Pushing the Limits in Extremity Reconstruction Using Virtual Surgical Planning: A Case Series Study.

SUMMARY: Technology is advancing in benefit to solving complex problems. Preoperative planning is essential in any reconstructive process given the importance of achieving good results. New technologies facilitate the process to anticipate intraoperative findings. Virtual surgical planning has contributed in the evolution of craniomaxillofacial surgery. However, limited reports have been published regarding its usefulness in extremity reconstruction. The aim of this study was to push the limits and evaluate the use of virtual surgical planning with three-dimensional images for reconstruction of complex extremity defects using a free, open-source software. Patient candidates for upper or lower extremity microsurgical reconstruction with multiple defects or defects requiring reconstruction of various tissue components were included. Computed tomography angiography images were analyzed for virtual surgical planning using Horos software (Horos, Annapolis, Md.). Two upper and eight lower extremities were reconstructed with free flaps using virtual surgical planning; six cases had multiple defects, and four cases underwent different tissue components reconstruction. The postoperative period was uneventful, and there was no flap failure. A didactic video of the process and examples of some cases are presented. Virtual surgical planning is a powerful planning method, and the authors propose its use in complex extremity defects reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prevention and Treatment of Posttraumatic Lymphedema by Soft Tissue Reconstruction With Lymphatic Vessels Free Flap: An Observational Study.

BACKGROUND: Extremities soft tissue damage may increase the risk of presenting posttraumatic lymphedema. This type of lymphedema is often ignored in trauma and reconstructive literature. We propose a microsurgical soft tissue reconstruction approach to prevent and/or treat posttraumatic lymphedema. PATIENTS AND METHODS: This is a multicentric retrospective observational study. Primary and secondary end points were to prevent and/or treat posttraumatic lymphedema and to achieve a stable soft tissue coverage, respectively. Patients with posttraumatic lymphedema and functional lymphatic channels in the indocyanine green lymphography, and patients with acute soft tissue trauma with lymphatic damage without lymphedema, either to treat and prevent lymphedema, respectively, were included as candidates for soft tissue reconstruction using a superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV). Patients with no pitting edema, fibrosis, or nonfunctional lymphatics channels were excluded. The inguinal lymphatic anatomy was studied with indocyanine green lymphography for designing and in-setting the flap. RESULTS: Eleven patients underwent to microsurgical reconstruction with SCIP-LV free flap; minimum follow-up was 12 months. There were no flap failures. In the posttraumatic lymphedema group, the mean reduction of excess volume was 63.01%. Quality of life improved 51.85%. No patients in the acute trauma group developed lymphedema after the preventive microsurgical approach. CONCLUSIONS: Soft tissue reconstruction with SCIP-LV free flap is an effective approach to prevent and treat posttraumatic lymphedema.

A New Planning Method to Easily Harvest the Superficial Circumflex Iliac Artery Perforator Flap.

BACKGROUND: The superficial circumflex iliac artery perforator flap (SCIP) is a thin, pliable, and versatile flap used mainly for extremities and head and neck reconstruction. Different planning methods have been described, but these are not yet standardized like in other flaps. The aim of this study is to present a fast, effective, and reliable method for SCIP flap planning using computed tomography angiography (CTA). PATIENTS AND METHODS: Between October 2017 and September 2018, CTA was performed on 40 patients. Preoperative planning of SCIP flaps based on the medial branch was performed analyzing CTA images. The perforating sites of the medial branch on the deep (point D) and superficial fascia (point S) were identified. Distances to those points, from the center of the umbilicus in the "y-axis" and the midline perpendicularly in the "x-axis," were measured. These measurements were transferred to the patient's skin as a guide for dissection. RESULTS: Eighty areas were studied identifying points D and S in CTA. Forty-three SCIP flaps were performed using this planning method. In 100% of the flaps, points D and S matched perfectly with handheld Doppler and surgical findings. CONCLUSION: Points D and S method for medial branch based SCIP planning with CTA is an easy to learn, efficient, fast, and reliable technique for preoperative planning, allowing a safe and predictable elevation of the flap.

Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: A case report.

Post-traumatic lymphedema is poorly understood. It is rarely considered in limb reconstruction decision-making approach. We report a case of a 41-year-old female who presented with right upper extremity lymphedema after degloving injury and split thickness skin graft, successfully treated with a superficial circumflex iliac artery perforator (SCIP) free flap restoring the lymphatic drainage. Right upper extremity had an excess of 258.7 mL or an excess volume of 27.86% compared to the healthy contralateral limb. A SCIP free flap including lymphatic vessels (SCIP-L) was performed to replace the skin graft in order to restore the lymphatic flow. Flap size was 19 × 8 cm and pedicle length was 4 cm. No lymph nodes were included and no lymphatic or lymphovenous anastomoses were performed. The surgery was uneventful, and there were no postoperative complications. Fourteen days after free tissue transfer, lymphedema showed clear improvement. At a 4-month follow-up, 55.6% reduction of excess volume was obtained. Indocyanine green lymphography performed at that time showed a restitution of lymph flow through the flap. Lymphedema improvements persisted at a 6-month follow-up. A successful treatment of post-traumatic lymphedema can be performed by using the SCIP-L free flap for soft tissue reconstruction of critical lymphatic drainage areas.

