Journal of reconstructive microsurgery最新文献

Background:  Patients with head and neck tumors undergoing free flap reconstructions are at high risk of postoperative venous thromboembolism (VTE). To date, no specific guidelines are available regarding VTE 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 5,000 units every 8 hours routinely utilized at our institution.

Methods:  PubMed and Embase databases were searched from inception until November 2023. Data were 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 tumors undergoing free tissue transfer at our institution between 2015 and 2021 was performed. Patients were restricted to those receiving 5,000 units of subcutaneous heparin every 8 hours postoperatively. Key outcomes included rates of VTE and surgical site hematoma.

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 and 29%. Our 6-year institutional analysis revealed 393 total patients. Overall, three episodes of VTE were identified (0.76%) consisting of one deep vein thrombosis and two pulmonary emboli. The overall rate of hematoma was 9.4% with a higher rate of hematoma at the recipient site (8.1%) than the donor site (1.3%).

Conclusion:  When compared with the existing literature this study found a low rate of VTE and a comparable incidence postoperative hematoma. This suggests that 5,000 units of subcutaneous heparin given every 8 hours may be a safe and effective postoperative anticoagulation regimen for these patients.

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 and 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:  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. Three independent reviewers transcribed, content-coded, and thematically analyzed the interviews. 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, whereas 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 other microsurgeons (e.g., a co-surgeon model) was crucial to success. Finally, microsurgeons hoped that future advances would expand access to microsurgical reconstruction for patients and plastic surgeons.

Conclusion:  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:  Hybrid deep inferior epigastric perforator (DIEP) flap and simultaneous silicone implant breast reconstruction procedures ("DIEP + I") have many conceptual advantages compared with 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 to 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 with implant-only reconstruction. The DIEP + I group had similar rates of wound healing and implant-related complications compared with 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:  To assess the burden of postdischarge health care 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 to 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 with nonreadmitted patients. There were no differences in readmission rates among 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% confidence interval: $8,537.72-9,405.84, p < 0.001) in hospital costs, which accounted for 15% of the total cost of IBR nationwide.

Conclusion:  The majority of inpatient health care 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.

Background:  Free tissue transplantations are commonly used to treat complex lower extremity defects caused by trauma, vascular disease, or malignancy, particularly when vital structures are exposed. This study aimed to expand the knowledge on patient-reported outcomes by comparing fasciocutaneous and muscle flaps, with the goal of facilitating patient counseling. Additionally, patient-level risk factors associated with decreased functioning and health-related quality of life were identified.

Methods:  This retrospective, cross-sectional, multicenter study included patients who underwent microsurgical lower extremity reconstruction using free fasciocutaneous or muscle flaps between 2003 and 2021, with a minimum follow-up of 12 months. Data were collected from medical records, pain scores, Short-Form 36 (SF-36), and Lower Extremity Functional Scale (LEFS). Mean scores were compared between flap types and predictors of LEFS, SF-36 mental component summary (MCS), and SF-36 physical component summary (PCS) scores were determined using a backward stepwise regression model.

Results:  Of the 206 patients eligible, 100 (49%) were included in the retrospective part. A total of 89 (43%) responded to the questionnaires, with 62 treated using a fasciocutaneous flap and 27 with a muscle flap. No significant differences in total LEFS, SF-36 PCS, or MCS scores were found between the two flap type. Pain was a significant predictor of decreased functional outcomes for both flap types and was also linked to poorer mental health in patients treated with fasciocutaneous flaps. Other predictors of low patient-reported outcome scores included obesity, diabetes, poorer mental health, and a follow-up of less than 2 years.

Conclusion:  Patients treated with fasciocutaneous and muscle flaps experience comparable levels of functionality and quality of life after surgery. Flap selection should be based on defect characteristics, along with the surgeon's individual skills and preferences. A comprehensive approach that considers physical comorbidities, pain, and mental health is essential, as these factors significantly impact patient functionality and quality of life.

Background:  Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-day postoperative complications between these two techniques.

Methods:  We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications.

Results:  A cohort of 8,403 breast cancer patients was analyzed. A total of 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p < 0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p < 0.001), exhibited a higher body mass index (31.73 vs. 26.93, p < 0.001), had a greater prevalence of diabetes mellitus (11.0 vs. 5.0%, p < 0.001). They also had a higher ASA classification (2.33 vs. 2.15, p < 0.001), shorter operative time (173.39 vs. 216.20 minutes, p < 0.001), and a higher proportion of outpatient procedures (83.7 vs. 39.5%, p < 0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients (4.2 vs. 10.9%, p < 0.001), including lower rates of surgical complications (2.2 vs. 8.0%, p < 0.001) and wound complications (1.9 vs. 4.8%, p = 0.005) compared with MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications.

