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Lim Z, Sebastin SJ, Chung KC. Health Policy Implications of Digital Replantation. Clin Plast Surg 2024; 51:553-558. [PMID: 39216941 DOI: 10.1016/j.cps.2024.02.017] [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] [Indexed: 09/04/2024]
Abstract
There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.
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Affiliation(s)
- Zhixue Lim
- Department of Hand & Reconstructive Microsurgery, National University Hospital, Level 11, National University Health System Tower Block, 1E Kent Ridge Road, 119228, Singapore
| | - Sandeep Jacob Sebastin
- Department of Hand & Reconstructive Microsurgery, National University Hospital, Level 11, National University Health System Tower Block, 1E Kent Ridge Road, 119228, Singapore.
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Hospital, 1500 E Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48109, USA
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2
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Thamm OC, Eschborn J, Schäfer RC, Schmidt J. Advances in Modern Microsurgery. J Clin Med 2024; 13:5284. [PMID: 39274497 PMCID: PMC11396389 DOI: 10.3390/jcm13175284] [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: 07/29/2024] [Revised: 08/26/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objectives: Microsurgery employs techniques requiring optical magnification and specialized instruments to operate on small anatomical structures, including small vessels. These methods are integral to plastic surgery, enabling procedures such as free tissue transfer, nerve reconstruction, replantation, and lymphatic surgery. This paper explores the historical development, advancements, and current applications of microsurgery in plastic surgery. Methods: The databases MEDLINE (via PubMed) and Web of Science were selectively searched with the term "(((microsurgery) OR (advances)) OR (robotic)) OR (AI)) AND (((lymphatic surgery) OR (peripheral nerve surgery)) OR (allotransplantation))" and manually checked for relevance. Additionally, a supplementary search among the references of all publications included was performed. Articles were included that were published in English or German up to June 2024. Results: Modern microsurgical techniques have revolutionized plastic surgery, enabling precise tissue transfers, improved nerve reconstruction, and effective lymphedema treatments. The evolution of robotic-assisted surgery, with systems like da Vinci and MUSA, has enhanced precision and reduced operative times. Innovations in imaging, such as magnetic resonance (MR) lymphography and near-infrared fluorescence, have significantly improved surgical planning and outcomes. Conclusions: The continuous advancements in microsurgery, including supermicrosurgical techniques and robotic assistance, have significantly enhanced the capabilities and outcomes of plastic surgery. Future developments in AI and robotics promise further improvements in precision and efficiency, while new imaging modalities and surgical techniques expand the scope and success of microsurgical interventions.
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Affiliation(s)
- Oliver C Thamm
- Clinic of Plastic and Aesthetic Surgery, Helios Hospital Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
- Clinic for Plastic and Reconstructive Surgery, Handsurgery, Burn Care Center, University Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Straße 200, 51109 Cologne, Germany
| | - Johannes Eschborn
- Clinic of Plastic and Aesthetic Surgery, Helios Hospital Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Ruth C Schäfer
- Clinic of Plastic, Reconstructive and Aesthetic Surgery, Helios Dr. Horst Schmidt Hospital Wiesbaden, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, Germany
| | - Jeremias Schmidt
- Clinic of Plastic and Aesthetic Surgery, Helios Hospital Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
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3
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Miyazaki T, Patanè L, Kanasaki M, Sakai H, Ribuffo D, Tsukuura R, Yamamoto T. Various handcrafted artificial vessels: Evaluation of practicality and feasibility for supermicrosurgery training. J Plast Reconstr Aesthet Surg 2024; 96:118-122. [PMID: 39084024 DOI: 10.1016/j.bjps.2024.07.017] [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: 04/07/2024] [Revised: 06/05/2024] [Accepted: 07/08/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Supermicrosurgery demands more refined skills compared to traditional microsurgery, necessitating comprehensive training prior to clinical implementation. Despite the existence of various training models, they often fall short in terms of cost, ethical considerations, and infection risk. Our objective was to develop and evaluate novel training models for supermicrosurgery that are cost-effective, ethical, and risk-free. METHODS We fabricated tubes using polyvinyl alcohol (PVA) liquid glue, polyvinyl acetate resin (PAR) wood glue, and hydrocolloid dressing (HCD), aiming to identify suitable, low-cost candidates for a supermicrosurgery training model. These tubes were anastomosed under a microscope using 10-0 or 11-0 nylon sutures. We assessed the time and cost involved in tube fabrication, their diameters, and the overall feasibility of the models. RESULTS The average time and cost to fabricate a 15-mm-long luminal tube were 33.5 min and 0.02 USD for the PVA group, 23 min and 0.02 USD for the PAR group, and 63 s and 0.40 USD for the HCD group, respectively. The average diameter of the tubes was 0.49, 0.58, and 1.55 mm in the PVA, PAR, and HCD groups, respectively. The PVA and PAR tubes, with their transparent and thin walls, facilitated easier evaluation of anastomosis patency compared to the HCD tubes. CONCLUSION We successfully used non-living materials to develop new supermicrosurgery training models, characterized by their low cost, absence of ethical concerns, and elimination of infection risk. The PAR and PVA tubes, in particular, are suitable for resident training in supermicrosurgery.
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Affiliation(s)
- Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Luca Patanè
- Department of Surgery, Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Maya Kanasaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Diego Ribuffo
- Department of Surgery, Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
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Soh JY, Pannuto L, Kannan RY. A Comprehensive Flap Classification: Beyond the Reconstructive Ladder. Ann Plast Surg 2024; 93:144-148. [PMID: 38785374 DOI: 10.1097/sap.0000000000003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.
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Affiliation(s)
- Jun Yi Soh
- From the Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, United Kingdom
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Wang L, Ma C, Shen Y, Haugen TW, He Y, Sun J. Application of tensor fascia lata perforator flap in head and neck reconstruction. Int J Oral Maxillofac Surg 2024; 53:551-557. [PMID: 38228464 DOI: 10.1016/j.ijom.2024.01.004] [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: 04/26/2023] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024]
Abstract
The aim of this study was to describe the authors' experience in head and neck reconstruction with the tensor fascia lata perforator flap (TFLPF). Between April 2009 and August 2020, 16 patients underwent head and neck reconstruction with a TFLPF. The flaps were designed in a vertical or transverse fashion based on perforators traveling along the medial or lateral aspect of the posterior edge of the tensor fascia lata muscle. Clinical details and postoperative results were recorded and analyzed. The size of the flap ranged from 7 × 5 cm2 to 25 × 9 cm2. The perforators were mostly septocutaneous (11 patients), allowing a simple and straightforward dissection of the perforator and TFLPF in most patients. There were either one or two perforators in all cases. The overall flap survival rate was 100%. All of the flaps healed uneventfully with no delayed wound healing or donor site dysfunction. Follow-up ranged from 18 to 120 months, during which all patients experienced satisfactory functional and aesthetic results, without serious complications at either the recipient or donor site. The TFLPF is a pliable and reliable flap that could be a first choice in selected head and neck reconstruction cases.
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Affiliation(s)
- L Wang
- Department of Oral and Maxillofacial - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - C Ma
- Department of Oral and Maxillofacial - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Y Shen
- Department of Oral and Maxillofacial - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - T W Haugen
- Department of Otolaryngology - Head and Neck Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Y He
- Department of Oral and Maxillofacial - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J Sun
- Department of Oral and Maxillofacial - Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Bian K, Qiu C, Lu GJ, Zhao Q, Wang C, Zhang F. Combined application of gluteus maximus muscle flaps and random pattern skin flaps in repairing sacrococcygeal sinus tracts: a prospective study and technical note. Updates Surg 2024; 76:1009-1014. [PMID: 38175503 DOI: 10.1007/s13304-023-01707-0] [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: 06/14/2023] [Accepted: 11/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Sacrococcygeal sinus ulcers are caused by pressure sores, trauma, or surgery. Several surgical techniques have been developed for its treatment; however, studies are ongoing to develop the ideal method. The present study aims to introduce an innovative application of gluteus maximus muscle flaps (GMMFs) packing combined with local random pattern skin flaps (RPSFs) in repairing sacrococcygeal sinus tracts (SSTs). METHODS This was a prospective analysis study conducted on the patients (n = 26) with SSTs underwent an innovative repairing surgery in Qilu Hospital of Shandong University, China between December 2015 and December 2020. The repairing surgery was GMMFs combined with RPSFs. The demographic information and the clinical parameters including operative time, postoperative healing time, and recurrence rate were used to evaluate the efficacy of the operation. RESULTS Except one case of partial necrosis at the edge of the flap due to severe fibrosis, which was cured after dressing change, all the other cases showed effective healing after the operation. CONCLUSION The combined application of GMMFs and RPSFs for the treatment of sacrococcygeal sinus tracts gains the advantages of short operative time, quick postoperative recovery, and low postoperative recurrence rate.
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Affiliation(s)
- Kai Bian
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, China
| | - Cheng Qiu
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, China
| | - Guo-Jun Lu
- Department of General Surgery, Peoples Hospital of LaoLing, No. 28, Anju Road, Leling, Dezhou, 253699, China
| | - Qi Zhao
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, China
| | - Chao Wang
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, China
| | - Fan Zhang
- Department of Burn and Plastic Surgery, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, China.
