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Necker FN, Cholok DJ, Shaheen MS, Fischer MJ, Gifford K, El Chemaly T, Leuze CW, Scholz M, Daniel BL, Momeni A. The Reconstructive Metaverse - Collaboration in Real-Time Shared Mixed Reality Environments for Microsurgical Reconstruction. Surg Innov 2024:15533506241262946. [PMID: 38905568 DOI: 10.1177/15533506241262946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
Plastic surgeons routinely use 3D-models in their clinical practice, from 3D-photography and surface imaging to 3D-segmentations from radiological scans. However, these models continue to be viewed on flattened 2D screens that do not enable an intuitive understanding of 3D-relationships and cause challenges regarding collaboration with colleagues. The Metaverse has been proposed as a new age of applications building on modern Mixed Reality headset technology that allows remote collaboration on virtual 3D-models in a shared physical-virtual space in real-time. We demonstrate the first use of the Metaverse in the context of reconstructive surgery, focusing on preoperative planning discussions and trainee education. Using a HoloLens headset with the Microsoft Mesh application, we performed planning sessions for 4 DIEP-flaps in our reconstructive metaverse on virtual patient-models segmented from routine CT angiography. In these sessions, surgeons discuss perforator anatomy and perforator selection strategies whilst comprehensively assessing the respective models. We demonstrate the workflow for a one-on-one interaction between an attending surgeon and a trainee in a video featuring both viewpoints as seen through the headset. We believe the Metaverse will provide novel opportunities to use the 3D-models that are already created in everyday plastic surgery practice in a more collaborative, immersive, accessible, and educational manner.
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Affiliation(s)
- Fabian N Necker
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David J Cholok
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mohammed S Shaheen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marc J Fischer
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, CA, USA
| | - Trishia El Chemaly
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Christoph W Leuze
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michael Scholz
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bruce L Daniel
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Arash Momeni
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Necker FN, Cholok DJ, Shaheen MS, Fischer MJ, Gifford K, Le Castillo C, Scholz M, Leuze CW, Daniel BL, Momeni A. Suture Packaging as a Marker for Intraoperative Image Alignment in Augmented Reality on Mobile Devices. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5933. [PMID: 38919516 PMCID: PMC11199004 DOI: 10.1097/gox.0000000000005933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/14/2024] [Indexed: 06/27/2024]
Abstract
Preoperative vascular imaging has become standard practice in the planning of microsurgical breast reconstruction. Currently, translating perforator locations from radiological findings to a patient's abdomen is often not easy or intuitive. Techniques using three-dimensional printing or patient-specific guides have been introduced to superimpose anatomy onto the abdomen for reference. Augmented and mixed reality is currently actively investigated for perforator mapping by superimposing virtual models directly onto the patient. Most techniques have found only limited adoption due to complexity and price. Additionally, a critical step is aligning virtual models to patients. We propose repurposing suture packaging as an image tracking marker. Tracking markers allow quick and easy alignment of virtual models to the individual patient's anatomy. Current techniques are often complicated or expensive and limit intraoperative use of augmented reality models. Suture packs are sterile, readily available, and can be used to align abdominal models on the patients. Using an iPad, the augmented reality models automatically align in the correct position by using a suture pack as a tracking marker. Given the ubiquity of iPads, the combination of these devices with readily available suture packs will predictably lower the barrier to entry and utilization of this technology. Here, our workflow is presented along with its intraoperative utilization. Additionally, we investigated the accuracy of this technology.
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Affiliation(s)
- Fabian N. Necker
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - David J. Cholok
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Mohammed S. Shaheen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Marc J. Fischer
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, Calif
| | - Chris Le Castillo
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, Calif
| | - Michael Scholz
- Institute of Functional and Clinical Anatomy, Digital Anatomy Lab, Faculty of Medicine, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph W. Leuze
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Bruce L. Daniel
- From the Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, Calif
| | - Arash Momeni
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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Shekouhi R, Chim H. Evolution and Application of Ultrasound for Flap Planning in Upper Extremity Reconstruction. Hand Clin 2024; 40:167-177. [PMID: 38553088 DOI: 10.1016/j.hcl.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Accurate preoperative localization of dominant perforators provides crucial information about their location and diameter, leading to reduced surgical time, improved flap viability, and decreased complications. Ultrasound has increased in popularity in recent years, with the advantages of providing reproducible, accurate, cost-effective, and real-time information while reducing radiation exposure. Precise preoperative mapping of perforators allows for rapid and safe elevation of suprafascial, thin, and superthin flaps. This review focuses on the role of ultrasound as a tool for preoperative flap planning in the upper extremities.
