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Latest Trends in Reconstructive Microsurgery: From Modification to Innovation

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A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Surgery".

Deadline for manuscript submissions: closed (10 January 2023) | Viewed by 31714

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Prof. Dr. Mario F. Scaglioni

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Guest Editor

Department of Hand and Plastic Surgery, Kantonsspital Luzern, Luzern, Switzerland
Interests: plastic and reconstructive surgery; microsurgery; breast surgery, lymphedema surgery
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Hidehiko Yoshimatsu

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Guest Editor

Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
Interests: lymphedema; reconstructive surgery; perforator flap; superficial circumflex iliac artery perforator flap
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Dear Colleagues,

In the plastic surgery field, there has been a clear trend over the last few years toward the use of microsurgical techniques. Many factors have contributed to this process, ranging from the development of more precise instruments to higher-resolution imaging evaluations and an improved understanding of anatomy and physiology. In certain respects, the advent of perforator-based flaps was revolutionary, overcoming most of the limits of previous autologous reconstructive procedures. They allowed major vessels to be spared, resulting in a much lower donor site morbidity combined with shortened dissection times and a lower incidence of postoperative complications. Further technical progress resulted in supermicrosurgery, which offers even more opportunities, and we now have the possibility to safely manipulate even the smallest vessels, such as the lymphatic vessels. Nowadays, lymphatic surgery also represents the latest evolution in the reconstructive field, with the purpose of treating and also preventing long-term sequelae.

The purpose of this Special Issue is to present and discuss the latest trends in the reconstructive microsurgery field, including lymphedema surgery and supermicrosurgery, as well as new technologies and tools employed in this setting. The scope of the issue is deliberately broad in order to encourage submissions on a wide range of topics and perspectives related to the many reconstructive procedures in addition to the new technologies associated with them.

This is a topic for which we are encountering continuous modifications of and innovations applied to well-known procedures. Thus, in this Special Issue, we would like to deeply focus on the great potential of the microsurgical technique in reconstructive settings, which may allow addressing and solving problems that were previously considered unsolvable. In particular, we wish to focus attention not only on structure restoration but also to complete functional preservation.

We are seeking original articles, literature reviews, and case reports/case series dealing with the most modern microsurgical techniques related to defect reconstruction throughout the body. Proposals for clinical treatment as well as anatomical studies are of interest.

Prof. Dr. Mario F. Scaglioni
Prof. Dr. Hidehiko Yoshimatsu
Guest Editors

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Keywords

reconstructive microsurgery
supermicrosurgery
perforator flap
lymphedema surgery
propeller flap
breast reconstruction
lower extremity reconstruction
free flap

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Related Special Issue

Latest Trends in Reconstructive Microsurgery: From Modification to Innovation—Volume II in Medicina (2 articles)

Published Papers (9 papers)

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Research

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12 pages, 3424 KiB

Open AccessArticle

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications

by Hidehiko Yoshimatsu, Ryo Karakawa, Yuma Fuse, Tomoyuki Yano, Satoru Muro and Keiichi Akita

Medicina 2023, 59(6), 1087; https://doi.org/10.3390/medicina59061087 - 5 Jun 2023

Viewed by 2218

Abstract

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery’s origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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10 pages, 3295 KiB

Open AccessArticle

Combined Free Flaps for Optimal Orthoplastic Lower Limb Reconstruction: A Retrospective Series

by Pietro G. di Summa, Gianluca Sapino, Daniel Wagner, Michele Maruccia, David Guillier and Heinz Burger

Medicina 2023, 59(5), 859; https://doi.org/10.3390/medicina59050859 - 28 Apr 2023