Augmented Reality Microsurgical Planning with a Smartphone (ARM-PS): A dissection route map in your pocket.

INTRODUCTION: Perioperative microsurgical planning increases the likelihood of successful results. Augmented reality (AR) is the addition of artificial information to allow the user to perform tasks more efficiently. The aim of our study is to report the use of AR for microsurgical planning with a smartphone (ARM-PS) as a dissection route map. PATIENTS AND METHODS: AR was used for superficial circumflex iliac artery perforator (SCIP) flap planning. Three-dimensional (3D) reconstruction images of the inguinal and lower abdomen vascular anatomy were obtained by computed tomography angiography. These 3D images were imported to a smartphone and an AR app was used to superimpose them with the camera. The drawings performed with ARM-PS were correlated with handheld Doppler and intraoperative findings. RESULTS: The correlation of ARM-PS drawings with handheld Doppler results was 100% for superficial inferior epigastric artery (SIEA) and superficial and deep branches of SCIP in 60 inguinal areas studied. Intraoperative findings matched perfectly in all 30 cases with ARM-PS drawings for the location of the mentioned vessels and lymph nodes. Flap harvest time decreased in 20% compared with our traditional timing. CONCLUSIONS: ARM-PS is an easy, noninvasive, and accurate method that provides a dissection route map, thereby standardizing flap harvesting, and shows a perfect correlation with intraoperative findings. It reduces operating time and may improve operative results, thus decreasing donor site morbidity.

Detection of Perforators for Free Flap Planning Using Smartphone Thermal Imaging: A Concordance Study with Computed Tomographic Angiography in 120 Perforators.

Design and preoperative planning of microsurgical flaps are fundamental steps for successful surgery. Currently, computed tomographic angiography is considered the gold standard, and new technologies such as thermography could complement its usefulness. The aim of this study was to determine the concordance between thermographic images obtained with a smartphone thermal camera and computed tomographic angiography for detecting perforators using the anterolateral thigh flap area as a model. A concordance study of diagnostic tests was performed in patients who underwent limb reconstruction in 2016. Perforators identified in thigh computed tomographic angiographic images and hotspots on thermographic images obtained by means of the FLIR ONE smartphone camera were compared based on the distance from the anterior superior iliac spine. The authors studied 20 patients, including 38 anterolateral thigh flap territories in total, and identified 117 perforators by computed tomographic angiography and 120 hotspots by thermography. The average mean distance from the anterior superior iliac spine using these methods was 193.14 mm, and the mean difference in distance was 2.37 mm, with both measurements being obtained within a radius of 20 mm, with a concordance kappa index of 0.975 (p < 0.001). Thermographic imaging presented a sensitivity of 100 percent and a specificity of 98 percent in detecting perforators. Thermographic images obtained with a smartphone thermal camera have a high concordance with the method considered the gold standard for perforator detection. In addition, its sensitivity and specificity are comparable to those of computed tomographic angiography, which makes it a very useful method for mapping perforators in free flap planning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Incidence of lower eyelid asymmetry: an anthropometric analysis of 204 patients.

BACKGROUND: To avoid complications and improve patient satisfaction with lower lid blepharoplasty, a precise assessment of any preoperative eyelid asymmetry is essential. OBJECTIVES: The authors describe a method of assessing preoperative eyelid asymmetry through readily available software and classifying the resulting measurements. METHODS: Digital images of 204 patients were analyzed using Photoshop CS3 Extended software (Adobe Systems, San Jose, California). The left eye was superimposed over the right eye using layers in the software program, and the lower eyelid margin and axis were outlined to obtain a diagram with the superimposed outlines of both eyes. Several measurements (ie, lateral canthal height, lower eyelid margin length and axis angle, and lower palpebral fissure surface area) were obtained for each patient. Differences between the right and left eyelids were recorded, and these data were compared between patients. RESULTS: Of the 204 patients studied, 184 (90.2%) had some degree of asymmetry. Most (118; 64.13%) presented with the right lower eyelid at a more inferior position than the left (R-), while 66 (35.87%) presented with the right lower eyelid at a higher position than the left (R+), a difference that was highly significant (P < .001). CONCLUSIONS: This software is a powerful and precise tool to evaluate and measure eyelid asymmetries. The use of this method showed a large degree of eyelid asymmetry preoperatively (more than 90%), which proves the importance of detecting and adequately analyzing this condition prior to surgery. The authors' simple method may be an important adjunct to obtaining optimal results in patients who seek eyelid surgery.