Microsurgery最新文献

Purpose: Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects.

Methods: We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review.

Results: Six patients with eight MVFFs were included. Five were adults and one was a child; four were females and two were males. All defects were located on the posterior trunk/buttocks. Flap types included four standard latissimus dorsi (LD), three anterolateral thigh (ALT), and one extended conjoined LD flap. Average skin paddle size was 232 cm² (±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases.

Conclusions: Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.

Purpose: When reconstructing extensive defects with large perforator flaps, incorporating multiple perforators from different perforasomes may improve perfusion reliability, for which intraflap anastomosis can be an effective strategy. Although well described in breast reconstruction, its application in other perforator flaps remains limited. This report reviews its application in thoracodorsal artery perforator (TDAP) and anterolateral thigh (ALT) flaps to explore feasible strategies.

Methods: Patients who underwent reconstruction with bipedicled ALT or TDAP flaps using intraflap anastomosis between 2019 and 2023 were reviewed. This technique was reserved for cases requiring large flaps without a single dominant perforator, necessitating multiple perforators from different source vessels. Operative details and postoperative outcomes were evaluated.

Results: Twelve cases (six TDAP and six ALT flaps) were analyzed. Median defect and flap sizes were 224 and 238.5 cm², respectively. In the TDAP group, the descending branch of the thoracodorsal artery was most commonly used as the primary pedicle, and its serratus branch served as the recipient for intraflap anastomosis with the dorsal intercostal or scapular artery perforator. In the ALT group, the descending branch of the lateral circumflex femoral artery was the primary pedicle, with the oblique or ascending branch as the secondary; the distal runoff of the descending branch served as the recipient. Except for one case of tip necrosis, no perfusion-related complications occurred.

Conclusion: This small retrospective report suggests that the intraflap anastomosis technique appears to be a feasible approach for expanding vascular territories in TDAP and ALT flaps, offering a valuable option for extensive defect reconstruction when indicated.

Background: Accurate preoperative localization of perforators is crucial for the success of perforator-based flaps. While handheld Doppler (HHD) is commonly used, newer modalities like infra-red (IR) thermography and indocyanine green (ICG) angiography may offer greater accuracy and precision. We aimed to compare the diagnostic accuracy of HHD, IR thermography, and ICG angiography in identifying perforators in the anterolateral thigh (ALT) flap.

Methods: This was a single-centre, three-arm parallel randomized controlled trial conducted from May 2023 to April 2025 in the Department of Burns and Plastic Surgery at a tertiary care center. Sixty patients undergoing ALT flap reconstruction were randomized (1:1:1) to HHD, IR thermography, or ICG angiography groups. The primary outcome was the diagnostic accuracy of each modality in perforator localization (defined as spatial concordance with intra-operative location). Secondary outcomes included flap complications and duration of flap harvest. Data were analyzed using ANOVA and chi-square tests.

Results: Oncological resection was the most common indication for flap surgery (53.3%), and the head and neck region was the commonest site of reconstruction. ICG angiography demonstrated the highest diagnostic accuracy (85%), sensitivity (94.4%), and positive predictive value (89.47%) compared to IR thermography (50%, 100%, and 50%) and HHD (15%, 75%, and 15.79%) (p < 0.0001). There was no significant difference in flap complication rates or hospital stay between groups. Diagnostic accuracy was lower in obese patients across all modalities.

Conclusion: The accuracy of ICG was better than IR Thermography and HHD in detecting perforators pre-operatively in patients undergoing ALT flap surgery.

Trial registration: CTRI/2023/05/053290.

Introduction: Peripheral nerve injuries often lead to significant functional impairment. While autografts remain the gold standard for repairing critical-sized nerve defects, donor site morbidity and limited graft availability have prompted the exploration of alternative strategies. Although studies investigating nerve regeneration using nerve conduits and biological agents are present in the literature, research investigating the effect of neurotrophic factors enriched secretome with biocompatible 3D conduits combination is insufficient. The aim of this study is to evaluate the regenerative potential of 3D biodegradable chitosan-PCL nerve conduit combined with BDNF-enriched secretome in peripheral nerve defects.

Methods: In this study, biodegradable three-dimensional (3D) nerve conduits composed of polycaprolactone (PCL) and chitosan (75:25 wt/wt) were fabricated and used to bridge 10 mm sciatic nerve defects in rats. The conduits were evaluated alone or in combination with the secretome derived from Wharton's Jelly mesenchymal stem cells (WJ-MSC), either in the native form or enriched with brain-derived neurotrophic factor (BDNF). Thirty-two adult male Wistar Albino rats (mean weight 300-400 g) were randomized into four groups: Autograft (Group 1), conduit only (Group 2), conduit and WJ-MSC derived secretome (Group 3), and conduit combined with BDNF-enriched WJ-MSC derived secretome (Group 4). Functional recovery was assessed using the sciatic functional index (SFI), electromyography (EMG), and gastrocnemius muscle wet weight. Morphological and histological evaluations were performed at 12 weeks postoperatively.

