Aim: The purpose of this study is to compare the surgical outcomes of treating recurrent carpal tunnel with recurrent carpal tunnel release only compared to recurrent carpal tunnel release with fat grafting as an adjunct.
Methods: Retrospective case-control study was performed of the recurrent carpal tunnels treated, excluding explicit nerve injury such as transections, neuromas in continuity, etc. Patients with recurrent carpal tunnel received re-release of carpal tunnel only or fat grafting as an adjunct. The outcomes of both groups were compared utilizing chi-square analysis.
Results: A total number of 81 patients were found to meet the inclusion criteria. Of the recurrences, a total of 16 patients did not receive fat grafting and 65 did. The rate of improvement in symptoms for performing a carpal tunnel release was only 50.0% and for performing carpal tunnel release with fat grafting was 92%, with
Conclusion: Adipose-derived stem cells as an adjunct to carpal tunnel release increased the rate of improvement in symptoms of carpal tunnel compression after recurrence compared to carpal tunnel release alone. Further studies need to be performed to confirm the validity of these findings.
Outpatient electrodiagnostic studies and intraoperative monitoring are essential tools for the surgical management of nerve injury. Decisions are based on the diagnostic certainty afforded by outpatient electrodiagnostic studies, which are more sensitive and specific than clinical examinations regarding the nature and localization of a nerve lesion. Intraoperative neurophysiologic monitoring detects changes in neurologic function during surgery. It provides significantly better information than visual inspection of the operative field, minimizing postoperative neurologic deficits due to surgical manipulation (e.g., stretching, compression, heating from electrocauterization, constriction, or clamping of local blood vessels). These techniques exploit similar neurophysiologic principles to afford enhanced diagnostic and real-time functional data during surgery. However, an understanding of their limitations is critical for the interpretation of these data. This review discusses these techniques, including their use, advantages, and disadvantages in diagnosing and managing three essential nerve lesions amenable to surgical management-radiculopathy, mononeuropathy, and brachial plexopathy.
Driven by the rapid development of big data, the amount of clinical data, including complex information, is expanding. Traditional data analysis methods cannot meet the need for mining data information, and artificial intelligence (AI) solves this problem. AI is increasingly being incorporated into modern medical practice. Algorithms provided by AI support advanced analysis and provide individualized aid to optimize medical decision-making. In plastic surgery, AI has made many breakthroughs in diagnosis, pre-operative surgical design, treatment decisions, and patient management. Plastic surgeons must recognize AI’s potential development and limitations. This review describes the current application of AI in plastic surgery and discusses the challenges and problems that need to be solved. This study aims to foster the application of this new AI technology in clinical practice.
Supermicrosurgical lymphaticovenular anastomosis (LVA) is the most sought-after procedure among lymphedema patients. However, the same enthusiasm is currently not shared among lymphedema surgeons due to the lackluster results of LVA. The common unfavorable experience with this famed procedure is at least partially caused by the difficulty in finding the lymph vessels. We share our time-tested indocyanine green-based lymph vessel mapping technique, which has helped us establish LVA as our procedure for all fluid-predominant lymphedema.
Aim: The aim of this systematic review was to summarize clinical and patient-reported outcomes (PROs) for various vascularized lymph node transfer (VLNT) donor sites and identify gaps in the literature to guide future research.
Methods: A literature search of five databases was performed for articles related to VLNT that were published prior to November 2021. Studies that included clinical outcomes or PROs from at least five adult patients who received VLNTs to treat lymphedema were included.
Results: Sixty-six studies met the study criteria. Most studies reported improved limb circumference/volume, reduction or discontinuation of conservative therapy, infection rate reduction, improved PROs, or postoperative imaging findings reflecting functional lymph nodes. There were significantly lower infection rates (P < 0.05) and a trend towards improved PROs in patients who received intra-abdominal flaps, but overall few studies reported these outcomes. There were no significant differences in complication rates at the donor or recipient site based on VLNT donor sites, or between intra-abdominal vs. extra-abdominal VLNT donor sites, although these outcomes are not uniformly reported.
Conclusion: This meta-analysis identified that intra-abdominal donor sites have the potential to reduce postoperative infectious episodes more than extra-abdominal donor sites. Though recent investigations address many understudied VLNT donor sites, larger comparative studies and a standardized methodology are needed to better characterize postoperative outcomes, which can offer more concrete evidence to guide surgical practice.
The recent development of robotic-assisted microsurgery and supermicrosurgery has raised great expectations to support some of the most demanding microsurgical procedures, which are applied in lymphatic reconstructive surgery to restore lymphatic vascular integrity and treat lymphedema. Procedures such as the establishment of lymphovenous anastomosis (LVA), the harvest of lymph nodes from anatomic locations that reduce donor-side morbidity and the transplantation of the vascularized lymph node flaps (VLNT) present procedures necessitating extreme precision and dexterity in often difficult-to-reach areas, thus pushing the physical limitations of the performing microsurgeon. Despite being limited in number, recent preclinical and clinical studies of independent groups using different robotic systems demonstrate the feasibility of robotic technology to perform supermicrosurgical procedures successfully. The robotic assistance offers unparalleled precision, refining the surgical techniques and minimizing potential side effects, with clinical outcomes comparable to the conventional techniques. Although the relative disadvantages of robotic assistance mostly appear to be related to adequate training and the prolonged learning curve, the technology promises to revolutionize the field of supermicrosurgery and improve the clinical outcomes of lymphatic reconstructive surgery.
Hand surgery has undergone substantial changes in recent years, especially for reconstructive surgery techniques. We discuss the management of soft tissue defects of the thumb, discussing indications, and operative pearls and pitfalls. We cover non-operative treatment and local advancement flaps for small distal soft tissue defects and pedicled flaps for more significant defects. We also discuss composite vascularized free flaps such as second-toe neurocutaneous flaps and partial hallux transfer for compound defects or total amputations. This article aims to provide hand surgeons with an update on reconstructing an injured thumb.
Peripheral nerve injury (PNI) is a common source of pain and disability in patients. While many patients are affected by PNI, peripheral nerve surgery advancements in the lower extremity have lagged behind the upper extremity. Subsequently, principles that have demonstrated success in the upper extremity have been implemented in the lower extremity. Interventions with recent advances include the advent of novel nerve transfers in the lower extremity and using stem cells and electrical stimulation (ES) for nerve regeneration. This article focuses on advances in nerve transfers for lower extremity PNI and provides details on the basic science and clinical applications of newer interventions.
Aim: Targeted muscle reinnervation (TMR) surgery has fundamentally changed the management of patients who have suffered or are about to undergo amputation. Providing nerve stumps with a muscle target has been shown to have profound effects on levels of post-amputation pain in relation to phantom limb pain (PLP) and neuroma pain (NP). The primary objective of this report was to quantify pain parameters for this population and to measure the impact on health-related quality of life (HRQol) before and after TMR surgery. In this case series, we evaluate the role of TMR in addressing both pain and the impact of the surgery on the patient’s quality of life.
Methods: A retrospective analysis of 15 upper limb amputee patients who underwent TMR by the Relimb Unit in London, UK. Participants’ perceptions of pain were determined using the 11-point numerical (Pain) rating scale (NRS) and HRQoL was calculated using the Euroqol EQ-5D-5L questionnaire at two time points, comparing both pain and perceived quality of life pre and post surgery. The Wilcoxon Signed Rank Test was used for the NRS data and a paired sample t-test was used for the EQ-VAS data.
