Abstract Background Microsurgical procedures are still rare in many countries especially in resource-constrained countries. Among reasons for this is the unavailability of operating microscopes that are costly. Operating loupes are considered inferior to the microscope and are most discouraged for many microsurgical procedures. We audit patients operated under loupes for the past 10 years and present our findings. Patients and Methods This was a prospective audit of patients who underwent microsurgical reconstructive procedures in the plastic surgery unit at Kenyatta National Hospital between January 2009 and December 2019. Results A total of 352 patients with 360 procedures were done over a 10-year period. The age range for the patients was 5 to 90 years. Free flaps accounted for 78% of the surgical procedures (n = 298) followed by nerve repairs 8.8% (n = 32) and reimplantation surgeries 8.5% (n = 30). The overall success rate for free flaps was 93.3% with reimplantations of 77%. Conclusion Microsurgical reconstructive procedures as demonstrated in this study can safely be done with loupes. Loupes provide an alternative means of magnification that is cost effective and cheaper. In good hands, good surgical outcomes can be achieved that are comparable to the operating microscopes.
{"title":"Microsurgery: A 10-Year Experience with Loupe Magnification","authors":"F. Nangole, S. Khainga","doi":"10.1055/s-0040-1718517","DOIUrl":"https://doi.org/10.1055/s-0040-1718517","url":null,"abstract":"Abstract Background Microsurgical procedures are still rare in many countries especially in resource-constrained countries. Among reasons for this is the unavailability of operating microscopes that are costly. Operating loupes are considered inferior to the microscope and are most discouraged for many microsurgical procedures. We audit patients operated under loupes for the past 10 years and present our findings. Patients and Methods This was a prospective audit of patients who underwent microsurgical reconstructive procedures in the plastic surgery unit at Kenyatta National Hospital between January 2009 and December 2019. Results A total of 352 patients with 360 procedures were done over a 10-year period. The age range for the patients was 5 to 90 years. Free flaps accounted for 78% of the surgical procedures (n = 298) followed by nerve repairs 8.8% (n = 32) and reimplantation surgeries 8.5% (n = 30). The overall success rate for free flaps was 93.3% with reimplantations of 77%. Conclusion Microsurgical reconstructive procedures as demonstrated in this study can safely be done with loupes. Loupes provide an alternative means of magnification that is cost effective and cheaper. In good hands, good surgical outcomes can be achieved that are comparable to the operating microscopes.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e90 - e94"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1718517","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43826940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Paul A. Niziol, A. Doval, Faryan Jalalabadi, M. Klebuc
Abstract Background Glioblastoma multiforme (GBM) produces a hypercoagulable environment and is associated the highest rates of deep venous thrombosis (DVT) and pulmonary emboli (PE) of any malignancy. The use of postoperative radiation in this generally compromised patient group is associated with the development of complex scalp wounds. Free tissue transfer reconstruction will be essential in selected cases despite the presence of an underlying hypercoagulable state. Methods A 67-year-old female with a history of previous DVT presented with osteoradionecrosis and infected scalp wound following GBM treatment. She underwent reconstruction with a free vastus lateralis flap and skin graft. Initial anticoagulation was provided with intravenous heparin and transitioned to oral apixaban. Wound cultures demonstrated coagulase-negative Staphylococcus, Actinomyces neuii, and Peptoniphilus harei and were treated with a 6-week course of intravenous cefepime and vancomycin. Results Despite the initial failure of a local scalp rotation flap, successful wound healing was achieved with a free muscle flap and a course of culture specific antibiotics. The patient succumbed to recurrent disease 22 months after surgery, underscoring the importance of limiting hospitalization and maximizing quality of life in this group of patients. Conclusion Free tissue transfer can be successfully achieved in the hypercoagulable GBM patient. Heparin and apixaban were employed successfully in the prevention of thrombotic events. Antiplatelet therapy should also be considered to counteract platelet aggregation induced by the transmembrane glycoprotein (podoplanin) that is expressed on GBM tumor cells. Enzyme-linked immunosorbent assay testing (ELISA) of blood soluble podoplanin may help determine the degree of hypercoagulability and guide therapy.