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Affiliation(s)
- Ramin Shekouhi
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, Gainesville, FL32610, USA
| | - Harvey Chim
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, Gainesville, FL32610, USA.
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Lu Y, Sun N, Wu P, Zhou G, Peng L, Tang J. The application of infrared thermography technology in flap: A perspective from bibliometric and visual analysis. Int Wound J 2023; 20:4308-4327. [PMID: 37551726 PMCID: PMC10681462 DOI: 10.1111/iwj.14333] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 08/09/2023] Open
Abstract
The application of infrared thermography technology (IRT) in flap has become a major focus of research, as it provides a non-invasive, real-time, and quantitative approach for monitoring flap perfusion. In this regard, we conducted a comprehensive visualization and scientometric analysis to systematically summarize and discuss the current state of research in this field. We systematically reviewed publications on the application of IRT in flap procedures from 1999 to 2022, using the Web of Science Core Collection (WoSCC). Through scientometric analysis, we examined annual trends, affiliations, countries, journals, authors, and their relationships, providing insights into current hotspots and future developments in this area. We analysed 522 English studies and found a steady increase in annual publications. The United States and Germany had the highest publication rates, with Beth Israel Deaconess Medical Center and Shanghai Jiaotong University being leading institutions. Notably, Lee BT and Alex Keller emerged as influential authors in this field. Compared to existing techniques, infrared-based technology offers significant advantages for non-invasive monitoring of flap perfusion, including simplicity of operation and objective results. Future trends should focus on interdisciplinary collaborations to develop new infrared devices and achieve intelligent image processing, enabling broader application in various clinical scenarios. This bibliometric study summarizes the progress and landscape of research on 'the Application of infrared thermography technology in flap' over the past two decades, providing valuable insights and serving as a reliable reference to drive further advancements and spark researchers' interest in this field.
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Affiliation(s)
- Yilei Lu
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- National Clinical Research Center of Geriatric DisordersXiangya Hospital, Central South UniversityChangshaChina
| | - Nianzhe Sun
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- National Clinical Research Center of Geriatric DisordersXiangya Hospital, Central South UniversityChangshaChina
| | - Panfeng Wu
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- National Clinical Research Center of Geriatric DisordersXiangya Hospital, Central South UniversityChangshaChina
| | - Guoling Zhou
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- Xiangya Nursing SchoolCentral South UniversityChangshaChina
| | - Lingli Peng
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- National Clinical Research Center of Geriatric DisordersXiangya Hospital, Central South UniversityChangshaChina
- Xiangya Nursing SchoolCentral South UniversityChangshaChina
- Teaching and Research Section of Clinical Nursing, Xiangya HospitalCentral South UniversityChangshaChina
| | - Juyu Tang
- Department of Orthopedics, Hand & MicrosurgeryXiangya Hospital, Central South UniversityChangshaChina
- National Clinical Research Center of Geriatric DisordersXiangya Hospital, Central South UniversityChangshaChina
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Bajus A, Streit L, Kubek T, Novák A, Vaníček J, Šedivý O, Berkeš A, Bayezid KC, Kunovský L, Dražan L. Color Doppler ultrasound versus CT angiography for DIEP flap planning: A randomized controlled trial. J Plast Reconstr Aesthet Surg 2023; 86:48-57. [PMID: 37696215 DOI: 10.1016/j.bjps.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Identifying relevant perforators is crucial in planning a deep inferior epigastric perforator (DIEP) flap. Color Doppler ultrasonography (CDU) has gained popularity for localizing perforators; however, current evidence on its efficiency is still inconclusive. This study aimed to compare the efficiency of CDU with that of computed tomography angiography (CTA) in localizing and selecting the relevant perforators. METHODS In this randomized controlled trial, 60 patients undergoing DIEP flap breast reconstruction (uni- or bilateral) were randomly assigned to the CDU group (i.e., CDU was performed to map and select the relevant perforators preoperatively) or the CTA+CDU group (i.e., mapping was based on CTA and supplemented by CDU). CDU was performed by the same surgeon with a well-defined sonography experience from our previous study. The reference XY coordinates of the dissected perforators were measured intraoperatively, and deviations from preoperatively deducted coordinates were calculated (ΔCDU or ΔCTA+CDU). The flaps were categorized according to the number of dissected perforators, and adherence to the preoperative strategy was evaluated. RESULTS Overall, 22 patients (30 flaps) in the CTA+CDU group and 27 (39 flaps) patients in the CDU group were evaluated. The average ΔCDU (0.6 cm) was significantly lower than the average ΔCTA+CDU (1.0 cm) (p < 0.001). Adherence to the mapping-based dissection strategy was higher in the CDU group; however, the difference was insignificant (p = 0.092). CONCLUSION CDU is not inferior to CTA + CDU in localizing and selecting relevant DIEA perforators. Therefore, CDU mapping is a possible complementary or substitute modality for CTA mapping.
