Journal of reconstructive microsurgery最新文献

Posttraumatic lymphedema is poorly discussed in literature. Flap reconstruction considering its lymphatic-axiality has been reported in preventing lymphedema development following trauma or sarcoma excision. In this study, we report the results of utilizing lymphatic flaps in treatment of established posttraumatic lymphedema.This was a retrospective study of 74 patients (60 lower limbs and 14 upper limbs) with posttraumatic lymphedema that underwent simultaneous soft tissue and lymphatic reconstruction using lymphatic skin flaps. The primary endpoint was providing stable soft tissue coverage and change in limb volume. Secondary endpoints were changes in lymph flow using both lymphoscintigraphy and indocyanine green (ICG) lymphography.Superficial circumflex iliac artery perforator (SCIP) flap was used in 46 cases (62.2%), anterolateral thigh flap in 14 cases (18.9), superficial inferior epigastric artery flap in 9 cases (12.2%), and deep inferior epigastric artery perforator (DIEAP) flap in 5 cases (6.8%). End (vein)-to-side (lymphatic) lymphaticovenous anastomosis was successfully performed in 21 cases (28.4%). During follow-up, significant change in volume was noted in all patients. Using ICG lymphography, lymphatic flow through the flaps was revealed in 59.5% of patients. No lymphatic flow within the flap was observed in 30 cases (40.5%). While qualitative lymphoscintigraphy showed significant changes in the parameters including improved symmetry in the uptake of Technitium⁹⁹ nanocolloids (89.2%), visualizing the proximal draining lymph nodes and major lymphatic ducts, and improvement in the dermal backflow.Lymphatic skin flaps allow simultaneous soft tissue and lymphatic reconstruction. Scar excision at the affected limb, flap selection, and insetting based on ICG navigation at both the recipients and donor sites is important for successful flap integration and spontaneous lymphatic communications.

Microsurgery remains largely nonexistent in sub-Saharan Africa due to a lack of access to specialized training and microsurgical instruments. However, smartphones with magnification capabilities are globally widespread, even in low-resource nations. The use of smartphones as simulators for microsurgery training has been previously reported, but little is known with respect to skills acquisition over time.A cohort of Ethiopian plastic surgery attendees and residents participated in a microsurgery training workshop. Before and after the workshop, as well as 6 months afterward, participants were recorded performing a synthetic vessel repair using a smartphone for magnification. Video recordings were graded by four microsurgeons using the Stanford Microsurgery and Resident Training (SMaRT) scale, a validated instrument for assessing microsurgical skills.A total of 13 participants were surveyed and recorded. Overall microsurgical performance SMaRT scores significantly improved (2.05 vs. 2.72 on a five-point scale; p = 0.001) upon completion of the workshop, and continued to increase (3.05), but not significantly so (p = 0.201) 6 months afterward. However, improvements were maintained at 6 months. Significant improvement was noted in all SMaRT scale domains postworkshop and further significant improvement in instrument handling was noted at 6 months.Our findings suggest that smartphones can serve as valuable tools for microsurgery training in low-resource settings. Further research is warranted to evaluate the long-term impact of smartphone-based simulation training on skill acquisition and clinical outcomes in low-resource settings, but even in the short-term participants were able to demonstrate significant improvement, as well as maintenance to improvement of skill at 6 months follow-up.

Chordomas are rare, malignant bone tumors of the axial skeleton. Soft tissue reconstruction is often needed postextirpation to reduce the risk of peritoneal content herniation. The purpose of this study is to describe presurgical factors associated with postchordoma resection reconstruction and evaluate postoperative outcomes.We retrospectively reviewed patients who underwent reconstruction postexcision of chordomas derived from the lumbar or sacral regions at a single institution between 2012 and 2023. Wilcoxon rank sum test, chi-square test, Fisher's exact test, and Kruskal-Wallis test were used to compare outcomes based on reconstruction method.Among 68 patients who met the inclusion criteria, 67 underwent sacrectomy. Patients primarily received gluteus muscle (GM) flaps (n = 36, 53%). Vertical rectus abdominus myocutaneous (VRAM) and paraspinous muscle (PSM) flaps were the second most common, each used in 12 patients (18%). Eight patients (12%) underwent reconstruction with fasciocutaneous local flaps only. GM and VRAM flaps were primarily used to reconstruct defects at the level of the sacrum (n = 47, 98%) while PSM flaps were used for lumbar (n = 7 [58%]) and sacral (n = 5 [42%]) reconstruction, respectively. The median tumor volumes were 468 cm³ (271-1,592) for VRAM flaps, 92 cm³ (12-246) for GM flaps, 77 cm³ (34-239) for PSM flaps, and 25 cm³ (16-86) for non-muscle reconstruction; tumor volume was significantly greater in patients who underwent VRAM flap reconstruction. Median defect diameter managed by VRAM flaps was significantly longer compared with GM flaps (33 [30-46] cm vs. 22 [15-30] cm, respectively; p = 0.001). VRAM and PSM flap reconstruction were more often associated with hardware placement (p < 0.01). Median follow-up was 34 months. Neither reconstruction type nor hardware placement was associated with the incidence of postoperative complications.We found that surgical reconstruction following chordoma resection varied depending on the chordoma spinal level, tumor volume, and defect diameter. Complication rates were similar among the included reconstructive options.

