Background: Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting "capillary nonsizable perforators" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions.
Methods: All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed.
Results: Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered "unsplittable," by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites.
Conclusion: A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative "fabricate" concept.
{"title":"Split Anterolateral Thigh Flap: A New Classification of Anatomical Variants and a Surgical Planning Algorithm.","authors":"Hsiang-Shun Shih, Ting-Han Chiu, Seng-Feng Jeng, Jill Chen","doi":"10.1055/a-2242-7194","DOIUrl":"10.1055/a-2242-7194","url":null,"abstract":"<p><strong>Background: </strong> Split anterolateral thigh flap is a versatile reconstruction option, yet long underestimated as no practical perforator classification and no optimal strategy were present. Harvesting \"capillary nonsizable perforators\" could potentially expand flap splits to those with no existing multiple sizable perforators. Concerns over defect characteristics, recipient vessels, pedicle length, and split timing should all be weighted equally in designing the suitable flap. Refinement is thus required to enable precise reconstructions.</p><p><strong>Methods: </strong> All patients undergoing anterolateral thigh flap harvests between 2014 and 2021 performed by a single surgeon were included. The perforator patterns of sizable pedicle, course, origin, and further successful flap-split methods were documented. Surgical outcome of flap survival was analyzed.</p><p><strong>Results: </strong> Anatomical variants of 134 (48.4%) dual, 123 (44.4%) single, and 20 (7.2%) no sizable perforators were found in a total of 277 anterolateral thigh flaps. The overall flap survival rate was 97.5%. Flap split was performed in 82 flaps, including 29 single and 5 no sizable perforator cases previously considered \"unsplittable,\" by utilizing a series of direct skin paddle split, capillary nonsizable perforators harvesting, and flow-through anastomosis technique. Comparable flap survivals were found between split and nonsplit flaps as well as between split segments supplied by sizable and capillary nonsizable perforators. Primary closure was achieved in 98.9% of the thigh donor sites.</p><p><strong>Conclusion: </strong> A new classification of the common anterolateral thigh flap anatomical variants was proposed and a comprehensive algorithm of split flap strategy was developed along with the innovative \"fabricate\" concept.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139424960","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01Epub Date: 2023-11-07DOI: 10.1055/a-2205-2337
Nicholas T Haddock, Cyrus Steppe, Sumeet S Teotia
Background: The most common method for autologous breast reconstruction is the deep inferior epigastric perforator (DIEP) flap. The umbilicus can be managed in various ways, including re-inset, neoumbilicus, and umbilectomy without reconstruction. This study evaluated the aesthetic differences in umbilicus reconstruction choice and variation in patients' postoperative satisfaction with their abdomen.
Methods: A retrospective review of 1,019 patients treated with DIEP flap breast reconstruction between August 2009 and January 2022 was conducted. Patients were stratified by management of the umbilicus: preservation and re-inset of the native umbilicus, umbilectomy with delayed reconstruction, and umbilectomy with no reconstruction. A crowdsourced survey was created to assess the aesthetic preference of each photograph using a Likert scale.
Results: There were 1,063 responses to the umbilicus preference crowd source survey. Patients who had delayed umbilicus reconstruction after umbilectomy were rated to be significantly more attractive (4.397 ± 1.697) than both preservation of the native umbilicus (4.176 ± 1.669) and lack of the umbilicus (3.994 ± 1.733; p < 0.001 and <0.001, respectively). In an analysis of the BREAST-Q scores, delayed reconstruction patients had a similar change across measures when compared to the re-inset group. The delayed group had a significantly higher change in overall satisfaction and well-being with abdomen when compared with the no reconstruction group (p = 0.006 and 0.027, respectively).
Conclusion: This study demonstrates that umbilectomy with delayed reconstruction yields a significantly higher aesthetic rating and comparable patient satisfaction when compared to re-inset of the umbilicus.