Results: A total of 15 patients completed the evaluation. We observed statistically significant reductions in both PLP (pre-operative mean: 7.6, post-operative mean: 2.7, P < 0.05) and NP (pre-operative mean: 6.4, post-operative mean: 2.5, P < 0.05) in these patients. Similarly, HRQoL observed on the EQ-VAS scale demonstrated a significant improvement in quality of life, from 68 pre-operatively to 78 post-procedure (P < 0.05).
Conclusion: This is the first quantified evaluation of changes in HRQoL after TMR surgery for upper limb amputation. There appears to be a significant improvement in both HRQoL and overall perception of pain. This finding may have important implications for funding and national resource allocation for TMR surgery.
Targeted muscle reinnervation (TMR) is a peripheral nerve procedure that can prevent and treat postamputation pain. The nerve transfer allows for organized nerve regeneration and repair after amputation surgery. The procedure can successfully prevent neuromas despite large size mismatches between the donor and recipient nerves. Here, we discuss the fundamentals of peripheral nerve injury and regeneration as it pertains to TMR. We propose axonal pruning to explain axon behavior when there are large size mismatches between transferred nerves. Given the increasing use of TMR for amputees, future studies should investigate the basic science of peripheral nerves in TMR. Advances in this field have the potential to significantly improve clinical outcomes for these patients.
Autologous fat grafting is an important surgical technique in aesthetic and reconstructive procedures. Fat grafting for breast reconstruction is now an established procedure for adding volume and improving cutaneous pliability; it can be used independently to replace more invasive flap procedures or implants, or as an adjunct for smaller volume supplementation. The breadth of applications in the breast necessitates diversity in technique and approach, and while there is no universally agreed-upon protocol, basic principles have guided the evolution of some commonly adopted tenets. Broadly, fat grafting outcomes are highly favorable but dependent on patient and procedure factors, requiring learned patient selection and expertise in recipient site assessment. Common complications from fat grafting, such as fat necrosis and the development of nodules, are particularly troublesome for post-oncologic patients, requiring considerable pre-surgical consultation for patient education and managing expectations. In addition to volume and contour augmentation, fat grafting has additional beneficial effects that have recently drawn increased attention including pain reduction from implant capsular contracture or post-mastectomy pain syndrome, improved skin quality and reduced fibrosis following radiation, and possible
Double-walled orbital fractures involving the floor and medial wall are commonly encountered in instances of significant midface trauma. Operative intervention is indicated in the presence of persistent diplopia, significant enophthalmos, or muscle entrapment. Surgical repair of these injuries may be challenging due to large fracture sizes or loss of bony supports. The transconjunctival and transcaruncular approaches have been popularized to reconstruct isolated floor and medial wall fractures, respectively. However, surgical approaches for fractures involving both these walls have not been well described in the literature. In this technical note, we detail a combined transcaruncular-transconjunctival approach that is safe, effective, and aesthetically sensitive.
Lower extremity peripheral nerve injuries can be highly morbid to patients and challenging problems for reconstructive surgeons to manage. Nerve transfers have recently emerged as a promising technique in the treatment of these injuries. The nerve-transfer paradigm is predicated on the use of an expendable, unaffected nerve as a donor of axons to restore motor or sensory function in the target end organ. Distal transfers close to the end motor or sensory organ may allow for earlier and more robust reinnervation compared to more proximal primary repair or grafting. However, as clinical data on outcomes and rigorous comparative studies remain scarce, reconstructive surgeons must rely on principle-based treatment including a detailed understanding of lower extremity neuromuscular anatomy, gait mechanics, and nerve physiology to develop an appropriate treatment plan for each patient with the goal of functional limb restoration and independent gait. In this article, we review current concepts of lower extremity nerve transfers, including techniques and outcomes according to indication.
Aim: Post-operative protocols following lower limb free flap surgery are not well defined, with a lack of consensus in the literature around limb dependency and weight bearing. The aim was to compare the complication rate for lower limb free flaps before and after the introduction of an enhanced lower limb free flap protocol with earlier dangling (day 3 vs. day 4) and weight bearing (day 5 vs. day 14) post lower limb free flap surgery.
Methods: All lower limb free flaps between June 2020-January 2022 were identified from a departmental flap database. Patient data were collected from the comprehensive lower limb free flap database, medical notes, and electronic records. Patients prescribed an extended non-weight-bearing period due to the method of bone fixation were excluded.
Results: A total of 37 patients, 15 pre- and 22 post-enhanced protocol, were identified for comparison. The mean age was 43 (17-72) with a M:F of 3:1. There was no difference in the type of flap reconstruction between groups, with the anterolateral thigh flap being the most common in both groups. No differences were identified in the number of complications related to dependency/weight bearing before and after the introduction of the enhanced protocol, with the mean length of stay reduced from 12.1 to 10.6 days (P = 0.34).
Conclusion: The new enhanced protocol remains the standard of care in our unit, as we demonstrated a reduction in length of stay with no difference in complication rates following early weight bearing after lower limb free flap surgery.
Aim: Iliac crest (IC) is the most common source of bone for alveolar cleft repair, as it allows for harvesting a large amount of cancellous bone with a high rate of favorable outcomes. Its drawback is the donor-site morbidity. We propose a new technique for alveolar cleft grafting using vomerine bone (VB), which, through bone grafting, reconstructs the alveolus with the VB and simultaneously corrects the nasal septum deviation.
Method: We performed 18 alveolar reconstructions with VB in patients with a small bony defect and septal deviation, which would benefit from septoplasty. A matched control group with IC bone grafting was selected. Panoramic X-rays were used for vertical assessment of ossification with the Bergland scale and CT scans for the evaluation of the thickness of the grafted area in the VB and IC groups and compared with an independent samples T-test. A paired T-test compared angular measurements of the septal deviation pre- and post- vomerine grafting.
Results: All grafts healed uneventfully, with no complications at the donor site and respiratory function was improved. There was no statistically significant difference in ossification height between VB and IC, the alveolar thickness at the occlusal and middle third was higher with IC. Septal deviation was reduced significantly.
Conclusion: Alveolar graft from VB seems to be a viable alternative to IC in patients who present with a mild bony alveolar defect in addition to septal deviation, allowing combined procedures while reducing the morbidity of the donor site.
Access to psychosocial care is considered a fundamental part of the care for conditions that result in a visible difference, such as cleft lip and palate. At the same time, there is a shortage of trained mental health professionals and structural resources, making it challenging to implement the psychosocial component of care for many healthcare providers worldwide. Therefore, there is a need to find innovative ways to facilitate psychosocial support. This article aims to describe the Cutting Edge Training program that was developed to increase the psychosocial understanding of healthcare professionals who provide care for patients undergoing appearance-altering procedures. The program consists of five modules, with a particular emphasis on social determinants and the impact of living in an appearance-focused society. The developed training program does increase knowledge and awareness of the negative impacts of appearance-related distress and how to improve patient care for those undergoing appearance-altering procedures. Furthermore, it promotes a broader social dialogue about the need to encourage positive attitudes towards diversity in appearance, thus enhancing the future social integration of those who are affected by visible differences.
Nasoalveolar molding (NAM) has been glorified and maligned. Supporters argue that NAM improves cleft outcomes and reduces secondary procedures. Critics highlight the expense, labor intensity, and inconsistent or transient results. We offer NAM to our patients and have been doing so for over a decade; nevertheless, our benefits assessments are nuanced. In the following paper, we present our rationale, evolution, technique, and outcomes of NAM, augmented with an analysis of the literature. We offer another perspective in this ever-evolving area of evidence-based cleft palate care.
