Journal of reconstructive microsurgery最新文献

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.

There is a growing emphasis on minimally invasive techniques as an alternative to surgical delay to promote vessel reorganization and prevent partial and total flap loss. This systematic review evaluates existing literature on these minimally invasive techniques, focusing on their potential applications in preventing ischemia-related complications.A systematic review was conducted in July 2024 using PubMed, MEDLINE, and Web of Science following preferred reporting items for systematic reviews and meta-analysis guidelines. Inclusion criteria were studies that included patients undergoing any flap-based reconstruction treated with minimally invasive delay. Exclusion criteria were non-English papers, other systematic reviews, nonhuman patients, and pediatric patients.Six studies were included (angiographic delay n = 143, heat preconditioning n = 191, ischemic preconditioning n = 60) which examined minimally invasive methods for perfusion optimization. Aggregated data from the three studies on angiographic delay demonstrated a 13% (18/143) combined skin or fat flap necrosis rate, which was lower than that of non-delayed flaps and comparable to more invasive traditional surgical ligation. Ischemic preconditioning showed no significant differences (p = 1.0) g compared with controls, whereas heat preconditioning led to reductions (26% vs. 35%) in flap necrosis and necrosis requiring surgical intervention (11% vs. 17%).Angiographic embolization presents a promising alternative to invasive surgical delay, effectively reducing flap necrosis risk. Heat and ischemic preconditioning also show potential for increasing flap survival, although current studies are limited by small sample sizes. Further research is essential to explore preoperative conditioning interventions to improve surgical outcomes for patients who require less invasive delay techniques.

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.