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Meroni M, Scaglioni MF. Revisiting the pedicled circumflex scapular artery (pCSA) perforator flap: From simple to complex locoregional reconstructions. J Plast Reconstr Aesthet Surg 2024; 90:336-345. [PMID: 37748998 DOI: 10.1016/j.bjps.2023.08.025] [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: 07/07/2023] [Accepted: 08/13/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Soft tissue defects involving the axilla and the upper back region are often complex to treat. The complexity of these defects may be extremely different, ranging from superficial skin damage to large loss of substance with lymphatic drainage impairment. The pedicled circumflex scapular artery (pCSA) perforator flap represents a valid procedure in this setting. It can be tailored according to the patient's needs, and its intraseptal pedicle allows a quick dissection with a wide range of motion. PATIENTS AND METHODS Twenty-four consecutive patients treated by means of pCSA perforator flap were included. All the flaps were pedicled and were used for locoregional reconstructions. The etiology of the defects was an oncologic resection in 15 cases, acne/hidradenitis suppurativa resection in 6 cases, lymphatic complication in 2 cases, and burn in 1 case. Patients' mean age was 61 years old; seventeen were males and seven were females. RESULTS All the patients were successfully treated with good aesthetic and functional results. One patient presented with a wound dehiscence, which required secondary surgical treatment. No partial or complete flap losses were encountered. Primary closure of the donor site was achieved in all cases. The mean follow-up period was 10.5 months (range 6-12). CONCLUSIONS This case series shows the reliability and versatility of the pCSA perforator flap for locoregional reconstructions. Because of its rich vascularisation, extensive or unconventionally-shaped flaps are possible. Moreover, its lymphatic rich tissues make it suitable for the treatment of complications related to axillary lymphadenectomy.
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Affiliation(s)
- Matteo Meroni
- Department of Hand and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Mario F Scaglioni
- Department of Hand and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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MacKenzie A, Dhoot A, Rehman U, Sohaib Sarwar M, Adebayo O, Brennan PA. Use of supermicrosurgery in craniofacial and head and neck soft tissue reconstruction: a systematic review of the literature and meta-analysis. Br J Oral Maxillofac Surg 2024; 62:140-149. [PMID: 38290861 DOI: 10.1016/j.bjoms.2023.11.014] [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: 11/09/2023] [Accepted: 11/28/2023] [Indexed: 02/01/2024]
Abstract
Supermicrosurgery is an evolving approach in the reconstruction of head and neck (HN) and craniofacial (CF) defects. This systematic review aims to evaluate the use of supermicrosurgery for arterial or combined arterial and venous anastomoses in the reconstruction of HN and CF soft tissue defects, and the associated success, total complication, and reoperation rates. A literature search was conducted on PubMed, Dynamed, DARE, EMBASE, Cochrane, and British Medical Journal (BMJ) electronic databases (PROSPERO ID: CRD42023476825). Nine studies fulfilled the inclusion criteria with 35 patients who underwent soft tissue reconstructive procedures using supermicrosurgery. Twenty-one flaps were performed on 20 patients (57.1%) with the remaining 15 patients (42.9%) undergoing supermicrosurgical replantation. The most common pathology requiring reconstruction was HN trauma (n = 16, 45.7%) followed by malignancy (n = 15, 42.9%). The pooled success rate for supermicrosurgery was 98% (95% CI 90 to 100, p = 1.00; I2 = 0%). The cumulative complication rate across all the studies was 46% (95% CI 13 to 80, p < 0.01; I2 = 0%), and the pooled rate of reoperation was 1% (95% CI 0 to 8, p = 0.23; I2 = 24%). The use of supermicrosurgery for HN and CF soft tissue reconstruction has an overall success rate of 98%, which is commensurate with traditional microsurgery for HN reconstruction. Complication and reoperation rates are comparable to previous literature. This study confirms the feasibility of supermicrosurgery as a safe and reliable reconstructive option for HN and CF defects.
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Affiliation(s)
| | - Amber Dhoot
- Department of Surgery, Queen Charlotte's and Chelsea Hospital, London, United Kingdom.
| | - Umar Rehman
- UCL Division of Surgery and Interventional Sciences, London, United Kingdom.
| | - Mohammad Sohaib Sarwar
- Department of Oral and Maxillofacial Surgery, The Queen Victoria Hospital, East Grinstead, United Kingdom.
| | | | - Peter A Brennan
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom.
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Lo Torto F, Firmani G, Patanè L, Turriziani G, Di Rocco A, Vestri A, Ribuffo D. Supermicrosurgery with perforator-to-perforator anastomoses for lower limb reconstructions - A systematic review and meta-analysis. Microsurgery 2024; 44:e31081. [PMID: 37394775 DOI: 10.1002/micr.31081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/11/2023] [Accepted: 06/23/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Supermicrosurgical flaps based on perforator-to-perforator microanastomoses have been described for lower limb reconstruction. This approach offers the benefit of raising short pedicles while sparing axial vessels, which effectively enables complex reconstructive techniques in comorbid patients at high risk of reconstructive failure. The aim of our study is to assess the surgical outcomes of perforator-to-perforator based flaps in comparison to conventional free flaps for reconstructions of the lower limb district, through a systematic review of literature and meta-analysis. METHODS A search on PubMed, Embase, Cohrane, and Web of Science was performed between March-July 2022. No restrictions were placed on study date. Only English manuscripts were assessed. Reviews, short communications, letters, correspondence were excluded after reviewing their references for potentially relevant studies. A Bayesian approach was used to conduct the meta-analysis comparing flap-related outcomes. RESULTS From 483 starting citations, 16 manuscripts were included for full-text analysis in the review, and three were included in the meta-analysis. Out of 1556 patients, 1047 received a perforator-to-perforator flap. Complications were reported in 119 flaps (11.4%), which included total flap failure in 71 cases (6.8%), partial flap failure in 47 cases (4.5%). Overall flap complications had a HR of 1.41 (0.94-2.11; 95% C.I.). Supermicrosurgical and conventional microsurgical reconstructions were not associated with statistically significant differences (p = .89). CONCLUSION Our evidence supports the safety of surgical outcomes, with acceptable flap complication rates. Nevertheless, these findings are limited by poor overall quality which must be addressed and used to encourage higher-level evidence in the field.
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Affiliation(s)
- Federico Lo Torto
- Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Guido Firmani
- Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Luca Patanè
- Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Gianmarco Turriziani
- Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Diego Ribuffo
- Department of Surgery "P. Valdoni," Unit of Plastic and Reconstructive Surgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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10
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Meroni M, Scaglioni MF. Pedicled circumflex scapular artery perforator flap with intra-axillary tunneling for axillary defect coverage after surgical excision of hidradenitis suppurativa: A case report and literature review. Microsurgery 2024; 44:e31102. [PMID: 37626471 DOI: 10.1002/micr.31102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/04/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Axillary defects represent a rather common issue in plastic surgery practice. Surgical resections related to skin disease are frequent in this region and their extension often requires soft tissue transfer for coverage. In this setting, locoregional pedicled flaps are usually preferred. The nearby tissues offer pliable but still resistant skin, which satisfy the "like-with-like" reconstructive principle. Over the years different procedures have been described for this purpose. Among them, a valuable and often underestimated technique is the circumflex scapular artery perforator flap (CSAP). This technique might be particularly suitable for thin but relatively large defects. Its main advantages are a low donor site morbidity, a very reliable anatomy, and a perforator pedicle able supply a large skin paddle. In the present work, we report the use of a pedicled vertical CSAP flap passed through the axillary canal in order to cover a 9 cm × 7 cm axillary defect after surgical excision of hidradenitis suppurativa resistant to conservative treatment. The perforator-based pedicled presented two branches, which allowed us to harvest safely a large skin paddle, which limited its range of motion. For this reason, we opted for a passage through the axillary canal for the flap inset. The postoperative course was uneventful and full shoulder range of motion was obtained at 3 months follow-up. Despite most of the descriptions of this flap available so far showed its employment for limb's reconstructions, we believe that it is a very useful tool also for locoregional coverage. Moreover, the unconventional passage below the axillary muscles allowed reaching the recipient site even with a shorter pedicle, such as the one encountered in this case.
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Affiliation(s)
- Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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11
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Banerjee A, Jou E, Wong KY. Supermicrosurgery: past, present and future. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37906072 DOI: 10.12968/hmed.2022.0482] [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] [Indexed: 11/02/2023]
Abstract
Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.
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Affiliation(s)
- Arka Banerjee
- Department of Plastic Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eric Jou
- Medical Sciences Division, Oxford University Hospitals, University of Oxford, Oxford, UK
- Kellogg College, University of Oxford, Oxford, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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12
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Yamamoto T. Day microsurgery: Further application of free flap transfer as an ambulatory surgery. J Plast Reconstr Aesthet Surg 2023; 84:567-573. [PMID: 37441853 DOI: 10.1016/j.bjps.2023.06.055] [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: 12/05/2022] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Free flap transfer (FFT) is essential in soft tissue reconstruction and can be done under local anesthesia. However, there is no study evaluating the feasibility of FFT without hospitalization. This study evaluated the feasibility of day microsurgery-FFT as a day surgery without hospitalization. METHODS Patients who underwent day microsurgery were included. The FFT was performed under local infiltration and/or block anesthesia without sedation by a surgeon with enough experience in supermicrosurgery. We focused on minimal dissection and secure hemostasis to prevent possible complications. Patient characteristics, operative findings, and postoperative course were evaluated. RESULTS Seventeen patients with a mean age of 40.4 years were included. All defects were of the upper extremity and due to trauma. Utilized anesthesia included local infiltration in 11 sites, digital block in 10 sites, wrist block in 12 sites, and elbow block in 4 sites. Used flap included superficial circumflex iliac artery perforator flap in 8 (47.1%) cases and short-pedicle partial toe flaps in 9 (52.9%) cases. The mean diameters of the anastomosed artery/vein were 0.88/1.29 mm, and the mean operation time was 68.9 min. All transferred flaps survived without total or partial necrosis. The postoperative course was uneventful except for 1 (5.9%) case with minor wound dehiscence. CONCLUSIONS FFT could safely be performed without hospitalization in selected cases of an upper extremity defect. Supermicrosurgery and careful patient selection play an important role in safe day microsurgery.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan; Department of Plastic Surgery, Noda Hospital, Chiba, Japan.