{"title":"Successful Free Tissue Transfer in the Profoundly Hypercoagulable Glioblastoma Multiforme Patient: Surgical Experience and Anticoagulation Protocol","authors":"Paul A. Niziol, A. Doval, Faryan Jalalabadi, M. Klebuc","doi":"10.1055/s-0040-1716386","DOIUrl":"https://doi.org/10.1055/s-0040-1716386","url":null,"abstract":"Abstract Background Glioblastoma multiforme (GBM) produces a hypercoagulable environment and is associated the highest rates of deep venous thrombosis (DVT) and pulmonary emboli (PE) of any malignancy. The use of postoperative radiation in this generally compromised patient group is associated with the development of complex scalp wounds. Free tissue transfer reconstruction will be essential in selected cases despite the presence of an underlying hypercoagulable state. Methods A 67-year-old female with a history of previous DVT presented with osteoradionecrosis and infected scalp wound following GBM treatment. She underwent reconstruction with a free vastus lateralis flap and skin graft. Initial anticoagulation was provided with intravenous heparin and transitioned to oral apixaban. Wound cultures demonstrated coagulase-negative Staphylococcus, Actinomyces neuii, and Peptoniphilus harei and were treated with a 6-week course of intravenous cefepime and vancomycin. Results Despite the initial failure of a local scalp rotation flap, successful wound healing was achieved with a free muscle flap and a course of culture specific antibiotics. The patient succumbed to recurrent disease 22 months after surgery, underscoring the importance of limiting hospitalization and maximizing quality of life in this group of patients. Conclusion Free tissue transfer can be successfully achieved in the hypercoagulable GBM patient. Heparin and apixaban were employed successfully in the prevention of thrombotic events. Antiplatelet therapy should also be considered to counteract platelet aggregation induced by the transmembrane glycoprotein (podoplanin) that is expressed on GBM tumor cells. Enzyme-linked immunosorbent assay testing (ELISA) of blood soluble podoplanin may help determine the degree of hypercoagulability and guide therapy.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e74 - e78"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1716386","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46479562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Fouad Saeg, Elvira Chiccarelli, H. Hilaire, F. Lau
Abstract Background In complex extremity wounds, free flap-based limb salvage (fLS) is the standard of care. However, fLS is resource- and cost-intensive, and the limited availability of pediatric microsurgical expertise exacerbates these challenges. Regenerative LS (rLS) addresses these barriers to care. The aim of this study was to quantify the efficacy, safety, and cost-effectiveness of rLS in complex pediatric extremity wounds. Methods We conducted a retrospective cohort study of pediatric LS at a single hospital. Subjects were treated with fLS or rLS based on surgeon preference. Primary outcome measures were: definitive wound closure rates and time, rates of return to ambulation, number and length of procedures to achieve definitive closure, and rates of perioperative complications. Statistical analyses were performed utilizing the Wilcoxon Mann–Whitney U test with statistical significance set at p < 0.05. Results Over a 2-year period, nine consecutive patients presented with complex extremity wounds requiring fLS (n = 4) or rLS (n = 5). Demographics and wound characteristics were similar between groups. Compared with fLS, the rLS group achieved definitive wound closure 85.8% more quickly (13.8 vs. 97.5 days, p < 0.02), required 64.5% less operative time (132.6 vs. 373.0 minutes, p < 0.02), had fewer perioperative complications (0 vs. 5), and required fewer intensive care unit stays (0 vs. 1.3 days). Conclusion These data indicate that rLS is a safe and efficacious option in pediatric patients requiring soft tissue reconstruction for LS. Use of this novel technique can restore the reconstructive ladder, thereby expand patient access to pediatric LS while minimizing morbidity and reducing LS-related resource utilization.