Conclusion:  OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared with MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.

Background:  Pedicled, prefabricated, and free nerve flaps have several drawbacks, such as requiring microsurgical anastomosis, the need for secondary operations and the risk of developing thrombosis. In this study, we aimed to vascularize the repaired nerve in a single session by establishing a connection between the epineurium of the repaired median nerve and the tunica adventitia of the brachial artery.

Methods:  The technique was performed on the median nerves of a total of 42 rats over 13 weeks. While group 1 didn't receive any intervention, the following three groups (2, 3, and 4) received classic treatments (coaptation, graft, and vein conduit). In addition to classic treatments, the other three groups (5, 6, and 7) were vascularized by attaching the adventitia of the brachial artery to the repaired nerves. Nerve regeneration was evaluated using functional tests, immunohistochemical analysis, and electron microscope.

Results:  The vascularized groups (5, 6, and 7) showed earlier functional recovery (p < 0.05). Vascularization reduced inflammation in the coaptation group, reduced fibrosis and degeneration in the nerve graft group, and reduced fibrosis, degeneration and disorganization while increased the number of passing fibers and myelination in the vein conduit group (p < 0.05). Vascularization provided superior ultrastructural findings. Microscopic analysis revealed a novel finding of "zone of neurovascular interaction" between the adventitia and the regenerating nerve.

Conclusion:  Vascularizing the repaired nerves with this new technique provided faster functional and better histological healing. Unlike classic vascularization techniques, this method does not require microsurgical anastomosis, does not carry the risk of thrombosis, and does not necessitate secondary operations. The "zone of neurovascular interaction" identified in this study revealed regenerating axon clusters alongside newly developed blood vessels. This important finding highlights a potential role of the tunica adventitia in nerve regeneration.

Background:  Primary closure of donor sites following large flap harvest may not be feasible. The use of perforator propeller flap (PPF) in this setting is gaining popularity, successfully resurfacing the wound and lessening potential donor-site morbidity. In this study, we aimed to review our experience and outcomes using PPFs in donor-site coverage throughout the body.

Methods:  A retrospective chart review was performed of all patients who underwent one or more PPFs surgery for donor site resurfacing between February 2009 and December 2021. Flap and defect characteristics were summarized. Postoperative complications and perioperative factors were analyzed.

Results:  Fifty-five patients underwent donor-site reconstruction using 68 PPFs. Of the 55 primary donor sites, 44 were covered with a single PPF, 9 with two PPFs, and 2 with three PPFs. One flap experienced complete necrosis and four flaps experienced distal flap necrosis, leading to an overall complication rate of 9.1%. No risk factors were found to be statistically significantly associated with the complication. All secondary PPF donor sites were closed primarily. During the average follow-up period of 15.1 months, none of the patients developed contour deformities or functional impairments.

Conclusion:  The PPF technique can be safely and effectively used for donor-site closure with minimal complications. It greatly frees surgeons to harvest a large workhorse flap for demanding soft tissue defect reconstruction.

Background:  Clinically, there has been increasing employment of the lateral femoral condyle flap. The objective of this study was to explore the vascular anatomy of the lateral femoral condyle in pigs and to explore the feasibility of using pigs as an animal model of the lateral femoral condyle flap.

Methods:  A total of 20 fresh cadaveric hindlimbs of 4-week-old hybrid pigs were used in this study. The origination, course, and branches of the nourishing vessels of the lateral femoral condyle were observed in 15 specimens. The primary parameters included the variability in the anatomy of the vessels and the length and outer diameter of the vessels. Surgical procedures for the lateral femoral condyle flap were conducted on five specimens.

Results:  The primary nourishing arteries of the lateral femoral condyle in pigs were the first superolateral geniculate artery, which was observed in all 15 specimens and had a diameter and length of 1.99 ± 0.44 mm and 2.27 ± 0.46 cm, respectively, as measured at their origination. The operation was performed in the lateral position. A 10-cm skin incision was made from the lower edge of the patella to the posterior lateral side of the distal femur. After blunt dissection of the intermuscular septum between the biceps femoris and vastus lateralis, the whole course of the first superolateral geniculate artery was exposed.

Conclusion:  The vascular anatomy of the lateral femoral condyle in pigs and that of humans exhibited great similarities. The harvesting of the lateral femoral condyle flap in pigs was as easy as that in humans. Pigs could serve as a suitable animal model for the lateral femoral condyle flap.