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13
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Wan J, Wang H, Wang D, Wang X, Hou R. Anatomical characterization of the intraosseous arteries of the porcine tibia. Heliyon 2023; 9:e18179. [PMID: 37519677 PMCID: PMC10372356 DOI: 10.1016/j.heliyon.2023.e18179] [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: 03/16/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Tibial fractures have a high rate of post-fracture complications. Blood supply is recognized as a positive factor in tibial fracture healing. However, it's difficult to assess blood supply damage after tibial fracture because of the lack of understanding of the tibial intraosseous arteries. This study aimed to delineate and anatomically characterize porcine tibial intraosseous arteries, as a model for the human system. Methods Twenty right calf specimens with popliteal vessels were prepared from ordinary Landrace pigs. Epoxy resin was perfused into the vasculature from the popliteal artery. After 24 h, casts of the intraosseous arteries of the tibia were exposed through acid and alkali corrosion. The distribution and anatomy of the exposed intraosseous arteries were observed and measured under a microscope, and the data were statistically analyzed. Results Sixteen complete specimens were obtained. The medullary artery bifurcated into the main ascending and descending branches, which each split into two upward primary branches that further divided into 1-3 secondary branches. Among all specimens, 56 ascending and 42 descending secondary branches, which were all ≥0.3 mm in diameter. Furthermore, the horizontal plane was divided into three zones-safety, buffer, and danger zones-according to the probability of the presence of intraosseous artery. Discussion The cast perfusion and corrosion approach was successfully applied for anatomical characterization of the intraosseous arteries of the porcine tibia. These observations provide a theoretical basis for understanding the tibial vasculature in humans and will facilitate the establishment of novel "safe corridor" in the tibia for the protection of the blood supply during surgery.
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Affiliation(s)
- Jiaming Wan
- Yangzhou University Medical College, Yangzhou, China
| | - Hongyu Wang
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Dingsong Wang
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Xiaosong Wang
- Suzhou Medical College of Soochow University, Suzhou, China
| | - Ruixing Hou
- Yangzhou University Medical College, Yangzhou, China
- Suzhou Ruihua Orthopedic Hospital, Suzhou, China
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Yi HS, Kim BS, Kim YS, Park JH, Kim HI. What Is the Minimum Number of Sutures for Microvascular Anastomosis during Replantation? J Clin Med 2023; 12:jcm12082891. [PMID: 37109227 PMCID: PMC10143759 DOI: 10.3390/jcm12082891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/09/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
As vessel diameter decreases, reperfusion after anastomosis becomes more difficult. When a blood vessel is sutured, its inner diameter becomes narrower owing to the thickness of the suture material and the number of sutures. To minimize this, we attempted replantation using a 2-point suture technique. We reviewed cases of arterial anastomosis in vessels with a diameter of less than 0.3 mm during replantation performed over a four-year period. In all cases, close observation was followed by absolute bed rest. If reperfusion was not achieved, a tie-over dressing was applied, and hyperbaric oxygen therapy was administered in the form of a composite graft. Of the 21 replantation cases, 19 were considered successful. Furthermore, the 2-point suture technique was performed in 12 cases, of which 11 survived. When three or four sutures were performed in nine patients, eight of these cases survived. Composite graft conversion was found in three cases in which the 2-point suture technique was used, and two of these cases survived. The survival rate was high in cases where 2-point sutures were used, and there were few cases of conversion to a composite graft. Reducing the number of sutures aids in optimizing reperfusion.
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Affiliation(s)
- Hyung-Suk Yi
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Byeong-Seok Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Yoon-Soo Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Jin-Hyung Park
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Republic of Korea
| | - Hong-Il Kim
- Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Republic of Korea
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15
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Zheng L, Lv XM, Shi Y, Huang MW, Zhang J, Liu SM. Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region. Int J Oral Maxillofac Surg 2023; 52:423-429. [PMID: 35987710 DOI: 10.1016/j.ijom.2022.04.019] [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: 09/29/2021] [Revised: 03/04/2022] [Accepted: 04/20/2022] [Indexed: 10/15/2022]
Abstract
Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.
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Affiliation(s)
- L Zheng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China.
| | - X-M Lv
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Y Shi
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - M-W Huang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - J Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - S-M Liu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
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16
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Ishiura R, Mitsui K, Banda CH, Danno K, Narushima M. Lymphaticovenular anastomoses training model for multiple stages of lymphedema by using efferent lymphatic plexus of the mesenteric lymph node of rats. Microsurgery 2023; 43:261-265. [PMID: 36382665 DOI: 10.1002/micr.30986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Lymphaticovenular anastomosis (LVA) has transformed lymphedema treatment and has become an important part of the surgical therapy. LVA requires supermicrosurgical skills and unique nontraumatic techniques as the lymphatic vessel diameter of varies with the progression of lymphedema from 0.3 to 0.8 mm. However, even though several supermicrosurgical vessel anastomosis training models have been reported, only few focus on LVA including both various sizes of lymphatic vessels and lymphatic dissection. We report the establishment of a novel in-vivo LVA training model using the rat efferent lymphatic plexus of the mesenteric lymph node. MATERIALS AND METHODS Lymphatic vessels in the efferent lymphatic plexus of the mesenteric lymph node and mesenteric veins of 10 male Wistar rats, 572-850 g, were used for LVA in an intima-to-intima coaptation manner using 12-0 nylon suture with 4-6 stitches in an end-to-end fashion. Postoperative patency was evaluated with indigo carmine blue after completion of anastomosis. Diameters of lymphatic vessels in the plexus and recipient veins were measured. RESULTS The diameters of lymphatic vessels in efferent lymphatic plexus of the mesenteric lymph nodes and mesenteric veins used as recipients were measured in all 10 male rats. The mean number of lymphatic vessels included in efferent lymphatic plexus of the mesenteric lymph nodes was 7.5 (range, 5-11) and the mean diameter of the lymphatic vessels was 0.34 mm (range, 0.1-1.2 mm). The mean diameter of lymphatic vessels used for LVA was 0.46 mm (range, 0.25-0.7 mm). The mean diameter of the recipient veins was 0.49 mm (range, 0.35-0.7 mm). The postoperative patency rate after LVA was 100% (10/10). CONCLUSION We reported the establishment of LVA model involving the use of the efferent lymphatic plexus of the mesenteric lymph node and mesenteric veins in rats.
