Journal of reconstructive microsurgery最新文献

Background:  Recent advancements in supermicrosurgery and promising preliminary outcomes have led to a surge in physiologic lymphedema surgery. This study is the first to evaluate lymphedema surgical education among U.S. plastic surgery residency programs, along with the background and experience of plastic surgeons subspecializing in the field.

Methods:  Cross-sectional evaluation of 103 accredited U.S. plastic surgery residency programs was performed in January 2023. Web-based searches of program curricula, faculty profiles, and main institutional pages indicated whether a program provided nonclinical or clinical exposure to lymphedema surgery. Review of online faculty profiles, surname searches, Doximity, and Scopus determined the perceived demographics, academic productivity, and procedures performed by lymphedema surgeons.

Results:  Compared with the 11 programs that incorporated lymphedema surgery into their online curriculum, 67 programs had a rotation site with a surgeon performing lymphedema procedures. Of the 33 programs without evidence of clinical exposure, 76% (n = 25) did not provide or specify providing elective time. Faculty perceived to be female or a race underrepresented in plastic surgery had significantly more assistant professor titles (p < 0.0214) and significantly fewer years of experience (p < 0.0293) than their counterparts.

Conclusion:  Great variation in lymphedema surgical education exists among U.S. plastic surgery residency programs. While few programs incorporate lymphedema surgery into their advertised curriculum, programs without clinical exposure frequently did not provide elective time to obtain it. Faculty that were female or a race underrepresented in plastic surgery were most often early in their career, suggesting lymphedema surgeons may grow increasingly diverse in years to come.

Background:  Gender bias in graduate medical evaluations remains a challenging issue. This study evaluates implicit gender bias in video-based evaluations of microsurgical technique, which has not previously been described in the literature.

Methods:  Two videos were recorded of microsurgical anastomosis; the first was performed by a hand/microsurgery fellow and the second by an expert microsurgeon. A total of 150 surgeons with microsurgical experience were recruited to evaluate the videos; they were told these videos depicted a surgical trainee 1 month into fellowship followed by the same trainee 10 months later. The only variable was the name ("Rachel" or "David") that each participant was randomly assigned to evaluate. Participants were asked to score each video for quality, technique, efficiency, as well as overall progression and development after the second video compared with the initial video. To focus on bias, these outcome measures were selected to be purposefully subjective and all ratings were based on a subjective 1to 10 scale (10 = excellent).

Results:  The analysis included 150 participants (75% male). There were no statistically significant differences in scores between the "female" and "male" trainee. The trainees received the same median initial (1-month video) and final (11th-month video) scores for all criteria except initial technique, in which the female trainee received a 7 and the male trainee received an 8. Notably, 11-month scores were consistently the same or lower than 1-month scores for both study groups (p < 0.001). There were also no differences within either study group based on participant sex. Microsurgery practitioners overall rated both groups lower than those who do not currently practice microsurgery.

Conclusion:  Our study did not identify a gender bias in this evaluation method. Further investigation into how we assess and grade trainees as well as the presence and impact of implicit biases on varying surgical assessment methods is warranted.

Background:  Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB).

Methods:  This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the "standard" end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively.

Results:  Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170).

Conclusion:  The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.

Background:  Interposition microvascular grafting may be required to bridge arterial defects during digital replantation or revascularization and has traditionally been performed utilizing a venous autograft. Arterial interposition grafting has been shown to be superior in maintaining patency in large vessel surgery; there are case reports of its use in microsurgery.

Methods:  Six fellowship-trained hand and microsurgeons performed arterial and venous interposition grafts on the femoral arteries of 40 Wistar rats. After sectioning one femoral artery a segment of the contralateral femoral artery or vein was obtained. The time was recorded per graft and patency tested 10 minutes following grafting by an independent assessor. Each surgeon also completed a questionnaire detailing regular microsurgical volume, technical ease, and conceptual preference for either graft.

Results:  Time for arterial interposition (median time 51.7 minutes) was longer than venous grafting (median time 45.9 minutes, p = 0.075). Arterial grafts were more likely to be patent or questionably patent (odds ratio [OR] = 6.77, p = 0.031). All surgeons found arterial interposition grafting technically easier and preferred it conceptually. Improvements were noted in patency rates (OR = 11.29, p = 0.018) and avoidance of anastomotic leak (OR = 0.19, p = 0.029) when surgeons performed moderate levels or greater of microsurgery within their regular practice.

Conclusion:  Greater immediate patency was noted with arterial interposition grafting in a rodent model when compared to venous grafting, although procedural time was greater. All surgeons found arterial grafting technically easier. Arterial microvascular grafting may be useful in the setting of digital replantation or revascularization with an arterial defect.

Background:  Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting.

Methods:  The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery.

Results:  Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram.

Conclusion:  The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Background:  Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction.

Methods:  A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann-Whitney tests were used for statistical analysis.

Results:  Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8-13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0-3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733).

Conclusion:  Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component.

Background:  In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery.

Methods:  A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery.

Results:  The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed-immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients.

Conclusion:  Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.

Background:  The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap.

Methods:  CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap.

Results:  A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm³ (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm³ (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm³ (SD = 62.40).

Conclusion:  The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Background:  Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction.

Methods:  A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m²) and Obese (BMI ≥ 30 kg/m²) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups.

Results:  Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time.

Conclusion:  The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.