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Affiliation(s)
- Adam Bajus
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Libor Streit
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Tomáš Kubek
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Adam Novák
- Department of Radiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Vaníček
- Department of Radiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Šedivý
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Andrej Berkeš
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - K Can Bayezid
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lukáš Kunovský
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Luboš Dražan
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Schalet G, Clenshaw M, Schulz S. The Recent Worldwide Shortage of Intravenous Contrast Dye: A Commentary on Its Implications for Plastic and Reconstructive Surgeons. Ann Plast Surg 2023; 90:531-532. [PMID: 37157148 DOI: 10.1097/sap.0000000000003554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Grant Schalet
- From the Department of Surgery, Broward Health Medical Center, Fort Lauderdale
| | - Michael Clenshaw
- From the Department of Surgery, Broward Health Medical Center, Fort Lauderdale
| | - Steven Schulz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Broward Health Medical Center, Fort Lauderdale, FL
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Subramaniam S, Tanna N, Smith ML. Operative Efficiency in Deep Inferior Epigastric Perforator Flap Reconstruction: Key Concepts and Implementation. Clin Plast Surg 2023; 50:281-288. [PMID: 36813406 DOI: 10.1016/j.cps.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The deep inferior epigastric perforator flap has become one of the most popular approaches for autologous breast reconstruction after mastectomy. As much of health care has moved to a value-based approach, reducing complications, operative time, and length of stay in deep inferior flap reconstruction is becoming increasingly important. In this article, we discuss important preoperative, intraoperative, and postoperative considerations to maximize efficiency when performing autologous breast reconstruction and offer tips on how to handle certain challenges.
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Affiliation(s)
- Sneha Subramaniam
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA
| | - Neil Tanna
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA
| | - Mark L Smith
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA.
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Customizing Anterolateral Thigh Flap With Magnetic Resonance Angiography Differential Subsampling With Cartesian Ordering Imaging for Individualized Reconstruction of Extremity Defects. J Surg Res 2023; 283:733-742. [PMID: 36463812 DOI: 10.1016/j.jss.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Magnetic resonance angiography (MRA) with the differential subsampling with cartesian ordering (DISCO) imaging technique is rarely used in anterolateral thigh (ALT) flap. In our series, MRA DISCO imaging technique is used as a tool to customize ALT flaps. The aim of this study was to report the accuracy of cutaneous perforators identified by the MRA DISCO imaging. METHODS Nineteen patients underwent the MRA DISCO imaging for perforator mapping before the ALT flap transfer. A total of 38 ALT regions were studied on the MRA DISCO images. Flap thinning was performed under the guidance of MRA DISCO imaging. RESULTS The lateral circumflex femoral artery (LCFA) most commonly stems from the deep femoral artery (84.2%), followed by the common femoral artery (15.8%). The average number of perforator vessels per LCFA was 10.2 ± 1.7. The distinct oblique branch was observed in 16 out of the 38 ALT regions (42.1%). Among the 19 ALT flaps harvested, 5 were septocutaneous perforator flaps and 14 musculocutaneous perforator flaps. Ten were harvested based on the descending branch, and 3 used the oblique branch as the flap vascular pedicle. In addition, the displayed course and types of perforator vessels on the DISCO images of the 18 skin flaps were consistent with the intraoperative findings, with an accuracy of 94.7%. CONCLUSIONS The state of the cutaneous perforators of LCFA can be identified on the MRA DISCO images. The 3D-CE-MRA DISCO imaging is a practical method, which can ameliorate the design and customization of ALT flap for an individualized reconstruction.