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Affiliation(s)
- Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, the University of Mie, Tsu, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, the University of Mie, Tsu, Japan
| | | | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, the University of Mie, Tsu, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, the University of Mie, Tsu, Japan
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Hong JP, Masoodi Z, Tzou CHJ. Attributes of a Good Microsurgeon-A Brief Counsel to the Up-and-Coming Prospects. Arch Plast Surg 2023; 50:130-140. [PMID: 36755651 PMCID: PMC9902200 DOI: 10.1055/s-0042-1759786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/17/2022] [Indexed: 02/09/2023] Open
Abstract
Microsurgery, which deservedly sits on top of the reconstruction ladder, has been a boon to plastic surgery. It is because of this marvelous tool that plastic surgeons the world over have been able to tackle many reconstructive dilemmas, which were once considered to be an improbability. Microsurgery-aided revolutions have rendered a new meaning to all forms of reconstruction-whether it is postoncological, posttraumatic, or postlymphedema reconstruction. As the most advanced reconstructive medium at our disposal that has broadened the horizons of plastic surgery exponentially, it is but obvious that many budding plastic surgeons are drawn toward this subspecialty. In lieu of the aforementioned facts, it is necessary to sensitize all such aspiring surgeons about the various intricacies concerning the field of microsurgery. This article with its focus on the six desirable microsurgical attributes of "Clarity, Curiosity, Perseverance, Passion, An Open Mindset and Action," is meant to be a modest attempt on part of the authors to share their microsurgical insights, procured through their respective journeys, with budding aspirants, hoping to sensitize as well as motivate them for the challenging path that lies ahead.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine and Asian Medical Center, Seoul, South Korea,Address for correspondence Joon Pio Hong, MD, PhD, MMM Division of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Asan Medical Center, University of Ulsan88 Olympic-ro 43-gil, Songpa-gu, SeoulSouth Korea
| | - Zulqarnain Masoodi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria,Plastic Surgery Division, Florence Hospital, Srinagar, Jammu and Kashmir, India
| | - Chieh-Han John Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria,Faculty of Medicine, Sigmund Freud University, Vienna, Austria,TZOU Medical, Vienna, Austria
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Badiul PO, Sliesarenko SV, Cherednychenko NO, Morgun OV. Efficiency Assessment of Multidetector-Row Computed Tomographic Angiography Using Reconstruction with Locoregional Perforator Flaps. Plast Surg (Oakv) 2023; 31:36-43. [PMID: 36755820 PMCID: PMC9900034 DOI: 10.1177/22925503211024750] [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: 02/18/2020] [Accepted: 04/25/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Reconstruction with the use of perforator flaps makes it possible to make the skin surface resistant to the influence of mechanical factors and as similar to the lost skin cover as possible. However, while planning any flap, along with the design of the required shape and size, its blood supply should be taken into account to ensure optimal viability. Therefore, the task to precisely determine the topographic-anatomical relationships suitable for the formation of a pedicle of perforators is still relevant. The aim of this study was to increase the efficiency of surgical reconstruction of wound defects by transposition of locoregional perforator flaps. Methods: The authors conducted a retrospective analysis of 72 cases of reconstruction by means of locoregional perforator flaps with vascular pedicle detachment to determine the efficiency of preoperative diagnostic preparation with the help of multidetector-row computed tomographic angiography (MDCT) in the process of reconstruction. Thirty-seven individual cases of surgical interventions were chosen using a case-controlled study from the study group when MDCT with angiography was used for preoperative planning of perforator flaps, as well as 35 control cases similar in terms of important predictive peculiarities with the reconstruction at the same level of difficulty. The patient groups were precisely matched by gender (P = .950), age (P = .804), flap area (P = .192), and type of reconstruction that was performed. Results: In all cases, the location of the perforator with a diameter greater than 1.0 mm was marked. All perforators determined during MDCT scanning were faultlessly localized intraoperatively. The distance between the intraoperative position of the perforator and the position obtained in the result of the examination did not exceed 1 cm. There was no need to change the planned design of the flap intraoperatively. In all cases where MDCT was performed, the duration of the surgical procedure varied from 60 to 150 minutes (average: 120.77 [18.90] minutes) and was reduced by 49.40 minutes (95% CI: 39.17-59.63) compared with the patients who did not undergo preoperative visualization of perforators where the average duration of the operation was 170.17 (19.19) minutes (from 140 to 220 minutes). Among the patients examined by MDCT, surgical complications were noted in 5 cases (13.51%) compared to 14 cases (40.00%) in the control group. Conclusions: The preoperative MDCT for the locoregional perforator flap reconstruction makes it possible to increase the efficiency of patient treatment given the reduction in surgery duration by 49.40 minutes (95% CI: 39.17-59.63) on average and the reduction in the level of postsurgery complications from 40% to 13.5% compared with the group of patients in whom presurgical visualization was not performed (P = .031).
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Affiliation(s)
- Pavlo O. Badiul
- Dnipropetrovsk Medical Academy of the Ministry of Health of
Ukraine, Dnipro, Ukraine
- Burn and Plastic Surgery Centre, Municipal Hospital #2, Dnipro,
Ukraine
| | | | - Nataliia O. Cherednychenko
- Oncology and Radiology Department, Dnipropetrovsk Medical Academy of the
Ministry of Health of Ukraine, Dnipro, Ukraine
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19
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Yamamoto T, Yamamoto N. Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic. J Reconstr Microsurg 2023; 39:131-137. [PMID: 35817051 DOI: 10.1055/s-0042-1750123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic. METHODS Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA. RESULTS LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed. CONCLUSION LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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20
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Scaglioni MF, Meroni M, Fuchs B, Knobe M, Fritsche E. The use of the chimeric conjoint flap technique for complex defects reconstruction throughout the body: Clinical experience with 28 cases. Microsurgery 2023; 43:109-118. [PMID: 35775973 DOI: 10.1002/micr.30936] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/17/2022] [Accepted: 06/15/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Large soft tissue defects reconstruction represents a frequent and complex challenge in plastic surgery. A critical point regards the equilibrium between the need of large amount of tissue, while minimizing donor site morbidity. This is a common issue that plastic surgeons face in their clinical practice. In this context, the chimeric conjoint flap technique can be a valuable option, allowing to better exploit many well-known procedures. The purpose of the present work is to show the reconstructive efficacy and reliability of this technique resorting to many different well-known flaps. No such a comprehensive collection of cases is available so far dealing with this procedure. PATIENTS AND METHODS Twenty-eight patients presenting large defects throughout the body were treated by means of different flaps, designed according to the chimeric conjoint flap concept. Patients' mean age was 61.9 years old (range 18-82 years), 20 were males and 8 females. The size of the defects ranged from 7 cm × 6 cm to 25 cm × 18 and presented shapes or localizations that were complex to be covered with a regular flap. The defects were located in 11 cases in the lower limbs, in 9 cases in the head and neck region, in 5 cases in the groin, and in 2 cases in the thorax. Cause of the defect was tumor resection in 20 cases, trauma-induced necrosis in 5 cases, Fournier's gangrene in 2 cases, and a chronic ulcer in 1 case. Fourteen flaps were free flaps while 14 were pedicled flaps. The chimeric conjoint flap technique consists in splitting the skin paddle a flap into two smaller island that can be rearranged in order to match the particular requirements of the recipient site. Different flaps were employed: the anterolateral thigh (ALT) flap was used in 19 cases, latissimus dorsi (LD) musculocutaneous flap in 4 cases, deep inferior epigastric (DIEP) in 3 cases, medial sural artery perforator (MSAP) in 1 case, free radial forearm flap (RFFF) in 1 case. RESULTS All the 28 patients were successfully treated. In 6 cases minor complications were encountered, 5 at recipient site and 1 at donor site, who were all managed conservatively. No second procedures were required. The mean follow-up period was 8.4 months (range 3-12 months). At the last follow-up evaluation all the patients reached an acceptable cosmetic result and, when limbs were affected, complete range of motion restoration. CONCLUSIONS The present case series provide promising evidence regarding the reliability and versatility of the chimeric conjoint flap technique for large and delicate defect reconstructions throughout the body.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Bruno Fuchs
- Department of Orthopedic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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21
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Saade F, Quemener-Tanguy A, Obert L, El-Rifai S, Bouteille C, Loisel F. Tricks in End-to-End Anastomosis in Microsurgery: a Systematic Review. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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22
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Le Hanneur M, Chaves C, Lauthe O, Salabi V, Bouché PA, Fitoussi F. Conventional versus fibrin-glue-augmented arterial microanastomosis: An experimental study. HAND SURGERY & REHABILITATION 2022; 41:569-575. [PMID: 35988913 DOI: 10.1016/j.hansur.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/04/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
The purpose of this experimental study was to develop an alternative technique of arterial microanastomosis using only 2 stay-sutures augmented with fibrin glue, and to compare it to the conventional technique in arteries of varying diameters mimicking hand arteries. Eight anastomoses were performed in 7 male rats, including 1 anastomosis each on the 2 femoral, iliac, and carotid arteries, and 2 on the subrenal aorta. The conventional technique was used on one side and on the first aorta anastomosis, while augmented anastomoses were performed on the other side and on the second aorta. Patency was tested 10 min after unclamping; clamping time, blood loss, anastomosis quality score (out of 15 points) and artery diameter were recorded. In arteries of diameter 0.5-2.2 mm, augmented anastomoses were on average 10.7 ± 3.2 min faster to perform (p < 0.0001), with an average of 1.3 ± 0.9 g less blood loss (p < 0.0001) and an average of 2.6 ± 2.5 points higher quality score (p < 0.0001). There were no significant differences between the two techniques in terms of patency rate, regardless of artery size. However, 3 of the 7 augmented anastomoses were non-permeable in the femoral subgroup (i.e., submillimetric arteries). This straightforward technique appears to be time-saving and reliable, provided that the repaired artery is of sufficient size. Subject to clinical validation, this technique might help surgeons treating extensive hand wounds with multiple severed neurovascular bundles.
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Affiliation(s)
- M Le Hanneur
- Hand to Shoulder Mediterranean Center, ELSAN, Clinique Bouchard, 77 rue du Dr Escat, 13006 Marseille, France; Department of Pediatric Orthopedics, Armand Trousseau Hospital - Sorbonne University, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - C Chaves
- Unité de Chirurgie de la Main, Clinique du Pré, 13 avenue René Laennec, 72000 Le Mans, France.
| | - O Lauthe
- Hand to Shoulder Mediterranean Center, ELSAN, Clinique Bouchard, 77 rue du Dr Escat, 13006 Marseille, France.
| | - V Salabi
- Hand to Shoulder Mediterranean Center, ELSAN, Clinique Bouchard, 77 rue du Dr Escat, 13006 Marseille, France.
