Microvascular and microneural surgery new horizons in facial plastic and reconstructive surgery

Fellowship training in microvascular surgery and post-fellowship practice patterns: a cross sectional survey of microvascular surgeons from facial plastic and reconstructive surgery programs

Background

There is a lack of published literature on the training in microvascular reconstructive techniques in facial plastic and reconstructive surgery (FPRS) fellowships or of the extent these techniques are continued in practice. This cross-sectional web-based survey study was conducted to describe the volume, variety, and intended extent of practice of free tissue transfers during fellowship and the post-fellowship pattern of microsurgical practice among FPRS surgeons in various private and academic practice settings across the United States.

Methods

This survey was sent to recent graduates (n = 94) of a subset of U.S. Facial Plastic and Reconstructive Surgery fellowship programs that provide significant training in microvascular surgery.

Results

Among survey respondents (n = 21, 22% response rate), two-thirds completed 20–100 microvascular cases during fellowship using mainly radial forearm, fibula, anterior lateral thigh, latissimus and rectus free tissue transfers. In post-fellowship practice, those who continue practicing microvascular reconstruction (86%) complete an average of 33 cases annually. The choice of donor tissues for reconstruction mirrored their training. They are assisted primarily by residents (73%) and/or fellows (43%), while some worked with a micro-trained partner, surgical assistant, or performed solo procedures. Interestingly, among those who began in private practice (29%), only half remained with that practice, while those who joined academic practices (71%) largely remained at their initial post-fellowship location (87%).

Conclusions

These results provide the first formal description of the training and practice patterns of FPRS-trained microvascular surgeons. They describe a diverse fellowship training experience that often results in robust microvascular practice. The maintenance of substantial microsurgical caseloads after fellowship runs counter to the perception of high levels of burnout from free tissue transfers among microvascular surgeons.

Trial Registration

This study was approved as exempt by the University of Florida Institutional Review Board (#201601526).

Baiting the cross-face nerve graft with temporary hypoglossal hookup

BACKGROUND

Cross-face nerve grafting yields inconsistent neural regeneration, and methods that promote more robust axonal traversing of the graft would expand the indications for this procedure.

OBJECTIVE

To test the hypothesis that hooking a cross-face nerve graft distally to a source of denervated muscle, rather than leaving it in the subcutaneous space, would positively affect neural ingrowth across the graft, based on elaboration of neurotrophins from the musculature.

METHODS

Twenty-four rats underwent cross-face nerve grafting in which the right facial nerve buccal branch was transected and coapted to the graft. The graft was placed across the neck and into the left side of the face. The distal end of the graft was placed either in the left subcutaneous space, coapted to the marginal mandibular branch of the left facial nerve, or coapted to the distal stump of the transected left hypoglossal nerve. Eight control animals underwent right buccal branch transection and placement of a cross-face nerve graft without any proximal and distal hookup. After 12 weeks, all experimental groups underwent hookup of the distal nerve graft to the left facial nerve buccal branch. Vibrissal function was assessed during the ensuing 12 weeks, and then the graft was harvested for histomorphometric analysis.

RESULTS

After 12 weeks, there was a significant difference in axon counts between the group coapted distally to the tongue (hypoglossal hookup) and that coapted to the facial musculature (marginal hookup). Twelve weeks later, after distal cross-face nerve graft hookup, this difference was not statistically significant, although the hypoglossally baited group demonstrated statistically significantly greater fiber maturity. Recovery of vibrissal movement did not differ among treatment groups.

CONCLUSION

Baiting the cross-face nerve graft via temporary hookup to the distal hypoglossal nerve and tongue musculature appears to improve nerve ingrowth through a nerve graft across the face, although a corresponding improvement in facial muscle function was not observed.