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9
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Preoperative Perforator Mapping in DIEP Flaps for Breast Reconstruction. The Impact of New Contrast-Enhanced Ultrasound Techniques. J Pers Med 2022; 13:jpm13010064. [PMID: 36675725 PMCID: PMC9862612 DOI: 10.3390/jpm13010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022] Open
Abstract
Deep inferior epigastric artery flaps (DIEP) represent the gold standard of autologous breast reconstruction. Due to significant variations in vascular anatomy, preoperative perforator mapping (PM) is mandatory in order to ensure the presence of a sufficient perforator within the flap. In this regard, CT angiography (CTA) is currently the method of choice. Therefore, we investigated the value of contrast-enhanced ultrasound (CEUS) techniques for preoperative PM in comparison to CTA. Patients underwent PM, utilizing both CTA and CEUS techniques. Documentation included the course of the vascular pedicle through the rectus muscle (M), fascial penetration (F), the subcutaneous plexus (P) and the skin point (SP) on either side of the abdomen. Thus, contrast-enhanced B-Flow (BCEUS), B-Flow ultrasound (BUS), CEUS, color Doppler ultrasound (CDUS) and CTA were evaluated in terms of the diagnostic consistency and effectiveness of PM. Precision (∆L) was then calculated in relation to the actual intraoperative location. Statistical analysis included Kruskall-Wallis, Levene and Bonferroni tests, as well as Spearman correlations. A total of 39 DIEP flaps were analyzed. Only CTA (∆L = 2.85 mm) and BCEUS (∆L = 4.57 mm) enabled complete PM, also including P and SP, whereas CDUS, CEUS and BUS enabled clear PM throughout M and F only. Regarding the number of detected perforators, PM techniques are ranked from high to low as follows: CTA, BCEUS, BUS, CEUS and CDUS. CTA and BCEUS showed sufficient diagnostic consistency for SP, P and F, while CDUS and CTA had a superior performance for M. BCEUS offers precise image-controlled surface tags and dynamic information for PM without imposing radiation and may, therefore, be considered a feasible add-on or alternative to CTA. However, BCEUS requires an experienced examiner and is more time-consuming.
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Kueckelhaus M, Kolbenschlag J, Kirschniak A, Beier JP, Enzinger S, Harder Y, Kneser U, Lehnhardt M, Rab M, Daigeler A. [New Technologies in Microsurgery: Potential, Indications and Economical Aspects - Report of the Consensus Workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]. HANDCHIR MIKROCHIR P 2022; 54:507-515. [PMID: 36283407 DOI: 10.1055/a-1942-6510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Recently, several new technologies to support microsurgeons have received European market approval. This article summarizes and discusses the impressions of an expert panel to classify the potential of new technologies in terms of benefits for the surgeon, specific indications and economic aspects during the 42nd Annual Meeting of the German-speaking Working Group for Microsurgery of Peripheral Nerves and Vessels (DAM) in Graz, Austria. In general, the expert panel addressed the principles and prerequisite for the successful establishment of new technologies and, in particular, novel optical and robotic systems. For this purpose, the current scientific literature was reviewed and initial clinical experience in the context of case series and retrospective studies was presented by the members of the expert panel. In the ensuing discussion, it was pointed out that it will first be necessary to identify patient subgroups in which the use of the new technologies is most likely to achieve a clinical benefit. Since clinical approval has already been granted for some systems, an approach can be developed for immediate clinical application from the simplest possible use to ever finer applications, i. e. from microsurgery to supermicrosurgery. Initially, funding for cost-intensive systems would presumably not be possible through revenue from standard care, but only through grants or subsidized clinical trials. In a final survey, the majority of meeting participants see the need for a price reduction of both visualization and surgical robotics technologies to enable widespread clinical establishment. Likewise, a majority of participants would prefer a combination of an exoscope or robotic microscope and a surgical robot for clinical use. The present consensus work addresses the development of a strategy for the effective establishment of new technologies, which should further increase the surgical quality of selected interventions.