| | - P-A Bouché
- Department of Pediatric Orthopedics, Armand Trousseau Hospital - Sorbonne University, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - F Fitoussi
- Department of Pediatric Orthopedics, Armand Trousseau Hospital - Sorbonne University, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
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23
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欧 昌, 罗 旭, 周 鑫, 邹 永, 李 迦, 杨 迎. [Free superficial circumflex iliac artery flap combined with deep inferior epigastric perforator flap for repair of large soft tissue defects of upper extremities]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1150-1154. [PMID: 36111479 PMCID: PMC9626290 DOI: 10.7507/1002-1892.202204071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/16/2022] [Indexed: 06/15/2023]
Abstract
Objective To investigate the effectiveness of free superficial circumflex iliac artery flap (SCIP) combined with deep inferior epigastric perforator flap (DIEP) in repairing large soft tissue defects of upper extremities. Methods Between February 2017 and January 2021, free SCIP combined with DIEP was used to repair 15 patients with large soft tissue defects of upper extremities. There were 12 males and 3 females, aged from 34 to 52 years, with a median age of 41 years. The causes of injury were mechanical injury in 11 cases and traffic accident injury in 4 cases. There were 9 cases of circular skin defect in the forearm and 6 cases of skin defect around the upper arm and elbow joint, with the defect in size of 15.5 cm×10.5 cm to 26.5 cm×15.5 cm, accompanied by exposure of deep tissues such as tendons and bones. There were 7 cases with open fractures and 8 cases with vascular and nerve injuries. The time from injury to operation ranged from 7 to 14 days, with an average of 7.5 days. The flaps in size of 16.0 cm×11.0 cm to 27.0 cm×16.0 cm were harvested; the thickness of the flaps was 0.8-1.3 cm, and the excess fat tissue was removed under the microscope after harvesting. The length of proximal vascular pedicle was 5.0-7.0 cm, and of distal vascular pedicle was 3.0-5.0 cm. The donor site was closed and sutured directly, and the navel was reconstructed. Results The flaps survived successfully in 14 cases, and the arterial crisis occurred in 1 case at 10 hours after operation, and the flap survived after surgical exploration. All the wounds in the donor and recipient sites healed by first intention. All 15 patients were followed up 3-14 months, with an average of 10.5 months. The appearance, elasticity, and texture of flap were good without obvious bloat, contracture, or adhesion. The donor site healed well, no abdominal wall hernia was found, and the appearance of reconstructed navel was good, only linear scar left. At last follow-up, 12 cases were evaluated as excellent and 3 cases were good according to the evaluation criteria of flap function of the Chinese Medical Association Microsurgery Branch. The sensation recovered to S 3 + in 7 cases and S 3 in 8 cases. Conclusion Free SCIP combined with DIEP has a large excision area and excellent skin ductility. It is an effective clinical method for repairing large soft tissue defects of upper extremities.
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Affiliation(s)
- 昌良 欧
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 旭超 罗
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 鑫 周
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 永根 邹
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 迦宇 李
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
| | - 迎秋 杨
- 西南医科大学附属中医医院骨科(四川泸州 646000)Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P. R. China
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An Innovative Simulation Model for Microvascular Training. Plast Reconstr Surg 2022; 150:189e-193e. [PMID: 35767635 DOI: 10.1097/prs.0000000000009209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Preclinical/clinical microsurgical training is essential for clinical practice. Therefore, various training models have been established, such as synthetic and cadaveric models. The most common limitation of these models is the lack of circulation, which limits the simulation of real intraoperative circumstances. Thus, the authors aimed to create a novel model that provides blood circulation with an extracorporeal perfusion device that they attached to rat cadavers for the reestablishment of a circulatory system. Patent blue and heparin were added to the perfusion fluid to visualize circulation and to dissolve thrombosis, and indocyanine green fluorescent imaging was applied to show the perfusion of the entire body. The femoral and brachial vessels were dissected, and an end-to-end anastomosis was performed on the femoral artery. The patency of the operated vessel was visualized with indocyanine green fluorescent imaging. Indocyanine green fluorescent imaging showed appropriate vessel patency and extremity perfusion through the anastomosis. The use of this novel rat model enables a solution for ethical problems encountered when using rats for surgical training courses. By practicing on these animal-sparing models with intact circulation, microsurgical skills can be improved. Future studies on further microsurgical techniques and vascular perfusion of organs or tumors may benefit from our model.
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Scaglioni MF, Meroni M, Fritsche E. Pedicled superficial circumflex iliac artery perforator flap for male genital reconstruction: A case series. Microsurgery 2022; 42:775-782. [PMID: 35730684 DOI: 10.1002/micr.30933] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 04/26/2022] [Accepted: 06/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Different issues may cause defects in the genital region, including urological, infective, oncological and genetic problems which often lead to significant defects. This is a very delicate region and a successful coverage requires a thin, pliable and reliable solution. In this setting the SCIP flap might be an outstanding procedure. Despite being a well-known solution in the groin region, its employment for genital reconstructions is still poorly described. For this reason, we gather our experience with this procedure showing the efficacy of the SCIP flap in this specific region. PATIENTS AND METHODS In the present case series we included 6 male patients who received a soft tissue defect reconstruction by means of pedicled SCIP flap over the last year. The average age was 53.6 years old (range 34-79 years). Among them, 5 patients received a surgical excision because of severe acne (2 cases), Fournier's gangrene (2 cases), or scrotal squamous cell carcinoma (1 case). In 1 case the cause of the missing volume was testicle agenesis and the reconstruction was performed for cosmetic purposes. Size of the defects ranged from 7 cm × 4 cm to 20 cm × 6 cm. Elliptical shaped flaps were designed either mono- or bilaterally according to the need. All the flaps were supplied by the superficial branch of the SCIA. The range of rotation varied between 150° and 180° in order to reach the affected area. RESULTS The flaps' dimension ranged from 8 cm × 4 cm to 20 cm × 6 cm. All the patients were successfully treated. In 1 case we encountered a small wound dehiscence, which was managed conservatively. The mean follow-up was 9.5 months (range 6-12 months). Good cosmetic result was achieved in all cases and no urinary or sexual dysfunctions were reported. CONCLUSIONS The pedicle SCIP flap represents a reliable solution for genital and inguinal defects reconstructions. Its versatility can be exploited throughout the region providing very good quality tissues that can be used for the most disparate situations.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Scaglioni MF, Meroni M, Knobe M, Fritsche E. Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases. Microsurgery 2022; 42:548-556. [PMID: 35475523 DOI: 10.1002/micr.30892] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 02/09/2022] [Accepted: 04/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases. PATIENTS AND METHODS Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm. RESULTS The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm2 (range 12-80 cm2 ) for the pedicle flaps and 104 cm2 (range 24-200 cm2 ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life. CONCLUSIONS The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Wu XQ, Liu HR, Yu ZY, Wang Y, Sun RT, Wang L, Gao Y. A Super-Microsurgery Training Model: The Mouse Caudal Artery Anastomosis Model. Front Surg 2022; 9:841302. [PMID: 35465440 PMCID: PMC9021413 DOI: 10.3389/fsurg.2022.841302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To establish a simple and practical model for super-microsurgery training using the middle caudal arteries of Kunming mice. Methods A ⊔-shaped incision was made approximately 1 cm from the root of the tail in the mouse, and the skin, together with the subcutaneous tissue, was turned up into a rectangular shape to the opposite side with exposure of the mouse middle caudal artery and the accompanying veins. The artery was freed for approximately 1 cm in length. The middle caudal artery was cut transversely at the site, and then the severed middle caudal artery was anastomosed end-to-end using 12-0 microsutures in the order of 6, 12, 3, and 9 o'clock with four stitches. Results The mouse caudal artery had a constant anatomical location accompanied by a vein. The immediate postoperative patency after vascular anastomosis was 100% (15/15) in all mouse models, the postoperative patency was 100% (5/5), 80% (4/5), and 75% (3/4) at 24 h, 3 days, and 1 week postoperatively, respectively. The outer diameter of the mouse middle caudal artery was 0.2 ~ 0.3 (0.22 ± 0.03) mm. The vascular anastomosis time was 6.5 ~ 15 (11.0 ± 2.5) min. Conclusion The mouse middle caudal artery was superficially located and anatomically constant, making it easy to be located and exposed. The small size of the opening made it suitable for establishing a useful model for training in super-microsurgery vascular anastomoses.
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Affiliation(s)
- Xue-Qiang Wu
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
| | - Hui-Ren Liu
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
- *Correspondence: Hui-Ren Liu
| | - Zhan-Yong Yu
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
| | - Yan Wang
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
| | - Ru-Tao Sun
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
| | - Li Wang
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, China
| | - Yuan Gao
- Institute of Trauma Surgery, Tangshan Second Hospital, Tangshan, China
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Moritz WR, Raman S, Pessin S, Martin C, Li X, Westman A, Sacks JM. The History and Innovations of Blood Vessel Anastomosis. Bioengineering (Basel) 2022; 9:75. [PMID: 35200428 PMCID: PMC8869402 DOI: 10.3390/bioengineering9020075] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Surgical technique and technology frequently coevolve. The brief history of blood vessel anastomosis is full of famous names. While the techniques pioneered by these surgeons have been well described, the technology that facilitated their advancements and their inventors deserve recognition. The mass production of laboratory microscopes in the mid-1800s allowed for an explosion of interest in tissue histology. This improved understanding of vascular physiology and thrombosis laid the groundwork for Carrel and Guthrie to report some of the first successful vascular anastomoses. In 1916, McLean discovered heparin. Twenty-four years later, Gordon Murray found that it could prevent thrombosis when performing end-to-end anastomosis. These discoveries paved the way for the first-in-human kidney transplantations. Otolaryngologists Nylen and Holmgren were the first to bring the laboratory microscope into the operating room, but Jacobson was the first to apply these techniques to microvascular anastomosis. His first successful attempt in 1960 and the subsequent development of microsurgical tools allowed for an explosion of interest in microsurgery, and several decades of innovation followed. Today, new advancements promise to make microvascular and vascular surgery faster, cheaper, and safer for patients. The future of surgery will always be inextricably tied to the creativity and vision of its innovators.
