Journal of reconstructive microsurgery最新文献

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.

The da Vinci Single-Port (SP) system is a robotic surgery platform that allows access into the abdominal cavity through a single short surgical incision. The omentum is an attractive donor site for vascularized omental lymph node transfer (VOLT) in the treatment of lymphedema. We hypothesize that SP robotic VOLT will allow for improvement in perioperative outcomes as compared to open laparotomy for omental flap harvest.A retrospective cohort study was performed, comprised of a study sample of patients with a diagnosis of lymphedema who presented to our institution for VOLT using either an open or SP robotic technique between May 2020 and February 2023. The primary outcome was length of hospital stay. The secondary outcomes included intraoperative complication rate, postoperative complication rate, and length of surgery.Fifteen patients underwent da Vinci SP omental flap harvest, and 14 patients underwent open harvest. There was no significant difference in average age, BMI, sex, or lymphedema etiology between the two groups. Average length of stay was 2.2 ± 1.7 days in the SP group and 2.3 ± 2.1 days in the open group (p = 0.91). There were no significant differences in terms of intraoperative or postoperative complications between the two groups. Ninety-three percent of SP robotic and 86% of open patients reported at least partial subjective improvement following VOLT (p = 0.50).Our findings suggest that SP robotic omental harvest for VOLT is feasible. Perioperative outcomes show comparable results in terms of length of hospital stay, complications, and subjective postoperative improvement when comparing the open to the SP approach.

Breast neurotization using autologous grafts has been indicated to be effective. Previous studies focused mainly on restoring sensation and optimizing the operative techniques of neurotization in microsurgical breast reconstruction. There are few studies on the adverse effects and potential risks associated with simultaneous microsurgical breast reconstruction and neurotization procedures. The rates of overall and pulmonary complications in patients receiving neurotization during autologous breast reconstruction were examined in this study.A retrospective comparative study was conducted between two groups of patients: 100 consecutive patients (reinnervation group) underwent neurotization procedures during deep inferior epigastric perforator (DIEP) breast reconstruction, while the other 100 patients (control group) underwent DIEP breast reconstruction alone. The patients' demographic data, reconstructive methods, postoperative complications, specific pulmonary complications, and length of hospital stay were reviewed.The overall complication rates were 23% in the reinnervation group and 20% in the control group (p = 0.731), and this difference was not statistically significant. The incidence rates of vascular insufficiency (7% vs. 9%), pneumothorax (5% vs. 3%), hematoma/seroma (2% vs. 3%), and wound infection (1% vs. 2%) were similar between the reinnervation group and the control group. A greater percentage of patients in the reinnervation group developed pleural effusion than did those in the control group (12% vs. 4%, p = 0.037), whereas the majority of the patients in the reinnervation group were asymptomatic and managed conservatively.Although harvesting the main intercostal nerve for breast neurotization may irritate the pleura, the effect was minimal and manageable. This procedure is safe and feasible and can be widely applied in breast reconstruction.

The deltoid fasciocutaneous free flap is a valuable reconstructive option for tissue defects following injury or tumor resection. However, limited studies have provided objective data on the anatomical characteristics of this flap. This study aimed to investigate the cadaveric anatomical characteristics of this flap and report our initial results for treating open infected fracture-related infection (FRI) with skin defects in the extremities.This prospective cross-sectional study involved the dissection of 27 adult cadavers (13 male and 14 female), including 16 formalin-fixed (32 deltoid regions) and 11 fresh cadavers (22 deltoid regions). Anatomical characteristics, including the blood supply area and neurovascular pedicle, were examined. The findings from the cadaveric investigation were then applied and analyzed in a clinical setting with 50 patients.The mean angiosome area was 20.41 × 12.36 cm². The main vascular pedicle supplying blood to the flap is the posterior circumflex humeral artery (PCHA), which originates from the axillary and subscapular arteries and was observed in 94.44% of cases. The cutaneous perforator branch is the posterior subcutaneous deltoid artery (PSDA), which was separate from the PCHA in 100% of cases. The mean PCHA length was 38.98 ± 3.88 mm, and mean diameter was 3.17 ± 0.7 mm. The mean PSDA length was 45.5 ± 3.65 mm, and mean diameter was 1.38 ± 0.13 mm. All deltoid free flaps were successfully transferred, and all open FRI demonstrated fracture consolidation in the postoperative course.In addition to clinically well-established free flaps, the deltoid fasciocutaneous free flap represents a valuable reconstructive option for treating open FRI with skin and soft tissue defects in the extremities, particularly when other well-established free flaps are not feasible or have previously been used.

