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Reconstructive Microsurgery: Challenges and New Perspectives

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Plastic, Reconstructive and Aesthetic Surgery/Aesthetic Medicine".

Deadline for manuscript submissions: closed (25 January 2024) | Viewed by 15680

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Dr. Albert H. Chao

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Guest Editor

Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, OH, USA
Interests: free flap; free tissue transfer; microsurgery

Special Issue Information

Dear Colleagues,

The subspecialty of reconstructive microsurgery utilizes microsurgical techniques to allow surgeons to operate on the smallest of structures, including vessels, lymphatics, and nerves. Traditionally, these procedures have been used by microsurgeons to reconstruct complex tissue defects through the use of free tissue transfer, which involves transfer of tissue (free flaps) between distant anatomic sites on the body. As the field has advanced, microsurgical techniques have been applied to even smaller structures, opening the door for new procedures, such as lymphatic reconstruction in the management of lymphedema and new types of free flaps. In addition, refinement in the technique has allowed microsurgeons to now perform many of these procedures with minimal donor site morbidity. Lastly, trends in plastic and reconstructive surgery have also resulted in more widespread use of other applications for microsurgery, such as gender-affirming surgery and vascularized tissue allotransplantation. This Special Issue seeks to present the latest challenges and perspectives in reconstructive microsurgery.

Dr. Albert H. Chao
Guest Editor

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Keywords

free flap
free tissue transfer
microsurgery

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Published Papers (10 papers)

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Research

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12 pages, 1161 KiB

Open AccessArticle

Maxillofacial Microvascular Free-Flap Reconstructions in Pediatric and Young Adult Patients—Outcomes and Potential Factors Influencing Success Rate

by Dominika Lech, Jeremi Matysek, Robert Maksymowicz, Cyprian Strączek, Robert Marguła, Łukasz Krakowczyk, Marcin Kozakiewicz and Krzysztof Dowgierd

J. Clin. Med. 2024, 13(7), 2015; https://doi.org/10.3390/jcm13072015 - 30 Mar 2024

Viewed by 746

Abstract

Background: Maxillofacial microvascular free-flap reconstructions are significant interventions in the management of congenital defects, traumatic injuries, malignancies, and iatrogenic complications in pediatric and young adult patients. Craniofacial disorders within this demographic can result in profound functional, cosmetic, and psychosocial impairments, highlighting the critical need for thorough investigation into factors that may influence procedural success and postoperative quality of life. This retrospective chart review aims to examine the outcomes and potential influencing factors, aiming to offer valuable insights into optimizing the effectiveness of these reconstructions and improving patient outcomes. Methods: A single head and neck surgical team performed all the included 136 procedures. Demographic and surgical patient data were recorded. Type of transfer performed in each recipient site and major complications were analyzed. Relevant influencing factors, such as age, gender, and etiology of defect were determined using the ANOVA test and χ² test of independence. Results: The results indicate a 90% success rate. No significant relationship was found between the incidence of total flap loss and patient age, etiology, or graft source. The maxillary reconstructions showed a higher incidence of total flap loss compared to mandibular reconstructions (11 vs. 3 cases). Conclusions: Despite the high success rate, the findings underline the necessity for further research to validate these observations and enhance surgical methods for pediatric and young adult patients. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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15 pages, 6021 KiB

Open AccessArticle

Building Complex Autologous Breast Reconstruction Program: A Preliminary Experience

by Min-Jeong Cho, Christopher A. Slater, Roman J. Skoracki and Albert H. Chao

J. Clin. Med. 2023, 12(21), 6810; https://doi.org/10.3390/jcm12216810 - 27 Oct 2023

Viewed by 909

Abstract

Autologous breast reconstruction is an increasingly popular method of reconstruction for breast cancer survivors. While deep inferior epigastric perforator (DIEP) flaps are the gold standard, not all patients are ideal candidates for DIEP flaps due to low BMI, body habitus, or previous abdominal surgery. In these patients, complex autologous breast reconstruction can be performed, but there is a limited number of programs around the world due to high technical demand. Given the increased demand and need for complex autologous flaps, it is critical to build programs to increase patient access and teach future microsurgeons. In this paper, we discuss the steps, pearls, and preliminary experience of building a complex autologous breast reconstruction program in a tertiary academic center. We performed a retrospective chart review of patients who underwent starting the year prior to the creation of our program. Since the start of our program, a total of 74 breast mounds have been reconstructed in 46 patients using 87 flaps. Over 23 months, there was a decrease in median surgical time for bilateral reconstruction by 124 min (p = 0.03), an increase in the number of co-surgeon cases by 66% (p < 0.01), and an increase in the number of complex autologous breast reconstruction by 42% (p < 0.01). Our study shows that a complex autologous breast reconstruction program can be successfully established using a multi-phase approach, including the development of a robust co-surgeon model. In addition, we found that a dedicated program leads to increased patient access, decreased operative time, and enhancement of trainee education. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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9 pages, 1959 KiB