{"title":"Aesthetic Evaluation and Validation: Umbilicus Reconstruction after DIEP Flap.","authors":"Nicholas T Haddock, Cyrus Steppe, Sumeet S Teotia","doi":"10.1055/a-2205-2337","DOIUrl":"10.1055/a-2205-2337","url":null,"abstract":"<p><strong>Background: </strong> The most common method for autologous breast reconstruction is the deep inferior epigastric perforator (DIEP) flap. The umbilicus can be managed in various ways, including re-inset, neoumbilicus, and umbilectomy without reconstruction. This study evaluated the aesthetic differences in umbilicus reconstruction choice and variation in patients' postoperative satisfaction with their abdomen.</p><p><strong>Methods: </strong> A retrospective review of 1,019 patients treated with DIEP flap breast reconstruction between August 2009 and January 2022 was conducted. Patients were stratified by management of the umbilicus: preservation and re-inset of the native umbilicus, umbilectomy with delayed reconstruction, and umbilectomy with no reconstruction. A crowdsourced survey was created to assess the aesthetic preference of each photograph using a Likert scale.</p><p><strong>Results: </strong> There were 1,063 responses to the umbilicus preference crowd source survey. Patients who had delayed umbilicus reconstruction after umbilectomy were rated to be significantly more attractive (4.397 ± 1.697) than both preservation of the native umbilicus (4.176 ± 1.669) and lack of the umbilicus (3.994 ± 1.733; <i>p</i> < 0.001 and <0.001, respectively). In an analysis of the BREAST-Q scores, delayed reconstruction patients had a similar change across measures when compared to the re-inset group. The delayed group had a significantly higher change in overall satisfaction and well-being with abdomen when compared with the no reconstruction group (<i>p</i> = 0.006 and 0.027, respectively).</p><p><strong>Conclusion: </strong> This study demonstrates that umbilectomy with delayed reconstruction yields a significantly higher aesthetic rating and comparable patient satisfaction when compared to re-inset of the umbilicus.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71482787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life.
Methods: A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed.
Results: Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m2. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (p = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (p = 0.02) and satisfaction with surgeon (p = 0.05) in the 2-year follow-up period compared with patients who had no revisions.
Conclusion: Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.
{"title":"Effects of Elective Revision after Breast Reconstruction on Patient-Reported Outcomes.","authors":"Amanda M Zong, Kayla E Leibl, Katie E Weichman","doi":"10.1055/a-2332-0359","DOIUrl":"10.1055/a-2332-0359","url":null,"abstract":"<p><strong>Background: </strong> There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life.</p><p><strong>Methods: </strong> A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015 to 2021. Patients were included if they had completed BREAST-Q preoperatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed.</p><p><strong>Results: </strong> Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and body mass index (BMI) was 29.55 ± 5.63 kg/m<sup>2</sup>. Forty-eight patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or preoperative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared with after initial reconstruction alone (<i>p</i> = 0.04). Autologous reconstruction patients who had at least one revision had significantly higher satisfaction with outcome (<i>p</i> = 0.02) and satisfaction with surgeon (<i>p</i> = 0.05) in the 2-year follow-up period compared with patients who had no revisions.</p><p><strong>Conclusion: </strong> Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141087297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Tayla Moshal, Sasha Lasky, Idean Roohani, Marah I Jolibois, Artur Manasyan, Naikhoba C O Munabi, Artur Fahradyan, Jessica A Lee, Jeffrey A Hammoudeh
Background: When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.
Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.
Results: A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.
Conclusion: This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.
{"title":"The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review.","authors":"Tayla Moshal, Sasha Lasky, Idean Roohani, Marah I Jolibois, Artur Manasyan, Naikhoba C O Munabi, Artur Fahradyan, Jessica A Lee, Jeffrey A Hammoudeh","doi":"10.1055/s-0044-1787741","DOIUrl":"https://doi.org/10.1055/s-0044-1787741","url":null,"abstract":"<p><strong>Background: </strong> When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.</p><p><strong>Methods: </strong> A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.</p><p><strong>Results: </strong> A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (<i>n</i> = 11) and case series (<i>n</i> = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (<i>n</i> = 46, 73.0%) and chronic wounds secondary to H&N masses (<i>n</i> = 9, 14.3%). Defects were most commonly located in the neck (<i>n</i> = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm<sup>2</sup> and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (<i>n</i> = 48, 71.6%) and based on the dorsal scapular artery (<i>n</i> = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (<i>n</i> = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.</p><p><strong>Conclusion: </strong> This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141450771","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Karaca Basaran, Asli Datli, Mehmet Sagir, Mehmet Sar, Esra Bilgi
Background: The study aims to investigate the zone of injury for major vessels after high-velocity traumas, as it is unclear whether avoiding vascular structures is necessary during microvascular anastomosis or how long it takes for them to be used again.
Methods: This study uses Doppler ultrasonography and a rat model to evaluate the histopathological changes and flow velocity of major vessels in the zone of injury after high-velocity trauma with closed femoral bone fracture. Osteosynthesis was performed using an intramedullary wire. Samples were collected from day 3 and week 3. The unaffected contralateral side is used as control.
