Microsurgery最新文献

Background

The purpose of this meta-analysis was to compare the surgical outcomes of head and neck reconstruction via free flap surgery, with neck vessels versus superficial temporal vessels as recipient vessels.

Methods

The PubMed, Embase, and Scopus databases were systematically searched via the following keywords: (“superficial temporal” OR “temporal”) AND (“free flap” OR “free tissue transfer”) AND (“head and neck” OR “face”). The following data were extracted: first author, publication year, flap type, reconstruction region, concordant vein graft, recipient vessel, and postoperative complications, including thrombosis, partial necrosis, and flap failure. The recipient vessels were divided into two groups: the superficial temporal artery (STA)/V group and the neck group.

Results

Six hundred and thirty-five studies that met the inclusion criteria were included and reviewed systematically for a meta-analysis. Compared with the neck vessel group, the STA/V vessel group had a significantly greater risk of flap failure (odds ratio: 2.18; 95% CI: 1.32–3.60; p = 0.002), with low heterogeneity (p = 0.84; I² = 0%). However, there were no significant differences in the rates of thrombosis or partial necrosis.

Conclusions

Compared with the use of neck vessels, the use of STA/V vessels as recipient vessels for head and neck reconstruction could increase the risk of total flap necrosis. Considering these findings, surgeons should exercise caution when selecting the STV as the recipient site, and as some authors have suggested, proximal dissection may be necessary during surgery.

Background

Indocyanine green fluorescence angiography (ICGFA) is gaining popularity for the assessment of reconstructive flap perfusion intraoperatively. This study analyses the literature with a focus on its clinical efficacy and cost-effectiveness across various plastic and reconstructive surgery procedures.

Methods

A systematic review was conducted in accordance with PRISMA guidelines on published studies in English comparing ICGFA with standard clinical assessment for flap perfusion. Meta-analysis concerned perfusion-related complications and cost data.

Results

Twenty-five studies met the inclusion criteria, of which two were randomized controlled trials (RCTs) and four were prospective cohort studies. Twenty-one studies were AHRQ Standard ‘Good’; however, the overall level of evidence remains low. ICGFA was predominantly performed in breast surgeries (n = 3310) and head and neck reconstruction (n = 701) albeit with inconsistency in protocols and predominantly subjective interpretations (only five studies utilized objective thresholds). In breast surgery, meta-analysis demonstrated significant reductions in mastectomy skin flap necrosis (odds ratio (OR) 0.58, p < 0.0001), fat necrosis (OR 0.31, p < 0.001), infection (OR 0.66, p = 0.02), and re-operation (OR 0.40, p < 0.0001), but no significant decrease in total or partial flap loss (OR 0.78, p = 0.57/OR 0.87, p = 0.56, respectively) or increase in dehiscence (OR 1.55, p = 0.11). In head and neck surgery, ICGFA significantly decreased total flap loss (OR 0.47, p = 0.04), although not partial flap loss (OR 0.37, p = 0.13) and reoperation (OR 0.92, p = 0.73). Lower limb (n = 104) and abdominal wall (n = 95) reconstructive surgeries were much less studied with no significant ICGFA impact. Seven studies reported cost savings with flap surgeries and breast reconstructions, although study heterogeneity precluded meta-analysis.

Conclusions

ICGFA appears to be a useful, cost-effective tool to identify otherwise unsuspected hypoperfusion in breast and head and neck reconstruction. There is a clear need for standardization, however, to avoid bias. Further RCTs are necessary to solidify these promising clinical findings.

Background

The lower extremities are the largest donor sites in the body for perforator flap reconstruction. Multislice row computed tomography angiography allows for a multiplanar assessment of perforators using a large number of three-dimensional images with high resolution. In this study, the effect of leg dominance on perforator flap donor site preference was investigated radiologically to increase preoperative perforator mapping precision and surgical success.

Patients and Methods

The study included 40 patients. Superior gluteal artery perforator (SGAP) flap, inferior gluteal artery perforator (IGAP) flap, superficial circumflex iliac artery perforator flap, anterolateral thigh (ALT) flap, profunda artery perforator (PAP) flap, medial sural artery perforator (MSAP) flap, peroneal artery perforator (PP) flap, and posterior tibial artery perforator (PTAP) flap were analyzed according to their number of perforators (> 0.8-mm perforators counted, number of larger perforators [nLP]), dominant perforator diameter (DPD), related muscle thickness (RMT), and related subcutaneous tissue thickness (RSTT) in each leg.

Results

Of these 40 patients, 35 (87.5%) were right-leg dominant and 5 (12.5%) were left-leg dominant. The dominant leg had higher DPD for MSAP, PTAP, and PP than the nondominant leg (p = 0.08, p = 0.06, and p = 0.06, respectively). The dominant leg had a significantly higher nLP (> 0.8 mm) in MSAP, PTAP, and PP flaps than the nondominant leg (p < 0.05). Except for the PAP flap (adductor magnus muscle; p > 0.05), RMT of all other perforator flaps (SGAP, IGAP, ALT, MSAP, PTAP, and PP) was statistically higher in the dominant leg (p < 0.05). There was no statistically significant difference in RSTT between any of the two groups (p > 0.05).