Early recognition and management of neonatal brachial plexus injury (NBPP) is key to optimizing outcomes and surgical options. Because up to a third of patients with birth palsy may require surgical intervention, the multidisciplinary team must follow up on the function and recovery of the entire upper extremity, from shoulder to fingertips, within the first few months of life. Options include neuroma resection and primary nerve grafting and/or nerve transfers, which can be intra- or extra-plexal, as adjunctive or standalone procedures. When limited proximal nerve roots are available for nerve grafting, or when too many nerve roots are involved, exceeding the supply of nerve graft, extra-plexal nerve transfers are then indicated. While early intervention is preferred (between 3 and 6 months for most authors), older children presenting late (> 1 year since birth) with partial nerve recovery may still potentially benefit from nerve transfers, which can be offered to late-presenting infants. Here we discuss the anatomy, indications, work-up, options, complications, and outcomes for such nerve transfers for upper, lower, and global plexus palsy in neonates. Nerve transfers are a common procedure done for the treatment of various types of birth plexus palsies. Currently, while there is an abundance of clinical reports and evidence, there is still a lack of clarity regarding best practices or in terms of the type of procedure and technique for the treatment of birth plexus palsy. Our hope is that this chapter provides a concise source after an extensive cumulative review of the evidence of best practices for nerve transfers in the case of birth plexus palsy.
In recent years, microsurgical reconstruction of the lymphatic system has opened new frontiers in the treatment of central lymphatic lesions. Central lymphatic lesions can be congenital or acquired. While the latter can result from any surgery or trauma in the area of the thoracic duct, congenital lymphatic lesions can show a plethora of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Regardless of the anatomical location of the thoracic duct lesion, these conditions cause recurrent chylous effusions and downstream lymphatic congestion and are associated with increased mortality due to the permanent loss of protein and fluid. In case of disruption of the lymphatic flow, microsurgical reconstructive surgery is indicated to treat downstream congestion leading to bronchitis plastica, protein-loosing enteropathy, chylothorax, and chylascites. Thoracic duct-vein anastomoses can reconstruct the physiological lymphatic flow.
Among the many challenges that the hand surgeon has to face in his daily work, nerve defects of the hand represent one of the hardest; unsatisfactory results in their treatment may cause severe limitations for the patient’s social and working life. Many advances have been made over the years in the treatment of such conditions, and at the current state, surgical treatment can achieve satisfactory results. This article aims to review the current concepts in hand innervation and nerve pathophysiology and to describe traditional and novel surgical techniques currently employed to correct these defects.
Breast cancer-related lymphedema (BCRL) is a debilitating disorder affecting an estimated 1 in 5 women and men treated for breast cancer. Fortunately, super microsurgical techniques have advanced in recent years and now provide better options for the treatment of lymphedema, allowing timely surgical intervention that can delay or even prevent lymphatic degeneration. Lymphovenous anastomosis (LVA), a physiologic procedure that restores lymphatic drainage by connecting functioning lymphatic vessels with nearby veins, has been shown to be both minimally invasive and highly effective. The authors describe innovative approaches to LVA that will help optimize outcomes for patients with BCRL.
Immediate lymphatic reconstruction (ILR) has become increasingly utilized for the prevention of breast cancer-related lymphedema (BCRL). A growing body of evidence has demonstrated the long-term efficacy of ILR in reducing the rate of BCRL. While certain risk factors for BCRL are well-recognized, such as axillary lymph node dissection, regional lymph node radiation, and elevated body mass index, other potential risk factors such as age and taxane-based chemotherapeutics remain under discussion. Our experience with ILR has highlighted an additional potential risk factor for BCRL. Lymphatic anatomy, specifically compensatory lymphatic channels that bypass the axilla, may play a largely underrecognized role in determining which patients will develop BCRL after ILR. Foundational anatomic knowledge has primarily been based on cadaveric studies that predate the twentieth century. Modern approaches to lymphatic anatomical mapping using indocyanine green lymphography have helped to elucidate baseline lymphatic anatomy and compensatory channels, and certain variations within these channels may act as anatomic risk factors. Therefore, the purpose of this review was to highlight ways in which variations in lymphatic anatomy can inform the application and improve the accessibility of this procedure. As ILR continues to advance and evolve, anatomical mapping of the lymphatic system is valuable to both the patient and lymphatic microsurgeon and is a critical area of future study.
Autologous free tissue transfer is a safe and effective option for breast reconstruction. It is an increasingly utilized technique with well-demonstrated improved patient satisfaction and quality of life. Microvascular thrombosis is a rare but significant complication of microsurgical breast reconstruction, often resulting in flap failure. Proper diagnosis and timely management of this complication are essential to free flap salvage. While microvascular thrombosis poses a threat to flap survival, several methods may be employed to mitigate its more devastating effects. Here, we present a comprehensive review of arterial and venous thrombotic complications in both the intraoperative and postoperative settings. We discuss preoperative risk assessment, methods for flap monitoring, and operative and medical management of thrombotic complications. We present an updated algorithm for the intraoperative management of microvascular thrombosis adapted to reflect the most recent literature and our novel algorithm for the postoperative management of microvascular thrombosis.
Soft tissue defects of the hand may result from trauma, oncological procedures, or severe infections. Different etiologies have been discussed. In all cases, an accurate clinical examination is mandatory to understand which structures are involved and what must be reconstructed. It can be helpful to simplify the decision-making process to classify these lesions. However, there is no consensus on which classification is best to be used among those described in the literature. This review presents the most common ones, differentiating those classically used to describe tissue loss consequential to a traumatic event from those used to classify soft tissue defects consequent to other events.
Aim: Genital lymphoedema (GL) is a chronic and debilitating disease, which can severely affect the patient’s quality of life with significant socio-economic impact. Nowadays, no gold standard algorithm exists for GL from diagnosis to treatment. This study proposes our therapeutic flowchart based on the three senior consultants’ experience in lymphatic surgery.
Methods: A retrospective investigation was conducted on a prospectively maintained database (2018-2022). Inclusion criteria involved all patients who underwent surgical procedures for treating GL in three plastic surgery departments (Lausanne, Bari, and Genova). Outcomes were assessed in terms of oedema reduction, stage regression, and functional reported outcomes.
Results: 16 patients with GL were included: 50% underwent debulking surgery, 18.8% microsurgery, and 31.2% debulking + microsurgery. We recorded a significant regression of the GL stage: 62.5% shifted from stage II/III to postoperative stage I. Similarly, we found an infection recurrency resolution in 50%, a scrotal oedema reduction in 62.5%, and a scrotal oedema resolution in 37.5% of the patients treated. While almost half of the patients (53.3%) with associated penile oedema described persistent postoperative penile oedema, only two patients complained of persistent lymphorrhea.
Conclusion: According to our clinical experience, preoperative and postoperative physical functional therapy is always recommended. For stages I and IIA, after the failure of the conservative treatment, lymph-venous shunts and lymph node transplantation surgery are proposed at the early time. When GL is already diagnosed at stages IIB and III, the debulking surgery, together with functional procedures, represents our first approach.
Breast reconstruction is one of the largest components of plastic and reconstructive surgery. Autologous free flap breast reconstruction continues to grow due to exceptionally high flap success rates. It provides patients with a durable and natural reconstruction with high patient satisfaction. A patent microvascular anastomosis is a key component to a successful autologous free flap breast reconstruction. Thrombus within the vascular anastomosis or the distal flap microcirculation is the most common cause of flap failure. This review aims to discuss microsurgical techniques including atraumatic handling of vessels, appropriate magnification, suture styles, anastomotic techniques, recipient vessel selection, the role of anticoagulation and antiplatelet therapy used to minimize the risk of thrombotic events. When microvascular thrombus occurs, early reoperation and reperfusion is imperative to flap survival. This review will discuss specific maneuvers and intraoperative interventions to maximize flap salvage.
