Journal of reconstructive microsurgery最新文献

Background:  The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. However, the conventional procedure's anterior sheath division, from perforating vessels to the pedicle origin, risks weakening the abdominal wall's primary strength layer. Employing the da Vinci Xi Surgical System with indocyanine green dye and near-infrared fluorescence imaging, we refined a robotic technique for bilateral DIEP flap harvest. This approach enhances safety during vessel dissection, utilizing smaller fascial incisions. This study will present this technique in detail to microsurgeons interested in robotic DIEP flaps.

Methods:  In a retrospective cohort study spanning July 2021 to September 2022, female patients undergoing robotic bilateral DIEP flap reconstruction were analyzed. Following suprafascial flap dissection, the surgical robot was docked to target the pelvis, identifying and exposing deep inferior epigastric vessels intracorporeally. Mobilization and division occurred at their bases, with retrieval through a minimal anterior fascial incision, minimizing disruption to the abdominal wall and its motor innervation.

Results:  The study comprised 23 patients (46 flaps), with a mean fascial length of 4.1 cm and mean pedicle length of 12.82 cm. Mesh usage was absent. Robotic time averaged 139 minutes, overall case length was 739 minutes, and the average length of stay was 3.9 days. Notably, no pedicle or intra-abdominal injuries were reported.

Conclusion:  This technique ensures safe and efficient pedicle dissection in robotic DIEP flap harvests. Given the limited number of plastic surgeons adept in minimally invasive abdominal surgeries, we recommend collaborative efforts, with general surgeons initially assisting microsurgeons in adopting the robotic approach. This strategy facilitates a smooth transition until plastic surgeons attain confidence and competence in independent robotic dissection.

Background:  The use of mesh to reinforce the abdominal wall after abdominal flap harvest has been reported to decrease the risk of bulging and herniation. However, the impact of the plane of mesh placement in relation to the anterior rectus sheath (vs. no mesh) on postoperative abdominal complications remains unclear.

Methods:  We retrospectively analyzed the length of stay and clinical outcomes in 158 female patients who underwent breast reconstruction with 250 free abdominal flaps. Group 1 consisted of patients who underwent polypropylene sublay-onlay ("sandwich") mesh placement (N = 70) versus polypropylene sublay-only mesh (group 2; N = 54) versus primary fascial repair without mesh (group 3; N = 34).

Results:  Patient demographics and comorbidities were comparable between study groups, except for rates of neoadjuvant chemotherapy (group 1: 53% vs. group 2: 33% vs. group 3: 24% [p < 0.01]), postoperative follow-up in months (group 1: 21.5; group 2: 11.5; group 3: 7.6 [p < 0.01]), and length of stay in days (group 1: 4.9 vs. group 2: 4.4 vs. group 3: 3.3 [p < 0.01]). No differences were observed in breast flap and donor-site complications between study groups. Patients in group 3 required significantly lower oral morphine equivalent units postoperatively compared with those in groups 1 and 2 (group 1:185.5 vs. group 2: 79.7 vs. group 3: 71.6 [p < 0.01]).

Conclusion:  Abdominal donor-site closure without mesh was associated with a shorter length of stay and less narcotic intake without an increase in donor-site complications. These findings should be considered when deciding to place mesh for donor-site closure after abdominal flap harvest.

Background:  Mastectomy, axillary lymph node dissection, and irradiation for breast cancer commonly result in perivascular and axillary scarring. This scarring is thought to cause functional venous stenosis that leads to downstream venous hypertension in the affected extremity. Standard surgical practice is to decompress perivascular scarring at the time of physiologic lymphedema surgery in patients with breast cancer-related lymphedema (BCRL). However, it is unknown whether this scar release influences surgical outcomes. The purpose of this study was to evaluate the prevalence of functional venous stenosis in patients with BCRL and determine whether scar decompression is a necessary step in physiologic lymphedema surgery.

Methods:  The authors conducted a retrospective review of 64 patients with unilateral BCRL that presented to our lymphedema center between January 2020 and October 2022. Radiologist reports of venous duplex ultrasound for the bilateral upper extremities identified any disturbances in venous flow or indications of venous stenosis.

Results:  Of the 64 patients with BCRL, 78% (n = 50) had prior axillary lymph node dissection. Forty-seven (73%) patients completed ultrasound imaging, of which, one patient (2%) had venous stenosis in the affected lymphedematous extremity identified on duplex ultrasound that may have suggested functional scarring. Vascularized lymph node transfer (VLNT) without scar decompression was performed in six patients (9%). Average preoperative Lymphedema Life Impact Scale and Lymphedema Index scores were 35 and 19 units, with a mean decrease of 23 (67%) and 6 (30%) units postoperatively.

Conclusion:  Most patients with BCRL did not have identifiable functional venous stenosis on duplex ultrasound, apart from one patient with suspected postthrombotic changes. All six patients that received VLNT without scar decompression had a successful outcome with decreased measures of lymphedema postoperatively. Scar decompression may therefore be unnecessary in physiologic lymphedema surgery, reducing operative times and avoiding risk of injury to neurovascular structures of the axilla.

Background:  Vascularized composite allotransplantation (VCA) involves transplanting a functional and anatomically complete tissue graft, such as a hand or face, from a deceased donor to a recipient. Although clinical VCA has resulted in successful outcomes, high rates of acute rejection and increased requirements for immunosuppression have led to significant long-term complications. Of note, immunosuppressed graft recipients are predisposed to infections, organ dysfunction, and malignancies. The long-term success of VCA grafts requires the discovery and implementation of unique approaches that avoid these complications altogether. Here, we describe our surgical technique and initial experience with a reproducible heterotopic porcine VCA model for the preclinical assessment of approaches to improve graft outcomes.

