A nomogram for predicting outcomes following pedicled flap reconstruction of the lower extremity.

INTRODUCTION: Lower extremity reconstructions with soft tissue flaps account for a significant proportion of reconstructive surgery. Pedicled flaps are a procedure of choice, particularly in multimorbid patients and those with small to medium-sized defects. Complication rates are high and should not be underestimated, with accurate preoperative risk factor assessment being imperative. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program Database (2008-2021), we analyzed all patients who underwent pedicled flap reconstruction of the lower extremity. Demographic data, comorbidities, and perioperative data were extracted. We identified risk factors of major surgical complications within 30 days of surgery through uni- and multivariate regression analyses. On this basis, a nomogram for predicting the risk of complications was developed to allow for feasible point-of-care risk assessment. RESULTS: A total of 6475 adult patients were identified. The most common comorbidities were hypertension (n = 3363, 51.9%) and obesity (n = 2306, 35.6%) and most common American Society of Anesthesiologists (ASA) class was class 3 (n = 3703, 57.2%). The most common complication was bleeding/transfusion (n = 1293, 19.9%). Multivariate regression revealed longer procedures, inpatient setting, higher ASA scores, hypertension, and procedures performed by orthopedic and vascular surgeons as predictors for higher risk of post-operative complications. CONCLUSION: Leveraging a risk- and case-mix-adjusted multi-institutional database, a nomogram for post-operative surgical complications within 30 days after pedicled flap reconstruction in the lower extremity was developed. This broadly applicable risk prediction tool can aid in decision-making when assessing patient eligibility.

Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases.

Background: The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. Methods: A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. Results: A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Conclusions: Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.

The Epidemiology and Outcomes of Perineal and Genital Burn Injury in Low- and Middle- Income Countries: A Global Burn Registry Study.

INTRODUCTION: The epidemiology, care, and outcomes of perineal and genital burns (PG) in high-income countries have been previously described, but an analysis of this topic in LMICs has yet to be performed. We use the World Health Organization's Global Burn Registry to fill this gap. METHODS: The GBR was searched from inception to November 2023 to identify all burn patients, excluding cases from high-income countries. Demographics and mechanism of injury were retrieved. Primary outcomes were length of hospital stay (LOHS), surgical intervention, discharge with physical impairment, and mortality. A multivariate regression analysis was performed controlling for burnt total body surface area (TBSA), age, sex, inhalation injury, mechanism of burn and care center characteristics. RESULTS: Of 9041 patients identified, 1213 (13.4 %) had PG burns with 136 (1.6 %) isolated to the PG region. PG patients had higher TBSA (p < 0.001) and more inhalation injury (p < 0.001). They had better access to rehabilitation and lower access to theater space for burns (p < 0.001). Multivariable analysis showed that PG patients had longer LOHS (p = 0.001), greater mortality (p < 0.001), were less likely to undergo surgery (p = 0.01) or be discharged home with physical impairment (p = 0.03). CONCLUSION: Similarities and differences exist between high- and low/middle-income countries in terms of the patterns of injury, care, and recovery in patients with PG burns. The longer LOHS and higher mortality among PG patients, previously reported in high-income countries, are verified. This highlights the importance of greater vigilance when caring for such patients.

[Modern concepts of interdisciplinary extremity reconstruction in open fractures]. / Moderne Konzepte der interdisziplinären Extremitätenrekonstruktion bei offenen Frakturen.

The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.

The Application of a Synthetic Biodegradable Temporizing Matrix in Extensive Burn Injury: A Unicenter Experience of 175 Cases.