The nose, centrally located on the face, plays a crucial role in facial aesthetics. Any imbalance in its length, width, tip position, or a gross deformity, such as dorsal hump and deviation, can significantly affect the overall facial harmony, which is thus a major concern for patients. When it comes to minor deformities, they have been treated with hyaluronic acid, toxin injection, and thread insertion since 2005. This study has originally been carried out to review the published medical literature on the non-surgical techniques for Medical Nose Reshaping (MNR): a PubMed search was carried out in December 2020 using the search terms: “Nose [and] filler”, “Nose [and] botulinum toxin” and “Nose [and] thread”. A large number of studies were identified and reviewed, and it was found that rhinoplasty remains the gold standard to correct nose defects; nevertheless, MNR is gaining popularity due to its minimal invasiveness, short downtime, and the market availability of different injectables, toxins, and threads. This study aims to provide an evidence-based approach to guide the use of non-surgical techniques for MNR by reviewing published medical literature and drawing on the authors’ experience.
The development of surgical treatment of lymphedema has been a challenging endeavor. Various surgical modalities have been proposed, but the results are often unsatisfactory. The lymphaticovenous anastomosis (LVA) revolutionized by Koshima et al. with the introduction of super microsurgery has gained traction in the treatment of lymphedema and has shown favorable results. However, super microsurgery requires excellent hand-eye coordination, meticulous tissue handling, dexterity, and operative flow, which are subject to multiple factors. Robot-assisted microsurgery (RAMS) has the potential to increase safety for clinicians and patients and create new possibilities in the field of super microsurgery. Therefore, plastic surgeons of the Maastricht University Medical Center (Maastricht, the Netherlands) teamed up with engineers from the Eindhoven University of Technology (Eindhoven, the Netherlands) and developed the first dedicated robotic platform for (super)microsurgery, the MUSA. The development of MUSA, from inception to the first clinical study in patients with lymphedema, has yielded promising results. This review aims to elucidate the development of the MUSA and its role in lymphatic surgery.
Breast reconstructive surgery utilizing free tissue transfer has revolutionized the restoration of aesthetic and functional outcomes for patients. Even for the most routine free flap procedures, substantial hospital resources and costs are necessary. The effectiveness of free flap surgery, along with any reconstructive procedure, hinges upon meticulous patient selection, thorough pre-operative planning, well-informed peri-operative decision-making, and diligent post-operative monitoring and care for the patient. This article presents a review of standard clinical care monitoring techniques during the post-operative period, as well as the diverse strategies currently employed for post-operative flap monitoring.
Skin flap necrosis is a common postoperative complication after breast reconstruction, with an incidence of up to 43.4% among patients undergoing nipple-sparing mastectomy. Necrosis can adversely impact aesthetics due to the need to excise nonviable tissue, and increase the risks of infection, implant loss, nipple-areola complex sacrifice and malposition. Patient-specific factors including age, body mass index, and breast size may affect the risk of necrosis. Mastectomy and reconstruction techniques (i.e., choosing between skin- and nipple-sparing mastectomy, and between autologous and alloplastic reconstruction) may also influence necrosis rates. Intraoperative measures such as indocyanine green angiography and autologous skin banking, and the postoperative use of nitroglycerin paste for high-risk patients and warming blankets for autologous reconstruction are methods to help prevent and minimize the morbidity of skin necrosis. Herein, we share our institution’s approaches to predicting and mitigating skin necrosis, and methods of optimizing outcomes for breast reconstruction patients.
Although digit replantation techniques and indications have evolved over time, resulting in improved overall outcomes, achieving ideal functional recovery remains a challenge. Secondary surgeries for replanted digits can be divided temporally into early- (weeks to months) and late-stage (months to years) procedures, with skin-coverage procedures being the most common in the early period and tenolysis being the most common procedures in the late postoperative stage. This article reviews the most common procedures, including available literature on secondary replant procedures involving nerve, tendon, bone, joint, and skin procedures. However, further larger-scale studies are necessary to establish clear guidelines regarding both postoperative protocols and indications for secondary surgery.
Partial flap loss (skin involved) or fat necrosis following autologous breast reconstruction remains a dreaded postoperative complication despite significant advances in microsurgical techniques. Several strategies have been proposed in the preoperative and intraoperative period to prevent this complication ranging from preoperative imaging, intra-operative tissue perfusion assessment, appropriate perforator selection (location and number), maximizing inflow and outflow with additional anastomoses and/or pedicles, and minimizing ischemia time. Postoperative management of partial flap loss (when there is skin involvement) and fat necrosis remains a challenge, with very little published data focusing on classification, timing, and techniques. Early intervention versus close observation may depend on multiple patient factors and the degree or volume of necrosis. Secondary intervention options include hyperbaric oxygen therapy, fat aeration with a needle, liposuction, fat grafting, addition of another flap or implant, depending on the nature of the defect. This review summarizes the current evidence for each of these strategies to help the current surgeon understand their options in preventing and managing patients suffering from partial flap loss.
This review discusses the latest literature-based evidence on reconstructive strategies following tendon losses, with a final focus on the innovative regenerative approach. Significant improvements in primary tendon repair techniques have radically reduced the failure rate and therefore decreased the use of reconstructive procedures. However, in specific conditions, such as crush injuries with loss of substance, avulsion injuries and inveterate injuries, the tendon gap cannot be repaired with a primary suture, making the procedure much more challenging for the surgeon. This article aims to guide the treatment of tendon losses, which is still a complex topic in hand surgery.
Pan-brachial plexus injuries present a challenging clinical problem, resulting in severe impairment of motor and sensory function in the upper extremity. Although current literature has outlined several promising methodologies for treatment, a consensus has yet to be reached. In this review, we present three general approaches for reconstructing the upper extremity in these complex cases.
Elbow flexion is essential to help position the hand in space and for functional use of the upper extremity. Loss of elbow function can be secondary to many etiologies, including but not limited to brachial plexus injury, traumatic muscle loss, oncologic treatment, poliomyelitis or congenital absence of motor function. The end result is a significant functional limitation of the upper extremity. One method to address the loss of elbow flexion is the use of a functional muscle transfer. These transfers can be performed as pedicled rotational transfers or free functional muscle transfers. This article reviews functional muscle transfers for restoration of elbow flexion as a treatment option for patients with an otherwise unreconstructable extremity.
Digit amputations are the most common amputation worldwide. This manuscript describes the impairments imposed by digit loss and the potential benefits of digit prosthetics. This review of the literature is designed to provide a reference for healthcare workers and patients for identifying and selecting prosthetic options for digit amputees.
Autologous free tissue transfer for breast reconstruction is a well-established and reliable form of reconstruction for women undergoing mastectomies. These surgeries are performed with high rates of success; however, the consequences of flap failure can be devastating to patients and surgeons. Breast reconstruction decision making following flap loss is a uniquely individualized process, based on considerations of safety, patient goals and preferences, as well as the surgeon’s skillset. The first priority following flap failure is to provide thoughtful patient counseling and support through this difficult time. The aims of reconstruction salvage after flap loss are to excise unhealthy tissue and restore a breast mound of normal anatomical shape. We present an algorithm as a possible approach to managing flap failures. We also review the management of breast reconstruction following free flap failure, including the role of hematologic investigation, anticoagulation recommendations and secondary or tertiary reconstruction with both prosthetic and autologous techniques.
Complications from autologous free flap reconstruction of the breast can present with both common surgical complications and unique complications at the chest recipient site. This review covers complications at the chest recipient site, including chest wall deformity, chronic pain, mastectomy skin flap necrosis, infection, pyoderma gangrenosum, bleeding complications, pneumothorax, chyle leak, and positive internal mammary lymph node metastasis.
