Journal of reconstructive microsurgery最新文献

The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, although its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures.A retrospective review was conducted between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage.A total of 769 free flaps met inclusion criteria for analysis. No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared with the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%.We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.

The design and preoperative planning of microsurgical free flaps are crucial for successful outcomes. Studies have shown that preoperative vascular mapping significantly shortens operative time, reduces complication rates, and lowers overall costs. Various methods of perforator detection have been introduced; however, none is ideal. Some surgeons propose that combining two or even three different methods could better meet clinical expectations. Therefore, this study sought to determine the effect of augmenting color Doppler ultrasound (CDUS) preoperative perforator detection with smartphone-based dynamic infrared thermography (DIRT) on concordance with intraoperative findings.The study included 46 patients scheduled for anterolateral thigh flap (ALTF) reconstruction. Patients were divided into two groups according to the method of perforator mapping: Group 1 underwent CDUS alone, while Group 2 underwent DIRT followed by CDUS. Assessments were performed by novice surgeons with limited ultrasound experience.The time required for perforator mapping was significantly shorter in Group 2 (9 min vs. 16 min, p < 0.0001). The mean number of detected perforators in the evaluated area was 2.5 in Group 1 and 2.96 in Group 2 (p = 0.046). Combining CDUS with DIRT significantly reduced the number of overlooked vessels (p < 0.01).DIRT plays an important role in perforator flap planning by identifying likely perforator locations before CDUS. In turn, CDUS provides detailed information on the perforator's course and hemodynamic properties. The combination of these two techniques offers a rapid, easily interpretable method for preoperative flap planning that can be used by any microsurgeon.

Hybrid breast reconstruction can alleviate the discordance between donor flap and desired breast volume in patients previously excluded from flap-based modalities. The authors review their consecutive experiences with two novel hybrid microsurgical breast reconstruction techniques.A review of all consecutive patients who received microsurgical flap reconstruction was performed over a 5-year period, both with and without hybrid techniques. The HyPAD® technique combines flap reconstruction with stacked prepectoral acellular dermal matrix (ADM), while the HyFIL® technique combines a flap, prepectoral implant, and fat transfer (lipofilling). Demographic, health-related, surgical, and outcome indicators were measured for comprehensive qualitative and quantitative analysis.During the study period (2018-2023), 101 patients with hybrid breast reconstruction (HyPAD® n = 40, HyFIL® n = 61) were compared with 208 patients who received DIEP flap reconstruction alone. Hybrid patients were significantly younger (47.3 versus 52.9 years, p < 0.01), had lower BMIs (24.9 versus 30.3 kg/cm², p < 0.01), and had reduced mastectomy weights (452.1 versus 652.0 g, p < 0.01) and flap weights (348.7 versus 683.5 g, p < 0.01). Hybrid patients had fewer clinically significant readmissions after discharge (1 versus 15, p = 0.02). No significant differences were found for length of stay of index admission (p = 0.56) or returns to the operating room upon index admission (p = 0.64). No implant or ADM extrusions occurred in the hybrid cohort.Hybrid microsurgical breast reconstruction is a safe and reliable method to enhance core projection and volume.

Reconstructive microsurgery remains a demanding field, requiring technical expertise and long operating hours. This places microsurgeons at increased risk of dissatisfaction and burnout. The co-surgeon model has been developed to mitigate these challenges. This study was designed to evaluate microsurgeon perspectives on the characteristics and impact of the co-surgeon model for microsurgical free flaps.An electronic anonymous survey was distributed via email to attending microsurgeon members of the American Society of Reconstructive Microsurgeons. The survey collected various demographic and practice-related information including Likert scale questions to assess microsurgeon perspectives on the utility of the co-surgeon model.A total of 862 microsurgeons received the survey, with 102 responses available for analysis. The average age of respondents was 46.6 (± 9.7) years. Most of the microsurgeons were male (71%) practicing in the United States (93%), with 74.5% of respondents utilizing a co-surgeon model in their practice. Bilateral breast flaps were the most common microsurgical procedure performed using a co-surgeon (85%), followed by head and neck free flaps (60%), with immediate lymphatic reconstruction being the least common (3.1%). On the day of the co-surgery case, the co-surgeon was more likely than the primary surgeon to have additional cases (68.4 and 36.4%, respectively), with the additional cases being rarely free flaps. More than 80% of microsurgeons stated that the co-surgeon model improves "very much" or "quite a bit" operative efficiency and duration, as well as surgeon well-being and career longevity.This study provides new insight into the utility of using a co-surgeon for free flap reconstruction by demonstrating that approximately 80% of microsurgeons have a positive perception of the model's impact on procedure efficiency, operative time, surgeon well-being, and career longevity. Therefore, adopting a co-surgeon model for microsurgical free flap reconstruction may be useful in reducing burnout and promoting well-being among microsurgeons.

