Journal Of Reconstructive Microsurgery[JOURNAL]
Sun
200 papers
One Size Does Not Fit All: Prediction of Nerve Length in Implant-based Nipple-Areola Complex Neurotization.
Zhang C, Moroni EA, Moreira AA
J Reconstr Microsurg · 2025 Sep · PMID 39612943 · Publisher ↗
Breast reconstruction with sensory restoration is gaining recognition as an important goal. Successful reinnervation has been shown in autologous reconstruction but not widely studied in implant-based reconstruction (IBR...
Breast reconstruction with sensory restoration is gaining recognition as an important goal. Successful reinnervation has been shown in autologous reconstruction but not widely studied in implant-based reconstruction (IBR). This article describes our technique for nipple-areola complex (NAC) neurotization to predict maximal nerve length. We also propose a novel equation that can be utilized preoperatively to estimate the total nerve length required for NAC neurotization.This is a retrospective study of patients who underwent nerve reconstruction with IBR between April 2021 and May 2022. An equation based on the arc length of a circle was utilized to predict the total nerve length required. Postoperative assessment of sensation was performed at 3, 6, and 12 months using Semmes-Weinstein monofilament testing in all four breast quadrants and the NAC. Patients completed the Breast-Q Sensation Module preoperatively and at 3, 6, and 12 months.NAC neurotization was performed in 58 patients undergoing IBR. The average length of intercostal nerve (ICN) harvested was 5.3 cm for staged reconstructions and 5.6 cm for direct-to-implant reconstruction. The average total nerve length (allograft + mobilized ICN) was 12.3 cm. On average, 6.9 cm of nerve allograft was used. The mean difference between total nerve length and predicted nerve length was 0.47 cm (range -3.5 to 4.6 cm). There was a significant improvement in sensory monofilament values measured in all four breast quadrants and the NAC between 3 to 6 and 6 to 12 months postoperatively.A thorough understanding of sensory anatomy and precise surgical techniques are essential to perform NAC neurotization successfully. Our early results suggest the positive impact of breast sensation on patient quality of life.
Sociodemographic Status Impacts Ambulatory Outcomes in Lower Extremity Flap Reconstruction.
Stanton EW, Manasyan A, Roohani I … +3 more , Wolfe E, Daar DA, Carey JN
J Reconstr Microsurg · 2025 Oct · PMID 39608765 · Publisher ↗
There is a lack of literature regarding the effects of language barriers, socioeconomic status, racial disparities, and travel distance to the hospital on the outcomes of lower extremity (LE) flap reconstruction. Consequ...
There is a lack of literature regarding the effects of language barriers, socioeconomic status, racial disparities, and travel distance to the hospital on the outcomes of lower extremity (LE) flap reconstruction. Consequently, this study assesses the potential influence of these factors on ambulation within this specific patient demographic.A retrospective review was performed between 2007 and 2022 of patients who underwent LE reconstruction with tissue flap placement at a single institution. The primary outcome was ambulation status, with cohorts compared between those who were ambulatory versus nonambulatory. Covariates included race, age, gender, primary language, distance from patient home to hospital, socioeconomic status (determined using area deprivation index [ADI]), and flap characteristics. Outcomes were assessed with multivariable logistic regression.A total of 242 patients who underwent LE flap reconstruction during the study period. The average time to final ambulatory status was 7.0 months (standard deviation: 11.0), with 51.7% requiring either a wheelchair or assistance device and 48.4% being fully ambulatory at final follow-up. The average state ADI for the cohort was 5.8, with Hispanic patients having significantly higher deprivation indexes (6.3 vs. 5.6, < 0.001). Multiple logistic regression demonstrated that when controlling for numerous covariates, patients in the highest 15th percentile of deprivation were significantly less likely to be fully ambulatory at final follow-up (odds ratio: 0.22, 95% confidence interval: 0.061-0.806, = 0.022).The current study emphasizes the substantial impact of socioeconomic disparities on postoperative outcomes in LE flap reconstruction. The finding that patients in the highest 15th percentile of deprivation were less likely to achieve full ambulation underscores the need to prioritize socioeconomic factors in clinical consideration and highlights a crucial avenue for future research.