Results: Results from arterial and venous flow assessments showed no evidence of ischemia in the extremities. Both arteries and veins were patent in both intervals and on the control side. The evaluation of the vessels showed arterial injury with a slightly reduced arterial flow on day 3 and week 3. The venous flow was slightly reduced on day 3 but not on week 3. Statistically, arterial endothelial injury was higher on day 3 than on week 3 (p = 0.006). Media inflammation was also higher on day 3 (p = 0.06). Arterial endothelization distribution was higher in week 3 (p = 0.006). No significant differences were found in arterial media irregularity, necrosis, platelet aggregation, bleeding, and wall rupture. Venous samples showed no significant differences in any parameter (p < 0.05).
Conclusion: High-velocity trauma increases the risk of thrombosis in vessels. Intravascular repair can start on day 2 and continue till week 3 with significant endothelization. Although physiologic findings do not alter arterial or venous flow, histologic findings support vessel injuries leading to potential complications. Microsurgery should be considered out of the injury zone until adequate vessel healing is achieved.
{"title":"Blunt Trauma Induced Closed Femoral Bone Fracture in a Rat Model: Are Vessels Safe to Use for Microsurgery? Further Insight into the Zone of Injury Concept.","authors":"Karaca Basaran, Asli Datli, Mehmet Sagir, Mehmet Sar, Esra Bilgi","doi":"10.1055/a-2332-0263","DOIUrl":"10.1055/a-2332-0263","url":null,"abstract":"<p><strong>Background: </strong> The study aims to investigate the zone of injury for major vessels after high-velocity traumas, as it is unclear whether avoiding vascular structures is necessary during microvascular anastomosis or how long it takes for them to be used again.</p><p><strong>Methods: </strong> This study uses Doppler ultrasonography and a rat model to evaluate the histopathological changes and flow velocity of major vessels in the zone of injury after high-velocity trauma with closed femoral bone fracture. Osteosynthesis was performed using an intramedullary wire. Samples were collected from day 3 and week 3. The unaffected contralateral side is used as control.</p><p><strong>Results: </strong> Results from arterial and venous flow assessments showed no evidence of ischemia in the extremities. Both arteries and veins were patent in both intervals and on the control side. The evaluation of the vessels showed arterial injury with a slightly reduced arterial flow on day 3 and week 3. The venous flow was slightly reduced on day 3 but not on week 3. Statistically, arterial endothelial injury was higher on day 3 than on week 3 (<i>p</i> = 0.006). Media inflammation was also higher on day 3 (<i>p</i> = 0.06). Arterial endothelization distribution was higher in week 3 (<i>p</i> = 0.006). No significant differences were found in arterial media irregularity, necrosis, platelet aggregation, bleeding, and wall rupture. Venous samples showed no significant differences in any parameter (<i>p</i> < 0.05).</p><p><strong>Conclusion: </strong> High-velocity trauma increases the risk of thrombosis in vessels. Intravascular repair can start on day 2 and continue till week 3 with significant endothelization. Although physiologic findings do not alter arterial or venous flow, histologic findings support vessel injuries leading to potential complications. Microsurgery should be considered out of the injury zone until adequate vessel healing is achieved.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141087333","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
William M Tian, Jess D Rames, Brooke E Schroeder, Kristina Dunworth, Victoria N Yi, Melissa Tran, Jennifer Gallagher, Robin Bachelder, Scott T Hollenbeck
Background: Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk of infection with prolonged use. We aimed to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience.
Methods: Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1 to 5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate.
Results: Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was 2 weeks (N = 13). The surgical site infection (SSI) rate requiring antibiotics was 28% (N = 8). On a scale of 1 to 5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were "frequently" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort.
Conclusion: Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to SSI. Overall, these data provide insight to drive future improvements in the patient drain experience.
{"title":"Perceptions of Surgical Drains among Breast Reconstruction Patients and Health Care Staff: A Qualitative Survey Study.","authors":"William M Tian, Jess D Rames, Brooke E Schroeder, Kristina Dunworth, Victoria N Yi, Melissa Tran, Jennifer Gallagher, Robin Bachelder, Scott T Hollenbeck","doi":"10.1055/a-2332-0444","DOIUrl":"10.1055/a-2332-0444","url":null,"abstract":"<p><strong>Background: </strong> Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk of infection with prolonged use. We aimed to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience.</p><p><strong>Methods: </strong> Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1 to 5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate.</p><p><strong>Results: </strong> Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was 2 weeks (<i>N</i> = 13). The surgical site infection (SSI) rate requiring antibiotics was 28% (<i>N</i> = 8). On a scale of 1 to 5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were \"frequently\" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort.</p><p><strong>Conclusion: </strong> Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to SSI. Overall, these data provide insight to drive future improvements in the patient drain experience.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141087300","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Idean Roohani, Tayla Moshal, Elizabeth M Boudiab, Eloise W Stanton, Paige Zachary, Jessica Lo, Joseph N Carey, David A Daar
Background: Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction.