Soft tissue sarcomas (STS) are rare malignancies requiring extensive surgical resection, often leading to significant soft tissue defects. Flap reconstruction is crucial for restoring function and appearance. Recent reconstructive microsurgery advancements, including high-resolution indocyanine green (ICG) imaging and ultra-high frequency ultrasonography (UHFU), have revolutionized preoperative planning and intraoperative guidance. We aimed to compare the surgical procedures and short-term outcomes of patients undergoing immediate flap reconstruction before and after our department's adoption of these technologies.We retrospectively analyzed 276 patients who underwent immediate flap reconstruction post-sarcoma resection between May 2014 and December 2023. They were categorized into pre- and post-technology groups based on the introduction of ICG angiography and UHFU in July 2019. We collected demographic, surgical, and postoperative data and compared outcomes using Fisher's exact and t-tests.The muscle preservation rate at the donor site was significantly higher in the post-Tech than in the pre-Tech group (no muscle damage: 65% vs. 37%, incision muscle damage: 25% vs. 26%, and muscle resection: 10% vs. 37%; p < 0.01). The proportions of complications (21% vs. 36%, p = 0.01), flap complications (17% vs. 30%, p = 0.01), partial flap loss (5% vs. 17%, p < 0.01), and flap dehiscence (9% vs. 25%, p < 0.01) were low in the post-Tech group. In the stratified analysis of free-flap reconstruction, the post-Tech group had a shorter operative time (7:01 vs. 8:13, p = 0.03) and fewer takebacks due to compromised flap perfusion (4% vs. 15%, p = 0.03) compared with the pre-Tech group.The introduction of ICG angiography and UHFU has improved surgical outcomes in STS flap reconstructions. These technologies facilitate precise preoperative planning and intraoperative decision-making, resulting in reduced operative times, low complication rates, and enhanced muscle preservation at the donor site.

Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Simultaneous symmetrizing surgery (SSS) at the time of unilateral free flap reconstruction has been described as a method to facilitate single-stage breast reconstruction. However, the impact on cost and number of additional procedures is not well described.Patients with unilateral free flap reconstruction were identified in national administrative data from 2017 to 2021 and followed for one year. Patients were stratified by immediate and delayed reconstruction, then further stratified into groups with and without SSS. Thirty-day complications included transfusion, wound dehiscence, surgical site infection, hematoma/seroma, and thromboembolism. The costs of initial hospitalization and subsequent surgeries were determined. Deferred symmetrizing surgeries within one year were identified. Chi-squared and Fisher exact tests and Wilcoxon tests were used for statistical analysis.A total of 1,136 patients were identified, out of which 638 were delayed reconstructions: 75 with SSS and 563 without. There were no significant differences in patient characteristics or 30-day complications. Within one year of index reconstruction, fewer patients with SSS underwent revision surgery (29% vs. 51%, [p = 0.001]) or at least one additional procedure (36% vs. 57%, p < 0.001). Patients with SSS had lower total costs ($35,897 vs. $50,521, p = 0.005). There were 498 immediate reconstructions: 63 with SSS and 435 without. There were no significant differences in patient characteristics, 30-day complications, subsequent surgeries, or total costs.Symmetrizing procedures at the time of unilateral reconstruction may decrease the cost and number of subsequent surgeries without increasing complications.