{"title":"Regenerative Limb Salvage: A Novel Technique for Soft Tissue Reconstruction of Pediatric Extremities","authors":"Fouad Saeg, Elvira Chiccarelli, H. Hilaire, F. Lau","doi":"10.1055/s-0040-1718420","DOIUrl":"https://doi.org/10.1055/s-0040-1718420","url":null,"abstract":"Abstract Background In complex extremity wounds, free flap-based limb salvage (fLS) is the standard of care. However, fLS is resource- and cost-intensive, and the limited availability of pediatric microsurgical expertise exacerbates these challenges. Regenerative LS (rLS) addresses these barriers to care. The aim of this study was to quantify the efficacy, safety, and cost-effectiveness of rLS in complex pediatric extremity wounds. Methods We conducted a retrospective cohort study of pediatric LS at a single hospital. Subjects were treated with fLS or rLS based on surgeon preference. Primary outcome measures were: definitive wound closure rates and time, rates of return to ambulation, number and length of procedures to achieve definitive closure, and rates of perioperative complications. Statistical analyses were performed utilizing the Wilcoxon Mann–Whitney U test with statistical significance set at p < 0.05. Results Over a 2-year period, nine consecutive patients presented with complex extremity wounds requiring fLS (n = 4) or rLS (n = 5). Demographics and wound characteristics were similar between groups. Compared with fLS, the rLS group achieved definitive wound closure 85.8% more quickly (13.8 vs. 97.5 days, p < 0.02), required 64.5% less operative time (132.6 vs. 373.0 minutes, p < 0.02), had fewer perioperative complications (0 vs. 5), and required fewer intensive care unit stays (0 vs. 1.3 days). Conclusion These data indicate that rLS is a safe and efficacious option in pediatric patients requiring soft tissue reconstruction for LS. Use of this novel technique can restore the reconstructive ladder, thereby expand patient access to pediatric LS while minimizing morbidity and reducing LS-related resource utilization.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e82 - e89"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1718420","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42878595","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Andrea Vicente-Pardo, A. Pérez-García, Jorge Balaguer-Cambra, A. Thione, A. Sánchez-García
We have read with interest the article entitled “ Utilization of Intraparotid Segments of Super fi cial Temporal Vessels (STV) for Head and Scalp Free Flap Micronastomosis: A Clinical, Histological, and Cadaveric Study. ” 1 We congratulate Venkatesh et al for their relevant work. Super fi cial temporal vessels (STV) are very suitable vessels for head and scalp reconstruction 2 due to their proximity and relative easy dissection. Because of their tortuous anatomy and their small diameter, STV have been historically considered to be prone to vasospasm, and not appropriate vessels for microanastomosis in free fl ap reconstruction. In their article, authors explain tech-niques to facilitate their dissection and make it more reliable. We would like to share our positive experience with these receptor vessels.Atourhospital,STVareconsideredasprimary recipient vessels in microsurgery reconstruction of the scalp and upper and middle thirds of the face. Between 2015 and 2020, 16 patients underwent head – free fl ap reconstruction in our department, utilizing STV for anastomosis. Preauricular segment of STV were used as recipient vessels in all the cases. Average age was 54.9 and 10 patients had prior radiation (62.5%). Defect etiology included surgical wound infection or necrosis (50%), tumor resection (25%), osteoradionecrosis (12.5%), arteriovenous malformation (6.25%)
{"title":"Superficial Temporal Vessels for Head and Scalp Microsurgical Reconstruction","authors":"Andrea Vicente-Pardo, A. Pérez-García, Jorge Balaguer-Cambra, A. Thione, A. Sánchez-García","doi":"10.1055/s-0040-1715583","DOIUrl":"https://doi.org/10.1055/s-0040-1715583","url":null,"abstract":"We have read with interest the article entitled “ Utilization of Intraparotid Segments of Super fi cial Temporal Vessels (STV) for Head and Scalp Free Flap Micronastomosis: A Clinical, Histological, and Cadaveric Study. ” 1 We congratulate Venkatesh et al for their relevant work. Super fi cial temporal vessels (STV) are very suitable vessels for head and scalp reconstruction 2 due to their proximity and relative easy dissection. Because of their tortuous anatomy and their small diameter, STV have been historically considered to be prone to vasospasm, and not appropriate vessels for microanastomosis in free fl ap reconstruction. In their article, authors explain tech-niques to facilitate their dissection and make it more reliable. We would like to share our positive experience with these receptor vessels.Atourhospital,STVareconsideredasprimary recipient vessels in microsurgery reconstruction of the scalp and upper and middle thirds of the face. Between 2015 and 2020, 16 patients underwent head – free fl ap reconstruction in our