With the remarkable advancement of microsurgery, surgical treatment for lymphedema has been increasing, and its good results are well established. However, surgical treatment for advanced-stage lymphedema is still a challenging task. We reviewed several methods of combining lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in breast cancer-related lymphedema (BCRL) patients. Representative VLNT flap options for BCRL patients include the omental flap, superficial circumflex iliac perforator (SCIP) flap, and deep inferior epigastric artery (DIEA) flap combined with inguinal lymph nodes performed simultaneously with breast reconstruction. The surgical outcome, technical details, and donor site morbidities of each surgical option were reviewed. While all three options show significant surgical benefits, each has its clear advantages and disadvantages. The decision on the surgical method may vary according to the needs of each patient and the clinical situation.
Dermal fillers have been commonly used for the filling of facial rhytids. As the use of dermal fillers has grown, so has the incidence of non-ischemic complications. These complications range from edema, bruising, and erythema to more complex conditions such as delayed hypersensitivity nodules and biofilms. This article sought to review the causes of various non-ischemic complications, discuss their risk factors, and review management techniques. Certain predisposing factors to delayed hypersensitivity nodules, such as Vycross technology, a history of viral illness, or coronavirus disease 19 (COVID-19) infections, are discussed in detail in this review. Prevention techniques such as patient counseling, elucidating certain patient history (viral illness, dental procedures), the use of aseptic technique, and procedural factors are also discussed. Understanding appropriate management for these complications can also help in treatment. Imaging, such as ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), has taken on a larger role in the management of non-ischemic complications.
Securing dilated lymphatic vessels with good function is challenging when performing lymphaticovenous anastomosis (LVA). To achieve this, we propose multi-point indocyanine green (ICG) lymphography and lymphatic ultrasound (D-CUPS; Doppler, Cross, Uncollapsible, Parallel, and Superficial fascia). With multi-point ICG lymphography, more lymphatic vessels can be found than with conventional ICG lymphography, which leads to better surgical results. Lymphatic ultrasound is more useful because it allows the observation of cross-sections of lymphatic vessels. It is known that lymphatic degeneration occurs in the lymphatic vessels in lymphedematous limbs, and LVA is most effective when dilated lymphatic vessels are anastomosed. The degree of lymphatic degeneration can be diagnosed with lymphatic ultrasound, and the proximity of dilated lymphatic vessels and veins suitable for anastomosis can be reliably identified and selected as the skin incision site for LVA. Lymphatic ultrasound is a safe, versatile and useful imaging technique that does not require a contrast agent and can be performed by anyone. By mastering multi-point ICG lymphography and lymphatic ultrasound (D-CUPS), the operation time can be shortened, and more effective LVA can be performed. In this Technical Note article, we comprehensively describe lymphatic function examinations that we have developed so far.
This study evaluated three prominent Large Language Models (LLMs)-Google’s AI BARD, Bing’s AI, and
Intra-thoracic defects continue to pose a challenge for the reconstructive surgeon. Stable soft tissue coverage and obliteration of dead space can be particularly challenging when complicated by infection or previous radiation. These cases may require a less conventional method of reconstruction. We describe a case in which vacuum-assisted closure followed by pedicled omental flap transposition was successfully used to reconstruct a complicated intra-thoracic wound following pneumonectomy, radiation therapy, and recurrent wound dehiscences secondary to chronic infection.
Lymph node transfer (LNT) and lymphatic anastomosis are popular reconstructive surgeries in managing lymphedema. However, lymphatic anastomosis requires the operator to be adept at super microsurgery, and LNT has significant donor-site lymphedema risks. To address these drawbacks, lymph-interpositional-flap transfer (LIFT), a novel lymphatic reconstruction method that does not require lymph node transfers or supermicrosurgical techniques, has been introduced. Lymph circulation after tissue replantation and free flap transfer was evaluated using indocyanine green (ICG) lymphography. Postoperative ICG lymphography showed linear to linear lymphatic reconnection between an amputee/flap and a recipient site in cases where the stumps of the lymph vessels were only approximated. This was a frequent phenomenon observed in replantation cases and some free tissue transfers. Based on these results, we developed a new lymphatic reconstruction using a flap designed to include the collecting lymph vessels for bridging a lymphatic gap. ICG is injected at the peripheries of donor sites or the distal boundaries of the lymphosome where the recipient site resides in. This allows us to visualize the axial lymphatic pathways. When LIFT is used to reconstruct a soft tissue defect, ICG is also injected at the proximal edge of it to visualize proximal lymph flows. The LIFT flap is designed to include lymphatic channels seen on pre-operative ICG lymphography. As these collecting lymph vessels reside deep in the superficial fascia, the flap is elevated with the deep fat intact. Intra-operative ICG lymphography is utilized to identify the proximal and distal lymphatic stumps on the flap, and absorbable sutures are used to tag these stumps for ease of recognition during the flap inset. LIFT is indicated for soft tissue defects in major lymphosomes, resulting in a significant lymphatic gap. The advantage of the LIFT technique is the ability to perform simultaneous soft tissue and lymphatic reconstruction. LIFT can also be applied in established lymphedema and elephantiasis.
Aim: Facial fractures have multiple etiologies, including motor vehicle collisions, interpersonal violence, falls, and sports-related accidents. The objectives of this study are to reassess, compare, and expand the epidemiologic analysis and postoperative complication rates of facial fracture treatment. Additionally, we sought to compare the length of stay and operative time outcomes between plastic surgeons and non-plastic surgeons.
Methods: NSQIP (National Surgical Quality Improvement Program) participant databases were queried to identify all patients undergoing facial fracture operations. Epidemiological data was divided into two groups and compared by surgeon specialty: patients operated on by a plastic surgeon and patients operated on by a non-plastic surgeon. Our primary outcomes of interest were operation time and length of stay. Postoperative complications included wound complications, mortality, return to the OR, and major bleeding.
Results: 3,354 patients underwent facial fracture repair (2012 to 2016). In men, the most common fracture was mandibular (40.9%); in women, the most frequent was orbital (32.4 %). 79.6% had single facial fractures and 20.4 % had multiple facial fractures. Plastic surgeons’ operating time was less than that of non-plastic surgeons (P = 0.0007). The average length of stay was higher for the plastic group (mean = 1.65 days, plastic) (P < 0.00001). Postoperative complication variables showed no statistically significant differences between the plastic and non-plastic groups.
Conclusion: Continuous epidemiologic analysis is vital for the proper allocation of healthcare resources to the most affected facial fracture patients in the US. Assessment of complication rates between surgical specialties allows a better understanding of the management of facial fracture patients on a national level. Our data analysis may allow surgeons to better counsel patients preoperatively and improve inter-specialty collaboration.
Over the past two decades, the cosmetic surgery industry has experienced significant global growth. This expansion has piqued the interest of healthcare professionals and product manufacturers, both aiming to enhance accessibility to surgery for a broader demographic. This manuscript presents the case example of “macrolane” hyaluronic acid. This product was introduced into the cosmetic surgery industry in 2007 and then removed from the market in 2012 by the manufacturer. The manuscript also presents and discusses the regulatory measures that were enacted following the introduction of macrolane into the European market. Specifically, these regulatory measures involved: insurance, professional qualifications and training, clinician representatives, sanitation, safety, cooling-off periods, informed consent, and advertising. Within the manuscript, it is also highlighted that interests from different stakeholders can create tension in the cosmetic industry, specifically: 1. clients might ask for a product, and they need to be protected; 2. healthcare providers are seeking a profit, and are subject to liability; 3. product’s manufacturers, who are seeking to expand their market, need to pass through regulatory processes. In conclusion, we wish to raise awareness of the ethical issues related to the regulatory measures implemented by European regulatory agencies responsible for public health, especially during the launch of a new product. These ethical considerations encompass several aspects: establishing accountability for validating research authenticity, delineating the functions of compensatory systems, overseeing educational processes, and supervising advertising and marketing practices. It should be noted that the comprehensive exploration of these ethical matters falls outside the scope of this manuscript, as they pertain more to public affairs rather than the realm of cosmetic surgery itself. Therefore, the discourse on these matters is better suited for engagement by experts in political and social ethics. Level of Evidence: Level V, analysis of current regulatory practices.
