Journal of reconstructive microsurgery最新文献

Microsurgery is a highly specialized field requiring years of dedicated training and proper support to sustain a practice. We sought to describe the career paths of young microsurgeons and investigate factors associated with switching jobs.Public data on surgeons who completed a microsurgery fellowship between 2016 and 2020 were collected. Analysis of job switching was determined using the Kaplan-Meier method.One hundred and sixty-seven graduates were analyzed. Most initially practiced microsurgery (92.2%) and 61.7% went into academics. Fifty-two (31.4%) have switched jobs and Kaplan-Meier estimates that 36.0% will switch by 5 years into practice. Over half (58%) changed practice setting type, 19% left academics, and 12% stopped performing microsurgery.Gender, residency training type, taking a job where they trained, and the presence of a microsurgery fellowship had no effect on job switching (p = 0.74, 0.95, 0.71, 0.26). Surgeons in academics were significantly more likely to change jobs (p = 0.04).Gender, residency training type, or taking a job where they trained had no effect on leaving academics (p = 0.89, 0.42, 0.37). Taking a first job where a microsurgery fellowship was present was significantly associated with staying in academics (p = 0.04)Most microsurgery fellows take jobs performing microsurgery. Thirty-six percent will switch jobs in 5 years, more than half will change practice setting type, and about 20% will leave academics. A minority will stop performing microsurgery. Surgeons in academics are more likely to switch jobs. Taking a job where there is a microsurgery fellowship is significantly associated with staying in academics during the switch.

To investigate the risk factors for plate exposure in primary oral cancer patients with mandibular defects undergoing tumor ablation followed by vascularized free fibular flap (FFF) transfer, we conducted a retrospective observational STUDY IN A SINGLE INSTITUTION IN TAIWAN: .The study was performed on a total of 292 primary oral cancer patients who underwent FFF reconstruction between 2015 and 2019. A variety of clinicopathological, surgical, and postoperative parameters were identified and assessed. The data were statistically analyzed with univariate and multivariate logistic regression, and the probability of plate exposure-free rate was plotted as Kaplan-Meier survival curve.The overall plate exposure rate was 28.76%. The re-exploration group had a higher rate of plate exposure than patients without re-exploration (12.2% vs. 5%, p < 0.05). The 3-year probability of plate exposure-free rates in patients with (n = 216) and without (n = 76) postoperative radiotherapy were 65.9 and 92.5%, and in patients with (n = 141) and without (n = 151) postoperative wound infection were 55.3 and 91.2%, respectively. The multivariate logistic regression showed postoperative radiotherapy and wound infection were independent risk factors for developing plate exposure (adjusted odds ratio [95% CI]: 3.73 [1.37-10.68] and 10.71 [5.15-22.26], p = 0.01 and p <0.001, respectively). More patients required surgical intervention to manage the exposure of hardware.Our study has highlighted that postoperative radiotherapy and postoperative wound infection are independent risk factors for plate exposure.

As surgical interventions for lymphedema become increasingly available, it is important to understand characteristics of patients that undergo lymphedema surgery. The goal of this study was to define clinical variables of patients evaluated at a medical center who underwent lymphedema surgery to better inform which referred patients are surgical candidates.A cross-sectional observational study was performed on patients referred to plastic surgery for lymphedema between January 2016 and June 2023. The operative group included patients who underwent lymphedema surgery, including physiologic surgery (PS) and excisional surgery (ES). The nonoperative group consisted of patients referred for lymphedema who did not undergo lymphatic surgery. Patient records were collected, and between-group comparisons were performed.A total of 285 total patients were identified (n = 66 operative, n = 219 nonoperative). The operative cohort had higher body mass index (BMI) than the nonoperative (33.5 vs. 31.2 kg/m², p < 0.035) and was more likely to have undergone physical therapy/occupational therapy (68.2 vs. 53.4%, p = 0.005). Within the operative cohort (PS = 37, ES = 29), PS patients were more likely to be White (91.9 vs. 69.0%, p = 0.043) and have lower BMI (32 vs. 42.7 kg/m², p = 0.007). PS patients were diagnosed for a longer period (8 vs. 3 years, p = 0.03) before seeing a plastic surgeon, more commonly had upper extremity lymphedema (43.2 vs. 13.8%, p = 0.016) and presented at an earlier lymphedema stage (stage 1 64.9 vs. 27.6%, p = 0.002). PS patients were more likely to have prior radiation (56.8 vs. 20.7%, p = 0.005), previous surgery (75.5 vs. 48.3%, p = 0.038), and prior lymphatic intervention (67.6 vs. 17.2%, p < 0.001) near the affected area.Defining patient characteristics associated with surgical intervention for lymphedema can aid surgeons to increase the proportion of patients seen in clinic who are surgical candidates. Factors relating to oncological and surgical history in the affected area may suggest a patient is more likely to undergo PS.