Objectives: Addressing extensive and deep burn wounds poses considerable challenges for both patients and surgeons. The NovoSorb® Biodegradable Temporizing Matrix (BTM) emerged as a novel dermal substitute and has been subjected to evaluation in large burn wound cases, with a specific focus on identifying risk factors associated with suboptimal take rates. Methods: All patients with burn wounds greater than 10% body surface that underwent BTM treatment between March 2020 and November 2023 were eligible for inclusion. Univariate analyses and linear regression models were employed to discern risk factors and predictors influencing the take rates of both the BTM and split-thickness skin grafts (STSGs). Results: A total of 175 patients (mean age 56.2 ± 19.8 years, 70.3% male) were evaluated. The mean take rates of the BTM and STSGs were 82.0 ± 24.7% and 87.3 ± 19.0%, respectively. There were significant negative correlations between BTM take and the number of surgeries before BTM application (r = -0.19, p = 0.01), %TBSA and STSG take (r = -0.36, p = <0.001) and significant positive correlations between BTM and STSG take (r = 0.41, p ≤ 0.001) in addition to NPWT and STSG take (r = 0.21, p = 0.01). Multivariate regression analyses showed that a larger number of surgeries prior to BTM application (OR -3.41, 95% CI -6.82, -0.03, p = 0.04) was associated with poorer BTM take. Allograft treatment before BTM application (OR -14.7, 95% CI -23.0, -6.43,p = 0.01) and failed treatment with STSG before BTM application (OR -20.8, 95% CI -36.3, -5.23, p ≤ 0.01) were associated with poorer STSG take, whereas higher BTM take rates were associated with overall higher STSG take (OR -0.15, 95% 0.05, 0.26, p = 0.01). The Meek technique was used in 24 patients and showed similar take rates (BTM: 76.3 ± 28.0%, p = 0.22; STSG: 80.7 ± 21.1, p = 0.07). Conclusions: This study summarizes our findings on the application of a BTM in the context of large burn wounds. The results demonstrate that successful treatment can be achieved even in patients with extensive burns, resulting in satisfying take rates for both the BTM and STSG. The data underscore the importance of promptly applying a BTM to debrided wounds and indicate good results when using Meek.

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery.

BACKGROUND: The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations. OBJECTIVE: To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes. METHODS: We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image. RESULTS: The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042). CONCLUSION: We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Free Flap Reconstruction of Sternal Defects after Cardiac Surgery: An Algorithmic Approach for Dealing with Sparse Recipient Vessels.

Background: Sparsity of recipient vessels poses a challenge for microsurgical free flap reconstruction of sternal defects following deep sternal wound infection after cardiac surgery. Methods: From January 2013, a standardized algorithm for dealing with sparse recipient vessels was strictly followed. In this retrospective study including 75 patients, we compared operative details, surgical complications, and reconstructive outcomes of patients treated according to this algorithm (group A: January 2013-May 2021; n = 46) with a historical control group (group B: January 2000-December 2012, n = 29). Results: The left internal mammary artery had been harvested for arterial bypass grafting in 40 of 46 cases (87%) in group A and in all cases in group B. The right internal mammary artery (RIMA) and right internal mammary vein (RIMV) were the first choice as recipient vessels. In case of unsuitability of the RIMV, a right cephalic vein (CV) turndown was used for venous outflow. If both RIMA and RIMV proved insufficient, a single-stage arterio-venous loop (AVL) between the CV and subclavian artery (CV-SA AVL), CV and thoracoacromial artery (CV-TA AVL), or subclavian artery and subclavian vein (SA-SV AVL) was established. The algorithmic approach significantly reduced partial flap necrosis [group A: n = 3 (7%) versus group b: n = 7 (24%); P = 0.04], and overall operation time [group A: 360 ±â€…88 min versus group B: 415 ±â€…80 min; P = 0.01]. Conclusions: Standardized approaches improve clinical outcomes in microsurgical free flap sternal reconstruction after cardiac surgery.

In Vivo Engineering and Transplantation of Axially Vascularized and Epithelialized Flaps in Rats.

The arteriovenous loop (AVL) model allows the in vivo engineering of axially vascularized flaps, the so-called AVL flaps. Although AVL flaps can be transplanted microsurgically to cover tissue defects, they lack an epithelial layer on the surface. Therefore, the objective of this study was to engineer axially vascularized AVL flaps with an accompanying epithelial layer for local defect reconstruction. In this study, AVLs were established in 20 male Lewis rats. Minimally invasive injection of keratinocytes onto the surface of the AVL flaps was performed on postoperative day (POD) 21. AVL flaps were explanted from 12 rats on POD 24 or POD 30, then the epithelium formed by the keratinocytes on the surface of the flaps was evaluated using immunofluorescence staining. In six other rats, the AVL flap was locally transposed to cover a critical defect in the rats' leg on POD 30 and explanted for analysis on POD 40. In two control rats, sodium chloride was applied instead of keratinocytes. These control flaps were also transplanted on POD 30 and explanted on POD 40. Our results revealed that 3 days after keratinocyte application, a loose single-layered epithelium was observed histologically on the AVL flaps surface, whereas after 9 days, a multilayered and structured epithelium had grown. The epithelium on the transplanted AVL flaps showed its physiological differentiation when being exposed to an air-liquid interface. Histologically, a layered epithelium identical to the rats' regular skin was formed. In the sodium chloride control group, no epithelium had been grown. This study clearly demonstrates that axially vascularized AVL flaps can be processed in the subcutaneous chamber by minimally invasive injection of keratinocytes. Thus, AVL flaps with an intact epithelial layer were engineered and could be successfully transplanted for local defect coverage in a small animal model.