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Affiliation(s)
- Maximilian Kueckelhaus
- Abteilung für Plastische und Rekonstruktive Medizin, Westfälische Wilhelms-Universität Münster Institut für Muskuloskelettale Medizin, Münster, Germany.,Abteilung für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie, Fachklinik Hornheide e V, Münster, Germany
| | - Jonas Kolbenschlag
- Universitätsklinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen, Tubingen, Germany
| | - Andreas Kirschniak
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Justus P Beier
- Department of Plastic Surgery, Hand Surgery - Burn Center, University Hospital RWTH Aachen, Aachen, Germany.,Universitätsklinik für Mund- Kiefer- und Gesichtschirurgie, Uniklinikum Salzburg - Christian-Doppler-Klinik, Salzburg, Austria
| | - Simon Enzinger
- Universitätsklinik für Mund- Kiefer- und Gesichtschirurgie, Uniklinikum Salzburg - Christian-Doppler-Klinik, Salzburg, Austria
| | - Yves Harder
- Plastic, Reconstructive and Aesthetic Surgery, Repubblica e Cantone Ticino Ente Ospedaliero Cantonale, Viganello - Lugano, Switzerland
| | - Ulrich Kneser
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie Schwerbrandverletztenzentrum Klinik für Plastische Chirurgie, BG Unfallklinik Ludwigshafenund Ruprecht-Karls-Universität Heidelberg, Ludwigshafen, Germany
| | - Marcus Lehnhardt
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG-Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Matthias Rab
- Abt. f. Plastische Ästhetische und Rekonstruktive Chirurgie, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Adrien Daigeler
- Klinik für Hand, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Unfallklinik Tübingen an der Eberhard Karls Universität Tübingen, Tübingen, Germany
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11
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Singh N, Aghayev A, Ahmad S, Azene EM, Ferencik M, Hedgire SS, Kirsch DS, Lee YJ, Nagpal P, Pass HA, Pillai AK, Ripley B, Tannenbaum A, Thomas R, Steigner ML. ACR Appropriateness Criteria® Imaging of Deep Inferior Epigastric Arteries for Surgical Planning (Breast Reconstruction Surgery): 2022 Update. J Am Coll Radiol 2022; 19:S357-S363. [PMID: 36436962 DOI: 10.1016/j.jacr.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Ayaz Aghayev
- Panel Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Ahmad
- University of Toronto, Toronto, Ontario, Canada; American College of Physicians
| | - Ezana M Azene
- Director of PERT, Chair Cancer Advisory Council, Medical Governor, Gundersen Health System, La Crosse, Wisconsin
| | - Maros Ferencik
- Section Head of Cardiovascular Imaging, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Sandeep S Hedgire
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Yoo Jin Lee
- University of California San Francisco, San Francisco, California
| | - Prashant Nagpal
- Head, Cardiovascular Imaging, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Helen A Pass
- Chief of Breast Surgery and Co-Director of the Breast Center, Stamford Hospital, Stamford, Connecticut; American College of Surgeons
| | - Anil K Pillai
- Section Chief, Interventional Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | | | - Richard Thomas
- Section Chief of Thoracic Imaging and Cardiac CT and Associate Magnetic Resonance Medical Director, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Michael L Steigner
- Director, Vascular CT/MR, Medical Director 3D Lab, Specialty Chair, Brigham & Women's Hospital, Boston, Massachusetts
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12
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Shen Y, Li X, Zhang C, Zhong H, Dou W. Differential Subsampling with Cartesian Ordering Contrast-Enhanced Magnetic Resonance Angiography for the Preoperative Assessment of Anterolateral Thigh Flap. Korean J Radiol 2022; 23:803-810. [PMID: 35762181 PMCID: PMC9340230 DOI: 10.3348/kjr.2021.0696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/29/2022] [Accepted: 04/21/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To investigate the clinical application of differential subsampling with Cartesian ordering (DISCO) contrast-enhanced (CE) magnetic resonance angiography for anterolateral thigh (ALT) flap transplantation, using operative findings as a