Scleroderma is a chronic connective tissue disease characterized by inflammation, vascular injury, and progressive skin fibrosis, resulting in significant aesthetic and functional impairments for patients. Current therapies are limited and insufficiently treat the cutaneous manifestations of scleroderma. Autologous fat transfer (AFT) is a surgical technique that has been utilized for many decades for facial rejuvenation. The adipose stem cells (ASCs) present in fat grafts have also shown significant promise for their anti-inflammatory and regenerative properties. Recently, AFT has been repurposed to treat the skin manifestations of systemic sclerosis and localized scleroderma. Studies suggest that AFT in scleroderma patients improves mouth and hand functions, Raynaud’s symptoms, and digital ulcerations. AFT is a safe procedure with rare postoperative complications, making it a promising intervention for the treatment of scleroderma. Further studies are required to better characterize the influence of fat grafts on the recipient site and to establish standards for fat transfer in fibrotic skin diseases.
Long-standing wounds are at high risk for infection. Therefore, it is critical to achieve wound healing in a timely manner; however, some complex wounds remain recalcitrant and difficult to treat. Local muscle flaps are an underutilized technique with great utility in the reconstruction of complex foot wounds. Providing a healthy bleeding base that promotes wound healing, these muscle flaps can greatly benefit the patient and prevent amputation. In this present report, we demonstrate the use of the abductor hallucis muscle flap in the reconstruction of a complex wound following bunion surgery.
Aim: Ovine models for osseointegrated prosthetics research are well established, but do not consider neural control of advanced prostheses. The validity of interfacing technologies, such as the Osseointegrated Neural Interface (ONI), in their ability to provide communication between native nerves and advanced prosthetics is required, necessitating a stable, longitudinal large animal model for testing. The objective of this study is to provide a detailed anatomic description of the major nerves distal to the carpal and tarsal joints, informing the creation of a chronic ONI for prosthetic control in sheep.
Methods: Six pelvic and six thoracic cadaveric limbs from mature female, non-lactating sheep were utilized. Radiographs were obtained to determine average bone length, medullary canal diameter, and cortical bone thickness. Microsurgical dissection was performed to discern topographical neuroanatomy and average circumferences of the major nerves of the pelvic and thoracic limbs. Histologic analysis was performed. A surgical approach for the creation of ONI was designed.
Results: Average metacarpal and metatarsal length was 15.0 cm (± 0.0) and 19.7 cm (± 1.0), respectively. Average intramedullary canal diameter was 12.91 mm (± 3.69) for forelimbs and 12.60 mm (± 3.69) for hindlimbs. The thoracic limb nerves consisted of one dorsal and three ventral nerves, with an average circumference of 5.14 mm
Conclusions: These anatomic data inform the surgical approach and manufacture of a sensory ONI for chronic testing in awake, freely ambulating animals for future clinical translation.
Traumatic facial nerve injuries can result in temporary or permanent loss of function. Restoration of facial expression may occur spontaneously or require surgical intervention. Although thorough examination and history can localize the site of facial nerve damage, it can be difficult to predict if and when recovery will occur. This is salient because the window for optimal outcomes from surgical re-neurotization can be as short as 1 to 2 years, after which functional loss may be irreversible. It is essential to offer patients the most appropriate treatment plan based on prognosis, and imaging plays an essential role in localizing the site and morphology of nerve injury. Multiple imaging modalities have been used to evaluate the facial nerve, including computed tomography (CT) and, more recently, advanced magnetic resonance imaging (MRI) and ultrasound (US). CT and MRI are more commonly implemented; however, Diffusion tensor tractography, high-resolution US, and functional US are gaining traction for studying cranial nerve pathology. Until recently, the morphology of facial nerve and other cranial nerve injuries could only be inferred using non-invasive diagnostic techniques. With the advent of newer imaging technologies and techniques to examine nerves, more refined assessment and prognostic information is now possible. This article reviews up-to-date cranial nerve imaging techniques from the last ten years and explores future avenues for facial nerve imaging.
Embodiment describes the sense of one’s own body, encompassing dimensions of being, having, and using a body. Regarding breast reconstruction, embodiment can be understood as how effectively the reconstructed breast replaces the patient’s missing breast. While there has been increasing attention in recent decades on understanding and measuring embodiment in the prosthetic limb, there is limited literature applying embodiment to the context of breast reconstruction. We posit that the literature on prosthetic embodiment can be applied to evolving discussions on breast reconstruction outcomes and patient satisfaction. As breast reconstruction techniques continue to evolve, such as advances in nerve coaptation and reinnervation of the breasts, the concept of embodiment may help broaden the scope of how patient outcomes can be more holistically evaluated. This systematic review examines existing literature on embodiment after breast reconstruction, summarizes embodiment and its subcomponents, and discusses how embodiment can be a helpful framework for the future of breast reconstruction outcome measures.
Aims: This paper aims to assess the existing evidence regarding oximetry and thermography by comparing postoperative rates of complications following microsurgical breast reconstruction.
Methods: A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative and quantitative analysis of all included studies was then performed.
Results: Fourteen studies were included with a total population of 2,529 female patients who underwent microvascular breast reconstruction, ultimately totaling 3,289 flaps. The mean age for the cohorts included in this study ranged from 48.9 to 57 years of age. A total of 15 complete flap losses were reported. Furthermore, this meta-analysis of proportion showed that total flap loss experienced was 0% (95%CI 0%-100%) for patients monitored with thermography compared to 0% (95%CI 0%-1%) for those monitored with oximetry. Partial flap loss occurred at a frequency of 1% [95%CI 0%-73%] for patients monitored with thermography compared to 1% (95%CI 0%-2%) for those monitored with oximetry. Furthermore, the results of this study showed that thermography prompted a return to the operating room (OR) in 1% (95%CI 0%-73%) of the patients compared to 5% (95%CI 3%-9%) for oximetry. Lastly, the overall complication rate was 12% (95%CI 1%-54%) for patients monitored with thermography compared to 10% (95%CI 4%-21%) for those monitored with oximetry.
Conclusion: Ultimately, this meta-analysis concludes that while oximetry monitoring currently has strong evidence for improving flap outcomes, trends in the current data indicate that further studies may demonstrate that thermography may be comparable to oximetry in achieving similar patient outcomes.
The medial plantar artery (MPA), as a terminal branch of the posterior tibial artery, provides perfusion to the musculature of the medial compartment of the plantar foot as well as cutaneous branches to the skin. The artery and its perforators serve as the foundation for several flaps based on various soft tissue components for the coverage of small defects of the foot. Most noteworthy is the fasciocutaneous flap, which utilizes the skin and the unique properties of the plantar foot. Understanding the anatomical relationship of the terminal branches of the MPA, the superficial and deep branches, is necessary in determining the type of tissue and the flap design to be utilized for reconstruction.
Preaxial polydactyly is a common congenital anomaly of the hand presenting at birth. Surgical treatment is aimed at creating a functional thumb capable of normal grip and pinch strength with acceptable aesthetics. Each case is unique and presents individual challenges to the hand surgeon. The aim of this review is to provide a synopsis of current knowledge and recommended surgical techniques for the duplicated thumb.