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes.

BACKGROUND: The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS: In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS: The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION: In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Robot-assisted Microsurgery in Lower Extremity Reconstruction]. / Roboter-assistierte Mikrochirurgie in der Rekonstruktion der unteren Extremität.

BACKGROUND: In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity. PATIENTS/MATERIAL AND METHODS: Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented. RESULTS: The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses. CONCLUSION: Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial.

BACKGROUND: Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS: RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS: A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS: Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.

NovoSorb® Biodegradable Temporising Matrix (BTM): What we learned from the first 300 consecutive cases.

INTRODUCTION: Extensive full-thickness soft-tissue defects remain a challenge in reconstructive surgery. NovoSorb® Biodegradable Temporising Matrix (BTM) represents a novel dermal substitute and was evaluated in wounds deriving from different aetiologies and to highlight risk factors for poor take rates. METHODS: All patients treated with BTM at our department between March 2020 and October 2022 were included. Differences in univariate and linear regression models identified predictors and risk factors for take rates of BTM and split-thickness skin grafts (STSG). RESULTS: Three hundred patients (mean age 54.2 ± 20.1 years, 66.3% male, 59.7% burns, 19.7% trauma and 20.6% others) were evaluated. Mean take rates of BTM and STSG after BTM delamination were 82.7 ± 25.2% and 86.0 ± 22.6%, respectively. Multiple regression analyses showed that higher body mass index (BMI, OR 0.43, 95% CI 0.86, -0.01, p = 0.44), prior allograft transplantation (OR 15.12, 95% CI 26.98, -3.31, p = 0.041), longer trauma-to-BTM-application intervals (OR 0.01, 95% CI 0.001, -0.001, p = 0.038), positive wound swabs before BTM (OR 7.15, 95% CI 13.50, -0.80, p = 0.028) and peripheral artery disease (OR 10.80, 95% CI 18.63, -2.96, p = 0.007) were associated with poorer BTM take. Higher BMI (OR 0.40, 95% CI 0.76, -0.08, p = 0.026), increasing BTM graft surface areas (OR 0.58, 95% CI -1.00, -0.17, p = 0.005), prior allograft (OR 12.20, 95% CI -21.99, -2.41, p = 0.015) or autograft transplantations (OR 22.42, 95% CI 38.69, -6.14, p = 0.001), tumour as the aetiology of the wound (OR 37.42, 95% CI 57.41, -17.83, p = 0.001), diabetes (OR 6.64, 95% CI 12.80, -0.48, p = 0.035) and impaired kidney function (OR 5.90, 95% CI 10.94, -0.86, p = 0.021) were associated with poorer STSG take after delamination of BTM, whereas higher BTM take rates were associated with better STSG take (OR 0.40, 95% CI 0.31,0.50, p < 0.001). CONCLUSION: Extensive complex wounds of different aetiologies unsuitable for immediate STSG can be successfully reconstructed by means of two-staged BTM application and subsequent skin grafting. Importantly, presence of wound contamination or infection and prior allograft coverage appear to jeopardise good BTM and STSG take.

Local flaps of the hand.

Hand injuries are common, and due to the complex functions of the hand, soft tissue defects present a surgical challenge in reconstruction. Hand defects exposing deeper structures warrant reconstruction with local flaps, but in Denmark, reconstruction surgery of the hand is routinely managed within the orthopaedic specialty alone with no plastic surgical involvement. This review aims at describing the most common local flaps of the hand and forearm and encourage to stronger collaboration between hand- and plastic surgeons in Denmark.

Using a Microsurgical Robotic Platform for In-flap Anastomosis in Autologous Bipedicular Breast Reconstruction.