Utilizing Perforator Propeller Flaps for Donor Site Closure: Harvesting Large Workhorse Flaps without Lingering Concerns.
Han T, Khavanin N, Zang M … +5 more , Zhu S, Li S, Chen Z, Jin S, Liu Y
J Reconstr Microsurg · 2025 Oct · PMID 39608764 · Publisher ↗
Primary closure of donor sites following large flap harvest may not be feasible. The use of perforator propeller flap (PPF) in this setting is gaining popularity, successfully resurfacing the wound and lessening potentia...
Primary closure of donor sites following large flap harvest may not be feasible. The use of perforator propeller flap (PPF) in this setting is gaining popularity, successfully resurfacing the wound and lessening potential donor-site morbidity. In this study, we aimed to review our experience and outcomes using PPFs in donor-site coverage throughout the body.A retrospective chart review was performed of all patients who underwent one or more PPFs surgery for donor site resurfacing between February 2009 and December 2021. Flap and defect characteristics were summarized. Postoperative complications and perioperative factors were analyzed.Fifty-five patients underwent donor-site reconstruction using 68 PPFs. Of the 55 primary donor sites, 44 were covered with a single PPF, 9 with two PPFs, and 2 with three PPFs. One flap experienced complete necrosis and four flaps experienced distal flap necrosis, leading to an overall complication rate of 9.1%. No risk factors were found to be statistically significantly associated with the complication. All secondary PPF donor sites were closed primarily. During the average follow-up period of 15.1 months, none of the patients developed contour deformities or functional impairments.The PPF technique can be safely and effectively used for donor-site closure with minimal complications. It greatly frees surgeons to harvest a large workhorse flap for demanding soft tissue defect reconstruction.
Oncoplastic Surgery with Volume Replacement versus Mastectomy with Implant-Based Breast Reconstruction: Early Postoperative Complications in Patients with Breast Cancer.
Ku GC, Desai A, Singhal M … +7 more , Mallouh M, King C, Rojas AN, Persing S, Homsy C, Chatterjee A, Nardello S
J Reconstr Microsurg · 2025 Oct · PMID 39608763 · Publisher ↗
Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with...
Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-day postoperative complications between these two techniques.We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications.A cohort of 8,403 breast cancer patients was analyzed. A total of 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years ( < 0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, < 0.001), exhibited a higher body mass index (31.73 vs. 26.93, < 0.001), had a greater prevalence of diabetes mellitus (11.0 vs. 5.0%, < 0.001). They also had a higher ASA classification (2.33 vs. 2.15, < 0.001), shorter operative time (173.39 vs. 216.20 minutes, < 0.001), and a higher proportion of outpatient procedures (83.7 vs. 39.5%, < 0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients (4.2 vs. 10.9%, < 0.001), including lower rates of surgical complications (2.2 vs. 8.0%, < 0.001) and wound complications (1.9 vs. 4.8%, = 0.005) compared with MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications.OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared with MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.
The Vascular Anatomy and Harvesting of the Lateral Femoral Condyle Flap in Pigs.
Zuo Y, Xiao S, Zhou X … +1 more , Yi L
J Reconstr Microsurg · 2025 Oct · PMID 39587045 · Publisher ↗
Clinically, there has been increasing employment of the lateral femoral condyle flap. The objective of this study was to explore the vascular anatomy of the lateral femoral condyle in pigs and to explore the feasibility...