Viewed by 3338

Abstract

Background and Objectives: Open fracture of the lower limb can lead to substantial bone and soft tissue damage, resulting in a challenging reconstructive scenarios, especially in presence of bone or periosteal loss, with a relevant risk of non-union. This work analyzes outcomes of using a double approach for orthoplastic reconstruction, adopting the free medial condyle flap to solve the bone defects, associated to a second free flap for specific soft tissue coverage. Indications, outcomes and reconstructive rationales are discussed. Materials and Methods: A retrospective investigation was performed on patients who underwent complex two-flap microsurgical reconstruction from January 2018 to January 2022. Inclusion criteria in this study were the use of a free femoral condyle periostal/bone flap together with a second skin-only flap. Only distal third lower limb reconstructions were included in order to help equalize our findings. Out of the total number of patients, only patients with complete pre- and post-operative follow-up (minimum 6 months) data were included in the study. Results: Seven patients were included in the study, with a total of 14 free flaps. The average age was 49. Among comorbidities, four patients were smokers and none suffered from diabetes. Etiology of the defect was acute trauma in four cases and septic non-union in three cases. No major complications occurred, and all flaps healed uneventfully with complete bone union. Conclusions: Combining a bone periosteal FMC to a second skin free flap for tailored defect coverage allowed achievement of bone union in all patients, despite the lack of initial bone vascularization or chronic infection. FMC is confirmed to be a versatile flap for small-to-medium bone defects, especially considering its use as a periosteal-only flap, with minimal donor site morbidity. Choosing a second flap for coverage allows for a higher inset freedom and tailored reconstruction, finally enhancing orthoplastic success. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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10 pages, 2739 KiB

Open AccessArticle

Clinical Application of the Computed-Tomography-Based Three-Dimensional Models in the Surgical Planning and Intraoperative Navigation of Ureteropelvic Junction Obstruction Complicated with Renal Calculi

by Shengwei Xiong, Mengmeng Zheng, Chunlin Liu, Kunlin Yang, Zhihua Li, Lei Zhang, Ye Tian, Liqun Zhou and Xuesong Li

Medicina 2022, 58(12), 1769; https://doi.org/10.3390/medicina58121769 - 30 Nov 2022

Viewed by 2014

Abstract

Background and Objectives: To clinically validate the computed tomography (CT)-based three-dimension (3D) model for treatment planning and intraoperative navigation of ureteropelvic junction obstruction (UPJO) complicated with renal calculi. Materials and Methods: We retrospectively collected the data of 26 patients with UPJO and renal calculi who were surgically treated in our institution from January 2019 to December 2021. Before surgery, 3D models based on preoperative CT scans were constructed in all patients. Additionally, the patients were divided into three groups according to the results of 3D models, distinguished by different treatment of renal calculi, that is, left untreated (1), pyelolithotomy (2), and endoscopic lithotomy (3). The quantitative analysis of renal calculi parameters, and perioperative and follow-up data were compared. Results: The mean number of involved renal calyces (p = 0.041), and the mean maximum cross-sectional area (p = 0.036) of renal stones were statistically different among the three groups. There were no significant differences among the three groups in the mean operative time, mean estimated blood loss, mean pararenal draining time, and mean hospital stay. The intraoperative stone clearance rates were 100% (11/11) and 77.8% (7/9) in group 2 and group 3, respectively. The trends of increased estimated glomerular filtration rate and decreased creatinine on the average levels after surgery were observed, although these changes were not statistically significant. At a mean follow-up of 19.4 ± 6.4 months, the overall surgical success rate of the UPJO was 96.2% (25/26), and the overall success rate of renal calculi removal was 80.8% (21/26). Renal stones in 66.7% (4/6) of patients in group 1 spontaneously passed out. Conclusions: Preoperative 3D CT models have exact clinical value in the surgical planning and intraoperative navigation of UPJO patients complicated with renal calculi. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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19 pages, 3334 KiB

Open AccessArticle

Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap

by Thomas Giesen, Olga Politikou, Ivan Tami and Maurizio Calcagni

Medicina 2022, 58(8), 1065; https://doi.org/10.3390/medicina58081065 - 7 Aug 2022