Central lymphatic disruption can result in devastating lymphedema, chylothorax, chylous ascites, metabolic deficiencies, and death. Literature from our institution has previously demonstrated the technical feasibility of lymphovenous anastomosis (LVA) for thoracic duct (TD) bypass. Here, we present our complete patient series with expanded follow-up utilizing a microsurgical venous coupler to facilitate LVA.A single-institution, retrospective review was conducted for adult patients who underwent LVA for TD bypass between 2019 and 2024. Demographic, etiological, and perioperative information was collected. Symptomatic resolution with or without radiographically confirmed patency was considered a successful bypass at follow-up.A total of 23 patients underwent LVA of the TD. The mean age was 49.7 years. Median postoperative follow-up was 395 days (interquartile range [IQR]: 150.5-554.5). Anastomotic targets included the EJV (n = 15), IJV (n = 4), AJV (n = 2), or another regional vein (n = 3). The technical success of the venous coupler was 100%. Three patients experienced a surgical site complication (13.0%). At follow-up, 13 patients (56.5%) had a patent TD anastomosis with symptomatic resolution. One patient (4.3%) had a patent anastomosis confirmed on imaging but experienced mild symptomatic recrudescence. The remaining patients (39.1%) had nonpatent anastomoses. The median venous coupler size was 3.0 mm for both the patent cohort and the nonpatent cohort.LVA for TD bypass with an anastomotic coupler is well tolerated and provided durable relief of symptoms in over half of our cohort. This data supports venous coupler utilization in LVA for thoracic TD occlusion. Patient accrual is ongoing to further evaluate and optimize outcomes.

Beyond its indication for chronic wounds, hyperbaric oxygen therapy (HBOT) is an adjunct to managing acutely compromised grafts and flaps. Because physicians have reported challenges obtaining insurance coverage for HBOT, this cross-sectional analysis reviews policy requirements and presents an algorithm to enhance the odds of successful reimbursement.We identified the 60 largest health insurers by market share and enrollment and collected their policies on HBOT. We then conducted a dual, blind extraction of policy details (e.g., continuing and prior authorization, documentation, treatment guidelines) and compiled these data into an insurance reimbursement algorithm to assist prescribing physicians.Fifty-three health insurers (88.3%) had policies on HBOT; 47.2% (n = 25) required prior authorization, and 61.9% (n = 13) required continuing authorization after a set number of HBOT sessions (median: 20 sessions, interquartile range [IQR]: 12-30 sessions). Thirty-eight (71.7%) permitted clinical judgment when defining flap or graft "compromise," and 35.7% (n = 15) considered any pressure greater than 1 atmosphere absolute to be "hyperbaric." Twenty-two insurers (41.5%) outlined documentation requirements for HBOT reimbursement; the most often requested documentation were medical records (n = 19, 86.4%), signs of healing (n = 12, 54.5%), images (n = 10, 45.5%), treatment goals (n = 8, 36.4%), and dive parameters (n = 5, 22.7%).Most insured Americans are eligible for 12 sessions of HBOT; however, medical necessity must be established early and reconfirmed often to increase the likelihood of reimbursement. Additionally, prescribing physicians should be aware that insurers differ in their documentation, prior authorization, and continuing authorization requirements.

Although autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap is a standard procedure, flap perfusion-associated complications remain a concern. This study aimed to investigate the correlation between blood flow information obtained through color Doppler ultrasonography (CDU) and flap perfusion assessed by indocyanine green (ICG) angiography.This prospective study included 30 female patients who underwent DIEP flap breast reconstruction between August 2023 and June 2024. Preoperative flow parameters, including arterial peak velocity, arterial volume flow, and venous peak velocity, were measured using CDU. Flap perfusion was evaluated using ICG angiography.The study demonstrated a positive correlation between venous flow and overall flap blood flow. Arterial peak velocity (r = 0.368, p = 0.046), arterial volume flow (r = 0.455, p = 0.011), and venous peak velocity (r = 0.399, p = 0.029) all showed significant associations with ICG-stained area percentages. These findings suggest that venous flow data can provide valuable information for predicting flap viability.This study demonstrates a significant correlation between flow information obtained through CDU and flap perfusion assessed via ICG angiography in patients undergoing DIEP flap breast reconstruction. Both arterial and venous flow data were shown to be crucial for predicting flap viability, with venous flow exhibiting a notable positive correlation with flap blood flow.