Open AccessArticle

Anterolateral Thigh Chimeric Flap: An Alternative Reconstructive Option to Free Flaps for Large Soft Tissue Defects

by Yoon Jae Lee, Junnyeon Kim, Chae Rim Lee, Jun Hyeok Kim, Deuk Young Oh, Young Joon Jun and Suk-Ho Moon

J. Clin. Med. 2023, 12(21), 6723; https://doi.org/10.3390/jcm12216723 - 24 Oct 2023

Cited by 1 | Viewed by 1634

Abstract

The anterolateral thigh (ALT) skin flap provides abundant, thin, pliable skin coverage with adequate pedicle length and calibre, and tolerable donor site morbidity. However, coverage of relatively large defects using the ALT flap alone is limited. We present our experience of using the ALT flap coupled with the vastus lateralis (VL) flap supplied by the same pedicle for large defect reconstruction. Between 2016 and 2020, ten patients with extensive lower-extremity or trunk defects were treated using the ALT/VL chimeric flap. The ALT portion was used to cover the cutaneous and joint defect while the VL part was used to resurface remnant defects, and a skin graft was performed. All flaps were based on the common descending pedicle, and branches to separate the components were individually dissected. All defects were successfully reconstructed using the ALT/VL chimeric flap. No surgery-related acute complications were observed, and the patients had no clinical issues with ambulation or running activities during the long-term follow-up period. With the separate components supplied by a common vascular pedicle, the ALT/VL chimeric flap allows us to reconstruct extensive defects with joint involvement or posterior trunk lesions. Thus, the ALT/VL chimeric flap may be a suitable alternative for extensive tissue defect reconstruction. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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11 pages, 6646 KiB

Open AccessArticle

Reliability of Long Vein Grafts for Reconstruction of Massive Wounds

by Brian Chuong, Kristopher Katira, Taylor Ramsay, John LoGiudice and Antony Martin

J. Clin. Med. 2023, 12(19), 6209; https://doi.org/10.3390/jcm12196209 - 26 Sep 2023

Cited by 1 | Viewed by 947

Abstract

When handling large wounds, zone of injury is a key concept in reconstructive microsurgery, as it pertains to the selection of recipient vessels. Historically, surgeons have avoided placing microvascular anastomosis within widely traumatized, inflamed, or radiated fields. The harvest of vein grafts facilitates reconstruction in complex cases by extending arterial and/or venous pedicle length. To illustrate the utility and fidelity of these techniques, this paper reviews the indications and outcomes for vein grafting in ten consecutive patients at a single tertiary referral center hospital. The case series presented is unique in three aspects. First, there are two cases of successful coaptation of the flap artery to the side of the arterial limb of an arteriovenous loop. Second, there is a large proportion of cases where vein grafts were used to elongate the venous pedicle. In these 10 cases, the mean vein graft length was 37 cm. We observed zero flap failures and zero amputations. Although limited in sample size, these case data support the efficacy and reliability of long segment vein grafting in complex cases in referral centers. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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0 pages, 590 KiB

Open AccessArticle

Risk Factors for Flap Loss: Analysis of Donor and Recipient Vessel Morphology in Patients Undergoing Microvascular Head and Neck Reconstructions

by Johannes G. Schuderer, Huong T. Dinh, Steffen Spoerl, Jürgen Taxis, Mathias Fiedler, Josef M. Gottsauner, Michael Maurer, Torsten E. Reichert, Johannes K. Meier, Florian Weber and Tobias Ettl