Conclusion

According to findings, the dominant leg could be considered a donor site preference to improve surgical outcomes and reduce microsurgical complications due to an increased nLP, perforator diameter, and RMT.

Introduction

Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field.

We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation.

Methods

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included.

Results

One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery.

Conclusion

Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.

Background

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a significant risk of morbidity and mortality in surgical patients, especially those undergoing head and neck cancer surgery with microvascular free flap reconstruction. These patients are at a heightened risk of VTE due to numerous patient and surgical risk factors. VTE chemoprophylaxis guidelines in these patients are limited due to a distinct paucity of research. This study aims to contribute to this scarcity of information, providing guidance for surgeons.

Methods

This retrospective cohort study evaluated the efficacy and safety of subcutaneous unfractionated heparin administered every 8 h versus every 12 h for postoperative VTE prophylaxis in patients undergoing head and neck resections with immediate free flap reconstruction. Data was collected from hospital medical records between January 2010 to December 2021. Patient demographics, operative details, and outcomes, including incidence of VTE and bleeding complications, were analyzed.

Results

Among 622 patients, those receiving heparin every 8 h (n = 393) demonstrated a significantly lower rate of VTE (0.8%) compared to 12-hourly group (n = 229; 3.9%) (p = 0.006). Additionally, there were no significant differences in the rates of postoperative hematoma between the two groups (9.4% versus 7.9% respectively, p = 0.510).

Conclusion

Our study suggests that an increased daily dose of unfractionated heparin every 8 h for VTE chemoprophylaxis is superior to a 12-hourly regimen with comparable bleeding profiles. Further multicentre, prospective studies are needed to validate these results and compare the efficacy and safety of unfractionated heparin with other agents such as low-molecular-weight heparin in this patient group.

Background

This study compares the outcomes of osteocutaneous radial forearm free flap (OC-RFFF) and fibula free flap (FFF) reconstruction of mandibular osteoradionecrosis (ORN).

Methods

Retrospective review of patients undergoing OC-RFFF/FFF reconstruction for mandible ORN between 2005 and 2020 at a tertiary center. Patient characteristics, postoperative complications, and functional outcomes were evaluated using chi-squared and logistic regression analysis.

Results

Fifty-six patients were included (OC-RFFF: 38; FFF: 18). Significantly more OC-RFFF patients had lateral mandible defects (94% vs. 61%, p = 0.0014). There were significantly more patients with exposed intraoral bone in the OC-RFFF group (23% vs. 0% p = 0.02), but no significant differences in hardware complications or flap failure. Donor site partial skin graft loss was more common in the FFF group (22% vs. 2.6%, p = 0.016), but no other significant differences in donor site morbidity were seen. Bivariable analysis showed no impact of flap type, tobacco/alcohol use, diabetes, or hypothyroidism on postoperative complications. Sixty percent of OC-RFFF, and 67% of FFF, patients resumed an oral diet after surgery. Oral diet was not impacted by flap type (OR = 0.769, 95% CI = 0.201–2.706, p = 0.688).

Conclusion

The OC-RFFF is an acceptable option in the reconstruction of ORN involving the lateral mandible, though there is increased risk of bone exposure. These findings can help guide surgeon selection of microvascular free flap donor sites and appropriate patient counseling.

Background

Vascularized lymphnode transfer (VLNT) is one of the most common surgical treatments for moderate and severe lymphedema. Various techniques have been described for harvesting lymph nodes from different donor sites. However, a standardized harvest procedure is still lacking. The transplantation of inguinal lymph nodes using the perforator-to-perforator technique may represent a significant advancement in this context. This approach relies always on the same vascular pedicle, offers a lower morbidity, and allows for a more superficial inset at the recipient site.

Patients and Methods

Between 2019 and 2022, 12 patients received a perforator-to-perforator VLNT for the treatment of late stage (Late II) lymphedema, both primary and secondary. In all cases, the lymphnodes were harvested from the groin supplied by the superficial circumflex iliac artery perforator (SCIP) vessels. The average age was 62.2 years old (range 47–73 years old); nine patients were females and three were males. In 11 cases, the lower limb was affected, and in one case, the upper limb was affected. Eight patients received additional lymphovenous anastomosis.

Results

All the patients reported an improvement of the symptoms after surgery in terms of tissue quality (tenderness, lymphangiectasia, and pain), and no cases of recurrent cellulitis were reported. Postoperative lymphoscintigraphy was performed at 6 months, and in all cases, the function of transplanted lymphnodes was confirmed. No complications were encountered, neither at donor nor at recipient site. The follow-up was at least 12 months in all patients.

Conclusions

Despite being more technically demanding, the systematic implementation of the perforator-to-perforator technique for the transfer of SCIP-based inguinal lymphnodes can be a valuable evolution of VLNT. The aim of this study is to present how this technical approach may become a standardized procedure for inguinal-based VLNT, offering a reduced donor and recipient site morbidity and potentially enhancing the lymph draining effects due to a more superficial inset.