reference. Materials and Methods Thirty patients (21 males and nine females; mean age ± standard deviation, 45.5 ± 15.6 years) who were scheduled to undergo reconstruction with ALT flaps between June 2020 and June 2021 were included in the prospective study. Before ALT flap transplantation, patients were scanned using CE-DISCO imaging. All acquired DISCO images of the 60 lower limbs (both sides from each patient) were analyzed using maximum intensity projection and volume rendering methods. Two experienced radiologists were employed to examine the patterns of the lateral circumflex femoral artery (LCFA), its branches, and perforators and their skin termini, which were compared with the operative findings. Results Using CE-DISCO, the patterns of the LCFA and its branches were clearly identified in all patients. Four different origins of the LCFA were found among the 60 blood vessels: type I (44/60, 73.3%), type II (6/60, 10.0%), type III (8/60, 13.3%), and type IV (2/60, 3.3%). Owing to a lack of perforators entering the skin, two patients did not undergo ALT flap transplantation. For the remaining 28 patients, the ALT flaps in 26 patients were successfully operated without flap re-selection during the operation, while the remaining two patients underwent other surgical procedures due to the thin diameter of the perforator or injury of the perforator during the operation. The success rate of flap transplantation was 92.8% (26/28). All transplanted flaps exhibited good blood supply and achieved primary healing without infection or delayed healing. Conclusion CE-DISCO imaging can be an effective method for preoperative perforator imaging before ALT flap transplantation.
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Affiliation(s)
- Yunfeng Shen
- Department of Radiology, The Second Hospital of Shandong University, Cheeloo Colleage of Medicine, Jinan, China
| | - Xiucun Li
- Department of Hand and Foot Surgery, The Second Hospital of Shandong University, Cheeloo Colleage of Medicine, Jinan, China
| | - Chao Zhang
- Department of Radiology, The Second Hospital of Shandong University, Cheeloo Colleage of Medicine, Jinan, China
| | - Hai Zhong
- Department of Radiology, The Second Hospital of Shandong University, Cheeloo Colleage of Medicine, Jinan, China.
| | - Weiqiang Dou
- MR Research China, GE Healthcare, Beijing, China
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13
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Classification and Segmentation Algorithm in Benign and Malignant Pulmonary Nodules under Different CT Reconstruction. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3490463. [PMID: 35495882 PMCID: PMC9050279 DOI: 10.1155/2022/3490463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/01/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Methods The imaging data of 55 patients with chest CT plain scan in the Xuancheng People's Hospital were collected retrospectively. The data of each patient included lung window reconstruction, mediastinum reconstruction, and bone window reconstruction. The depth neural network and 3D convolution neural network were used to construct the model and train the classification and segmentation algorithm. The pathological results were the gold standard for benign and malignant pulmonary nodules. The classification and segmentation algorithms under three CT reconstruction algorithms were compared and analyzed by analysis of variance. Results Under the three CT reconstruction algorithms, the classification accuracy of pulmonary nodule density types was 98.2%, 96.4%, and 94.5%, respectively. The Dice coefficients of all nodule segmentation were 80.32% ± 5.91%, 79.83% ± 6.12%, and 80.17% ± 5.89%, respectively. The diagnostic accuracy between benign and malignant pulmonary nodules under different reconstruction algorithms was 98.2%, 96.4%, and 94.5%, respectively. There was no significant difference in the classification accuracy, Dice coefficients, and diagnostic accuracy of pulmonary nodules under three different reconstruction algorithms (all P > 0.05). Conclusion The depth neural network algorithm combined with 3D convolution neural network has a good efficiency in identifying benign and malignant pulmonary nodules under different CT reconstruction classification and segmentation algorithms.