Clinically, there has been increasing employment of the lateral femoral condyle flap. The objective of this study was to explore the vascular anatomy of the lateral femoral condyle in pigs and to explore the feasibility of using pigs as an animal model of the lateral femoral condyle flap.A total of 20 fresh cadaveric hindlimbs of 4-week-old hybrid pigs were used in this study. The origination, course, and branches of the nourishing vessels of the lateral femoral condyle were observed in 15 specimens. The primary parameters included the variability in the anatomy of the vessels and the length and outer diameter of the vessels. Surgical procedures for the lateral femoral condyle flap were conducted on five specimens.The primary nourishing arteries of the lateral femoral condyle in pigs were the first superolateral geniculate artery, which was observed in all 15 specimens and had a diameter and length of 1.99 ± 0.44 mm and 2.27 ± 0.46 cm, respectively, as measured at their origination. The operation was performed in the lateral position. A 10-cm skin incision was made from the lower edge of the patella to the posterior lateral side of the distal femur. After blunt dissection of the intermuscular septum between the biceps femoris and vastus lateralis, the whole course of the first superolateral geniculate artery was exposed.The vascular anatomy of the lateral femoral condyle in pigs and that of humans exhibited great similarities. The harvesting of the lateral femoral condyle flap in pigs was as easy as that in humans. Pigs could serve as a suitable animal model for the lateral femoral condyle flap.
Deep Inferior Epigastric Perforator Flap with Implant Placement has a Favorable Complication Profile Compared with Implant-Only or Flap-Only Reconstruction.
Wang C, Roy N, Montalmant KE … +7 more , Shamamian P, Seyidova N, Oleru O, Graziano F, Jacobs JMS, Sbitany H, Henderson PW
J Reconstr Microsurg · 2025 Sep · PMID 39587044 · Publisher ↗
Hybrid deep inferior epigastric perforator (DIEP) flap and simultaneous silicone implant breast reconstruction procedures ("DIEP + I") have many conceptual advantages compared with either reconstruction method alone, but...
Hybrid deep inferior epigastric perforator (DIEP) flap and simultaneous silicone implant breast reconstruction procedures ("DIEP + I") have many conceptual advantages compared with either reconstruction method alone, but the outcomes of DIEP + I reconstruction have not yet been well studied. Therefore, the purpose of this study was to compare the outcomes of DIEP + I with implant-only and DIEP-only reconstruction.A retrospective review was conducted of patients undergoing DIEP + I, implant-only, and DIEP-only breast reconstruction from 2019 to 2023 at a single institution. Demographics and complication rates were compared between groups.A total of 145 patients were included in the DIEP + I ( = 26), implant-only ( = 59), and DIEP-only ( = 60) groups. The DIEP + I group had a lower overall complication rate than implant-only reconstruction (18.4 vs. 41.1%, = 0.014), which was primarily due to the lower incidence of infections in the DIEP + I group (2.6 vs. 22.2%, = 0.006). Accordingly, DIEP + I reconstruction decreased the odds of infection by 90% (OR = 0.095, = 0.024) compared with implant-only reconstruction. The DIEP + I group had similar rates of wound healing and implant-related complications compared with the implant-only and DIEP-only groups, and no patients in the DIEP + I group experienced flap loss.DIEP + I breast reconstruction had a lower rate of infectious complications than implant-only reconstruction, and no higher rate of flap compromise or wound healing complications. This technique could be considered as a means of minimizing infection risk in patients with other risk factors who are seeking implant-based reconstruction, and of enhancing breast projection in patients who are seeking DIEP flap reconstruction.
The Impact of Perioperative Blood Transfusion on Flap Survival: A Single-Center Review of Limb Salvage in the Trauma Setting.
O'Brien D, Pekcan A, Stanton E … +5 more , Roohani I, Zachary P, Parikh N, Daar DA, Carey JN
J Reconstr Microsurg · 2025 Sep · PMID 39587043 · Publisher ↗
Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the oppo...
Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction.A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007 and October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis.In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf - ) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf + ). Overall flap survival rates were similar across both cohorts (Tf + : 92.9 vs. Tf - : 96.6%, = 0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9 vs. 2.0.%, < 0.001), amputation (6.0 vs. 0.7%, = 0.015), and postoperative hardware infection (10.6 vs. 2.7%, = 0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis ( = 0.033).Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.
