Nishant Kumar, Samyd S. Bustos, Scott K. Odorico, Aparna Vijayasekaran
The deep inferior epigastric perforator (DIEP) flap remains the preferred flap option for autologous breast reconstruction following mastectomy. This case report presents the novel use of the cephalic vein (CV) as an interposition graft to alleviate venous congestion in a patient undergoing DIEP flap reconstruction. A 42-year-old woman experienced venous congestion following her initial autologous reconstruction, attributed to thrombus formation from kinking of the vascular pedicle. Despite initial attempts to resolve the congestion, the condition persisted. Since the flap was based on a single perforator, we decided to attempt a CV turndown. The CV was noted to be attenuated and not feasible for use in turndown; therefore, venous salvage was completed by using the CV as an interposition graft to bypass the affected flap vena comitans. The procedure successfully restored venous flow, allowing for flap salvage and subsequent healing. This case underscores the potential of CV as an interposition graft in autologous breast reconstruction, particularly when traditional CV turndown is not possible due to vessel attenuation.
{"title":"Cephalic Vein Interposition Graft for Salvage of Compromised DIEP Flap in Breast Reconstruction","authors":"Nishant Kumar, Samyd S. Bustos, Scott K. Odorico, Aparna Vijayasekaran","doi":"10.1002/micr.70124","DOIUrl":"10.1002/micr.70124","url":null,"abstract":"<div>\u0000 \u0000 <p>The deep inferior epigastric perforator (DIEP) flap remains the preferred flap option for autologous breast reconstruction following mastectomy. This case report presents the novel use of the cephalic vein (CV) as an interposition graft to alleviate venous congestion in a patient undergoing DIEP flap reconstruction. A 42-year-old woman experienced venous congestion following her initial autologous reconstruction, attributed to thrombus formation from kinking of the vascular pedicle. Despite initial attempts to resolve the congestion, the condition persisted. Since the flap was based on a single perforator, we decided to attempt a CV turndown. The CV was noted to be attenuated and not feasible for use in turndown; therefore, venous salvage was completed by using the CV as an interposition graft to bypass the affected flap vena comitans. The procedure successfully restored venous flow, allowing for flap salvage and subsequent healing. This case underscores the potential of CV as an interposition graft in autologous breast reconstruction, particularly when traditional CV turndown is not possible due to vessel attenuation.</p>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 7","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145213085","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Victor F. A. Almeida, Glaudir Donato, Andressa Alves de Carvalho, Wanessa Alves de Carvalho, Ammar Lakda, Yara Dias, Manoela Dantas, Pedro Danielian, Eliana F. R. Duraes
Background
Autologous breast reconstruction using abdominally based flaps is common post-mastectomy, but donor-site pain often leads to prolonged opioid use. The transversus abdominis plane (TAP) block is a common regional anesthesia technique, with bupivacaine as the standard anesthetic. Liposomal bupivacaine (LB), a prolonged-release formulation, aims to extend pain relief and reduce opioid consumption, though its efficacy remains debated.
Objective
This systematic review and meta-analysis compared LB versus plain bupivacaine (PB) in TAP blocks for autologous breast reconstruction, focusing on opioid consumption, pain scores, and hospital stay.
Methods
A systematic search identified randomized controlled trials and observational studies comparing LB (with or without PB) to PB in TAP blocks. Data were pooled using a random-effects model (I2 ≥ 25%) or fixed-effects model (I2 < 25%).
Results
Six studies (429 patients) met inclusion criteria. LB was associated with significant reduction in opioid consumption on postoperative days (POD) 1 (MD = −4.99 mg; 95% CI: [−8.42; −1.56], p < 0.01, I2 = 0%) and POD 2 (MD = −3.35 mg; 95% CI: [−5.74; −0.96], p < 0.01, I2 = 0%). Pain scores were significantly lower on POD 2 and POD 3. No difference in hospital stay was found (MD = −0.17; 95% CI: [−0.52; 0.18], p = 0.34, I2 = 83.1%).
Conclusion
LB reduced opioid consumption during the first 48 h postoperatively and modestly improved pain control on POD 2 and POD 3, but did not shorten hospital stay. Further large-scale RCTs are needed to validate its benefits.