Results: At the end of 12 weeks, Group 4 (-49.48 ± 2.82) exhibited significantly improved SFI values compared to Group 2 (-66.62 ± 5.31) and Group 3 (-60.60 ± 5.34) (p < 0.05). Electromyographic analysis revealed higher compound muscle action potential amplitutes in Group 4 (19.72 ± 3.62 mV) than Group 2 and Group 3 (p < 0.05), with values compared to the autograft group. Gasrtrocnemius muscle wet weight ratios were also significantly higher in Group 4 (69.09% ± 9.88%) than in Groups 2 and 3. Histological analyses showed enhanced axonal regeneration, reduced inflammation, and better myelination in Group 4. Scanning electron microscopy confirmed the conduit structural integrity and stability over the 12-week period.

Conclusion: The combination of a 3D biodegradable chitosan-PCL conduit with BDNF-enriched WJ-MSC-derived secretome significantly enhanced peripheral nerve regeneration in a rat model. This strategy shows strong potential as an alternative to autografts for treating critical-sized nerve defects.

Nasal reconstruction is one of the most challenging procedures in plastic surgery, requiring restoration of the three-dimensional structure, precise contour, internal lining, and airway function. These challenges are further amplified when traditional donor sites are unavailable, particularly in elderly patients or those undergoing concomitant treatments. We report the case of a 78-year-old man on immunosuppressive therapy following kidney transplantation, presenting with recurrent basal cell carcinoma affecting the middle and lower thirds of the nose. After tumor excision resulting in a 7 × 5 cm defect, and given the patient's characteristics and limitations of conventional options, a customized super-thin anterolateral thigh (ALT) flap (7 × 16 × 0.8 cm) combined with nasal septal and auricular cartilage grafts was chosen for reconstruction. Postoperative recovery was uneventful, and at 6 months, the patient demonstrated normal nasal contour, an open airway, and no signs of recurrence. Despite inherent limitations related to skin and subcutaneous tissue quality and thickness, a super-thin ALT flap may represent a reliable single-stage alternative for total nasal reconstruction in selected high-risk patients.

Background: Free tissue transfer requires meticulous postoperative monitoring to detect vascular occlusion. Although experimental studies have explored the relationship between interstitial glucose levels and tissue perfusion, long-term evaluation of glucose levels during and after occlusion-reperfusion has not been thoroughly investigated. The study objective was to investigate the correlation between controlled venous and arterial occlusion and changes in interstitial tissue glucose, using a remote interstitial glucose monitoring device.

Materials and methods: This experimental study was conducted on eight New Zealand White rabbits, each weighing between 3.2 and 3.8 kg, under general anesthesia, utilizing a 4 × 8 cm perforator flap supplied by skin perforators originating from the thoracodorsal artery. Interstitial glucose levels within the flaps were continuously monitored using FreeStyle Libre flash glucose monitoring system. Baseline glucose levels were recorded 1 day prior to vascular occlusion, followed by monitoring between 15 min intervals during experimental clamping of both venous ischemia (75 min), venous decongestion (75 min), and arterial occlusion (45 min). Criteria for detecting vessel occlusion were established based on changes in interstitial glucose concentration.

Results: Venous occlusion was associated with a significant increase in interstitial glucose levels. At 15 min post-occlusion, interstitial glucose increased by 47.8%, which was significantly higher than baseline (p = 0.018). However, at 30 min post-unclamping, interstitial glucose declined by 18.3% (p = 0.028) and by 57.4% over 75 min. In contrast, arterial occlusion was associated with a rapid decline in glucose levels. At 15 min post-occlusion, interstitial glucose decreased by 56% (p = 0.018). Total necrosis was observed in all flaps followed by arterial occlusion.

Conclusions: Interstitial glucose monitoring appears to be a reliable method for detecting vascular occlusion in free tissue transfers within this experimental model. This technique may offer a rapid, minimally invasive, and cost-effective approach for postoperative vascular monitoring of free flaps. Further investigation in human trials is warranted to confirm these findings and assess clinical utility.