J. Clin. Med. 2023, 12(16), 5206; https://doi.org/10.3390/jcm12165206 - 10 Aug 2023

Cited by 4 | Viewed by 1260 | Correction

Abstract

In microvascular head and neck reconstruction, various factors such as diabetes, alcohol consumption, and preoperative radiation hold a risk for flap loss. The primary objective of this study was to examine the vessel morphology of both recipient and donor vessels and to identify predictors for changes in the diameters of H.E.-stained specimens associated with flap loss in a prospective setting. Artery and vein samples (N = 191) were collected from patients (N = 100), with sampling from the recipient vessels in the neck area and the donor vessels prior to anastomosis. External vessel diameter transverse (ED), inner vessel diameter transverse (ID), thickness vessel intima (TI), thickness vessel media (TM), thickness vessel wall (TVW), and intima-media ratio (IMR) for the recipient (R) and transplant site (T) in arteries (A) and veins (V) were evaluated using H.E. staining. Flap loss (3%) was associated with increased ARED (<italic>p</italic> = 0.004) and ARID (<italic>p</italic> = 0.004). Preoperative radiotherapy led to a significant reduction in the outer diameter of the recipient vein in the neck (<italic>p</italic> = 0.018). Alcohol consumption (<italic>p</italic> = 0.05), previous thrombosis (<italic>p</italic> = 0.007), and diabetes (<italic>p</italic> = 0.002) were associated with an increase in the total thickness of venous recipient veins in the neck. Diabetes was also found to be associated with dilation of the venous media in the neck vessels (<italic>p</italic> = 0.007). The presence of cardiovascular disease (CVD) was associated with reduced intimal thickness (<italic>p</italic> = 0.016) and increased total venous vessel wall thickness (<italic>p</italic> = 0.017) at the transplant site. Revision surgeries were linked to increased internal and external diameters of the graft artery (<italic>p</italic> = 0.04 and <italic>p</italic> = 0.003, respectively), while patients with flap loss showed significantly increased artery diameters (<italic>p</italic> = 0.004). At the transplant site, alcohol influenced the enlargement of arm artery diameters (<italic>p</italic> = 0.03) and the intima–media ratio in the radial forearm flap (<italic>p</italic> = 0.013). In the anterolateral thigh, CVD significantly increased the intimal thickness and the intima–media ratio of the graft artery (<italic>p</italic> = 0.01 and <italic>p</italic> = 0.02, respectively). Patients with myocardial infarction displayed increased thickness in the <italic>A. thyroidea</italic> and artery media (<italic>p</italic> = 0.003). Facial arteries exhibited larger total vessel diameters in patients with CVD (<italic>p</italic> = 0.03), while facial arteries in patients with previous thrombosis had larger diameters and thicker media (<italic>p</italic> = 0.01). The presence of diabetes was associated with a reduced intima–media ratio (<italic>p</italic> < 0.001). Although the presence of diabetes, irradiation, and cardiovascular disease causes changes in vessel thickness in connecting vessels, these alterations did not adversely affect the overall success of the flap. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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11 pages, 467 KiB

Open AccessArticle

The Controlling Nutritional Status (CONUT) Score for Prediction of Microvascular Flap Complications in Reconstructive Surgery

by Rihards P. Rocans, Janis Zarins, Evita Bine, Renars Deksnis, Margarita Citovica, Simona Donina and Biruta Mamaja

J. Clin. Med. 2023, 12(14), 4794; https://doi.org/10.3390/jcm12144794 - 20 Jul 2023

Viewed by 1056

Abstract

Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659–0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99–16.11 vs. 25.38, 14.82–35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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10 pages, 1167 KiB

Open AccessArticle

What Is the Minimum Number of Sutures for Microvascular Anastomosis during Replantation?

by Hyung-suk Yi, Byeong-seok Kim, Yoon-soo Kim, Jin-hyung Park and Hong-il Kim

J. Clin. Med. 2023, 12(8), 2891; https://doi.org/10.3390/jcm12082891 - 15 Apr 2023

Viewed by 3156

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. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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12 pages, 1286 KiB

Open AccessArticle

Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea

by Krzysztof Dowgierd, Rafał Pokrowiecki, Andrzej Myśliwiec and Łukasz Krakowczyk

J. Clin. Med. 2023, 12(3), 1124; https://doi.org/10.3390/jcm12031124 - 31 Jan 2023

Cited by 4 | Viewed by 2818

Abstract

This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4–17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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Review

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14 pages, 5339 KiB

Open AccessReview

Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction

by Z-Hye Lee, Ana Canzi, Jessie Yu and Edward I. Chang

J. Clin. Med. 2024, 13(5), 1311; https://doi.org/10.3390/jcm13051311 - 26 Feb 2024

Viewed by 864

Abstract

The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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Other

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14 pages, 2090 KiB

Open AccessSystematic Review

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

by Nikita Roy, Christopher J. Alessandro, Taylor J. Ibelli, Arya A. Akhavan, Jake M. Sharaf, David Rabinovitch, Peter W. Henderson and Alice Yao

J. Clin. Med. 2023, 12(15), 4951; https://doi.org/10.3390/jcm12154951 - 27 Jul 2023

Cited by 4 | Viewed by 1296

Abstract

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor’s letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy. Full article

(This article belongs to the Special Issue Reconstructive Microsurgery: Challenges and New Perspectives)

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