department, utilizing STV for anastomosis. Preauricular segment of STV were used as recipient vessels in all the cases. Average age was 54.9 and 10 patients had prior radiation (62.5%). Defect etiology included surgical wound infection or necrosis (50%), tumor resection (25%), osteoradionecrosis (12.5%), arteriovenous malformation (6.25%)","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e49 - e49"},"PeriodicalIF":0.0,"publicationDate":"2020-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1715583","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48733242","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Background An adipofascial flap in the rat may provide new options for adding vascularization to scarred or nonvascularized beds for a variety of research studies. Current literature lacks sufficient description for a simple reproducible flap model for a vascularized pedicled flap in rats, in particular for neovascularization of allograft nerves for the reconstruction of sciatic nerve defects. The purpose of this study was to describe a surgical technique and determine long-term survivability for the pedicled superficial inferior epigastric artery fascial (SIEF) flap in the rat to meet requirement for a tunneled adipofascial flap to add vascularization to the sciatic nerve area. Methods The technique and use of a 4 × 3-cm SIEF flap are described. Twenty Lewis rats underwent the technique to determine feasibility. The flap was wrapped around processed allograft nerve reconstructions and viability of the flap was evaluated after 12 and 16 weeks. To visualize vessels, nerve grafts were harvested at 12 weeks and stained with hematoxylin-eosin and an antibody against microvessels (CD-34). Results All flaps remained viable after survival of 12 and 16 weeks. Complications included one hematoma formation and two lymphocele formations that did not have any impact on the flap. Immunohistochemistry confirmed an increase in microvessels and Schwann cell nuclei in the SIEF group compared with nerve samples from the unoperated, contralateral side. Conclusion A pedicled adipofascial flap model in the rat to provide a vascular bed for sciatic nerve reconstruction is detailed with long-term survivability evaluation of the flap. This flap is technically simple to be harvested and is suitable for revascularization procedures of various tissues in the lower abdomen, genital area, thigh, or upper limb of the rat.
{"title":"The Superficial Inferior Epigastric Artery Fascia Flap in Rats","authors":"T. Saffari, A. Bishop, A. Shin","doi":"10.1055/s-0040-1701201","DOIUrl":"https://doi.org/10.1055/s-0040-1701201","url":null,"abstract":"Abstract Background An adipofascial flap in the rat may provide new options for adding vascularization to scarred or nonvascularized beds for a variety of research studies. Current literature lacks sufficient description for a simple reproducible flap model for a vascularized pedicled flap in rats, in particular for neovascularization of allograft nerves for the reconstruction of sciatic nerve defects. The purpose of this study was to describe a surgical technique and determine long-term survivability for the pedicled superficial inferior epigastric artery fascial (SIEF) flap in the rat to meet requirement for a tunneled adipofascial flap to add vascularization to the sciatic nerve area. Methods The technique and use of a 4 × 3-cm SIEF flap are described. Twenty Lewis rats underwent the technique to determine feasibility. The flap was wrapped around processed allograft nerve reconstructions and viability of the flap was evaluated after 12 and 16 weeks. To visualize vessels, nerve grafts were harvested at 12 weeks and stained with hematoxylin-eosin and an antibody against microvessels (CD-34). Results All flaps remained viable after survival of 12 and 16 weeks. Complications included one hematoma formation and two lymphocele formations that did not have any impact on the flap. Immunohistochemistry confirmed an increase in microvessels and Schwann cell nuclei in the SIEF group compared with nerve samples from the unoperated, contralateral side. Conclusion A pedicled adipofascial flap model in the rat to provide a vascular bed for sciatic nerve reconstruction is detailed with long-term survivability evaluation of the flap. This flap is technically simple to be harvested and is suitable for revascularization procedures of various tissues in the lower abdomen, genital area, thigh, or upper limb of the rat.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e7 - e14"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1701201","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48677884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. Sayadi, Jennifer E. Fligor, Sean Couchois, G. Evans, A. Widgerow, B. Lanier