The use of intraoperative methadone has received considerable attention due to reports of reduced postoperative pain and opioid consumption without increased risk of opioid-related side effects. The purpose of this study was to compare perioperative opioid requirements in patients who received intraoperative methadone to those who did not receive intraoperative methadone following autologous breast reconstruction (ABR).A retrospective review of patients who underwent ABR from July 2023 to August 2024 was performed. Patients were stratified into an intraoperative methadone and nonintraoperative methadone cohort. Patient demographics, operative characteristics, hospital length of stay, and perioperative opioid consumption per patient were collected. The primary outcome was daily postoperative opioid requirements, recorded in morphine milligram equivalents (MME).A total of 112 patients who underwent ABR breast reconstruction were identified, 54 in the intraoperative methadone cohort and 58 in the nonintraoperative methadone cohort. Mean opioid consumption was significantly less for the methadone cohort intraoperatively (23.7 ± 13.7 MME vs. 44.5 ± 18.8 MME, p < 0.01), on postoperative day (POD) 1 (29.04 ± 28.9 MME vs. 44.4 ± 37.9 MME, p = 0.04), POD-2 (22.9 ± 25.7 MME vs. 38.7 ± 38.2 MME, p = 0.04), and overall throughout hospitalization compared with the nonintraoperative methadone patients (87.4 ± 87.1 vs. 139.1 ± 121.2; p = 0.03).Intraoperative methadone significantly reduces inpatient opioid use after undergoing ABR on POD-1, POD2, and overall throughout hospitalization. Our findings support the need for well-designed prospective trials to further assess the effectiveness of intraoperative methadone in managing perioperative pain and reducing opioid use during ABR.

The gracilis flap is a versatile muscle flap that can be utilized as a muscle-only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity.We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013 to 2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications, including seroma, hematoma, infection, dehiscence, and persistent numbness.We identified 128 gracilis flaps, including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 days vs. 8.4 days vs. 7.4 days, respectively, p = 0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%) or free muscle flaps (11.4%, p = 0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complications as compared to pedicled muscle flaps (OR: 1.23, p < 0.001), while free muscle flaps were not associated with increased odds of major complications (OR: 1.08, p = 0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%), and seroma (21.1%).The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications, including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

Efferent lymphaticovenular anastomosis (ELVA) uses efferent lymphatic vessels from inguinal lymph nodes, which receive multiple afferent inputs from the lower extremity, to drain substantial lymphatic fluid. However, nodal degeneration during disease progression may impair function and affect ELVA efficacy. This study evaluated ELVA outcomes for lower extremity and pelvic lymphedema based on the presence or absence of nodal degeneration.This retrospective study included 30 patients who underwent LVA using the ELVA technique for pelvic and lower extremity lymphedema (LEL) following gynecological cancer treatment. Preoperative ultrasonography was performed to assess the vascularity of the inguinal lymph nodes. Patients with preserved nodal vascularity were classified into the primary ELVA group and underwent ELVA as the initial treatment. Those without detectable vascular flow were initially treated with leg LVA; ELVA was subsequently performed once the vascularity of the inguinal nodes improved. Treatment efficacy was evaluated based on changes in pelvic and leg volume indices.Based on preoperative ultrasonography, seven patients were classified into the primary ELVA group and 23 into the secondary ELVA group. Preoperative ICG lymphography revealed significantly lower severity in the primary group (p < 0.01). The mean postoperative follow-up period was 31.5 months. Significant volume reductions were observed in leg and pelvic regions, with LEL index reduced from 275.1 ± 33.8 to 247.8 ± 28.2 (p < 0.01), and pelvic lymphedema index from 1,053.2 ± 81.2 to 972.7 ± 76.5 (p < 0.01). No significant differences in volume reduction were found between the two groups.ELVA may be effective for both pelvic and LEL, even in advanced cases when performed after nodal function recovery.