Free flap reconstruction in the setting of lower extremity trauma continues to be a challenging clinical problem fraught with a high risk of complications including flap compromise. Although studies have described certain risk factors that predispose these patients to poor outcomes, there remains a paucity of literature detailing frailty as a risk factor. As such, the aim of our study was to examine the application of the 5-item modified frailty index (mFI-5) in trauma patients undergoing lower extremity free flap reconstruction.The 2012 to 2020 American College of Surgeons-National Surgical Quality Improvement Program database was queried for lower extremity free flap reconstructive procedures. After excluding nontrauma etiologies, patients were stratified into three cohorts by their respective mFI-5 score (0, 1, and ≥2). Univariate and multivariate logistic regressions were performed to assess the effect of mFI-5 scores on postoperative complications.A total of 219 patients were included (64.8% male) with an average age of 47.6 ± 16 years. A total of 22.4% (n = 49) of patients had at least one complication. An increased mFI-5 score was associated with an increase in any complication (p < 0.001), hematological complication (p = 0.023), and reoperation (p = 0.004) rates. A high mFI-5 score was found to be an isolated risk factor for having at least one complication (mFI-5 ≥ 2: odds ratio [OR]: 3.829; p < 0.007; 95% confidence interval [CI]: 1.445-10.145) and reoperation (mFI-5 ≥ 2: OR: 5.385; p < 0.002; 95% CI: 1.826-15.877).Our results indicate that the mFI-5 can be a helpful assessment tool for lower extremity trauma patients undergoing free flap reconstruction to predict the risk of surgical complications and reoperation rates. Patients with an mFI-5 score > 2 should be counseled preoperatively of their increased risk of complications.

Defects of the lower extremity often require free tissue transfer to provide adequate soft tissue reconstruction. Patients typically undergo a postoperative dangle protocol to condition the flap to withstand the increase in venous pressure. The purpose of this study was to evaluate the safety and postoperative length of stay after early initiation of dangle.A retrospective review of patients undergoing lower extremity free tissue transfer reconstruction at the Grady Memorial Hospital from 2012 to 2022 was conducted. Patient demographics, surgical characteristics, and outcomes were analyzed. Patients were categorized into two groups: early (within 5 days after surgery) and late dangle (day 6 or greater). Univariate and multivariate statistical analyses were performed, with significance determined to be p < 0.05.A total of 83 of 99 available patients met inclusion criteria; 22 patients underwent early and 61 late dangle. Free flap survival was 90.9% in the early and 90.2% in the late group. The mean postoperative length of stay in the early and late groups were 12.3 and 18.8 days, respectively (p = 0.0018). There was no difference in the number of patients who had wound healing complications, flap failure, and a need for amputation in each group.Our results demonstrate that initiation of an early dangle protocol does not affect surgical outcome and leads to a reduction in postoperative length of stay. These results can be used to inform evidence-based recommendations for flap management in lower extremity reconstruction.

High-level median or ulnar nerve injuries and repairs typically result in suboptimal reinnervation of distal muscles. Functioning free muscle transplantation (FFMT) is increasingly recognized as an effective method to restore function in chronic muscle denervation cases. This study investigates the efficacy of using an additional FFMT, neurotized by lateral sprouting axons from a repaired high-level mixed nerve in the upper limb, to enhance distal hand function.Thirty-five Sprague-Dawley rats were divided into four groups to evaluate the proposed FFMT technique. The infraclavicular median nerve (MN) was transected and repaired in each animal. The nearby musculocutaneous nerve (MCN) was transected, and the terminal nerve after the biceps muscle was divided and embedded into the biceps muscle, creating an FFMT model. The distal stump of the MCN was anchored to the MN, 1.5 mm distal to the MN repair site. Assessments of nerve and muscle function were conducted 4 months postoperatively.Behavioral analysis, along with measurements of biceps muscle weight and tetanic contraction force, indicated significant recovery in the biceps muscle. Histological staining confirmed reinnervation of the MCN from the repaired MN. Additionally, functional examination of the flexor digitorum superficialis muscle revealed no deterioration associated with the repaired MN.The study demonstrates the potentiality of utilizing lateral sprouting axons from a repaired high-level MN to reinnervate an additional FFMT to enhance flexor digitorum superficialis function. The surgical strategy promises recovery of distal muscle function and implies for diverse clinical applications.