{"title":"Liposomal Bupivacaine in Transversus Abdominis Plane Block for Postoperative Pain Control After Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis","authors":"Victor F. A. Almeida, Glaudir Donato, Andressa Alves de Carvalho, Wanessa Alves de Carvalho, Ammar Lakda, Yara Dias, Manoela Dantas, Pedro Danielian, Eliana F. R. Duraes","doi":"10.1002/micr.70126","DOIUrl":"10.1002/micr.70126","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Autologous breast reconstruction using abdominally based flaps is common post-mastectomy, but donor-site pain often leads to prolonged opioid use. The transversus abdominis plane (TAP) block is a common regional anesthesia technique, with bupivacaine as the standard anesthetic. Liposomal bupivacaine (LB), a prolonged-release formulation, aims to extend pain relief and reduce opioid consumption, though its efficacy remains debated.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>This systematic review and meta-analysis compared LB versus plain bupivacaine (PB) in TAP blocks for autologous breast reconstruction, focusing on opioid consumption, pain scores, and hospital stay.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A systematic search identified randomized controlled trials and observational studies comparing LB (with or without PB) to PB in TAP blocks. Data were pooled using a random-effects model (<i>I</i><sup>2</sup> ≥ 25%) or fixed-effects model (<i>I</i><sup>2</sup> < 25%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Six studies (429 patients) met inclusion criteria. LB was associated with significant reduction in opioid consumption on postoperative days (POD) 1 (MD = −4.99 mg; 95% CI: [−8.42; −1.56], <i>p</i> < 0.01, <i>I</i><sup>2</sup> = 0%) and POD 2 (MD = −3.35 mg; 95% CI: [−5.74; −0.96], <i>p</i> < 0.01, <i>I</i><sup>2</sup> = 0%). Pain scores were significantly lower on POD 2 and POD 3. No difference in hospital stay was found (MD = −0.17; 95% CI: [−0.52; 0.18], <i>p</i> = 0.34, <i>I</i><sup>2</sup> = 83.1%).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>LB reduced opioid consumption during the first 48 h postoperatively and modestly improved pain control on POD 2 and POD 3, but did not shorten hospital stay. Further large-scale RCTs are needed to validate its benefits.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 7","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/micr.70126","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145213137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Recently, the immunomodulatory effects of mesenchymal stem cells have been reported in several studies. The purpose of this study was to evaluate the effect of the administration of human amnion–derived mesenchymal stem cells (hAm-MSCs) in a rat vascularized composite allotransplantation model.
Materials and Methods
A total of 18 Lewis (LEW) rats and 6 Brown-Norway (BN) rats were used. Sixteen LEW rats as recipients were divided randomly into four groups: Isograft (Iso), Untreated (UT), FK, and MSC groups (n = 4, each group). Hind limb transplantation was performed. In the Iso group, 2 LEW rats were used as donors. In the other groups, 6 BN rats were used as donors. In the UT group, no immunosuppressant was used. In the FK group, 0.2 mg/kg/day of FK506 (tacrolimus) was administered from day 0 to day 6. In the MSC group, 2 × 106 hAm-MSCs were administered on day 7 after tacrolimus administration (day 0–6). Graft survival was assessed by daily inspection, histology, and immunohistology with the TUNEL (terminal deoxynucleotidyl transferase dUTP nick-end labeling) assay. Cytokine mRNA expression analysis using real-time, reverse transcription PCR (RT-PCR) of the grafts was analyzed.
Results
Graft survival in the MSC group (14.8 days) was significantly prolonged compared with that of the FK group (13 days; p < 0.05). Histology and immunohistology with the TUNEL assay showed a significant reduction of mononuclear cell infiltration and apoptotic cells in the MSC group compared with the FK group (p < 0.05). RT-PCR analysis of cytokine mRNA expression showed a significant decrease of IL-2 and an increase of TGFβ in graft muscle (p < 0.05).
Conclusions
hAm-MSCs prolonged graft survival in the rat vascularized composite allotransplantation model. hAm-MSCs could be an alternative immunomodulatory agent to avoid the side effects of conventional immunosuppressant.