Microsurgeon Development, Attrition, and Hope for the Future: A Qualitative Analysis.
Mauch JT, Byrnes YM, Kotian AA … +3 more , Catzen HZ, Byrnes ME, Myers PL
J Reconstr Microsurg · 2025 Oct · PMID 39587042 · Publisher ↗
The field of microsurgery continues to grow, yet barriers to practice still exist. This qualitative study aims to elucidate factors both strengthening and threatening this subspecialty through structured interviews with...
The field of microsurgery continues to grow, yet barriers to practice still exist. This qualitative study aims to elucidate factors both strengthening and threatening this subspecialty through structured interviews with fellowship-trained microsurgeons.An interview guide was designed, and structured interviews were conducted with practicing fellowship-trained microsurgeon members of the American Society of Reconstructive Microsurgeons between August 2021 and May 2022. Three independent reviewers transcribed, content-coded, and thematically analyzed the interviews. Themes and subthemes were discussed and finalized.Twenty-one practicing microsurgeons were interviewed, hailing from all four Census geographical regions of the United States. The most common practice model was academic (43%, = 9). Five overarching themes emerged: a passion for microsurgery, training and mentorship, practical considerations, team support, and hope for the future. Microsurgeons reported early exposure to microsurgery as catalyzing their passion, whereas a strong training foundation and lifelong mentors sustained it. Practical challenges arose when establishing and maintaining a microsurgery practice, such as poor reimbursement and unfavorable referral patterns. Team support from staff and other microsurgeons (e.g., a co-surgeon model) was crucial to success. Finally, microsurgeons hoped that future advances would expand access to microsurgical reconstruction for patients and plastic surgeons.This unique, qualitative description of the current landscape of microsurgery revealed that though practical barriers exist, team-based models can alleviate some difficulties. Future advances that increase accessibility may further strengthen this unique and versatile field.
Free Fasciocutaneous versus Muscle Flaps in Lower Extremity Reconstruction: Implications for Functionality and Quality of Life.
List EB, Hahn BA, Qiu SS … +6 more , de Jong T, Rakhorst HA, Verheul EM, Maarse W, Coert JH, Krijgh DD
J Reconstr Microsurg · 2025 Oct · PMID 39587041 · Full text
Free tissue transplantations are commonly used to treat complex lower extremity defects caused by trauma, vascular disease, or malignancy, particularly when vital structures are exposed. This study aimed to expand the kn...
Free tissue transplantations are commonly used to treat complex lower extremity defects caused by trauma, vascular disease, or malignancy, particularly when vital structures are exposed. This study aimed to expand the knowledge on patient-reported outcomes by comparing fasciocutaneous and muscle flaps, with the goal of facilitating patient counseling. Additionally, patient-level risk factors associated with decreased functioning and health-related quality of life were identified.This retrospective, cross-sectional, multicenter study included patients who underwent microsurgical lower extremity reconstruction using free fasciocutaneous or muscle flaps between 2003 and 2021, with a minimum follow-up of 12 months. Data were collected from medical records, pain scores, Short-Form 36 (SF-36), and Lower Extremity Functional Scale (LEFS). Mean scores were compared between flap types and predictors of LEFS, SF-36 mental component summary (MCS), and SF-36 physical component summary (PCS) scores were determined using a backward stepwise regression model.Of the 206 patients eligible, 100 (49%) were included in the retrospective part. A total of 89 (43%) responded to the questionnaires, with 62 treated using a fasciocutaneous flap and 27 with a muscle flap. No significant differences in total LEFS, SF-36 PCS, or MCS scores were found between the two flap type. Pain was a significant predictor of decreased functional outcomes for both flap types and was also linked to poorer mental health in patients treated with fasciocutaneous flaps. Other predictors of low patient-reported outcome scores included obesity, diabetes, poorer mental health, and a follow-up of less than 2 years.Patients treated with fasciocutaneous and muscle flaps experience comparable levels of functionality and quality of life after surgery. Flap selection should be based on defect characteristics, along with the surgeon's individual skills and preferences. A comprehensive approach that considers physical comorbidities, pain, and mental health is essential, as these factors significantly impact patient functionality and quality of life.