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Affiliation(s)
- William R. Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Shreya Raman
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Sydney Pessin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Amanda Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
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Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps. Plast Reconstr Surg 2022; 149:750-760. [PMID: 35080525 DOI: 10.1097/prs.0000000000008873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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75 Years of Excellence: The Story of Reconstructive Surgery. Plast Reconstr Surg 2021; 148:1423-1428. [PMID: 34847136 DOI: 10.1097/prs.0000000000008529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kwon JG, Hong DW, Choi JW. Clinical Applications of Augmented Reality Technology in Microsurgical Planning of Head and Neck Reconstruction. J Craniofac Surg 2021; 33:863-866. [PMID: 34538780 DOI: 10.1097/scs.0000000000008176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To perform head and neck reconstruction, the exact location of recipient vessels must be evaluated preoperatively. This study aimed to superimpose arterial and venous pathways identified by computed tomography angiography (CTA) on patients using augmented reality (AR) techniques to freely select recipient vessels. METHODS Patients who underwent reconstructive microsurgery due to defects on the scalp, forehead, and glabella from July 2019 to October 2019 were enrolled. The superficial temporal artery (STA) and superficial temporal vein (STV) were marked using hand-held Doppler. Furthermore, the three-dimensional reconstructed CTA image was superimposed on the patient's face using a smartphone application, Camera-Lucida, and marked. The accuracy of mapping was evaluated intraoperatively. Success rates and the time consumed for mapping were compared. RESULTS Twelve patients underwent preoperative marking. Success rates of STA mapping using the AR technology and hand-held Doppler were 100% and 83%, respectively (P = 0.48). The mean time consumed for STA marking was 90.2 ± 17.7 seconds and 121.0 ± 117.7 seconds, respectively (P = 0.75). The success rate of STV marking with the AR technology was superior to that with hand-held Doppler (100% versus 58.3%; P = 0.037). STV marking was faster with the AR technology than with hand-held Doppler (mean time, 91.2 ± 25.7 seconds versus 94.5 ± 101.6 seconds; P = 0.007). CONCLUSIONS The AR technology could be the paradigm shift in the field of microsurgical reconstruction. It can connect three-dimensional CTA data with patient topography, leading to not only more precise operations but also improved outcomes in patients undergoing microsurgical reconstruction.
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Affiliation(s)
- Jin Geun Kwon
- Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Perforator-to-perforator anastomosis as a salvage procedure during harvest of a perforator flap. Arch Plast Surg 2021; 48:467-469. [PMID: 34352962 PMCID: PMC8342250 DOI: 10.5999/aps.2020.02194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/09/2021] [Indexed: 11/22/2022] Open
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Gasteratos K, Morsi-Yeroyannis A, Vlachopoulos NC, Spyropoulou GA, Del Corral G, Chaiyasate K. Microsurgical techniques in the treatment of breast cancer-related lymphedema: a systematic review of efficacy and patient outcomes. Breast Cancer 2021; 28:1002-1015. [PMID: 34254232 PMCID: PMC8354929 DOI: 10.1007/s12282-021-01274-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/17/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Secondary lymphedema is the abnormal collection of lymphatic fluid within subcutaneous structures. Patients with lymphedema suffer a low quality of life. In our study, we aim to provide a systematic review of the current data on patient outcomes regarding breast cancer-related lymphedema (BCRL), and the most prevalent reconstructive techniques. METHODS A PubMed (MEDLINE) and Scopus literature search was performed in September 2020. Studies were screened based on inclusion/exclusion criteria. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO), and it was reported in line with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). RESULTS The search yielded 254 papers from 2010 to 2020. 67 were included in our study. Lymphaticovenous anastomosis (LVA)-a minimally invasive procedure diverting the lymph into the dermal venous drainage system-combined with postoperative bandaging and compression garments yields superior results with minimal donor site lymphedema morbidity. Vascularized lymph node transfer (VLNT)-another microsurgical technique, often combined with autologous free flap breast reconstruction-improves lymphedema and brachial plexus neuropathies, and reduces the risk of cellulitis. The combination of LVA and VLNT or with other methods maximizes their effectiveness. Vascularized lymph vessel transfer (VLVT) consists of harvesting certain lymph vessels, sparing the donor site's lymph nodes. CONCLUSION Together with integrated lymphedema therapy, proper staging, and appropriate selection of procedure, safe and efficient surgical techniques can be beneficial to many patients with BCRL.
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Affiliation(s)
- Konstantinos Gasteratos
- Department of Plastic and Reconstructive Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | | | | | | | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Kongkrit Chaiyasate
- Division of Plastic and Reconstructive Surgery, Oakland University William Beaumont School of Medicine, William Beaumont and Beaumont Children's Hospital, 3555 W 13 Mile Rd, Suite N120, Royal Oak, MI, 48073, USA.
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Yoshida S, Koshima I, Imai H, Uchiki T, Sasaki A, Nagamatsu S, Yokota K. Investigation of flow velocity in recipient perforator artery for a reliable indicator for the flap transfer with perforator to perforator anastomosis. Microsurgery 2021; 41:550-556. [PMID: 34213025 DOI: 10.1002/micr.30783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION In flap transfer with perforator to perforator anastomosis (FTPPA), encountering poor pulsation and blood flow in a recipient perforator intraoperatively often makes FTPPA impossible. This study sought to identify color and spectral Doppler ultrasonography (CSDUS) parameters that can aid reliable preoperative selection of a recipient perforator artery. PATIENTS AND METHODS The study enrolled 38 patients with lower extremity lymphedema who underwent vascularized lymphatic tissue transfer with perforator to perforator anastomosis for physiological lymphatic flow reconstruction. In all cases, three candidate recipient perforators were searched in each lower extremities, and vessel diameter and peak systolic flow velocity (PSFV) were measured. The inclusion criteria for candidates were a vessel diameter of >0.5 mm and a PSFV of >10 cm/s. These measures were compared with intraoperative findings, diameters and if there was pulsation and visible spurting evident. RESULTS A total of 114 candidates were selected, and 52 of the candidates were dissected until suitable perforators were found. PSFV (cm/s) on CSDUS was ≥20.0 in 32 perforators (84.2%) and was 15.0-19.9 in 6 perforators (15.8%) in the group with pulsation and visible spurting evident, and 15.0-19.9 in one perforator (7.1%) and ≤ 14.9 in 13 perforators (92.9%) in the group without pulsation and visible spurting evident. There was a statistically significant correlation between preoperative PSFV and intraoperative pulsation and visible spurting evident after dissection (P = 0.021 × 10-3 ). The flap survival rate was 92.1%. CONCLUSION PSFV is an important preoperative determinant of the suitability of a recipient perforator artery for FTPPA.
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Affiliation(s)
- Shuhei Yoshida
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Isao Koshima
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Imai
- The International Center for Lymphedema, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Uchiki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Ayano Sasaki
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Shogo Nagamatsu
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
| | - Kazunori Yokota
- Plastic and Reconstructive Surgery, Hiroshima University, Hiroshima, Japan
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Bosselmann T, Kolbenschlag J, Goertz O, Zahn P, Prantl L, Lehnhardt M, Behr B, Sogorski A. Improvement of Superficial and Deep Cutaneous Microcirculation Due to Axillary Plexus Anesthesia Impaired by Smoking. J Clin Med 2021; 10:2114. [PMID: 34068862 PMCID: PMC8153641 DOI: 10.3390/jcm10102114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Understanding microvascular physiology is key to any reconstructive procedure. Current concepts in anesthesia increasingly involve regional peripheral nerve blockade during microvascular reconstructive procedures. Whereas favorable effects on perfusion due to these techniques have been reported earlier, little evidence focusing on its effects in most peripheral vascular compartments is available. METHODS A total of 30 patients who were to receive axillary plexus blockade (APB) were included. Microcirculatory assessment of the dependent extremity was conducted utilizing combined laser-Doppler flowmetry and white light spectroscopy. Two probes (1-2 and 7-8 mm penetration depth) were used to assess changes in microcirculation. RESULTS APB resulted in significant changes to both superficial and deep cutaneous microcirculation. Changes in blood flow were most prominent in superficial layers with a maximum increase of +617% compared to baseline values. Significantly lower values of +292% were observed in deep measurements. Consecutively, a significant enhancement in tissue oxygen saturation was observed. Further analysis revealed a significant impairment of perfusion characteristics due to reported nicotine consumption (max Bf: +936% vs. +176%). CONCLUSION Cutaneous microcirculation is strongly affected by APB, with significant differences regarding microvascular anatomy and vascular physiology. Smoking significantly diminishes the elicited improvements in perfusion. Our findings could influence reconstructive strategies as well as dependent perioperative anesthetic management.