{"title":"Human Amnion-Derived Mesenchymal Stem Cells Prolong Graft Survival in a Rat Hind Limb Allotransplantation Model","authors":"Daichi Sakamoto, Ryosuke Ikeguchi, Tomoki Aoyama, Maki Ando, Koichi Yoshimoto, Terunobu Iwai, Kazuaki Fujita, Tetsuya Miyamoto, Takashi Noguchi, Shuichi Matsuda","doi":"10.1002/micr.70125","DOIUrl":"10.1002/micr.70125","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Recently, the immunomodulatory effects of mesenchymal stem cells have been reported in several studies. The purpose of this study was to evaluate the effect of the administration of human amnion–derived mesenchymal stem cells (hAm-MSCs) in a rat vascularized composite allotransplantation model.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Materials and Methods</h3>\u0000 \u0000 <p>A total of 18 Lewis (LEW) rats and 6 Brown-Norway (BN) rats were used. Sixteen LEW rats as recipients were divided randomly into four groups: Isograft (Iso), Untreated (UT), FK, and MSC groups (<i>n</i> = 4, each group). Hind limb transplantation was performed. In the Iso group, 2 LEW rats were used as donors. In the other groups, 6 BN rats were used as donors. In the UT group, no immunosuppressant was used. In the FK group, 0.2 mg/kg/day of FK506 (tacrolimus) was administered from day 0 to day 6. In the MSC group, 2 × 10<sup>6</sup> hAm-MSCs were administered on day 7 after tacrolimus administration (day 0–6). Graft survival was assessed by daily inspection, histology, and immunohistology with the TUNEL (terminal deoxynucleotidyl transferase dUTP nick-end labeling) assay. Cytokine mRNA expression analysis using real-time, reverse transcription PCR (RT-PCR) of the grafts was analyzed.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Graft survival in the MSC group (14.8 days) was significantly prolonged compared with that of the FK group (13 days; <i>p</i> < 0.05). Histology and immunohistology with the TUNEL assay showed a significant reduction of mononuclear cell infiltration and apoptotic cells in the MSC group compared with the FK group (<i>p</i> < 0.05). RT-PCR analysis of cytokine mRNA expression showed a significant decrease of IL-2 and an increase of TGFβ in graft muscle (<i>p</i> < 0.05).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>hAm-MSCs prolonged graft survival in the rat vascularized composite allotransplantation model. hAm-MSCs could be an alternative immunomodulatory agent to avoid the side effects of conventional immunosuppressant.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 7","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145186267","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sophia Arbuiso, Makayla Kochheiser, Albert Truong, Samuel J. Medina, Matthew W. Liao, Sarah Diaddigo, Gianni Thomas, Leslie Cohen, Jason A. Spector, David M. Otterburn
Background
Connective tissue diseases (CTDs) are associated with impaired wound healing and hypercoagulability. There is currently a paucity of research examining postoperative outcomes in these patients following microsurgical procedures. We aimed to analyze postoperative outcomes in patients with CTDs following breast reconstruction with the deep inferior epigastric perforator (DIEP) flap.
Methods
A single-institution retrospective study was conducted consisting of all patients that underwent breast reconstruction with DIEP flaps between 2015 and 2023. Outcomes were assessed in the 90-day postoperative period, and Fisher's exact test was used to compare results between patients diagnosed with a CTD and patients who do not have CTDs.
Results
Five hundred ten DIEP flaps were performed on 286 patients. Eight of these patients, who underwent 13 DIEP flaps, were diagnosed with CTDs. The patients with and without CTDs were similar with respect to patient demographics. Patients with CTDs were not at increased risk of experiencing any major complication. However, patients with CTDs were at increased risk of experiencing fat necrosis, particularly of the breast (p < 0.05).
Conclusion
Our data suggests that breast reconstruction using DIEP flaps is a safe procedure for patients who have CTDs; however, they may be at increased risk for fat necrosis of the breast, which does not require significant intervention.