Efficacy and Safety of Subcutaneous Unfractionated Heparin Administered Every 8 hours for Venous Thromboembolism Prophylaxis in Reconstructive Head and Neck Tumor Patients: A Systematic Review and 6-Year Institutional Case Series.
Cevik J, Newland DP, Cheong E … +2 more , Cabalag M, Ramakrishnan A
J Reconstr Microsurg · 2025 Sep · PMID 39587040 · Publisher ↗
Patients with head and neck tumors undergoing free flap reconstructions are at high risk of postoperative venous thromboembolism (VTE). To date, no specific guidelines are available regarding VTE prophylaxis in this pati...
Patients with head and neck tumors undergoing free flap reconstructions are at high risk of postoperative venous thromboembolism (VTE). To date, no specific guidelines are available regarding VTE prophylaxis in this patient group. This study aims to contribute to this scarcity of information by reviewing the literature regarding anticoagulation regimens in this patient group and evaluating the efficacy and safety of postoperative subcutaneous heparin dosed at 5,000 units every 8 hours routinely utilized at our institution.PubMed and Embase databases were searched from inception until November 2023. Data were collected and levels of evidence were evaluated according to the Oxford Centre for Evidence Based Medicine guidelines. Additionally, a retrospective review of all patients with head and neck tumors undergoing free tissue transfer at our institution between 2015 and 2021 was performed. Patients were restricted to those receiving 5,000 units of subcutaneous heparin every 8 hours postoperatively. Key outcomes included rates of VTE and surgical site hematoma.This systematic review found 15 studies eligible for inclusion ranging from 1998 to 2023. Anticoagulation regimens were markedly heterogenous. Among the literature, VTE rates reported ranged from 0 to 9.6% and bleeding rates ranged between 3.5 and 29%. Our 6-year institutional analysis revealed 393 total patients. Overall, three episodes of VTE were identified (0.76%) consisting of one deep vein thrombosis and two pulmonary emboli. The overall rate of hematoma was 9.4% with a higher rate of hematoma at the recipient site (8.1%) than the donor site (1.3%).When compared with the existing literature this study found a low rate of VTE and a comparable incidence postoperative hematoma. This suggests that 5,000 units of subcutaneous heparin given every 8 hours may be a safe and effective postoperative anticoagulation regimen for these patients.
Antithrombotic Agents after Free Tissue Transfer in the Pediatric and Adolescent Population.
Weiss JBW, Kollár B, Eisenhardt SU
J Reconstr Microsurg · 2025 Sep · PMID 39496320 · Publisher ↗
Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric...
Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear.We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study.Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3, 21.9, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). A total of 58.9% of the population received postoperative antithrombotic agents. The rate of flap revision surgery was similar (11.6 and 10.0%, respectively), with and without antithrombotic treatment ( > 0.05). There were no major bleeding complications or deep vein thrombosis.The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.
Unplanned 180-day Readmissions and Health Care Utilization after Immediate Breast Reconstruction for Breast Cancer.
Rios-Diaz AJ, Habarth-Morales TE, Isch EL … +6 more , Amro C, Davis HD, Broach RB, Jenkins M, Fischer JP, Serletti JM
J Reconstr Microsurg · 2025 Sep · PMID 39496319 · Publisher ↗
To assess the burden of postdischarge health care utilization given by readmissions beyond 30 days following immediate breast reconstruction (IBR) nationwide.Women with breast cancer who underwent mastectomy and concurre...