Methods: Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels.
Results: A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10-9-0.285], p = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction =0.010).
Conclusion: This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.
导言:从历史上看,在下肢游离皮瓣重建术中使用血管加压剂会对皮瓣存活率产生不利影响,因为人们担心会影响皮瓣灌注。本研究旨在分析创伤性下肢(LE)重建术患者术中使用血管加压药和输液对术后效果的影响:回顾性研究了2015-2023年间在一级创伤中心接受下肢游离皮瓣重建术的患者。研究人员进行了统计分析,以评估使用血管加压药和术中输液与皮瓣部分/完全坏死之间的关联,以及使用血管加压药对不同输液水平的皮瓣结果的不同影响:结果:在8年时间里,共进行了105例LE皮瓣手术。19例(18.0%)术中使用了血管加压剂。皮瓣总存活率和肢体挽救率分别为97.1%和93.3%。术中使用血管加压剂降低了术后皮瓣坏死的总体风险(OR 0.00005,95% CI [9.11x10-9-0.285],p=0.025),而较低的净液体平衡则增加了这一结果的风险(OR 0.9985,95% CI [0.9975-0.9996],p=0.007)。进一步的交互分析显示,在净体液平衡较高的情况下,使用血管加压剂会增加皮瓣坏死的风险(OR 1.0032,95% CI [1.0008-1.0056],p-交互=0.010):本研究表明,术中使用血管加压素和充足的体液状态可能有利于改善左侧肢体重建的皮瓣预后。在创伤性左侧肢体微血管重建过程中,必要时使用血管加压素并进行充分的液体管理可优化血流动力学稳定性,而无需担心皮瓣缺血风险的增加。
{"title":"The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction.","authors":"Idean Roohani, Tayla Moshal, Elizabeth M Boudiab, Eloise W Stanton, Paige Zachary, Jessica Lo, Joseph N Carey, David A Daar","doi":"10.1055/a-2331-8174","DOIUrl":"10.1055/a-2331-8174","url":null,"abstract":"<p><strong>Background: </strong> Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction.</p><p><strong>Methods: </strong> Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels.</p><p><strong>Results: </strong> A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10<sup>-9</sup>-0.285], <i>p</i> = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], <i>p</i> = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], <i>p</i>-interaction =0.010).</p><p><strong>Conclusion: </strong> This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141087348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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.
{"title":"The Arterial System of the Fasciocutaneous Deltoid Flap Pedicle on 320-Detector Row Computed Tomography and Clinical Application in the Foot and Hand.","authors":"Nguyen Ngoc-Huyen, Nguyen The-Hoang, Khanh Lam, Nguyen Quang-Vinh, Rainer Staudenmaier","doi":"10.1055/s-0044-1787774","DOIUrl":"https://doi.org/10.1055/s-0044-1787774","url":null,"abstract":"<p><strong>Background: </strong> 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.</p><p><strong>Methods: </strong> 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.</p><p><strong>Results: </strong> 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.</p><p><strong>Conclusion: </strong> 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.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141446452","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hani I Naga, Joshua Kim, Kristina Dunworth, Nicholas Oleck, Emmanuel Emovon, Margaret Graton, Suhail K Mithani
Background: Reconstruction of upper extremity osseous diaphyseal defects often requires complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects.
Methods: A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python.
Results: Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic nonunion (125, 34.3%), postoncologic resection (125, 34.3%), septic nonunion (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53 ± 5.14 cm. A total of 67 (18.4%) cases had defects < 6 cm, and 166 cases (45.6%) had defects > 6 cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only two (0.6%) VBF losses reported in the included cases, and donor-site complications were similarly rare (17, 4.7%).
Conclusion: VBF reconstruction is often utilized for postoncologic defects and recalcitrant nonunions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.
