 ± 1.0. ChatGPT answered at a mean grade level of 19.8 ± 20.1. Qualitatively, physician reviewers complimented the organizational clarity of the responses (n = 4/10) and the AI's ability to provide information on possible surgical complications (n = 4/10). While one response was noted to present explicitly incorrect information about preoperative preparation protocols and when they should be initiated, the majority of responses (n = 6/10) left out key postoperative information, notably dangle protocols and compression.ChatGPT provides accurate and comprehensive responses to FAQs related to patients undergoing ALT flap surgery for the treatment of DFUs. The AI-generated responses were praised for organizational clarity and informative content regarding surgical complications, but lacked essential postoperative care details. Therefore, while ChatGPT is a valuable informational tool, further refinement is necessary to ensure that fully comprehensive information is provided to DFU patients.

Muscle flaps were historically considered superior to fasciocutaneous (FC) flaps for coverage of open fractures and exposed hardware. However, both flap types are now commonly used in modern lower extremity (LE) reconstruction, and it remains unclear whether postoperative infections rates differ. This study compares postoperative infection rates between muscle and FC flaps in free flap reconstruction following open LE fractures.A retrospective review was conducted on patients aged ≥18 years treated from 2011 to 2021 for open LE fractures requiring flap reconstruction after internal fixation. Demographics, injury characteristics, and perioperative factors were collected. The primary outcome was postoperative infection that could not be treated with antibiotics alone and required an unplanned return to the operating room for washout within 9 months of reconstruction. Univariate and multivariate analyses compared outcomes between muscle and FC flaps in free flap reconstruction.Of 164 patients, 86 (52.4%) had muscle flaps and 78 (47.6%) had FC flaps. Muscle flaps were more commonly used in patients with higher injury severity scores and injuries involving the knee/lower leg. The overall postoperative infection rate was 23.2%, with no significant difference between muscle or FC flaps (25.6 vs. 20.5%, p = 0.56). On multivariate analysis, muscle and FC flap types were not predictors postoperative infection. Other outcomes, including reoperation, length of hospital stay postreconstruction, time to ambulation, and secondary amputation rates, were similar between flap types.In reconstruction of open LE fractures, muscle and FC flaps yield comparable infection rates and complication profiles. Therefore, flap selection should be guided by injury characteristics, patient factors, and reconstructive goals.

Blood loss is a critical component of all surgical procedures. Excess blood loss may require a blood transfusion and increase the risk of complications after autologous breast reconstruction.Retrospective cohort of 264 consecutive autologous breast reconstruction patients between July 2017 and June 2022. Patients were stratified by reconstruction timing and bilateral versus unilateral reconstruction. Postoperative hemoglobin reduction and transfusion incidence were the primary outcomes of interest.Average preoperative hemoglobin (12.6 g/dL) was equivalent among all groups. Comparing bilateral immediate (n = 77) and delayed (n = 50) patients, immediate reconstructions had greater postoperative hemoglobin losses (-3.26 g/dL vs. -1.98 g/dL, p < 0.01) and higher transfusion rates (14% vs. 2.0%, p = 0.02). Comparing unilateral immediate (n = 99) and delayed (n = 38) patients, immediate reconstructions had greater hemoglobin losses (-2.60 g/dL vs. -1.41 g/dL, p < 0.0001) and higher transfusion rates (12.1% vs. 0.0%, p = 0.03). Using regression analysis, controlling for confounding variables and intraoperative resuscitation risk factors for blood transfusion requirement, were postmastectomy radiation therapy requirement (odds ratio [OR]: 10.3, p < 0.01) and vascular disease (OR: 14.5, p = 0.02). Unilateral reconstruction was protective from requiring transfusion (OR: 0.20, p = 0.03). Increasing BMI was protective, and with each increasing unit of BMI, transfusion requirement incidence decreased by 12.3% (p = 0.04). Transfusion was not associated with flap thrombosis or flap loss.Compared to immediate autologous breast reconstruction, a staged approach to both unilateral and bilateral patients can help minimize the risk of transfusion requirement. These factors, as well as additional modifiable and nonmodifiable risk factors, should be considered when determining the timing of autologous breast reconstruction for a patient.

The intersaphenous veins are inconstant veins interconnecting the great and the small saphenous veins. Due to the inclination of the superficial venous system to be rather inconsistent, this topic has never been described thoroughly and adequately before. The aim of our research was to observe intersaphenous veins and give a profound description of their variable anatomy.Sixty-three body donor limbs of Central European origin embalmed in formaldehyde were dissected. The tips of the medial and lateral malleoli were selected as suitable points of reference for measurements on the vertical axis of the leg. Additionally, each fibula was measured and related to the average length of the fibula in our examined sample. Consequently, each measurement was recalculated by this coefficient.Five types of arrangement were described: no connection (22.22%), one connection (46.03%), two connections (19.05%), three connections (11.11%), and four connections (1.59%). The average point of communication between the great saphenous vein and the intersaphenous vein was located 21.50 ± 9.64 cm proximal to the medial malleolus and between the small saphenous vein and the intersaphenous vein, 18.45 ± 6.05 cm proximal to the lateral malleolus. Multiple heatmaps were created for an easier comprehension of the topic.This research provides a detailed anatomy of intersaphenous veins of the leg. Yet variable in their arrangement, intersaphenous veins were found in the majority of investigated limbs. Thanks to their favorable anatomy, intersaphenous veins offer new alternatives to the traditional venous grafts from the saphenous veins, not only for heart bypasses.