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14
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Perez-Iglesias CT, Laikhter E, Kang CO, Nassar AH, Maselli AM, Cauley R, Lee BT. Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps. J Reconstr Microsurg 2022; 38:221-227. [DOI: 10.1055/s-0041-1740955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.
Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.
Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.
Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.
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Affiliation(s)
- Carolina Torres Perez-Iglesias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine O. Kang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amer H. Nassar
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy M. Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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15
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Nischwitz SP, Luze H, Schellnegger M, Gatterer SJ, Tuca AC, Winter R, Kamolz LP. Thermal, Hyperspectral, and Laser Doppler Imaging: Non-Invasive Tools for Detection of The Deep Inferior Epigastric Artery Perforators-A Prospective Comparison Study. J Pers Med 2021; 11:jpm11101005. [PMID: 34683146 PMCID: PMC8538291 DOI: 10.3390/jpm11101005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022] Open
Abstract
Perforator flaps have become one of the leading procedures in microsurgical tissue transfer. Individual defects require a tailored approach to guarantee the most effective treatment. A thorough understanding of the individual vascular anatomy and the location of prominent perforators is of utmost importance and usually requires invasive angiography or at least acoustic Doppler exploration. In this study, we aimed at evaluating different non-invasive imaging modalities as possible alternatives for perforator location detection. After a cooling phase, we performed thermal, hyperspectral and Laser Doppler imaging and visually evaluated a possible detection of the perforator for a period of five minutes with an image taken every minute. We identified the most prominent perforator of the deep inferior epigastric artery by handheld acoustic Doppler in 18 patients. The detected perforator locations were then correlated. Eighteen participants were assessed with six images each per imaging method. We could show a positive match for 94.44%, 38.89%, and 0% of patients and 92.59%, 25.93%, and 0% of images for the methods respectively compared to the handheld acoustic Doppler. Sex, age, abdominal girth, and BMI showed no correlation with a possible visual detection of the perforator in the images. Therefore, thermal imaging can yield valuable supporting data in the individualized procedure planning. Future larger cohort studies are required to better assess the full potential of modern handheld thermal imaging devices.
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Affiliation(s)
- Sebastian P. Nischwitz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (H.L.); (A.-C.T.); (R.W.); (L.-P.K.)
- COREMED—Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, 8010 Graz, Austria;
- Correspondence:
| | - Hanna Luze
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (H.L.); (A.-C.T.); (R.W.); (L.-P.K.)
- COREMED—Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, 8010 Graz, Austria;
| | - Marlies Schellnegger
- COREMED—Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, 8010 Graz, Austria;
- Division of Macroscopic and Clinical Anatomy, Medical University of Graz, 8036 Graz, Austria
| | | | - Alexandru-Cristian Tuca
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (H.L.); (A.-C.T.); (R.W.); (L.-P.K.)
| | - Raimund Winter
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (H.L.); (A.-C.T.); (R.W.); (L.-P.K.)
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (H.L.); (A.-C.T.); (R.W.); (L.-P.K.)
- COREMED—Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, 8010 Graz, Austria;
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In Vivo Perforasome Perfusion in Hemi-DIEP Flaps Evaluated with Indocyanine-green Fluorescence Angiography and Infrared Thermography. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3560. [PMID: 34036020 PMCID: PMC8140778 DOI: 10.1097/gox.0000000000003560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/22/2021] [Indexed: 12/24/2022]
Abstract
There are no in vivo studies that evaluate the effect of perforator dissection on the perfusion territory of a perforator (perforasome). In this study, indocyanine green fluorescence angiography (ICG-FA) and infrared thermography (IRT) were used intraoperatively to evaluate perforasome perfusion in hemi-DIEP flaps.
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