Abstract Background Time spent under the microscope is often a limiting factor as plastic surgery residents work toward proficiency in microsurgery. This study describes and assesses a novel application of a digital microscope compatible with smart devices which can consistently and reliably magnify microsurgical fields. Methods A digital microscope was used to display an “operating” field on a tablet device. Two junior plastic surgery residents participated in multiple training sessions. During each session, residents completed two sessions of a knot-tying task and a chicken vessel anastomosis task. The sessions were recorded on the tablet, photographed, and graded by an experienced microsurgeon utilizing three standardized microsurgery training scales (OWOMSA, OSATS, and Global scale) for evaluation. Between sessions, the residents received feedback from the experienced microsurgeon. Results Statistically significant improvements (p < 0.05) in microsurgical technique were observed across 16 areas assessed by the standardized evaluation scales. Additionally, the residents' surveys suggest favorable attitudes toward the digital microscope and its value as a training device. Conclusion Traditional operating microscopes present considerable barriers for effective microsurgical training. The digital microscope analyzed in the present study provides solutions to several of these barriers: it is economical, lightweight, portable, and can be set up by the trainee on any flat surface; photographing and recording capabilities via the connected tablet device make the digital microscope setup optimized for education. Our study demonstrates measurable improvements in trainee's skills with use of—as well as favorable trainee attitudes toward—the digital microscope, which could present a valuable addition to plastic surgery education.
{"title":"A Novel Application of Digital Microscope for Microsurgery Training","authors":"L. Sayadi, Jennifer E. Fligor, Sean Couchois, G. Evans, A. Widgerow, B. Lanier","doi":"10.1055/s-0040-1710346","DOIUrl":"https://doi.org/10.1055/s-0040-1710346","url":null,"abstract":"Abstract Background Time spent under the microscope is often a limiting factor as plastic surgery residents work toward proficiency in microsurgery. This study describes and assesses a novel application of a digital microscope compatible with smart devices which can consistently and reliably magnify microsurgical fields. Methods A digital microscope was used to display an “operating” field on a tablet device. Two junior plastic surgery residents participated in multiple training sessions. During each session, residents completed two sessions of a knot-tying task and a chicken vessel anastomosis task. The sessions were recorded on the tablet, photographed, and graded by an experienced microsurgeon utilizing three standardized microsurgery training scales (OWOMSA, OSATS, and Global scale) for evaluation. Between sessions, the residents received feedback from the experienced microsurgeon. Results Statistically significant improvements (p < 0.05) in microsurgical technique were observed across 16 areas assessed by the standardized evaluation scales. Additionally, the residents' surveys suggest favorable attitudes toward the digital microscope and its value as a training device. Conclusion Traditional operating microscopes present considerable barriers for effective microsurgical training. The digital microscope analyzed in the present study provides solutions to several of these barriers: it is economical, lightweight, portable, and can be set up by the trainee on any flat surface; photographing and recording capabilities via the connected tablet device make the digital microscope setup optimized for education. Our study demonstrates measurable improvements in trainee's skills with use of—as well as favorable trainee attitudes toward—the digital microscope, which could present a valuable addition to plastic surgery education.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e32 - e35"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1710346","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45434183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
T. Uemura, Mamoru Kikuchi, Hidetaka Watanabe, T. Yanai
Abstract Background The selection of appropriate recipient vessels is essential to the successful outcome of free flap transfer. To improve blood perfusion after reconstruction and reduce the risk of postoperative obstruction of flap vessels, multiple vessels should be chosen as candidate recipients. Methods For certainty of venous drainage, we have been performing venous anastomosis to the distal end of the recipient vein to utilize the reverse venous flow. Results A total of 48 cases of reconstruction of the head and neck or breast region with free flaps using retrograde venous anastomosis were performed. The method possibly improves flap circulation and the success rate of the free tissue transfer and reduces the need to extend surgery to search for multiple recipient veins. Conclusion We emphasized that retrograde limb of vein is useful as a second and/or rescued recipient in free tissue transfer. Retrograde venous anastomosis is a fine and reasonable option when appropriate recipient vessels cannot be found near the defect in the head and neck such as frozen neck or breast region.