Autologous microsurgical breast reconstruction has become a standard of care. As techniques become more individualized and aim for less-invasive approaches, vessels ever smaller in diameter are considered for flap anastomosis. Robot-assisted surgery has great potential to reduce tremor and enhance precise motion. The Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Del.) is a robotic platform designed for microsurgery. It was used for a microsurgical in-flap anastomosis of a bipedicular deep inferior epigastric artery flap for unilateral breast reconstruction. The procedure included fully robot-assisted anastomoses with significant size mismatches using a 3D-exoscope for magnification. Arterial and venous anastomoses were entirely robot-assisted completed in 23 minutes (seven stitches) and 28 minutes (eight stitches) using 9/0 nylon sutures. The intra- and postoperative course was uneventful. This robotic platform facilitates in-flap anastomoses of small vessels by increasing the precision of instrument handling and eliminating tremor. The combination of robotic platforms and exoscopes provides superior ergonomics in comparison with conventional (super)microsurgery. We expect robotic platforms to play a significant role in modern microsurgical breast reconstruction.

Comparison of Decellularized Human Dermal Scaffolds versus Bovine Collagen/Elastin Matrices for Engineering of Soft-Tissue Flaps.

BACKGROUND: Free flap-based soft-tissue reconstruction comes at the price of donor-site morbidity. The arteriovenous loop (AVL) technique can overcome this issue by allowing for the de novo generation of axially vascularized soft-tissue flaps from vein grafts embedded into different matrices. Application of the AVL technique has been limited by insufficient long-term volume retention and poor tissue stability. The authors investigated the suitability of a novel human dermal scaffold to improve volume retention and tissue stability. METHODS: AVLs were created in 28 immunocompetent rats and embedded in either decellularized human dermal scaffolds (experimental group, n = 14) (Epiflex) or bovine collagen/elastin matrices (control group, n = 14) (MatriDerm) in subcutaneous polytetrafluoroethylene chambers. The weight and volume of engineered tissues, the extent of angiogenesis, and the proportion of proliferating cells were compared between groups on postoperative days (PODs) 21 and 28 by means of immunohistochemistry and micro-computed tomography. RESULTS: On POD 28, both groups displayed homogeneous microvascular networks on histopathology and micro-computed tomography. Mean microvessel counts and surface areas and the percentage of proliferating cells did not differ between the groups. However, the experimental human scaffold group displayed significantly smaller volume loss and significantly less tissue degradation compared with bovine matrix controls (volume retention, 102% ± 5% versus 27% ± 7% on POD 21, and 79% ± 12% versus 12% ± 7% on POD 28, respectively; P < 0.0001). CONCLUSION: Compared with bovine matrices, decellularized human scaffolds allow for superior volume retention and tissue stability of de novo engineered soft-tissue AVL flaps in rats. CLINICAL RELEVANCE STATEMENT: AVLs allow for the de novo generation of vascularized soft-tissue flaps. However, insufficient long-term volume retention is still an issue. The authors' study shows that decellularized human matrices guarantee superior volume stability of de novo grown soft-tissue flaps in rats.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis.

BACKGROUND: A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS: We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS: A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION: At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Migration of nephrostomy tube into right atrium during percutaneous nephrolithotomy: A case report.

INTRODUCTION AND IMPORTANCE: Percutaneous nephrolithotomy (PCNL) is one of the most commonly performed surgeries in urology. Due to blind nature of the procedure unexpected events are inevitable. Misplacement of percutaneous nephrostomy (PCN) during PCNL into the venous system is one of the rarest complications causing great stress to both physician and the patient. Due to scarcity of data, no standard treatment has been proposed. Here, we present a case with misplaced PCN into venous system moving up to the right atrium and discuss its management with a review of the literature. CASE PRESENTATION: After stone removal of a 65-year old man by PCNL, PCN was passed through access sheath supposedly into renal pelvis but it actually misplaced into venous system and traversed into right atrium. The complication was diagnosed by immediate CT scan and managed by PCN pulling back without the need to perform open surgery. CLINICAL DISCUSSION: Blind nature of PCNL makes it susceptible to inadvertent complications. Misplaced PCN into venous system is very rare, happening in about 13 patients worldwide. While some ended up open surgery, all of them were managed by pulling the PCN backwards. Our case is the first case in whom PCN traversed through IVC and reached right atrium during PCNL. Pulling back the PCN was a successful treatment in our case either. CONCLUSION: While horrifying, misplaced PCN into venous system can be managed conservatively by pulling it backwards, even if it reaches the right atrium as happened in our case.