Efficacious therapeutics for peripheral nerve injuries remain incompletely described in the literature. However, over the last several decades, delivery of FK506 (Tacrolimus) and electrostimulation have demonstrated great promise for supplementing surgical advances in treating peripheral nerve injuries. This review describes the discovery, mechanistic investigations, and clinical translation of these strategies to promote functional recovery. FK506 has demonstrated the ability to increase the regeneration rate after nerve injury by a variety of hypothesized mechanisms, yet clinical utility remains limited due to systemic immunosuppression. Local administration of FK506 continues to be an active area of inquiry for minimizing side effects while maintaining its neuroregenerative effects. Electrostimulation of a nerve proximal to the site of surgical nerve repair has demonstrated increased axonal regeneration and accelerated recovery of both motor and sensory nerves. In addition, electrostimulation also appears to improve axon matching during reinnervation from motor to motor and sensory to sensory pathways and is used clinically in our surgeries. However, the specific parameters to best incorporate electrostimulation into the operating theater are still evolving. Utilizing translational rodent and murine models, surgical techniques and these therapeutic strategies have gradually become more viable as safety profiles and mechanisms are gradually understood. This review presents the state of the field for these therapeutic avenues and discusses further areas of research.
Hand coverage in infected soft tissue loss (STL) is a challenging clinical condition. Appropriate and well-timed antibiotic therapy and careful debridement are crucial for the success of the subsequent reconstructive procedure. Debridement must be radical, and all nonviable or infected tissue should be removed. Strict medical control and multiple procedures can be required when infection recurrence is observed after primary procedure. Secondary healing of STL is usually necessary in these complex conditions. Negative pressure wound therapy (NPWT) is often used as a temporary instrument to reduce oedema and drainage, facilitating the attainment of a clean wound for subsequent reconstruction. According to the type and size of the defect, multiple options ranging from skin grafts and substitutes to local and free flaps can be selected for the treatment of infected STL. A reconstructive ladder approach and case-by-case decision making should always be considered. Due to the unique function and role of the hand, the surgical strategy must also take into account aesthetic and functional factors. Orthopedic and Plastic surgeons should manage this wide variety of treatment options in a multidisciplinary and high-specialized context including radiologists, microbiologists, infectious disease specialists and physiotherapists, customizing the treatment path to the specific patient's situation.
Volumetric muscle loss (VML) refers to a composite, en bloc loss of skeletal muscle mass resulting in functional impairment. These injuries normally heal with excessive fibrosis, minimal skeletal muscle regeneration, and poor functional recovery. Functional muscle transfer is a treatment option for some patients but is limited both by the degree of functional restoration as well as donor site morbidity. As such, new therapeutic options are necessary. De novo regeneration of skeletal muscle, by way of tissue engineering, is an emerging strategy to treat VML. This review evaluates available scaffolds for promoting skeletal muscle regeneration and functional recovery following VML. The use of growth factors and stem cell therapies, which may augment scaffold integration and skeletal muscle reconstitution, are also discussed. Regenerative medicine with the use of scaffolds is a promising area in skeletal muscle reconstruction and VML treatment.
Most East Asian women prefer a smaller and smoother facial contour. To meet this aesthetic preference, the concept and surgical techniques of modern facial bone contouring surgery have evolved. Initially, facial bone contouring surgery was limited to procedures like mandibular angle and malar reductions. However, contemporary Asian facial bone contouring surgery now places a stronger emphasis on addressing the entire facial profile from a three-dimensional perspective, a concept referred to as Profiloplasty. In this article, we review the evolution of surgical techniques in Asian facial bone contouring surgery and present its current surgical concepts, particularly focusing on the three-dimensional aspects.
Vascularized lymph node transfers (VLNT) are useful options for the surgical treatment of lymphedema. Conventional VLNT does not include the reconstruction of physiological lymphatic outflow, which may pose a risk of postoperative lymphatic vessel obstruction and lymph node sclerosis. We report a case of lymph flow bypass reconstruction using a superficial circumflex Iliac artery perforator (SCIP) flap, including VLNT with efferent lymphatico-lymphatic anastomosis. A 63-year-old female with severe right upper extremity lymphedema after mastectomy was reconstructed using a SCIP free flap, which included a vascularized lymph node elevated from the left groin area and transferred to the right axilla area. The SCIP vessels were anastomosed to the medial intercostal artery perforator vessels and the efferent lymphatic vessel from the vascularized lymph node was anastomosed to the internal mammary lymphatic vessels using supermicrosurgical technique. Indocyanine green lymphography showed the reconstructed lymphatic flow from the right hand to the right internal mammary lymphatics through the transferred flap. Postoperatively, lymphedema improved and there was no lymphedema at the donor site with a 2-year follow-up. Lymphatic flow bypass reconstruction using VLNT with efferent lymphatico-lymphatic anastomosis may provide a useful option for the treatment of severe lymphedema.
Gender-affirming genital surgery includes a constellation of pelvic procedures that can help feminize or masculinize the genitalia. Technological advances in robotic surgery can aid surgical access to and visualization of the pelvis, thereby facilitating certain procedures. In this scoping review, we will discuss the developing role of the robot in genital affirming genital surgery. Indications, techniques, and outcomes using the robot in both feminizing and masculinizing genital procedures will be reviewed.
The "like with like" and the "flap thinning" are two workhorse principles the surgeon must keep in mind to achieve a functional and cosmetic reconstruction of the hand. These principles are underpinned by a thorough knowledge of anatomy and functional hand units, with a wide range of reconstructive procedures that must be finalized to the necessity of the impaired structures. "Like with like" means that a lost tissue must be replaced with another one that can be compared in appearance and function. In addition, good cosmetic is often associated with good function because the complex attempt to get a proper aesthetic always traduces itself into a better functional reconstruction. "Flap thinning" is essential because soft tissue injuries of the hand represent a more difficult reconstructive challenge than similar injuries elsewhere, and the need for thin tissue to wrap the superficial noble structures of the hand is constant. However, the procedure of thinning a flap can be dangerous and must adhere to the vascular architecture of the flap. This paper aims to review and briefly summarize the current literature in this field.
Vascularized lymph node transfer is a surgical treatment for lower extremity lymphedema aimed at restoring physiological lymphatic flow. Much variation exists in determining the appropriate donor site from which to harvest lymph nodes as well as the optimal recipient site to anastomose the new lymph nodes. This article reviews the underlying principles of free vascularized lymph node transfer and discusses patient-specific, disease-specific and surgery-specific factors in considering recipient sites from the proximal, middle, and distal lower extremity. The clinical outcomes of published studies in lymphatic surgery for lower extremity lymphedema are presented. An omental flap to the middle lower extremity (mid-thigh, popliteal fossa, or medial calf) is then recommended due to the abundance of lymphatic tissue, proximity to pooled lymph fluid, and avoidance of added bulk or poor cosmesis of the distal lower extremity. However, additional clinical outcomes studies are needed and represent an area of further investigation.
Pediatric trigger thumb is an acquired flexion deformity of the interphalangeal (IP) joint. It presents most commonly as a fixed flexion deformity, but can present as intermittent triggering or even a fixed extension deformity. Roughly one-third of patients will develop bilateral trigger thumbs. Studies have shown that the deformity can resolve with time on its own, but prolonged deformity is concerning for permanent IP joint contracture and/or deviation and metacarpophalangeal (MCP) joint compensatory hyperextension. Treatment is controversial, ranging from observation, splinting and stretching, to surgical release of the A1 pulley. Surgery is considered the definitive treatment with low complication rates, although the timing of surgery is highly variable among surgeons.
