Seminars in Plastic Surgery最新文献

Microsurgical free tissue transfer has become the standard for complex head and neck reconstruction. One of the most feared scenarios is the so-called "vessel-depleted neck" (VDN), in which prior surgery, irradiation, or multiple reconstructions are thought to preclude suitable recipient vessels. However, definitions of VDN remain inconsistent, and many patients are not truly "depleted." A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed and Web of Science were searched (1980-2025) using terms related to "vessel-depleted neck," "recipient vessels," and "head and neck reconstruction." Eligible studies included case series, cohorts, and case reports describing reconstructive strategies following prior neck dissection, irradiation, or multiple reconstructions. Fifty-six reports met the inclusion criteria. In addition, we contextualized these findings with the Chang Gung Memorial Hospital (CGMH) experience of >10,000 microvascular reconstructions. The review identified a spectrum of recipient vessel options and technical innovations. Common second-tier choices included the transverse cervical vessels, superficial temporal system, and contralateral cervical vessels. Less common strategies involved cephalic vein transposition, internal mammary vessels, thoracoacromial, or subclavian system. Techniques to overcome pedicle length constraints included vein grafts, Corlett loops, vascular bridge flaps (VBFs), and in situ pedicle lengthening. Local and regional flaps, such as the pectoralis major (PM) and supraclavicular flaps, provided salvage options when free flaps were not feasible. At CGMH, even after multiple reconstructions, ipsilateral vessels (transverse cervical, superior thyroid, facial artery) remained usable in most patients, with contralateral or vein graft use required in fewer than 20%. The concept of a "VDN" is often overstated and may serve as a psychological barrier to optimal reconstruction. Most patients retain viable recipient vessels, and free flaps remain achievable with careful planning and surgical expertise. We advocate reframing these cases as "vessel challenged necks," emphasizing technical demands rather than depletion, to improve decision-making and outcomes.

The free fibula flap has transformed mandibular reconstruction, evolving from simply for bone defect reconstruction to including immediate dental rehabilitation and from a staged to a simultaneous procedure. This paper chronicles the progression from delayed implant placement to the modern-day single-stage "jaw in a day" (JIAD) procedure, enabled by advances in CAD/CAM (computer aided design/computer aided manufacturing) technology, virtual surgical planning, and digital prosthesis. Pioneering work contributing to fibula-jaw reconstruction and rehabilitation from Chang Gung Memorial Hospital is also highlighted. The anatomical study of the fibula osteoseptocutaneous flap makes its clinical application also possible when simultaneous skin/mucosal coverage is needed. The early and vast experience of secondary and primary dental implantation has allowed us to develop and advocate for the "jaw during admission" after several initial attempts at JIAD reconstruction. In this approach, the dental prosthesis is delayed to the day before discharge from the hospital after confirming the success of the transferred fibula. It not only avoids an unnecessary step in complicated fibula flap transfer procedures, but in case of failure, it also mitigates logistical and technical challenges of prosthesis conversion, while maintaining the benefits of immediate dental implant restoration. This review also examines current evidence surrounding implant success, complications like osteoradionecrosis, and outcomes in malignant versus benign cases.

The orthoplastic approach to extremity reconstruction represents a paradigm shift in the management of complex limb injuries, integrating orthopedic and plastic surgery principles to optimize functional and aesthetic outcomes. This review examines the evolution of this approach, its hierarchical framework for addressing tissue defects, and the essential technical competencies required for successful implementation. Key components of orthoplastic extremity reconstruction are illustrated through current evidence focusing on soft tissue management with high free flap success rates, vascularized bone transfers utilizing fibula, iliac crest, and medial femoral condyle flaps, and advanced techniques for amputee reconstruction including regenerative peripheral nerve interfaces and targeted muscle reinnervation. Meta-analysis evidence demonstrates that the synergistic collaboration between orthopedic and plastic surgery specialties achieves significant reduction in infection rates, improved limb salvage rates, and decreased health care costs through reduced hospital stay and revision surgeries. This article emphasizes the importance of multidisciplinary collaboration, comprehensive preoperative planning, and technical expertise in achieving optimal results in complex extremity reconstruction while addressing recent advances in reconstructive microsurgery protocols.