Methods:  Six heterotopic porcine allogeneic vertical rectus abdominis myocutaneous flap transplants were performed using Sinclair donors and Yucatan recipients. Immunosuppressive therapy was not used. Each flap was based on the left external iliac vessel system. Animals were followed postoperatively for surgery-related complications.

Results:  The six pigs underwent successful VCA and were euthanized at the end of the study. Each flap demonstrated complete survival following vessel anastomosis. For the allogeneic recipients, on average, minimal erythema and healthy flap color were observed from postoperative days 1 to 4. There were no surgery-related animal deaths or complications.

Conclusion:  We have developed a reproducible, technically feasible heterotopic porcine VCA model based on the left external iliac vessel system. Our results demonstrate this model's potential to improve VCA graft outcomes by exploring tolerance induction and rejection biomarker discovery in preclinical studies.

Background:  Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps.

Methods:  A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications.

Results:  Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157).

Conclusion:  This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

Background:  The Flapbot chatbot assists in free-flap monitoring, emphasizing accessibility, user-friendliness, and global reliability. This study assesses Flapbot's worldwide validity and usability and uses qualitative analysis to identify areas for future enhancement.

Methods:  Flapbot, built on Google's DialogFlow, was evaluated by international plastic surgeons. Invitations were sent to the International Lower Limb Reconstruction Collaborative (INTELLECT), International Confederation of Plastic Surgery Societies (ICOPLAST), and the International Microsurgery Club. Out of the 42 surgeons who agreed to participate, 21 tested the Flapbot and completed an online survey on its validity and usability. The survey had 13 validity items and 10 usability items. Data analysis involved computing the individual content validity index (I-CVI) and scale-wide content validity index (S-CVI) for validity, and the system usability score (SUS) for usability. Thematic analysis distilled free-text responses to identify key themes.

Results:  Nine of 13 items had an I-CVI over 0.78, denoting significant relevance. The S-CVI score stood at 0.82, indicating high relevance. The SUS score was 68, representing average usability. Themes highlighted issues with the current model, development suggestions, and surgeons' concerns regarding growing reliance on digital tools in health care.

Conclusion:  Flapbot is a promising digital aid for free-flap monitoring. While it showcases notable validity and usability, improvements in functionality, usability, and accessibility are needed for broader global use.

Background:  Large defects of the lower lip often require free tissue coverage. Fasciocutaneous free flaps have been traditionally used, but innervated muscular free flaps may fundamentally address orbicularis oris deficiency and improve dynamic competence. This review aimed to determine if innervated muscular free flaps provided benefit over fasciocutaneous free flaps for reconstruction of defects of more than 50% of the lower lip. Outcomes of interest included functional oral outcomes including oral competence, aesthetic outcomes, and patient-reported outcome measures.

Methods:  Five databases (PubMed, Embase, Web of Science, CINAHL, and CENTRAL) were searched for variations of "lip" and "free flap." Two authors screened articles and included primary research of free flap reconstruction of more than 50% of the lower lip from any etiology in living humans with an English full-text available. Composite bony flaps were excluded. Oral competence and aesthetic satisfaction, reconstruction details, and complications were extracted. Proportional meta-analyses were used to synthesize results for fasciocutaneous free flaps, which were compared with those for muscular free flaps.

Results:  Fifty-nine articles describing 242 patients were included. Muscular free flaps reported significantly higher proportional oral competence than fasciocutaneous free flaps (98 vs. 83%, p = 0.01). Aesthetic outcomes (98 vs. 97%, p = 0.22) and complications (17 vs. 18%, p = 0.79) were equivalent between fasciocutaneous and muscular free flaps.

Conclusion:  Muscular free flaps may address the fundamental orbicularis oris defect that causes oral incompetence and seem to provide better functional results. Aesthetic outcomes and complications seem to be equivalent.

Background:  One of the most devastating deficits of facial paralysis is eyelid dysfunction, which is controlled by the orbicularis oculi muscle (OOM), as it leads to loss of the protective mechanism of the eye. This study used a rat model to assess the functional outcomes of neurotized platysma muscle grafts (PMGs) for OOM replacement.

Methods:  Forty male Sprague-Dawley rats with iatrogenic right eyelid dysfunction were divided into five groups: one control group and four groups utilizing PMG with different sources of nerve innervation. Eyelid function recovery was assessed at 2, 4, 6, and 8 weeks. The PMGs were harvested for pathological examination at the end of the study.

Results:  All rats except those in the control group and one from the group using ipsilateral frontal and upper zygomatic frontal nerve branches directly neurotized to the PMG (nerve-to-muscle) recovered eyelid closure function within 8 weeks of the study period. The mean recovery time was 3.87 ± 1.28 weeks. A total of 87.5% of rats that had the contralateral zygomatic branch as the donor nerve regained the consensual corneal reflex (p-value < 0.001).

Conclusion:  Replacement of neurotized PMG for OOM function is successful in a rat model. Using the upper zygomatic branch as the donor nerve, it was possible to restore the consensual corneal reflex. This method shows promise for further human studies.

The attainment of microsurgical competency is an important milestone for plastic surgery trainees. Technical skill and a practiced disposition are required to successfully perform microsurgical procedures. Microsurgical skills curricula may foster both proficiency with technical movements and facilitate performance with minimal cognitive burden while using the operating microscope. The microsurgical skills curriculum presented in this article focuses on three fundamental principles: intrinsic muscle strength, accuracy and precision of movement, and supervised practice. Progressive operative entrustment of trainees is earned through successful completion of deliberate microsurgical exercises rather than timed anastomosis trials. The overarching goal of this curriculum is to develop unconscious competence in microsurgery.