{"title":"Investigating the Safety of Breast Reconstruction With the Deep Inferior Epigastric Flap in Patients With Connective Tissue Diseases","authors":"Sophia Arbuiso, Makayla Kochheiser, Albert Truong, Samuel J. Medina, Matthew W. Liao, Sarah Diaddigo, Gianni Thomas, Leslie Cohen, Jason A. Spector, David M. Otterburn","doi":"10.1002/micr.70092","DOIUrl":"10.1002/micr.70092","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Connective tissue diseases (CTDs) are associated with impaired wound healing and hypercoagulability. There is currently a paucity of research examining postoperative outcomes in these patients following microsurgical procedures. We aimed to analyze postoperative outcomes in patients with CTDs following breast reconstruction with the deep inferior epigastric perforator (DIEP) flap.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A single-institution retrospective study was conducted consisting of all patients that underwent breast reconstruction with DIEP flaps between 2015 and 2023. Outcomes were assessed in the 90-day postoperative period, and Fisher's exact test was used to compare results between patients diagnosed with a CTD and patients who do not have CTDs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Five hundred ten DIEP flaps were performed on 286 patients. Eight of these patients, who underwent 13 DIEP flaps, were diagnosed with CTDs. The patients with and without CTDs were similar with respect to patient demographics. Patients with CTDs were not at increased risk of experiencing any major complication. However, patients with CTDs were at increased risk of experiencing fat necrosis, particularly of the breast (<i>p</i> < 0.05).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Our data suggests that breast reconstruction using DIEP flaps is a safe procedure for patients who have CTDs; however, they may be at increased risk for fat necrosis of the breast, which does not require significant intervention.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 6","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145137905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diwakar Phuyal, Fuad Abbas, Osama Darras, Zoe E. Belardo, Jack Sims, Risal Djohan, Steven L. Bernard, Graham Schwarz, Raffi Gurunian, Sarah N. Bishop
Background
Lymphedema is a chronic condition that can occur in patients following axillary lymph node dissection (ALND). Breast reconstruction has been reported to reduce lymphedema risk. When immediate lymphatic reconstruction (ILR) is combined with implant-based breast reconstruction (IBR), it offers the potential for both functional and esthetic benefits in one surgery. However, its impact on postoperative complications, such as infection and wound dehiscence, among others, remains underexplored.
Methods
An IRB-approved retrospective review was conducted on patients who underwent ALND and immediate implant reconstruction (IBR). Data collected included patient demographics, treatment characteristics, and complication rates. Assessed complications included major infection requiring intravenous antibiotic or reoperation, minor infection requiring oral antibiotic, hematoma, seroma, wound issues, deep vein thrombosis, mastectomy flap necrosis, reoperation, implant explantation, and rehospitalization. The primary outcome was a comparison of complication rates between patients who received ILR and those who did not.
Results
The study included 178 patients (68 with ILR and 110 without ILR), accounting for implant reconstruction in 266 breasts. Mean operative time was significantly longer in the ILR group (326 min vs. 245, p < 0.001). Despite this, overall complication rates were comparable (38% vs. 34%, p = 0.63). No significant differences were observed in infection rates, seroma formation, reoperations, or implant explantations over a three-year follow-up period. Age and BMI were identified as independent predictors of complications.
Conclusions
Despite longer operative times, ILR demonstrates a comparable safety profile to implant-based breast reconstruction when performed concurrently following ALND.