To assess the burden of postdischarge health care utilization given by readmissions beyond 30 days following immediate breast reconstruction (IBR) nationwide.Women with breast cancer who underwent mastectomy and concurrent IBR (autologous and implant-based) were identified within the 2010 to 2019 Nationwide Readmission Database. Cox proportional hazards and generalized linear regression controlling for patient- and hospital-level confounders were used to determine factors associated with 180-day unplanned readmissions and incremental hospital costs, respectively.Within 180 days, 10.7% of 100,942 women were readmitted following IBR. Readmissions tended to be publicly insured (30.8 vs. 21.7%, < 0.001) and multimorbid (Elixhauser Comorbidity Index > 2 31.6 vs. 19.6%, < 0.001) compared with nonreadmitted patients. There were no differences in readmission rates among types of IBR (tissue expander 11.2%, implant 10.7%, autologous 10.8%; > 0.69). Of all readmissions, 40% occurred within 30 days and 21.7% in a different hospital and 40% required a major procedure in the operating room. Infection was the leading cause of readmissions (29.8%). In risk-adjusted analyses, patients with carcinoma in situ, publicly insured, low socioeconomic status, and higher comorbidity burden were associated with increased readmissions (all < 0.05). Readmissions resulted in additional $8,971.78 (95% confidence interval: $8,537.72-9,405.84, < 0.001) in hospital costs, which accounted for 15% of the total cost of IBR nationwide.The majority of inpatient health care utilization given by readmissions following mastectomy and IBR occurs beyond the 30-day benchmark. There is evidence of fragmentation of care as a quarter of readmissions occur in a different hospital and over one-third require major procedures. Mitigating postoperative infectious complications could result in the highest reduction of readmissions.
Impact of Insurance Status on Postoperative Recovery after Microsurgical Breast Reconstruction.
Lu YH, Rothchild E, Yan Y … +3 more , Mahajan L, Park M, Ricci JA
J Reconstr Microsurg · 2025 Sep · PMID 39496318 · Publisher ↗
Persistent disparities in breast reconstruction access have been widely documented, yet a significant research gap remains in understanding the impact of social determinants of health (SDOH) on postoperative outcomes and...
Persistent disparities in breast reconstruction access have been widely documented, yet a significant research gap remains in understanding the impact of social determinants of health (SDOH) on postoperative outcomes and complications.A retrospective chart review was performed on all patients who underwent abdominal-based free-flap breast reconstruction between August 2018 and December 2022 at a racially, ethnically, and socioeconomically diverse urban academic institute with a historically underserved patient population. Patients were stratified by the public (Medicare and Medicaid) versus private insurance as a proxy for SDOH. Patient demographics, length of stay (LOS), timing in progression through postoperative recovery milestones, and complications were compared.A total of 162 patients were included, and 57% of patients had public insurance, with this group more likely to be Hispanic (odds ratio [OR] 2.7; = 0.003) and Spanish-speaking (OR 3.4; = 0.003). Privately insured patients were more likely to be non-Hispanic Black (OR 2.7; = 0.006). Patients with public insurance had a higher rate of unplanned return to the operating room within 90 days and a higher incidence of complications, though not statistically significant. They also experienced a significantly longer LOS than privately insured patients (3.6 ± 1.0 vs. 3.0 ± 0.7 days; < 0.0001). Logistic regression identified an LOS exceeding 3 days as independently associated with public insurance status (OR 3.0; = 0.03), bilateral procedure (OR 5.6; = 0.0007), preoperative functional-dependent status (OR 7.0; = 0.04), and higher body mass index (BMI; OR 1.1; = 0.03). Patients with public insurance were more likely to encounter delays in achieving recovery milestones.Public insurance status, serving as a proxy for a disadvantage in SDOH, is predictive of extended LOS and postoperative recovery delays following microsurgical breast reconstruction. This underscores the need for future quality improvement efforts to address and mitigate these disparities.
Effects of Neoadjuvant Radiation and Recipient Vessel Characteristics on Microvascular Complication Rates in Reconstruction of Lower Extremity Soft Tissue Sarcoma Defects.