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Affiliation(s)
- Talia Bosselmann
- Center of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany;
| | - Ole Goertz
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital, 14193 Berlin, Germany
| | - Peter Zahn
- Department of Anesthesiology, Intensive Care Medicine, Palliative and Pain Medicine, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany;
| | - Lukas Prantl
- Center of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
| | - Marcus Lehnhardt
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
| | - Björn Behr
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
| | - Alexander Sogorski
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
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Gong Z, Zhang S, Li P, Liu J, Xu Y. Femoral artery-nourished anteromedial thigh flap: A new perspective in oral and maxillofacial defect reconstruction. Oral Oncol 2021; 117:105295. [PMID: 33887634 DOI: 10.1016/j.oraloncology.2021.105295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/05/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the feasibility and efficacy of the femoral artery (FA)-nourished anteromedial thigh (AMT) flap for reconstructing oral and maxillofacial defects. PATIENTS AND METHODS The authors analyzed a retrospective case series of 13 patients who underwent the reconstruction of oral and maxillofacial defects with the FA-nourished AMT flap. The flap design and the methods for defect reconstruction are described, and the reconstructive efficacy is reported. RESULTS Of the 13 patients, 12 were men, and 1 was woman, with an average age of 52.2 years. Of these FA-supplied AMT flaps, 7 were singly used, 5 were combined with the anterolateral thigh (ALT) flap or its chimeric flaps, and 1 was separately used with the ALT flap. Postoperatively, all flaps survived completely, without vascular compromise or major wound complications. CONCLUSIONS The FA-nourished AMT flap can also be used to reconstruct some common oral and maxillofacial defects, especially as a new alternative to the ALT flap. In addition, this flap can be combined with the ALT flap or its chimeric flaps or separately used with the ALT flap for the reconstruction of complex defects.
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Affiliation(s)
- Zhaojian Gong
- Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | - Shanshan Zhang
- Department of Stomatology, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Panchun Li
- Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Jiang Liu
- Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Yuming Xu
- Department of Stomatology, the Second Xiangya Hospital, Central South University, Changsha 410011, China
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Scaglioni MF, Meroni M, Fritsche E. Application of the "Open-Y" technique in recipient perforator vessels: A comparison study between "Open-Y" and conventional end-to-end anastomosis in terms of postoperative complications. Microsurgery 2021; 41:527-532. [PMID: 33566367 DOI: 10.1002/micr.30718] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/16/2020] [Accepted: 01/28/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Over the last few years, the increasing employment of perforators as both donor and recipient vessels for free flap tissue transfer lead the surgeons to perform increasingly smaller anastomosis. Size discrepancy is a common problem that might affect the patency rate. This has many implications in the outcome of the procedure and the "Open-Y" technique might be useful to perform an easier anastomosis by using a bifurcation area. PATIENTS AND METHODS Between April 2018 and April 2020 a total of 98 patients who received a free tissue transfer reconstruction throughout the body were retrospectively recruited. The "Open-Y" technique of anastomosis was used in the recipient artery of 40 perforator-based flaps, while in 58 cases a conventional anastomosis with nonperforator vessel was performed. The size discrepancy rate and the arterial anastomotic site-related complications were evaluated and compared. RESULTS The flap success rate was 100% (40/40) in the "Open-Y" group, slightly better than the conventional group (96.5%; 56/58) despite a higher size discrepancy rate in the "Open-Y" group (27.5%; 11/40) compared to the conventional one (12%; 7/58) (p value, .053). The rate of complications was different, too. Better results were obtained in the "Open-Y" group with 4/40 (10%) complications compared to the 18/58 (31%) of the conventional group (p value, .013). CONCLUSIONS The "Open-Y" technique is a simple and interesting procedure to increase the vessels' diameter thus reducing size discrepancy and increasing the reliability of the anastomosis. This is extremely valuable in the perforator-to-perforator free tissue transfer setting where surgeons are often forced to work in a supermicrosurgical field. Every time a suitable bifurcation is encountered this might be a useful procedure to increase the end-surface available for the anastomosis or to reduce vessels size discrepancy.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Abstract
Supermicrosurgery is defined as microsurgery working on vessels less than 0.8 mm, allowing applications in smaller-dimension microsurgery, such as lymphedema, minimal invasive reconstruction, small parts replantation, and application of perforator as recipient. To accommodate this technique, developments and use of finer instruments, smaller sutures, new diagnostic tools, and higher-magnification microscopes have been made. Although supermicrosurgery has evolved naturally from microsurgery, it has developed into a unique field based on different thinking and tools to solve problems that once were difficult to solve.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea.
| | - Changsik John Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, 88 Olympicro 43 gil, Songpagu, Seoul 05505, Korea
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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Accuracy of infrared thermography for perforator mapping: A systematic review and meta-analysis of diagnostic studies. J Plast Reconstr Aesthet Surg 2021; 74:1173-1179. [PMID: 33573886 DOI: 10.1016/j.bjps.2020.12.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Infrared thermography allows the detection of infrared radiation which can be reliably associated with skin temperature. Modern portable thermography devices have been used to identify the location of skin perforators by detecting subtle differences in skin temperature. The aim of this study is to conduct a diagnostic accuracy systematic review to determine the specificity and sensitivity of infrared thermography. MATERIALS AND METHODS A PRISMA-compliant systematic review and meta-analysis was conducted, scrutinising PUBMED and EMBASE databases for diagnostic studies measuring the accuracy of infrared thermography for perforator identification. Article screening, review and data gathering was conducted in parallel by two independent authors. Eligible studies were subject to a formal risk of bias was assessment using the QUADAS2 instrument. RESULTS A total of 254 entries were obtained, of which 7 satisfied our pre-established inclusion criteria. These studies reported a total of 435 perforators in 133 individuals. The most commonly investigated locations were the antero-lateral thigh and abdominal wall. Reported sensitivity values ranged from 73.7% to 100%. A meta-analysis demonstrated a cumulative sensitivity of 95%. Specificity was not routinely reported. All studies presented a moderate to high risk of bias according to QUADAS2. DISCUSSION Affordable infrared thermography devices are an interesting alternative to traditional preoperative investigations for perforator mapping. They are sensitive enough to reliably identify a large proportion of perforators as "hot-spots". However, there is limited evidence to estimate the specificity of this technology, as studies have failed to report true negative values associated with "cold-spots".
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Habibi K, Ganry L, Luca-Pozner V, Atlan M, Qassemyar Q. Thin submental artery perforator flap for upper lip reconstruction: A case report. Microsurgery 2021; 41:366-369. [PMID: 33398906 DOI: 10.1002/micr.30703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/27/2020] [Accepted: 12/16/2020] [Indexed: 11/06/2022]
Abstract
Reconstruction of upper lip defects can be challenging even for experienced surgeons. In order to restore both function and morphology, the use of quality soft tissue is essential. To this effect, the most common solution is the use of local flaps, or, in extreme situations, a free flap. However, a thin cutaneous upper lip defect may require a different approach. Perforator flaps are versatile and may allow an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. We present the case of a 41-year-old female with a 1 × 1.5 cm basal cell carcinoma of the right-side upper lip, initially treated with a full thickness skin graft. Due to poor aesthetic and functional result, a thin submental artery perforator (SMAP) flap reconstruction was performed. Flaps' dimensions were 6 cm long and 4 cm wide and it was based on a perforator arising from the submental artery. Dissection was conducted above the platysma muscle, and the SMAP flap was transferred into the defect through a subcutaneous tunnel created below the mandible and posterior to the anterior belly of digastric muscle. The pedicle length of 6.5 cm was adequate for a tension free inset of the flap. Postoperative course was uneventful and the patient was discharged after 2 days. The 4-month follow-up showed a satisfying functional and aesthetic outcome with a concealed donor site scar. This report points out the coverage potential of the thin SMAP flap, which can be successfully used for a harmonious reconstruction in both color and texture of the upper lip.