Trophic ulceration represents a significant complication following free flap reconstruction of the plantar surface. Despite successful microvascular tissue transfer for posttraumatic defects, these ulcers develop due to biomechanical incompatibility, sensory deficits, and altered pressure distribution. This review examines the multifaceted pathophysiology of trophic ulcers in reconstructed plantar surfaces, comparing tissue characteristics across different flap options and exploring evidence-based preventive and management strategies. Understanding the biomechanical principles, including friction forces, shear stress, and viscoelastic properties, is crucial for optimizing surgical planning and postoperative care to reduce ulceration risk and preserve long-term foot function.

Free functioning muscle transfer (FFMT) is widely used to reconstruct complex lower limb defects involving muscle deficits. This review explores ways to optimize FFMT outcomes by examining biomechanical considerations, particularly balancing the needs for stable joint positioning (isometric function) and active motion (isotonic function) for specific reconstructive objectives. We discuss knee extension, ankle dorsiflexion, and ankle plantarflexion reconstruction, recommending suitable donor muscles based on their mechanical properties and functional requirements. Important considerations include careful donor muscle selection, accurate muscle tensioning during surgery, secure tendon attachment methods, and targeted rehabilitation timed with nerve recovery. This approach offers practical advice for surgeons aiming to restore movement and improve overall function in patients undergoing complex lower limb reconstructions.

Artificial intelligence (AI) and machine learning (ML) technologies are transforming reconstructive microsurgery through data-driven approaches that enhance precision and standardize clinical workflows. These innovations address long-standing challenges, including subjective assessment methodologies, operator-dependent decision-making, and inconsistent monitoring protocols across the perioperative continuum. Contemporary applications demonstrate remarkable capabilities in preoperative risk stratification, with ML algorithms achieving high predictive accuracy for complications such as flap loss and donor site morbidity. CNNs have revolutionized perforator localization, with advanced models achieving Dice coefficients of 91.87% in anatomical structure detection from CT angiography. Intraoperative assistance through AI-enhanced robotic platforms provides submillimeter precision and tremor filtration, particularly beneficial in supermicrosurgery involving vessels measuring 0.3- to 0.8-mm diameter. Postoperative monitoring represents a particularly promising domain, where AI-based image analysis systems achieve 98.4% accuracy in classifying flap perfusion status and detecting early vascular compromise. Automated platforms may enable continuous surveillance with reduced clinical workload while maintaining superior consistency compared with traditional subjective methods. Patient communication benefits from AI-driven visual simulation and large language models (LLMs) that generate personalized educational materials, enhancing informed consent processes. Critical implementation challenges include data quality, algorithmic bias, and inherent dataset imbalance, where complications represent rare but clinically crucial events. Future advancement requires explainable AI systems, multi-institutional collaboration, and comprehensive regulatory frameworks. When thoughtfully integrated, AI serves as a powerful augmentation tool that elevates microsurgical precision and outcomes while preserving the fundamental importance of surgical expertise and clinical judgment.

Vascularized composite allotransplantation (VCA) represents one of the most complex frontiers in reconstructive surgery, requiring simultaneous transfer of multiple tissue types, including skin, muscle, bone, and nerves. Success depends on the multidisciplinary integration of immunology, surgery, rehabilitation, and psychology. Chang Gung Memorial Hospital has established itself as a pioneer in clinical VCA in Taiwan, contributing significantly through innovative basic research and successful clinical outcomes. This review explores our institutional experience, highlighting clinical cases and groundbreaking preclinical research within our comprehensive VCA program.

Soft tissue reconstruction in the extremities is complicated by the fact that injuries often involve composite defects of skin, muscle, tendon, nerve, and bone. In both the upper and lower limbs, achieving reliable soft tissue coverage, restoring function, and reducing complications are critical goals. The upper extremity requires precision and fine manipulation, whereas the lower limb should be reconstructed to support weight-bearing and mobility. Free flaps have become a routine part of the surgical armamentarium, offering flexible solutions tailored to different needs. Donor sites in the lower extremities are favored due to the availability of high-quality tissue, minimal visible scarring, and the possibility of a two-team approach. Careful planning not only improves wound healing but also accelerates rehabilitation and reduces the need for revision surgeries, underscoring the importance of flap choice, anatomical knowledge, and surgical skill.