Cited by 6 | Viewed by 2861

Abstract

Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6–15). The flap dimensions ranged from 6 cm² to 136 cm². All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm²). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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10 pages, 7875 KiB

Open AccessArticle

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

by Yuma Fuse, Hidehiko Yoshimatsu, Ryo Karakawa and Tomoyuki Yano

Medicina 2022, 58(5), 670; https://doi.org/10.3390/medicina58050670 - 18 May 2022

Cited by 1 | Viewed by 2674

Abstract

Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: −1.6 days (95% confidence interval: −2.8 to −0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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9 pages, 2210 KiB

Open AccessFeature PaperArticle

Soft Tissue Defect Reconstruction and Lymphatic Complications Prevention: The Lymphatic Flow-Through (LyFT) Concept

by Mario F. Scaglioni, Matteo Meroni and Elmar Fritsche

Medicina 2022, 58(4), 509; https://doi.org/10.3390/medicina58040509 - 2 Apr 2022

Cited by 3 | Viewed by 3128

Abstract

Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap’s veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6–14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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8 pages, 43161 KiB

Open AccessArticle

Filling the Upper Pole with the Pectoralis Major Muscle Flap in Profunda Femoris Artery Perforator Flap Breast Reconstruction

by Hidehiko Yoshimatsu, Hiroki Miyashita, Ryo Karakawa, Yuma Fuse and Tomoyuki Yano

Medicina 2022, 58(4), 458; https://doi.org/10.3390/medicina58040458 - 22 Mar 2022

Cited by 1 | Viewed by 2477

Abstract

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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Review

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14 pages, 4724 KiB

Open AccessReview

Innovative Strategies in Microvascular Head and Neck Reconstruction

by Z-Hye Lee, Tarek Ismail, John W. Shuck and Edward I. Chang

Medicina 2023, 59(7), 1194; https://doi.org/10.3390/medicina59071194 - 24 Jun 2023

Cited by 2 | Viewed by 2907

Abstract

The field of reconstructive microsurgery has witnessed considerable advancements over the years, driven by improvements in technology, imaging, surgical instruments, increased understanding of perforator anatomy, and experience with microsurgery. However, within the subset of microvascular head and neck reconstruction, novel strategies are needed to improve and optimize both patient aesthetics and post-operative function. Given the disfiguring defects that are encountered following trauma or oncologic resections, the reconstructive microsurgeon must always aim to innovate new approaches, reject historic premises, and challenge established paradigms to further achieve improvement in both aesthetic and functional outcomes. The authors aim to provide an up-to-date review of innovations in head and neck reconstruction for oncologic defects. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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18 pages, 2513 KiB

Open AccessReview

Current Concepts in the Management of Primary Lymphedema

by Jenna-Lynn B. Senger, Rohini L. Kadle and Roman J. Skoracki

Medicina 2023, 59(5), 894; https://doi.org/10.3390/medicina59050894 - 6 May 2023

Cited by 16 | Viewed by 8775

Abstract

Primary lymphedema is a heterogeneous group of conditions encompassing all lymphatic anomalies that result in lymphatic swelling. Primary lymphedema can be difficult to diagnose, and diagnosis is often delayed. As opposed to secondary lymphedema, primary lymphedema has an unpredictable disease course, often progressing more slowly. Primary lymphedema can be associated with various genetic syndromes or can be idiopathic. Diagnosis is often clinical, although imaging can be a helpful adjunct. The literature on treating primary lymphedema is limited, and treatment algorithms are largely based on practice patterns for secondary lymphedema. The mainstay of treatment focuses on complete decongestive therapy, including manual lymphatic drainage and compression therapy. For those who fail conservative treatment, surgical treatment can be an option. Microsurgical techniques have shown promise in primary lymphedema, with both lymphovenous bypass and vascularized lymph node transfers demonstrating improved clinical outcomes in a few studies. Full article

(This article belongs to the Special Issue Latest Trends in Reconstructive Microsurgery: From Modification to Innovation)

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