Postoperative hyperglycemia has been associated with higher rates of complications and prolonged hospitalization. This study aimed to evaluate the effect of postoperative hyperglycemia on outcomes after microvascular free tissue transfer for upper and lower limb salvage.This was a retrospective review of all patients undergoing free tissue transfer for limb salvage at our institution from 2014 to 2024. Rates of surgical site infection (SSI), wound healing complications, flap loss, length of stay, and readmission were compared between patients with postoperative hyperglycemia (≥140 mg/dL within 48 hours of surgery) and normoglycemic patients.One hundred forty-one patients had perioperative glucose values measured and thus were included. Fifty-nine point five seven percent (n = 84) were normoglycemic, while 40.43% (n = 57) had postoperative hyperglycemia. Hyperglycemic patients had higher rates of SSI (33.33% vs. 9.52%, p < 0.01) and wound healing complications (35.09% vs. 21.43%, p = 0.07) compared to normoglycemic patients. The mean length of stay was longer (41.00 vs. 32.83 days, p = 0.04) for hyperglycemic compared to normoglycemic patients. On multivariate analysis, postoperative hyperglycemia was a significant predictor of SSI. Notably, the diagnosis of diabetes mellitus was not a significant predictor of complications (p > 0.05).Postoperative hyperglycemia following free tissue transfer for limb salvage is associated with increased length of stay, and with higher rates of SSI and wound healing complications. Maintenance of perioperative normoglycemia after free tissue transfer is important to optimize patient outcomes.

Over the past 10 years, microsurgery fellowship programs and positions have increased by 50%, underscoring the need to understand graduate career paths and provide trainees context about future practice. This study analyzed who pursues microsurgery fellowships and factors associated with academic careers.This cross-sectional analysis examined graduates from the past 10 years from fellowships recognized by the American Society of Reconstructive Microsurgery or graduates of international fellowships who completed residency in the United States. Demographic variables included gender, race, residency location, and integrated versus independent plastic surgery residency. bibliometric indices at the time of graduation and October 2024 were measured. Initial and current practice settings were categorized as academic (full-time faculty), "private affiliated" (involved in teaching but not full-time faculty), or private practice.Overall, 423 graduates were identified. The majority were male (62.9%) and White (63.4%). Most completed Integrated residency (72.6%). Five fellowships accounted for 48.0% of graduates: MD Anderson (80), Memorial Sloan Kettering (46), University of Pennsylvania (38), Stanford University (23), and The Buncke Clinic (16). After fellowship, 68.0% of graduates entered academia, and 63.2% of graduates are in academia currently out of 419 analyzed. Fellowship location was associated with initial academic practice (p = 0.01), many graduates from International (80.0%), and Southern (78.4%) fellowships entering academia. Graduates in initial academic practice had higher median initial g-index (13 vs. 10, p = 0.03) and median initial publications (15 vs. 11, p = 0.02). Multiple logistic regression found initial publications and fellowship location to be the best predictors of initial academic practice.While most graduates pursue academia, a significant number enter private practice, indicating it is a viable option. Southern or International fellowships send more graduates into academia, but this is likely influenced by popular fellowships. Nuanced factors like personal preference, financial considerations, and networking likely play a significant role in career choices.

The "continuous enrollment provision" of the Families First Coronavirus Response Act of 2020 (FFCRA) maintained states' Medicaid enrollments throughout the COVID-19 public health emergency. This study evaluated the impact of the continuous enrollment requirement on Medicaid patients' access to reconstructive breast surgery.A retrospective cohort study was conducted on all patients who received reconstructive breast surgery procedures at a large academic institution between July 1, 2013, and July 1, 2023. The Medicaid continuous enrollment period was defined as March 18, 2020, to July 1, 2023. Univariate analysis, multivariable logistic regression, and difference-in-difference analysis were performed.Three thousand five hundred sixty-four patients were included, of whom 252 patients were insured by Medicaid. Patients' odds of Medicaid insurance before and during the continuous enrollment period did not differ (p = 0.096). The distribution of Medicaid and non-Medicaid insurance among autologous breast reconstruction patients similarly did not differ during the continuous enrollment period (p = 0.86). Difference-in-difference analysis confirmed that Medicaid prevalence among autologous breast reconstruction patients did not change with the continuous enrollment requirement (p = 0.07). Increased age was predictive of Medicaid insurance (odds ratio [OR]: 1.043; p < 0.001); however, age-dependent differences decreased during the continuous enrollment period. Patients with non-English language preferences had lower odds of Medicaid insurance (OR: 0.38; p = 0.035); this difference remained unchanged with the continuous enrollment requirement (p = 0.59).The continuous enrollment requirement alleviated certain age-dependent barriers for Medicaid patients but may not have addressed other patient-level, system-level, and procedure-specific barriers to reconstructive breast surgery.