{"title":"Evaluating the Safety of Immediate Lymphatic Reconstruction With Implant-Based Breast Reconstruction: Eight-Year Institutional Review","authors":"Diwakar Phuyal, Fuad Abbas, Osama Darras, Zoe E. Belardo, Jack Sims, Risal Djohan, Steven L. Bernard, Graham Schwarz, Raffi Gurunian, Sarah N. Bishop","doi":"10.1002/micr.70119","DOIUrl":"10.1002/micr.70119","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Lymphedema is a chronic condition that can occur in patients following axillary lymph node dissection (ALND). Breast reconstruction has been reported to reduce lymphedema risk. When immediate lymphatic reconstruction (ILR) is combined with implant-based breast reconstruction (IBR), it offers the potential for both functional and esthetic benefits in one surgery. However, its impact on postoperative complications, such as infection and wound dehiscence, among others, remains underexplored.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>An IRB-approved retrospective review was conducted on patients who underwent ALND and immediate implant reconstruction (IBR). Data collected included patient demographics, treatment characteristics, and complication rates. Assessed complications included major infection requiring intravenous antibiotic or reoperation, minor infection requiring oral antibiotic, hematoma, seroma, wound issues, deep vein thrombosis, mastectomy flap necrosis, reoperation, implant explantation, and rehospitalization. The primary outcome was a comparison of complication rates between patients who received ILR and those who did not.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The study included 178 patients (68 with ILR and 110 without ILR), accounting for implant reconstruction in 266 breasts. Mean operative time was significantly longer in the ILR group (326 min vs. 245, <i>p</i> < 0.001). Despite this, overall complication rates were comparable (38% vs. 34%, <i>p</i> = 0.63). No significant differences were observed in infection rates, seroma formation, reoperations, or implant explantations over a three-year follow-up period. Age and BMI were identified as independent predictors of complications.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Despite longer operative times, ILR demonstrates a comparable safety profile to implant-based breast reconstruction when performed concurrently following ALND.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 6","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145069894","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Microvascular free-flap transfer is a widely used technique for reconstructing complex tissue defects. While early postoperative flap survival depends on intact vascular anastomoses, neovascularization may contribute to long-term viability. However, direct intraoperative human evidence of early neovascularization in free flaps remains limited. This case report aims to provide direct intraoperative evidence of early neovascularization in a free SCIP flap. We present a case of an 88-year-old female who underwent wide resection of a soft tissue sarcoma and reconstruction with a free superficial circumflex iliac artery perforator (SCIP) flap. The flap survived uneventfully, but on postoperative Day 19, the patient sustained a fall, resulting in a tibial fracture requiring a secondary operation. During this procedure, multiple neovascular perforators were observed between the recipient bed and the previously transplanted SCIP flap. Specifically, at least two neovascular perforators measuring 0.3 mm and 0.5 mm were identified, confirming active neovascularization. This case provides rare intraoperative human evidence of neovascularization in a free flap. While previous studies have questioned the extent of neovascularization, our findings suggest that new vascular connections may form under favorable conditions, such as a well-vascularized recipient site. Neovascularization may offer an additional layer of vascular support in free flaps, particularly in cases of partial vascular compromise. Further research is needed to determine its clinical significance and potential implications for reconstructive surgery.
{"title":"Intraoperative Evidence of Early Neovascularization in a SCIP Flap Following Postoperative Trauma: A Case Report","authors":"Lorena Ballerini, Ryo Karakawa, Tomoyuki Yano","doi":"10.1002/micr.70121","DOIUrl":"10.1002/micr.70121","url":null,"abstract":"<div>\u0000 \u0000 <p>Microvascular free-flap transfer is a widely used technique for reconstructing complex tissue defects. While early postoperative flap survival depends on intact vascular anastomoses, neovascularization may contribute to long-term viability. However, direct intraoperative human evidence of early neovascularization in free flaps remains limited. This case report aims to provide direct intraoperative evidence of early neovascularization in a free SCIP flap. We present a case of an 88-year-old female who underwent wide resection of a soft tissue sarcoma and reconstruction with a free superficial circumflex iliac artery perforator (SCIP) flap. The flap survived uneventfully, but on postoperative Day 19, the patient sustained a fall, resulting in a tibial fracture requiring a secondary operation. During this procedure, multiple neovascular perforators were observed between the recipient bed and the previously transplanted SCIP flap. Specifically, at least two neovascular perforators measuring 0.3 mm and 0.5 mm were identified, confirming active neovascularization. This case provides rare intraoperative human evidence of neovascularization in a free flap. While previous studies have questioned the extent of neovascularization, our findings suggest that new vascular connections may form under favorable conditions, such as a well-vascularized recipient site. Neovascularization may offer an additional layer of vascular support in free flaps, particularly in cases of partial vascular compromise. Further research is needed to determine its clinical significance and potential implications for reconstructive surgery.</p>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 6","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145075788","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The aim of this study is to compare the traditional triple innervation technique with a new version, designed to reduce eye-mouth synkinesis. To reduce unpleasant synkinesis, the authors proposed changing the connection between the masseteric nerve and the injured facial nerve, analyzing the outcome in terms of reduction of synkinesis and power of contraction of the mimic muscle. The traditional technique conveys the quantitative stimuli from the masseteric nerve to the temporofacial branch and from the hypoglossal nerve (30%) to the cervicofacial branch. Traditionally, the stimulus coming from the masseteric nerve is directed in that way to both the orbicularis oculi and the great zygomatic muscle, leading to eye-mouth synkinesis. The evolved technique connects the masseteric nerve more distally on the branch directed to the great zygomatic muscle and the hypoglossal nerve (30%) to the main trunk of the injured facial nerve. Long-term follow-up could be interesting to check what happens to the eye without the stimulus coming from the masseteric nerve.