Management of chronic osteomyelitis (COM) remains a challenge for plastic and orthopedic surgeons. Among many perforator flaps utilized in COM, chimeric flaps reported superior successful outcomes. The objective of this study is to evaluate the efficacy of chimeric superficial circumflex iliac artery perforator (SCIP) in treatment of various forms of COM.A retrospective analysis was performed of all patients with posttraumatic COM who underwent reconstruction using chimeric SCIP flaps between September 2019 and November 2023. Patients with insufficient data or follow-up less than 1 year were excluded from the study. The preoperative basic data and the operative details and postoperative follow-up data were collected and statistically analyzed. Correlation between recurrence and the following factors was analyzed: comorbidities, type of trauma, duration of COM, and limb vascularity condition.A total of 59 patients were analyzed, with a mean age 35.31 years. A total of 29 patients underwent chimeric SCIP skin-iliac bone flap reconstruction, 16 received chimeric skin-iliac periosteal flaps, and 4 had chimeric flaps combining skin, periosteum, and bone. There were two cases of total flap loss and two cases of partial flap loss. Additionally, three patients (5.08%) experienced a recurrence of COM. The significant predictor of COM recurrence was major vascular injury. Although not statistically significant, COM recurrence was more prevalent among patients with comorbidities, smoking, and diabetes.Chimeric SCIP flaps can be effectively used to treat COM with composite tissue defects, eliminate inflammation of the affected limbs, allow composite tissue reconstruction, and promote wound healing.

Microsurgical breast reconstruction is intraoperatively complex. Evidence of standardized workflows improving outcomes exists, but the impact of staffing cases with familiar personnel is not documented.All microsurgical breast reconstructions (July 2021-June 2024) at our institution were analyzed for staff familiarity at granular time intervals (T₀: setup to incision, T₁-T₃: each third of procedure). Staff were deemed "unfamiliar" if they staffed <2 microsurgical breast reconstructions with the attending in past 4 months. Intraoperative setbacks included anastomotic revisions, vessel damage, switching recipient vessels, or mastectomy flap defect. Major complications included operative takeback or flap loss.Among 291 surgeries (5 attendings, 2 hospitals), 35.1% were immediate, 77.3% used standard hemiabdominal DIEP flaps, 58.4% were bilateral, and 49.5% had prior radiation. Intraoperative setbacks occurred in 19.7%, major complications in 7.4%, average duration was 631.6 minutes, and supply costs averaged $5,216. Unfamiliar scrub-techs correlated with increased intraoperative setbacks (OR: 2.11, p < 0.05), particularly in early time intervals (T₁: 1.91, p = 0.06; T₂: 2.09, p < 0.05). Unfamiliar circulators correlated with increased supply costs (+12.2%, p < 0.05), especially in later time intervals (T₂: +12.2%, p < 0.05; T₃: +16.0%, p < 0.05). In addition to staff familiarity, at univariate level, intraoperative setbacks also correlated with prior radiation (p < 0.05), duration correlated with laterality, immediate reconstructions, mastectomy type, and anastomoses (p < 0.05), and costs correlated with anastomoses (p < 0.05). Multivariate analysis confirmed unfamiliar scrub-techs and circulators were significantly correlated with increased intraoperative setbacks and higher costs (p < 0.05), with a trend toward longer duration (p = 0.06).In microsurgical breast reconstruction, unfamiliar teams correlated with increased intraoperative setbacks, costs, and durations. Adjusting staffing models to prioritize familiarity may provide medical, financial, and logistical benefits.

Autologous breast reconstruction using the bipedicled deep inferior epigastric perforator (DIEP) flap poses unique challenges in Asian patients with a low BMI and limited donor volume. While internal mammary vessels (IMA/Vs) remain the standard recipient site, the rise of minimally invasive mastectomy has limited access to IMA/Vs. This study compared the results of thoracodorsal and lateral thoracic vessels (lateral-based) versus IMA/Vs (medial-based) in bipedicled DIEP flap breast reconstruction.A retrospective review was conducted on 62 patients who underwent bipedicled DIEP flap reconstruction between 2018 and 2023 by a single senior surgeon. Patients were stratified by incision placement and recipient vessel choice into medial- and lateral-based groups. Clinical outcomes, complication rates, and long-term aesthetic results were analyzed.Despite a higher re-exploration rate in the lateral-based group (12.5% versus 4.5%; p = 0.298), flap survival was comparable between the groups. Fat necrosis rates were lower in flaps without re-exploration (5.4%) and increased significantly following compromised perfusion (33.3%). The lateral-based group achieved superior aesthetic outcomes in breast shape (p = 0.043) and scar visibility (p < 0.001), with a reduced need for secondary fat grafting. Dual vascular sources provided more reliable perfusion and improved long-term fat survival, although further validation with perfusion imaging is warranted.The lateral-based approach, despite technical challenges, is a viable alternative to the medial-based method in certain patients, offering reliable perfusion and superior aesthetic outcomes with fewer revisions. An algorithmic approach to recipient vessel selection can optimize outcomes of bipedicled DIEP flap reconstruction.