Objective: Free tissue transfer is standard in head and neck reconstruction, with the thigh serving as a primary donor site. Contemporary evidence specifically addressing the tensor fascia lata perforator (TFLp) flap, particularly as an immediate alternative when anterolateral thigh (ALT) perforators are absent or unreliable, remains limited. This study aimed to evaluate the TFLp flap as a reliable lateral thigh-based backup option and clinical relevance.

Methods: A retrospective study was conducted on 20 patients with oral cancer who underwent microsurgical reconstruction of head and neck defects using TFLp flaps, based on data collected from 957 thigh-based flap reconstructions over 5 years from 2019 to 2023. All TFLp flaps were harvested in cases without visible or sizable perforator of the ALT flap during dissection at the same donor thigh region. Patient demographics, clinical characteristics, flap dimensions, perforator characteristics, and surgical outcomes were retrospectively reviewed and analyzed.

Results: The harvested TFLp flaps ranged in size from 6 × 4 cm to 20 × 13 cm. Sixty percent of the musculocutaneous perforators required intramuscular dissection, while 40% were septocutaneous. Most flaps (70%) included a single perforator, whereas (30%) had two or more perforators. The overall flap success rate was 95%, with 19 out of 20 flaps surviving successfully. Complications occurred in five patients (25%), including two cases of vascular complications, two hematomas, and one infection. Four of these complications were successfully salvaged. Complications were observed in patients with higher BMI (p-value = 0.0049) and hypertension (p-value = 0.032).

Conclusion: The TFLp flap is an effective alternative lateral thigh-based option in cases in which the ALT flap could not be used for complex head and neck reconstructions.

Introduction: Tranexamic acid (TXA), an antifibrinolytic agent, has demonstrated efficacy in reducing perioperative bleeding across multiple surgical interventions. While increasingly utilized in breast reconstruction, evidence regarding its role in free flap procedures remains limited and inconsistent. This study evaluates the impact of preoperative TXA administration on postoperative outcomes in free flap breast reconstruction.

Methods: A retrospective cohort study was performed using the TriNetX research network to identify patients undergoing free flap breast reconstruction. Patients receiving preoperative TXA were compared with those who did not. Propensity score matching was applied to balance demographic and clinical variables. Primary outcomes included hematoma, seroma, bleeding, venous thrombosis, and flap loss.

Results: Among 20,778 patients, 524 (2.5%) received preoperative TXA. After 1:1 propensity score matching, 524 TXA patients were compared with 524 controls. Hematoma rates were significantly higher in the TXA group (21.2% vs. 15.3%, RR 0.72, 95% CI 0.55-0.94, p = 0.01). Seroma occurred more frequently in TXA patients (23.2% vs. 18.9%) but was not statistically significant (p > 0.05). Postoperative bleeding, venous thrombosis, and flap loss rates were comparable. Intraoperative hemorrhage occurred exclusively in the non-TXA group (≤ 1.9% vs. 0%, p = 0.001).

Conclusions: Contrary to prior reports, preoperative TXA use in free flap breast reconstruction was associated with a higher incidence of hematoma, without significant reduction in the rate of other complications.

Background: Reconstructing spinal defects complicated by surgical site infection (SSI) is challenging, with SSIs occurring in 1%-4% of spine surgeries, often involving hardware exposure. These infections increase hospital stays, costs, and risks of poor outcomes. Effective management strategies are crucial for addressing infected spinal wounds.

Methods: We conducted a systematic review following PRISMA-P guidelines across six databases. Included studies reported flap coverage for spinal reconstructions with or without hardware. Outcomes of interest included flap loss, partial flap necrosis, wound dehiscence, venous thrombosis, and infection rates. Quality was evaluated using ASPS criteria and the ROBINS-I tool.

Results: Out of 4436 articles, 32 studies were included, comprising 969 patients, with 496 undergoing reconstructions for infected chronic wounds. The mean patient age was 52.1 years. Infection contributors included spinal instrumentation, radiotherapy, smoking, and diabetes, with Staphylococcus aureus being the most common organism (52.7%). Paraspinal muscle flaps and latissimus dorsi flaps were most frequently used. Out of the 27 studies that investigated the need for hardware removal, eight reported patients required it in the postoperative period. The pooled flap survival rate was 89%, with muscle flaps showing higher effectiveness compared to fasciocutaneous flaps (92% vs. 85%). Other complications included wound dehiscence (12%), flap necrosis (8%), and reinfection (10%).

Conclusions: This study provides evidence-based insights into managing complex spinal defects. Flap reconstruction remains a viable solution for soft-tissue coverage, highlighting the importance of tailored surgical planning based on defect characteristics and patient factors.