While the need for reconstructive microsurgical procedures has increased across the developing world, several constraints in low- and middle-income settings prevent its consistent performance. Our study aimed to understand the impact of microsurgery training on local capacity in a low-income setting, and to understand limitations that may affect long-term build-up of microsurgical capacity.Cross-sectional study evaluating survey responses of trainees and surgeons who participated in a Flap Transfer and Microsurgery course held in Ibadan, Nigeria. The survey consisted of a pre- and postcourse questionnaire, and a 2-year posttraining survey. The questionnaire sought to assess training impact on microsurgical capacity and limitations at each participants institution. Fourteen surgeons completed all questionnaires and were included in the study.Thirteen (92.3%) participants had encountered at least one defect requiring microvascular surgery within 2 years of the training, and 9 (69.2%) reported having performed at least one surgery. Most surgeons indicated having performed less procedures than needed across all defect anatomical site/etiology. The most common limitation reported by participants consisted of man-power shortage (78.6%), followed by expense of each procedure, difficulty procuring materials, and trainers with limited experience.There is a significant need for microsurgical reconstruction in sub-Saharan Africa, with varied local challenges preventing consistent delivery of microsurgical care. The analysis complements previous literature on microsurgical care in developing countries and highlights significant constraints preventing widespread adoption and the role of local training opportunities that help in building long-term local capacity.

Head and neck squamous cell carcinoma accounts for 4.5% of all new cancers diagnosed. A fibula free flap is often performed after tumor resection. Preoperative acknowledgment of the branching patterns of the popliteal artery is important to avoid flap failure or leg ischemia after flap harvest. We performed this extensive study using a modified classification to help thoroughly recognize variations.The subjects were Taiwanese patients who received radiologic examinations of their lower limbs at a single medical center from May 2006 to December 2022. Only digital subtraction angiography, computed tomography angiography, and magnetic resonance angiography, which reveal the vasculature of the lower limbs, were included. All images were viewed by the same plastic surgeon on the same computer screen. Statistical analysis was subsequently performed on the data.In total, 1,244 right legs and 1,198 left legs (2,442 legs in total) from 1,485 Taiwanese patients were included in this study. In addition to normal branching, type IA, other branching patterns as variations occurred in 4.1% (n = 100) of the included legs. The second and third common patterns were type IIIA (1.06%, n = 26) and IB (0.98%, n = 24), respectively. Forty-seven patients presented with variation and had both legs evaluated, and 29.8% of them presented with bilateral variations.A preoperative vascular examination is strongly recommended before harvesting a free fibular flap because some patients might have a blood supply to the foot and lower leg, mainly from the planned-to-be-harvested peroneal artery (PR), or might not have a workable PR. Using fibular vessels as a flap pedicle might not be able to be performed in up to 1.84% of legs.

Postoperative anticoagulation is widely used in microsurgical flap reconstruction to reduce the risk of thrombosis and flap complications. However, their effectiveness and safety in relation to flap outcomes remain uncertain. This systematic review and meta-analysis evaluate the existing evidence on postoperative anticoagulant use in microsurgical flap reconstruction.A literature search was performed in the PubMed database for studies published from 1995 until January 2025 that compared flap outcomes with postoperative prophylactic anticoagulation regimens in microsurgical flap procedures. Outcomes of interest included hematoma, complete flap failure, and reoperation. Relevant data were extracted and analyzed using meta-analytic techniques.In total, 11 studies were included in the final review and meta-analysis. Seven studies comparing patients who received postoperative anticoagulation with those who did not demonstrated a significantly higher rate of hematoma in the anticoagulated group (5.0% vs. 3.0%; p = 0.03). However, there were no significant differences in flap failure or reoperation rates. In subgroup analyses, only studies using unfractionated heparin showed increased hematoma risk, whereas low-molecular-weight heparin (LMWH) showed no significant effect. Four studies compared patients receiving postoperative anticoagulation plus aspirin with those receiving anticoagulation alone and found a higher reoperation rate when aspirin was added (17.5% vs. 10.0%; p < 0.01), with no significant differences in flap failure rates.Postoperative heparin increases the risk of hematoma without improving flap survival. Additionally, combining aspirin with LMWH may increase reoperation rates. These results suggest that routine anticoagulation may not benefit all patients and support a risk-based approach to postoperative management in microsurgical reconstruction.

Fibula free flap (FFF) surgery complications can arise from vascular disease within the donor peroneal artery. Computed tomography angiography (CTA) has become standard for preoperative evaluation. However, current methods rely on qualitative assessments to determine surgical eligibility. This study aims to improve preoperative risk evaluation by implementing two quantitative scoring systems, the Bollinger score and the lower limb arterial calcification score (LLACS), assessing distinct vascular health components. The Bollinger score quantifies intraluminal stenosis caused by atherosclerotic plaques, while the LLACS quantifies arteriosclerosis by evaluating calcification within the arterial walls.A retrospective review was conducted on all head and neck microvascular FFF procedures performed at a university-affiliated tertiary care center between August 2021 and March 2023. Data collected included patient demographics, medical history, operative details, and postoperative complications (infection, hematoma, seroma, fistula, dehiscence, or flap failure) within 90 days. Peroneal artery Bollinger scores and crural segment LLACSs from the donor lower extremity were calculated from preoperative CTAs.A total of 117 patients were included. Increasing Bollinger scores were significantly associated with an increased risk of complications and longer hospital stays, even after controlling for potential confounders. Combining both scores improved risk stratification, with high-risk patients experiencing an 8.36-fold higher risk of complications.Our findings suggest that quantitative preoperative peroneal vessel assessment improves risk stratification for patients undergoing FFF surgery. These scoring systems may enhance patient selection and guide strategies to minimize postoperative complications. Integrating multiple scoring systems is key to the comprehensive assessment of vascular health.