Surgical reconstruction of pelvic defects aims to restore pelvic floor anatomy and function after oncological resection, infection, or trauma. The functional demands of the pelvis and proximity to anogenital flora can complicate wound healing, often necessitating locoregional flap reconstruction. While enhanced recovery after surgery (ERAS) protocols have shown benefits in other surgeries, they lack standardization for pedicled flap-based pelvic and perineal reconstructions.PubMed and Embase were queried for articles from January 2000 to January 2025 reporting pedicled flap-based pelvic and perineal reconstruction. Single case reports were excluded. Data regarding postoperative mobility protocols, including bed rest, mobilization, sitting, drain management, discharge timing, and complication rates, were extracted and categorized by the flap donor site region.Out of 536 articles identified, 42 met inclusion criteria. Remobilization protocols varied across different flap types. The median out-of-bed remobilization times for vertical rectus abdominis myocutaneous, inferior gluteal artery perforator, internal pudendal artery perforator, anterolateral thigh, and gracilis flaps were 5, 2, 5, 2, and 1 days postoperatively, respectively, with an overall range of 0 to 36 days. Sitting was allowed at 15, 6, 14, 14, and 2 days postoperatively for these flaps.The findings advocate for standardized ERAS protocols with early mobilization and graded sitting, challenging traditional prolonged bed rest practices. We propose specific guidelines for pedicled flap reconstruction of the pelvic and perineal areas, including 1 to 2 days of strict bed rest followed by short-distance ambulation. Gradual sitting protocols should start in the second week with attention to cushioning and offloading. For more vulnerable perineal-based flaps, 4 to 5 days of bed rest and sitting beginning in the third week are recommended. Continuing recovery at a rehabilitation center is also advised. Future studies are needed to examine and modify these protocols, taking into consideration patient factors, disease severity, such as radiation exposure, and the type of reconstruction performed.

Although arterial inflow considerations dominate microsurgical planning, venous outflow is equally vital for flap survival. Patients requiring free tissue transfer (FTT) for lower extremity (LE) reconstruction frequently present with occult preoperative venous thrombosis (VT), yet there are little data guiding perioperative management in this setting. This study examines the prevalence and clinical characteristics of patients with preoperative venous thrombosis (VT) undergoing LE FTT, as well as postoperative outcomes, to evaluate the feasibility of successful microsurgery in this high-risk cohort.A retrospective review of patients with preoperative VT undergoing LE FTT at a single institution was conducted.Among 279 patients, 43 (15.4%) were positive for VT. The overall deep VT (DVT) incidence in this population was 5.7% (n = 16/279) and the superficial VT (SVT) incidence was 10.0% (n = 28/279). Most thromboses were chronic (67.8%). There were two cases of takeback (4.7%) due to thrombosis (one arterial and one venous), of which one flap was salvaged. By a median follow-up duration of 9.7 months, a limb salvage rate of 88.4% was achieved.Preoperative VT is common in microsurgical candidates for limb salvage; however, it is not a contraindication to FTT if proper adjustments are made perioperatively. Considerations include (1) routine use of venous ultrasound to identify VT; (2) perioperative anticoagulation management, including IVC filter placement when indicated; (3) selection of recipient veins that are unaffected by VT; (4) prioritizing the use of two deep veins for anastomosis when feasible; and (5) incorporating implantable devices to monitor venous outflow.

Polyethylene glycol (PEG) hydrogel is capable of fusing transected axons and restoring axonal continuity. The technique requires precise nerve coaptation alignment and stability, which is difficult to achieve utilizing conventional microsuture neurorrhaphy. Nerve Tape (NT) is a microhook-based nerve coaptation device engineered to facilitate stable and accurate nerve end alignment. The primary objective was to modify and validate NT-assisted PEG fusion using a rabbit proximal tibial nerve repair model at an intermediate time point.Three groups of rabbits underwent mid-thigh tibial nerve transection and immediate repair with NT + PEG (n = 6), Suture + PEG (n = 6), or Suture only (n = 6). PEG-induced axonal fusion was acutely confirmed via demonstration of compound motor action potential (CMAP) restoration. Final outcome testing at 16 weeks included electrodiagnostic testing, nerve histomorphology, and muscle morphology.All 18 animals demonstrated immediate restoration of CMAPs. At 16 weeks, there were no statistical differences in nerve conduction velocity or amplitude, no statistical differences between groups in axon counts or g-ratios either near the nerve coaptations or at the ankle, and no differences in normalized gastrocnemius weight or girth.PEG fusion did not improve nerve regeneration or functional recovery in a rabbit tibial nerve repair model at 16 weeks. Modified NT did not improve the reliability or efficacy of the PEG fusion process compared with microsuture neurorrhaphy.