The transverse myocutaneous gracilis flap (TMG) for breast reconstruction: ipsi vs. contralateral harvest-aesthetic outcome and refinement procedures.

BACKGROUND: The TMG flap is a popular choice for breast reconstruction. However, it remains unclear whether the side of flap harvest, subsequent flap shaping and inset impacts breast appearance and volume dispersion. This study compares the aesthetic outcome of the reconstructed breast following TMG flap harvest from the ipsilateral or contralateral thigh. PATIENT AND METHODS: A retrospective matched-pair multi-center study was conducted. Patients were grouped according to the side of flap harvest (ipsilateral vs. contralateral) and matched for age, BMI and mastectomy type. Between 01/2013 and 03/2020, 384 TMG breast reconstructions were performed, of which 86 were included (43 ipsilateral vs. 43 contralateral). Standardized pre- and postoperative photographs were evaluated using a modified assessment scale comprising of a symmetry score (SymS, max. 20 points), a volume discrepancy score (VDS, max. 8 points) and an aesthetic appearance score (AS, max. 10 points). Autologous fat grafting (AFG) procedures for breast refinement were compared. RESULTS: Pleasing breast symmetry (SymS Ipsi: 14.5/20; Contra: 14.9/20), volume (VDS Ipsi: 3.3/8; Contra: 2.4/8) and aesthetic appearance (AS Ipsi: 6.7/10; Contra: 6.7/10) were achieved with both surgical methods. No significant changes were present regarding the VDS (F(1.82) = 2.848, p = 0.095) or the SymS (F(1.82) = 1.031, p = 0.313) pre- to postoperatively. Significantly more autologous fat grafting was done in the contralateral group (p < 0.001). CONCLUSION: The side of the TMG flap harvest, different shaping and inset techniques do not impact the aesthetic breast outcome. Both surgical methods result in pleasing breast symmetry and volume. Secondary procedures are common and should be entailed in the reconstructive strategy.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes.

BACKGROUND: Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates. METHODS: Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05. RESULTS: The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group. CONCLUSIONS: Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

[The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects]. / Die freie kombinierte Musculus latissimus dorsi- und Paraskapular-Lappenplastik zur Rekonstruktion besonders ausgedehnter Weichteildefekte.

OBJECTIVE: Durable and resilient soft tissue reconstruction of vast defects of the extremities or the torso. INDICATIONS: Reconstruction of disproportionately large defects, particularly in cases of simultaneous bone and joint reconstruction. CONTRAINDICATIONS: History of surgery or irradiation of upper back and axilla, impossibility of surgery under lateral positioning; relative contraindications in wheelchair users, hemiplegics, or amputees. SURGICAL TECHNIQUE: General anesthesia and lateral positioning. First, the parascapular flap is harvested, with the initial skin incision made medially in order to identify the medial triangular space and the circumflex scapular artery. Flap raising then proceeds from caudal to cranial. Second, the latissimus dorsi is harvested, with the lateral border being dissected free first, before the thoracodorsal vessels are visualized on its undersurface. Flap raising then proceeds from caudal to cranial. Third, the parascapular flap is advanced through the medial triangular space. If the circumflex scapular and thoracodorsal vessels originate separately from the subscapular axis, an in-flap anastomosis is warranted. Subsequent microvascular anastomoses should be performed outside the zone of injury, typically in an end-to-end fashion of the vein and end-to-side fashion of the artery. POSTOPERATIVE MANAGEMENT: Postoperative anticoagulation with low-molecular-weight heparin under anti-Xa monitoring (semitherapeutic in normal-risk and therapeutic in high-risk cases). Hourly clinical assessment of flap perfusion for 5 consecutive days, followed by stepwise relaxation of immobilization and commencement of dangling procedures in cases of lower extremity reconstruction. RESULTS: Between 2013 and 2018, 74 conjoined latissimus dorsi and parascapular flaps were transplanted to cover vast defects of the lower (n = 66) and upper extremity (n = 8). The mean defect size was 723 ± 482 cm2 and the mean flap size was 635 ± 203 cm2. Eight flaps required in-flap anastomoses for separate vascular origins. There was no case of total flap loss.