{"title":"Use of the Retrograde Recipient Vein for Additional Outflow in Free Tissue Transfer","authors":"T. Uemura, Mamoru Kikuchi, Hidetaka Watanabe, T. Yanai","doi":"10.1055/s-0039-1701031","DOIUrl":"https://doi.org/10.1055/s-0039-1701031","url":null,"abstract":"Abstract Background The selection of appropriate recipient vessels is essential to the successful outcome of free flap transfer. To improve blood perfusion after reconstruction and reduce the risk of postoperative obstruction of flap vessels, multiple vessels should be chosen as candidate recipients. Methods For certainty of venous drainage, we have been performing venous anastomosis to the distal end of the recipient vein to utilize the reverse venous flow. Results A total of 48 cases of reconstruction of the head and neck or breast region with free flaps using retrograde venous anastomosis were performed. The method possibly improves flap circulation and the success rate of the free tissue transfer and reduces the need to extend surgery to search for multiple recipient veins. Conclusion We emphasized that retrograde limb of vein is useful as a second and/or rescued recipient in free tissue transfer. Retrograde venous anastomosis is a fine and reasonable option when appropriate recipient vessels cannot be found near the defect in the head and neck such as frozen neck or breast region.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e1 - e6"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0039-1701031","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48683458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Grace C. Lee, C. Cetrulo, A. Muniappan, Kei Yamada, K. Lillemoe
Abstract Background Chylous ascites is a debilitating condition characterized by milky, triglyceride-rich fluid accumulating in the peritoneum due to disruption of the intraabdominal lymphatic system. Medical management includes low-fat diets, somatostatin analogues, and therapeutic paracentesis, but is unsuccessful in one-third of patients. Methods We present a 59-year-old man with massive chylous ascites and chylothorax secondary to chronic pancreatitis, who failed medical therapies for nearly two years, before being successfully treated with a novel surgical technique. Demographic and clinical data were obtained from the electronic medical record at Massachusetts General Hospital from 2015 to 2019. Patient information was kept anonymous and informed consent was obtained for publication of this report. Results Based on a previously published small case series, we created a vascularized lymphatic cable flap based on the superior epigastric vessels, which we anastomosed to mesenteric vessels, permitting chylous drainage superiorly through the thoracic duct. With two years of follow-up, our patient has no evidence of recurrent ascites or chylothorax, and robust nutritional and functional status. Conclusion We present this novel surgical technique as a promising intervention for patients with chylous ascites and/or chylothorax who have failed medical management.