Aim: The frontal branch of the facial nerve is particularly vulnerable to traumatic injury or during surgery. While the larger branches of the facial nerve, such as the buccal branch, are more easily identifiable and amenable to repair, the repair of the frontal branch is not common due to its complex branching pattern and smaller size. The description of the surgical approach to repair the frontal branch of the facial nerve is limited in the literature. In this study, we aim to explore the outcomes of patients who underwent frontal branch facial nerve repair in our centre.
Method: In a retrospective case review at a single, tertiary Plastic Surgery centre, we performed frontal branch repair for eight patients (n = 8) who sustained complete or partial division of the frontal branch of the facial nerves. These patients were followed up postoperatively and assessed with the Sunnybrook Facial Grading System.
Results: Using super microsurgical techniques, primary nerve coaptations, fascicular nerve flaps, and direct neurotisations were performed. All eight patients (100%) demonstrated improvements in terms of resting brow symmetry. There was a significant improvement in brow and frontalis function following surgical repair of the frontal branch, with 87.5% (seven patients) demonstrating improvement in forehead movement.
Conclusion: In this case series, we demonstrated that the repair of the frontal branch of the facial nerve is relevant, with reasonably good functional outcomes. Repair of the frontal branch of the facial nerve should ideally be done as early as possible following the injury. Nevertheless, delayed repair may still be beneficial within 18 months after the injury.
Lymphedema is a debilitating disorder caused by impaired drainage of the lymphatic system. In the Western world, lymphedema most often arises secondary to the treatment of malignancy. Patients with lymphedema experience progressive swelling, pain, numbness, and tingling, and decreased quality of life. Those with persistent symptoms may be subject to chronic cellulitis. The advent of microsurgery has enabled clinicians to transplant donor lymph nodes and their blood supply from a healthy site to the affected area in a procedure known as vascularized lymph node transplant (VLNT). One donor region is the omentum. Vascularized omental lymph node transfer (VOLT) has been shown to decrease limb volume, circumference, and subjective symptoms of lymphedema. The immunologic properties of the omentum make it a particularly useful lymph node donor site for patients with lymphedema-related cellulitis. The omentum may be harvested laparoscopically, with robotic assistance, or through a small laparotomy incision. In this review, we describe the relevant anatomy and history of VOLT as well as operative techniques. The risks, benefits, and relevant outcome studies will be reviewed. Recent applications of robotic surgery to VOLT will be addressed.
Radiation induced fibrosis (RIF) can be understood as a form of chronic radiation-induced bystander effect (RIBE). It is a fibrotic process different than acute radiation syndrome (ARS), which is an inflammatory process that has different mediators and effector cells. It is triggered by Reactive Oxygen Species (ROS) activation of the matrix-embedded L-TGF-β complex. TGF-β acts by directing cellular processes that culminate in a fibrotic state. These include epithelial and endothelial mesenchymal transition (EMT and EnMT), G1 phase growth arrest, stimulation of fibrosis, and apoptosis, characterized by hypocellularity with a predominance of fibrocytes and myofibroblasts, fibrosis, and variable loss of tissue function. Fat grafting is the only clinically available tool to reverse RIF. The reversal of RIF is mediated by the mesenchymal stem cells (MSCs) embedded in the stromal vascular fraction (SVF) adipose tissue. The mechanism of action is the release of HGF (hepatocyte growth factor) by the MSCs into the surrounding RIF tissue. The HGF initiates a “mitotic growth program” that reprograms cell behavior. These changes include EMT and EnMT, stimulation of cell proliferation and morphogenesis, anti-apoptosis, downregulation of TGF-β, dissolution of fibrosis, and cell motility. The “mitotic growth program” culminates in tissue regeneration and reversal of RIF.
Microvascular free flap reconstruction based on the subscapular system is an established and versatile method of reconstructing complex head and neck defects. Since the first published description in the mid-1980s, advances have been made to the harvest technique, positioning, use of virtual surgical planning, and endosseous implants. Here, the most recent literature is reviewed for innovations related to the subscapular system. Microvascular head and neck surgeon preferences related to the subscapular system are surveyed and discussed. The concordance between virtual surgical plans using scapula cutting guides and pre-contoured plates with the postoperative result is assessed, and novel applications of the scapula free flap are presented. Subscapular system free flaps are an established and essential component of the reconstructive armamentarium for head and neck defects with minimal limitations and low donor site morbidity.
Head and neck surgical complications can result in significant morbidity for patients. Innovations over the past few years have shown promise in mitigating these effects. Specifically, new medications, bioactive agents, and bioengineered materials may reduce the resultant morbidity. Certain historic existing medical therapies, such as oxandrolone, tissue plasminogen activator, and royal jelly/honey, have new applications in the management of challenging head and neck surgical complications. This review describes some of the more common and challenging complications in head and neck surgery and modern techniques for management.
Recent studies suggest that acellular nerve allografts (ANA) have similar efficacy as nerve autografts in certain applications of nerve surgery. However, multiple studies also demonstrate the limitations of nerve allografts, resulting in poor patient outcomes. This submission discusses a recent case series of patients who failed allograft use with subsequent histologic analyses of these allografts. Recommendations on the treatment of nerve gaps are presented, drawing from our current understanding of allograft and autograft utility in reconstruction. Factors taken into account include recipient critical nerve function, existent nerve gap, and nerve diameter.
Aim: Lymphaticovenous anastomosis (LVA) is the mainstay for treating breast cancer-related lymphedema (BCRL). Preoperative ultrasonography is useful to assess the locations and characteristics of lymphatics and veins to improve LVA success remarkably even in cases of advanced BCRL. Aim: The aim of the study was to describe the use of ultrasonography to reliably map suitable lymphatics and veins and successfully perform LVA surgery in cases of advanced BCRL.
Method: This retrospective cohort study included 41 cases of BCRL who underwent LVA surgery using preoperative ultrasound to map and characterize lymphatics and veins. Cases were analyzed for the following: (1) whether preoperative ultrasonographic detection of both lymphatics and veins correlate to actual intraoperative findings and (2) improvement in mean limb circumference measurements at 1 and 3 months of follow-up in this patient cohort.
Results: For 155 LVA incisions, 212 LVA procedures were performed. Among them, 133 (62.7%) lymphatics and 196 (92.4%) anti-reflux veins were successfully detected and characterized on preoperative sonography. Mean preoperative circumference at the wrist, 10cm below elbow, elbow, and 10cm above elbow were 18.86 cm, 27.79 cm, 29.75 cm, and 33.77 cm, respectively. The mean measurements improved at 1 month correspondingly to 17.14 cm, 24.86 cm, 26.91 cm, and 30.50 cm (9.12%, 10.54%, 9.54%, 9.70% improvement, respectively), and at 3 months to 16.59 cm, 24.28 cm, 26.55 cm, and 30.05 cm (12.02%, 12.63%, 10.73%, 11.02% improvement, respectively). For each individual patient, their four measured circumferences were also added to obtain the Total Circumference (TC). The TC ranged from 89-135 cm (mean 109.46 cm) preoperatively, 83.5-129.5 cm (mean 98.74 cm) 1-month post-op, and 80.5-128 cm (mean 96.55 cm) 3 months post-op. Compared to the preoperative value, each patient had a TC decrease of 2.79%-20.35% (mean 9.80%) at 1-month post-op and 4.39-28.30% (mean 11.80%) at 3 months post-op. These differences were all statistically significant (P < 0.0001).
Conclusion: Preoperative ultrasonography is a useful adjunct to detect lymphatic vessels and anti-reflux veins, thereby increasing the chances of successfully performing LVA surgery even in cases of advanced upper limb lymphedema. It can contribute to long-lasting outcomes.