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Affiliation(s)
- Koohyar Habibi
- Plastic Reconstructive and Aesthetic Surgery-Microsurgery, Hospital Tenon, Paris, Île-de-France, France
| | - Laurent Ganry
- Plastic and Reconstructive Surgery, Hôpital Armand-Trousseau, Paris, Île-de-France, France.,Sorbonne University, Paris, Île-de-France, France
| | - Vlad Luca-Pozner
- Plastic and Reconstructive Surgery, Hôpital Armand-Trousseau, Paris, Île-de-France, France.,Sorbonne University, Paris, Île-de-France, France
| | - Michael Atlan
- Plastic Reconstructive and Aesthetic Surgery-Microsurgery, Hospital Tenon, Paris, Île-de-France, France.,Sorbonne University, Paris, Île-de-France, France
| | - Quentin Qassemyar
- Plastic Reconstructive and Aesthetic Surgery-Microsurgery, Hospital Tenon, Paris, Île-de-France, France.,Plastic and Reconstructive Surgery, Hôpital Armand-Trousseau, Paris, Île-de-France, France.,Sorbonne University, Paris, Île-de-France, France
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Yamamoto T, Yamamoto N. A triple-component deep inferior epigastric artery perforator chimeric free flap for three-dimensional reconstruction of a complex knee defect complicated with patella osteomyelitis. Microsurgery 2020; 41:370-375. [PMID: 33368468 DOI: 10.1002/micr.30698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/05/2020] [Accepted: 12/16/2020] [Indexed: 11/09/2022]
Abstract
Reconstruction of a complex knee defect is challenging, especially when complicated with osteomyelitis. Complex knee defect requires multi-component three-dimensional reconstruction using a chimeric flap. Although anterolateral thigh (ALT) flap is the most workhorse chimeric flap, another chimeric flap is required when ALT flap is not available. In this report, we present a case of complex knee defect successfully treated with a free triple-component chimeric deep inferior epigastric artery perforator (DIEP) flap transfer. A 36 year-old male sustained right above-knee amputation and Gustilo IIIB open fracture of the left patella after being run over by a train. Stump formation was performed for the right limb amputation, and the left knee wound resulted in skin necrosis complicated with patella osteomyelitis. After debridement, the left knee wound showed a 3 × 2 cm articular capsule defect, 5 × 2 cm exposed patella stump, and a 16 × 9 cm skin defect. A triple-component chimeric DIEP flap, containing a 7 × 3 cm rectus abdominis muscle (RAM), a 3 × 2 cm RAM's fascia, and a 23 × 10 cm skin was transferred. The RAM's fascia was used to reconstruct the joint, the RAM to cover the exposed patella's stump and the reconstructed joint, and the skin paddle to cover the skin defect. Six months after the surgery, the patient could walk without osteomyelitis recurrence, and there was no limitation in the left knee joint's range of motion. Although indication is limited, a multi-component chimeric DIEP flap may be an option for three-dimensional reconstruction of a complex defect.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan.,Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Scaglioni MF, Meroni M, Fritsche E. Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience. J Plast Reconstr Aesthet Surg 2020; 74:1791-1800. [PMID: 33388271 DOI: 10.1016/j.bjps.2020.12.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/06/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body. PATIENTS AND METHODS Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps). RESULTS Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%. CONCLUSIONS Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Wallner C, Kolbenschlag J, Daigeler A, Stambera P, Andree C, Rieger UM, Behr B, Schaefer DJ, Kneser U, Lehnhardt M. Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. HANDCHIR MIKROCHIR P 2020; 52:310-315. [PMID: 32823366 DOI: 10.1055/a-1205-1309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Perioperative management in microsurgery is a key element of success in reconstructive surgery. There are no uniform concepts for this in the German-speaking countries and individual schemes differ significantly from each other, as ascertained in an expert survey. In the course of the 41st Annual Conference of the German-speaking Working Group for Microsurgery (DAM) held in Munich in November 2019, concepts were evaluated and a survey was carried out and summarised as a position paper in due consideration of the scientific literature.
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Affiliation(s)
- Christoph Wallner
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Jonas Kolbenschlag
- Universitätsklinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen
| | - Adrien Daigeler
- Universitätsklinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, BG Klinik Tübingen
| | - Peter Stambera
- Klinik für Plastische und Ästhetische Chirurgie, Sana-Kliniken Düsseldorf, Krankenhaus Gerresheim, Akademisches Lehrkrankenhaus der Heinrich Heine Universität Düsseldorf
| | - Christoph Andree
- Klinik für Plastische und Ästhetische Chirurgie, Sana-Kliniken Düsseldorf, Krankenhaus Gerresheim, Akademisches Lehrkrankenhaus der Heinrich Heine Universität Düsseldorf
| | - Ulrich Michael Rieger
- Klinik & Praxis für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus
| | - Björn Behr
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
| | - Dirk Johannes Schaefer
- Universitätsklinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, BG-Klinik Ludwigshafen, Klinik für Plastische und Handchirurgie an der Universität Heidelberg
| | - Marcus Lehnhardt
- Universitätsklinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil
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Gileva KS, Ivanova ED. [Reverse perforator submental flap for closing soft tissue defects]. STOMATOLOGII︠A︡ 2020; 99:41-46. [PMID: 32608948 DOI: 10.17116/stomat20209903141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents the clinical results of using a new surgical method, involving the reverse perforator submental flap for reconstruction of soft tissue defects in the maxillofacial area in 5 patients aged from 41 to 62 years. The purpose of the study was to expand the indications for the use of the submental flap. A feature of the method is the sampling of a primary thin perforator submental flap with reverse blood flow with a minimal risk of postoperative complications. An algorithm for surgical flap taking has been developed. The study proves the safety and efficiency of the proposed method.
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Affiliation(s)
- K S Gileva
- National Medical Research Center of Dentistry and Maxillofacial Surgery of Ministry of Health of the Russian Federation, Moscow, Russia
| | - E D Ivanova
- National Medical Research Center of Dentistry and Maxillofacial Surgery of Ministry of Health of the Russian Federation, Moscow, Russia
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Liu C, Li P, Liu J, Xu Y, Wu H, Gong Z. Management of Intraoperative Failure of Anterolateral Thigh Flap Transplantation in Head and Neck Reconstruction. J Oral Maxillofac Surg 2020; 78:1027-1033. [DOI: 10.1016/j.joms.2020.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/05/2020] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
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Drobot A, Bez M, Abu Shakra I, Merei F, Khatib K, Bickel A, Ganam S, Bogouslavski G, Karra N, Mahran B, Kassis W, Kogan L, Drobot D, Weiss M, Koshima I, Kakiashvili E. Microsurgery for management of primary and secondary lymphedema. J Vasc Surg Venous Lymphat Disord 2020; 9:226-233.e1. [PMID: 32446874 DOI: 10.1016/j.jvsv.2020.04.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.
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Affiliation(s)
- Assi Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Maxim Bez
- Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Ibrahim Abu Shakra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Fahed Merei
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Kamal Khatib
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Grigori Bogouslavski
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Nour Karra
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Badran Mahran
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Walid Kassis
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Leonid Kogan
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Denis Drobot
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Michael Weiss
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Isao Koshima
- International Center for Lymphedema, Hiroshima University Hospital, Hiroshima
| | - Eli Kakiashvili
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine of the Galilee, Bar-Ilan University, Ramat Gan, Israel; Medical Corps, Israel Defense Forces, Ramat Gan, Israel.
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The Exoscope versus operating microscope in microvascular surgery: A simulation non-inferiority trial. Arch Plast Surg 2020; 47:242-249. [PMID: 32453933 PMCID: PMC7264907 DOI: 10.5999/aps.2019.01473] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/02/2020] [Indexed: 12/14/2022] Open
Abstract
Background The Exoscope is a novel high-definition digital camera system. There is limited evidence signifying the use of exoscopic devices in microsurgery. This trial objectively assesses the effects of the use of the Exoscope as an alternative to the standard operating microscope (OM) on the performance of experts in a simulated microvascular anastomosis. Methods Modus V Exoscope and OM were used by expert microsurgeons to perform standardized tasks. Hand-motion analyzer measured the total pathlength (TP), total movements (TM), total time (TT), and quality of end-product anastomosis. A clinical margin of TT was performed to prove non-inferiority. An expert performed consecutive microvascular anastomoses to provide the exoscopic learning curve until reached plateau in TT. Results Ten micro sutures and 10 anastomoses were performed. Analysis demonstrated statistically significant differences in performing micro sutures for TP, TM, and TT. There was statistical significance in TM and TT, however, marginal non-significant difference in TP regarding microvascular anastomoses performance. The intimal suture line analysis demonstrated no statistically significant differences. Non-inferiority results based on clinical inferiority margin (Δ) of TT=10 minutes demonstrated an absolute difference of 0.07 minutes between OM and Exoscope cohorts. A 51%, 58%, and 46% improvement or reduction was achieved in TT, TM, TP, respectively, during the exoscopic microvascular anastomosis learning curve. Conclusions This study demonstrated that experts’ Exoscope anastomoses appear non-inferior to the OM anastomoses. Exoscopic microvascular anastomosis was more time consuming but end-product (patency) in not clinically inferior. Experts’ “warm-up” learning curve is steep but swift and may prove to reach clinical equality.
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Application of Suprafascially Harvested Anterolateral Thigh Perforator Flap for the Reconstruction of Oral and Maxillofacial Defects. J Craniofac Surg 2020; 31:e673-e676. [DOI: 10.1097/scs.0000000000006511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Yamamoto T, Yamamoto N, Kageyama T, Sakai H, Fuse Y, Tsuihiji K, Tsukuura R. Supermicrosurgery for oncologic reconstructions. Glob Health Med 2020; 2:18-23. [PMID: 33330769 DOI: 10.35772/ghm.2019.01019] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 11/08/2022]
Abstract
With advancement of microsurgical techniques, supermicrosurgery has been developed. Supermicrosurgery allows manipulation (dissection and anastomosis) of vessels and nerves with an external diameter of 0.5 mm or smaller. Because quality of life of cancer survivors is becoming a major issue, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques attracts attention. Conventional free flap reconstruction usually sacrifices major vessels and muscle functions, whereas supermicrosurgical free flaps can be transferred from anywhere using innominate vessels without sacrifice of major vessel/muscle. Since a 0.1-0.5 mm vessel can be anastomosed, patient-oriented least invasive reconstruction can be accomplished with supermicrosurgery. Another important technique is lymphatic anastomosis. Only with supermicrosurgery, lymph vessels can be securely anastomosed, because lymph vessel diameter is usually smaller than 0.5 mm. With clinical application of lymphatic supermicrosurgery, various least invasive lymphatic reconstruction has become possible. Lymphatic reconstruction plays an important role in prevention and treatment of lymphatic diseases following oncologic surgery such as lymphedema, lymphorrhea, and lymphocyst. With supermicrosurgery, various tissues such as skin/fat, fascia, bone, tendon, ligament, muscle, and nerves can be used in combination to reconstruct complicated defects; including 3-dimensional inset with multi-component tissue transfer.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takashi Kageyama
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kanako Tsuihiji
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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