{"title":"Massive Chylous Ascites and Chylothorax Secondary to Chronic Pancreatitis: A Novel Surgical Option","authors":"Grace C. Lee, C. Cetrulo, A. Muniappan, Kei Yamada, K. Lillemoe","doi":"10.1055/s-0040-1710344","DOIUrl":"https://doi.org/10.1055/s-0040-1710344","url":null,"abstract":"Abstract Background Chylous ascites is a debilitating condition characterized by milky, triglyceride-rich fluid accumulating in the peritoneum due to disruption of the intraabdominal lymphatic system. Medical management includes low-fat diets, somatostatin analogues, and therapeutic paracentesis, but is unsuccessful in one-third of patients. Methods We present a 59-year-old man with massive chylous ascites and chylothorax secondary to chronic pancreatitis, who failed medical therapies for nearly two years, before being successfully treated with a novel surgical technique. Demographic and clinical data were obtained from the electronic medical record at Massachusetts General Hospital from 2015 to 2019. Patient information was kept anonymous and informed consent was obtained for publication of this report. Results Based on a previously published small case series, we created a vascularized lymphatic cable flap based on the superior epigastric vessels, which we anastomosed to mesenteric vessels, permitting chylous drainage superiorly through the thoracic duct. With two years of follow-up, our patient has no evidence of recurrent ascites or chylothorax, and robust nutritional and functional status. Conclusion We present this novel surgical technique as a promising intervention for patients with chylous ascites and/or chylothorax who have failed medical management.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e22 - e26"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1710344","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44991208","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Background In traumatic extremity reconstruction, it is preferable to perform microvascular anastomoses outside the zone of injury. Alternatively, a recipient-vessel thrombectomy can be performed to improve the arterial inflow, potentially avoiding further proximal dissection and the use of a vein graft. The objective of this study was to evaluate the outcomes of microvascular anastomosis after thrombectomy in the zone of injury. Methods A retrospective review of patients who underwent free tissue transfer for traumatic extremity reconstruction by the senior author from 2013 to 2017 was conducted. Patient demographic and clinical data were gathered as well as use of vein grafts, recipient-vessel thrombectomy, postoperative anticoagulation, and flap outcomes. Results A total of 23 patients underwent 24 free flap procedures for traumatic extremity reconstruction. Ten patients underwent recipient-vessel thrombectomy with 2-Fr Fogarty catheter and were placed on postoperative anticoagulation. In this group overall, there was one case of flap loss due to late wound infection resulting in a 90% success rate. A total of 13 patients underwent 14 free flaps without the use of thrombectomy and vein grafts were performed for 3/14 (21%) patients. In this group, there were four cases of flap loss, resulting in a 71% overall success rate. Conclusion In traumatic extremity reconstruction, if the artery appears to be visibly appropriate with weak inflow, one may consider attempting thrombectomy to restore pulsatile flow prior to harvesting a vein graft. This study suggests this may be effective and safe with no anastomosis-related flap loss in the thrombectomy group. Further research is required to confirm our results.
{"title":"Recipient Vessel Thrombectomy and Anastomosis within the Zone of Injury in Microvascular Extremity Reconstruction","authors":"J. Powers, J. Choi, S. Kale","doi":"10.1055/s-0040-1710347","DOIUrl":"https://doi.org/10.1055/s-0040-1710347","url":null,"abstract":"Abstract Background In traumatic extremity reconstruction, it is preferable to perform microvascular anastomoses outside the zone of injury. Alternatively, a recipient-vessel thrombectomy can be performed to improve the arterial inflow, potentially avoiding further proximal dissection and the use of a vein graft. The objective of this study was to evaluate the outcomes of microvascular anastomosis after thrombectomy in the zone of injury. Methods A retrospective review of patients who underwent free tissue transfer for traumatic extremity reconstruction by the senior author from 2013 to 2017 was conducted. Patient demographic and clinical data were gathered as well as use of vein grafts, recipient-vessel thrombectomy, postoperative anticoagulation, and flap outcomes. Results A total of 23 patients underwent 24 free flap procedures for traumatic extremity reconstruction. Ten patients underwent recipient-vessel thrombectomy with 2-Fr Fogarty catheter and were placed on postoperative anticoagulation. In this group overall, there was one case of flap loss due to late wound infection resulting in a 90% success rate. A total of 13 patients underwent 14 free flaps without the use of thrombectomy and vein grafts were performed for 3/14 (21%) patients. In this group, there were four cases of flap loss, resulting in a 71% overall success rate. Conclusion In traumatic extremity reconstruction, if the artery appears to be visibly appropriate with weak inflow, one may consider attempting thrombectomy to restore pulsatile flow prior to harvesting a vein graft. This study suggests this may be effective and safe with no anastomosis-related flap loss in the thrombectomy group. Further research is required to confirm our results.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e15 - e21"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1710347","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45810117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