Methods
Exactly 32 patients were included, subdivided into two groups based on the type of surgical technique. Static symmetry, voluntary movements, and synkinesis were evaluated with eFACE software.
Results
Both techniques allowed to obtain excellent outcomes: pre- and post-operative parameters showed a statistically significant improvement in both groups and no differences between the two groups, except in palpebral fissure width forced eye closure, in oculo and midfacial synkinesis: a significant reduction of synkinesis was evident in the evolved version group.
Conclusions
The new triple innervation offers significant improvements in reducing synkinesis, ocular and mid-facial muscle spasm, leading to a more relaxed tone at rest.
{"title":"Evolution of Triple Innervation Technique in the Treatment of Facial Paralysis","authors":"Fabiana Allevi, Amelia Beretta, Federico Bolognesi, Filippo Tarabbia, Valeria Battista, Federico Biglioli","doi":"10.1002/micr.70111","DOIUrl":"https://doi.org/10.1002/micr.70111","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The aim of this study is to compare the traditional triple innervation technique with a new version, designed to reduce eye-mouth synkinesis. To reduce unpleasant synkinesis, the authors proposed changing the connection between the masseteric nerve and the injured facial nerve, analyzing the outcome in terms of reduction of synkinesis and power of contraction of the mimic muscle. The traditional technique conveys the quantitative stimuli from the masseteric nerve to the temporofacial branch and from the hypoglossal nerve (30%) to the cervicofacial branch. Traditionally, the stimulus coming from the masseteric nerve is directed in that way to both the orbicularis oculi and the great zygomatic muscle, leading to eye-mouth synkinesis. The evolved technique connects the masseteric nerve more distally on the branch directed to the great zygomatic muscle and the hypoglossal nerve (30%) to the main trunk of the injured facial nerve. Long-term follow-up could be interesting to check what happens to the eye without the stimulus coming from the masseteric nerve.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Exactly 32 patients were included, subdivided into two groups based on the type of surgical technique. Static symmetry, voluntary movements, and synkinesis were evaluated with eFACE software.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Both techniques allowed to obtain excellent outcomes: pre- and post-operative parameters showed a statistically significant improvement in both groups and no differences between the two groups, except in palpebral fissure width forced eye closure, in oculo and midfacial synkinesis: a significant reduction of synkinesis was evident in the evolved version group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The new triple innervation offers significant improvements in reducing synkinesis, ocular and mid-facial muscle spasm, leading to a more relaxed tone at rest.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 6","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145057819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Free flap transfer is an essential technique for head and neck reconstruction after oncological ablative resection. Selection of recipient vessels can be challenging in patients with a history of neck dissection and/or radiotherapy. We analyzed outcomes with regard to recipient vessel selection and flap failure, referring to patients' histories of radiotherapy and/or neck dissection.
Methods
Records of 671 patients who had undergone head and neck reconstruction in our institution from April 2018 to March 2024 were retrospectively reviewed. We divided patients into four groups based on their treatment history: radiotherapy alone (RT, n = 82), neck dissection alone (ND, n = 43), both radiotherapy and neck dissection (NDRT, n = 39), and intact neck with no history of radiotherapy or neck dissection (IN, n = 488). We collected data on flap types, defect areas, selected recipient vessels, and the occurrence of flap failure. We also assessed the risk factors for flap failure.