背景:上肢骨骺缺损的重建通常需要复杂的重建。在这项研究中,我们对现有的关于上肢骨骺缺损游离血管化骨瓣(VBF)重建的文献进行了归纳和总结:采用系统综述和荟萃分析扩展首选报告项目(Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews,PRISMA-ScR)进行了范围界定综述。在主要电子数据库中进行文献检索,以确定与上肢长骨缺损VBF重建管理相关的期刊文章。包含患者层面数据的文章也被纳入其中。使用 Python 进行描述性统计:本研究共纳入了 364 名患者。VBF最常见的适应症包括萎缩性骨不连(125例,34.3%)、肿瘤切除术后(125例,34.3%)、化脓性骨不连(56例,15.4%)和创伤(36例,9.9%)。平均缺损大小为 8.53±5.14 厘米。67例(18.4%)的缺损为6厘米。腓骨是使用最多的VBF(272例,74.73%),其次是股骨内侧髁皮瓣(69例,18.96%)。总体而言,初次愈合率为 87.1%。后续皮瓣骨折率为3.3%。在纳入的病例中,仅有2例(0.6%)报告了VBF损失,供体部位并发症同样罕见(17例,4.7%):结论:VBF重建常用于肿瘤后缺损和顽固的非椎体畸形。腓骨是最常用的VBF,但股骨内侧髁皮瓣也常用于较小的缺损。在各种适应症中,VBF 重建显示出较高的结合率和较低的皮瓣骨折率。
{"title":"Upper Extremity Diaphyseal Osseous Gap Reconstruction with Free Vascularized Bone Flaps: A Scoping Review.","authors":"Hani I Naga, Joshua Kim, Kristina Dunworth, Nicholas Oleck, Emmanuel Emovon, Margaret Graton, Suhail K Mithani","doi":"10.1055/a-2332-0150","DOIUrl":"10.1055/a-2332-0150","url":null,"abstract":"<p><strong>Background: </strong> Reconstruction of upper extremity osseous diaphyseal defects often requires complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects.</p><p><strong>Methods: </strong> A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python.</p><p><strong>Results: </strong> Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic nonunion (125, 34.3%), postoncologic resection (125, 34.3%), septic nonunion (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53 ± 5.14 cm. A total of 67 (18.4%) cases had defects < 6 cm, and 166 cases (45.6%) had defects > 6 cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only two (0.6%) VBF losses reported in the included cases, and donor-site complications were similarly rare (17, 4.7%).</p><p><strong>Conclusion: </strong> VBF reconstruction is often utilized for postoncologic defects and recalcitrant nonunions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-06-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141087351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Huseyin Karagoz, Feng Zhang, Sara C Chaker, William C Lineaweaver
Background: The intricacies of nerve regeneration following injury have prompted increased research efforts in recent years, with a primary focus on elucidating regeneration mechanisms and exploring various surgical techniques. While many experimental animals have been used for these investigations, the rat continues to remain the most widely used model due to its cost-effectiveness, accessibility, and resilience against diseases and surgical/anesthetic complications. A comprehensive evaluation of all the experimental rat models available in this context is currently lacking.
Methods: We summarize rat models of cranial nerves while furnishing descriptions of the intricacies of achieving optimal exposure.
Results: This review article provides an examination of the technical exposure, potential applications, and the advantages and disadvantages inherent to each cranial nerve model.
Conclusion: Specifically in the context of cranial nerve injury, numerous studies have utilized different surgical techniques to expose and investigate the cranial nerves in the rat.
{"title":"Experimental Cranial Nerve Models in the Rat.","authors":"Huseyin Karagoz, Feng Zhang, Sara C Chaker, William C Lineaweaver","doi":"10.1055/s-0044-1787729","DOIUrl":"https://doi.org/10.1055/s-0044-1787729","url":null,"abstract":"<p><strong>Background: </strong> The intricacies of nerve regeneration following injury have prompted increased research efforts in recent years, with a primary focus on elucidating regeneration mechanisms and exploring various surgical techniques. While many experimental animals have been used for these investigations, the rat continues to remain the most widely used model due to its cost-effectiveness, accessibility, and resilience against diseases and surgical/anesthetic complications. A comprehensive evaluation of all the experimental rat models available in this context is currently lacking.</p><p><strong>Methods: </strong> We summarize rat models of cranial nerves while furnishing descriptions of the intricacies of achieving optimal exposure.</p><p><strong>Results: </strong> This review article provides an examination of the technical exposure, potential applications, and the advantages and disadvantages inherent to each cranial nerve model.</p><p><strong>Conclusion: </strong> Specifically in the context of cranial nerve injury, numerous studies have utilized different surgical techniques to expose and investigate the cranial nerves in the rat.</p>","PeriodicalId":16949,"journal":{"name":"Journal of reconstructive microsurgery","volume":null,"pages":null},"PeriodicalIF":2.1,"publicationDate":"2024-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141419559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}