P. Kumbla, S. Henry, C. Boyd, Patrick K. Kelley, Ashley Q. Thorburn, René P. Myers
Abstract Background Negative pressure wound therapy has allowed for significant advances in the treatment of wounds. This occurs through a process of angiogenesis, microdeformation, macrodeformation, and decrease in exudate and bacterial load. It is routinely used as a bolster in the management of skin grafts. However, its role as a dressing over free muscle flaps has not gained widespread acceptance due to the fear of flap compromise. Methods A retrospective review of 97 patients over 9 years was performed. All patients underwent free muscle flap coverage of various wounds with immediate split-thickness skin grafting. A negative pressure dressing was applied, with windows made in the foam sponge to enable Doppler monitoring as well as visual inspection of the flap. Complications including flap failure, skin graft loss, hematoma, distal flap necrosis, negative pressure dressing failure, partial muscle necrosis, and mild flap congestion were assessed. Results Flap loss occurred at a rate of 8.2% (eight flaps). Four of these flaps were lost due to patient factors not attributable to the dressing. In the remaining four flaps (4.1% of the series), it is conceivable that the negative pressure dressing was a contributing factor. However, this failure rate is comparable to flap loss rates in studies where negative pressure dressings were not used. The rates of skin graft failure, hematoma, distal flap necrosis, inability to maintain seal, partial muscle necrosis, and mild flap congestion were also acceptable and similar to studies where negative pressure dressings were not used. Conclusion Negative pressure dressings over free muscle flaps with immediate split-thickness skin grafts are effective and safe to use while allowing for postoperative flap monitoring and skin graft protection.
{"title":"Negative Pressure Dressings over Free Muscle Flaps with Immediate Split-Thickness Skin Grafting: A 9-Year Experience","authors":"P. Kumbla, S. Henry, C. Boyd, Patrick K. Kelley, Ashley Q. Thorburn, René P. Myers","doi":"10.1055/s-0040-1710345","DOIUrl":"https://doi.org/10.1055/s-0040-1710345","url":null,"abstract":"Abstract Background Negative pressure wound therapy has allowed for significant advances in the treatment of wounds. This occurs through a process of angiogenesis, microdeformation, macrodeformation, and decrease in exudate and bacterial load. It is routinely used as a bolster in the management of skin grafts. However, its role as a dressing over free muscle flaps has not gained widespread acceptance due to the fear of flap compromise. Methods A retrospective review of 97 patients over 9 years was performed. All patients underwent free muscle flap coverage of various wounds with immediate split-thickness skin grafting. A negative pressure dressing was applied, with windows made in the foam sponge to enable Doppler monitoring as well as visual inspection of the flap. Complications including flap failure, skin graft loss, hematoma, distal flap necrosis, negative pressure dressing failure, partial muscle necrosis, and mild flap congestion were assessed. Results Flap loss occurred at a rate of 8.2% (eight flaps). Four of these flaps were lost due to patient factors not attributable to the dressing. In the remaining four flaps (4.1% of the series), it is conceivable that the negative pressure dressing was a contributing factor. However, this failure rate is comparable to flap loss rates in studies where negative pressure dressings were not used. The rates of skin graft failure, hematoma, distal flap necrosis, inability to maintain seal, partial muscle necrosis, and mild flap congestion were also acceptable and similar to studies where negative pressure dressings were not used. Conclusion Negative pressure dressings over free muscle flaps with immediate split-thickness skin grafts are effective and safe to use while allowing for postoperative flap monitoring and skin graft protection.","PeriodicalId":34024,"journal":{"name":"Journal of Reconstructive Microsurgery Open","volume":"05 1","pages":"e27 - e31"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1055/s-0040-1710345","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46458068","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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