Results
In Group RT, 66 of 84 (79%) recipient vessels were located within irradiated areas. In contrast, in Group ND, 37 of 45 (82%) recipient vessels were outside the dissected areas. No significant association was observed between overall flap failure and variables we assessed. However, our additional flap failure analysis by arterial or venous factors showed an association with the patients' history of radiation treatment (p < 0.05) and in cases where anastomosed vessels were actually located within irradiated areas (p < 0.05).
Conclusion
In patients with previous radiotherapy history, recipient vessels even within irradiated areas can often be successfully used as recipient vessels. However, after undergoing irradiation treatment, the risk of venous-related flap failure may be higher compared with the non-irradiated area; thus, it necessitates careful consideration during reconstruction.
背景游离皮瓣移植是肿瘤消融切除后头颈部重建的重要技术。对于有颈部剥离和/或放疗史的患者，选择受体血管可能具有挑战性。我们分析了有关受体血管选择和皮瓣失败的结果，参考了患者的放疗史和/或颈部剥离。方法回顾性分析我院2018年4月至2024年3月671例头颈部重建术患者的临床资料。我们根据患者的治疗史将患者分为四组：单纯放疗组（RT, n = 82）、单纯颈部清扫组（ND, n = 43）、同时放疗和颈部清扫组（NDRT, n = 39）、完整颈部且无放疗或颈部清扫史（IN, n = 488）。我们收集了皮瓣类型、缺损区域、选择的受体血管和皮瓣失败的发生等数据。我们还评估了皮瓣失败的危险因素。结果RT组84只受体血管中有66只（79%）位于辐照区。相反，在ND组，45条受体血管中有37条（82%）位于解剖区之外。我们所评估的变量与皮瓣整体失效之间没有明显的关联。然而，我们通过动脉或静脉因素进行的额外皮瓣失效分析显示，与患者的放射治疗史（p < 0.05）以及吻合血管实际上位于辐照区域的病例（p < 0.05）有关。结论既往有放疗史的患者，即使在放疗区域内，也可成功使用受体血管。然而，在接受辐照治疗后，静脉相关皮瓣失效的风险可能高于未辐照区；因此，在重建过程中需要仔细考虑。
{"title":"Vessel Selection in Head and Neck Reconstruction After Neck Dissection or Radiotherapy","authors":"Yasufumi Makiuchi, Daisuke Kageyama, Masaki Arikawa, Satoshi Akazawa","doi":"10.1002/micr.70116","DOIUrl":"https://doi.org/10.1002/micr.70116","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Free flap transfer is an essential technique for head and neck reconstruction after oncological ablative resection. Selection of recipient vessels can be challenging in patients with a history of neck dissection and/or radiotherapy. We analyzed outcomes with regard to recipient vessel selection and flap failure, referring to patients' histories of radiotherapy and/or neck dissection.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Records of 671 patients who had undergone head and neck reconstruction in our institution from April 2018 to March 2024 were retrospectively reviewed. We divided patients into four groups based on their treatment history: radiotherapy alone (<i>RT</i>, <i>n</i> = 82), neck dissection alone (<i>ND</i>, <i>n</i> = 43), both radiotherapy and neck dissection (<i>NDRT</i>, <i>n</i> = 39), and intact neck with no history of radiotherapy or neck dissection (<i>IN</i>, <i>n</i> = 488). We collected data on flap types, defect areas, selected recipient vessels, and the occurrence of flap failure. We also assessed the risk factors for flap failure.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>In <i>Group RT</i>, 66 of 84 (79%) recipient vessels were located within irradiated areas. In contrast, in <i>Group ND</i>, 37 of 45 (82%) recipient vessels were outside the dissected areas. No significant association was observed between overall flap failure and variables we assessed. However, our additional flap failure analysis by arterial or venous factors showed an association with the patients' history of radiation treatment (<i>p</i> < 0.05) and in cases where anastomosed vessels were actually located within irradiated areas (<i>p</i> < 0.05).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>In patients with previous radiotherapy history, recipient vessels even within irradiated areas can often be successfully used as recipient vessels. However, after undergoing irradiation treatment, the risk of venous-related flap failure may be higher compared with the non-irradiated area; thus, it necessitates careful consideration during reconstruction.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18600,"journal":{"name":"Microsurgery","volume":"45 6","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145007988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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