Farmer RL, Easton J, Sanchez R … +2 more , Emanuelli E, Mah E
J Reconstr Microsurg · 2025 Sep · PMID 39496317 · Publisher ↗
The treatment approach for soft tissue sarcomas (STS) of the lower extremity has shifted toward the use of neoadjuvant radiation combined with limb-sparing surgery (LSS). The resulting defects often require reconstructio...
The treatment approach for soft tissue sarcomas (STS) of the lower extremity has shifted toward the use of neoadjuvant radiation combined with limb-sparing surgery (LSS). The resulting defects often require reconstruction with free tissue transfer for adequate outcomes. Data have demonstrated a potentially increased risk of microvascular complications for free flaps performed using irradiated recipient vessels. Similarly, certain anatomic areas of the lower extremity have a high proportion of unnamed perforators that are available as recipient vessels, increasing the technical difficulty. We aimed to determine if the characteristics of recipient vessels that were used for the reconstruction of STS defects influenced rates of microvascular complications in our patients.A retrospective chart review of all patients who underwent reconstruction of lower extremity STS defects with free tissue transfer from 2009 to 2020 was conducted. Data regarding recipient vessel type (axial vessel vs. unnamed perforator), radiation status of the recipient vessels (irradiated vs. non-irradiated), and microvascular complications were compared across groups.A total of 204 free flaps were included. The overall microvascular complication rate was 13.7% (28 cases). Most microvascular complications were detected postoperatively (82.1%) rather than intraoperatively, with the majority involving venous congestion/thrombosis (20 cases, 71.4%). While there was a trend toward increased microvascular complications with the use of irradiated recipient vessels (27 cases, 96.4%), this did not reach statistical significance (OR = 1.98, = 0.52). The use of perforating branches as recipient vessels did not confer an increased risk of microvascular complications (OR = 0.87, = 0.75).The reconstruction of irradiated lower-extremity STS defects represents a particularly challenging issue. This analysis demonstrates that free tissue transfer can be safely performed using irradiated vessels without a significantly increased risk of microvascular complications. Furthermore, unnamed perforating branches can be successfully used for reconstruction in anatomically challenging areas of the lower extremity.
Evaluation of Modified Frailty Index for Predicting Postoperative Outcomes after Upper Extremity Replantation and Revascularization Procedures.
Desai A, Luo A, Borowsky PA … +4 more , Bustos VP, Fullerton N, Xu KY, Tadisina KK
J Reconstr Microsurg · 2025 Sep · PMID 39496316 · Publisher ↗
Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid cond...
Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures.A retrospective study was done using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0-5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories.Of 2,305 patients, the mean age and body mass index (BMI) were 53.13 years and 28.53 kg/m, respectively. The 5-mFI ≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant.5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI ≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions.
Further Validating the Robotic Microsurgery Platform through Preclinical Studies on Rat Femoral Artery and Vein.
Cho J, Kim D, Kim T … +3 more , Pak CJ, Suh HP, Hong JP
J Reconstr Microsurg · 2025 Sep · PMID 39496315 · Full text
This research aims to validate the proficiency and accuracy of the robotic microsurgery platform using rat femoral vessel model.A total of 256 rat femoral vessels were performed, half using robotic and the other by manua...
This research aims to validate the proficiency and accuracy of the robotic microsurgery platform using rat femoral vessel model.A total of 256 rat femoral vessels were performed, half using robotic and the other by manual microanastomosis by eight microsurgeons with less than 5 years of experience given eight trials (rats) each. Vessel demographics, proficiency (duration of suture and Structured Assessment of Robotic Microsurgical Skills [SARMS]), and accuracy (patency and scanning electron microscopic [SEM]) were analyzed between the two groups.Using the robot, an average of four trials was needed to reach a plateau in total anastomosis time and patency. Significant more time was required for each vessel anastomosis (34.33 vs. 21.63 minutes on the eighth trial, < 0.001) one factor being a higher number of sutures compared with the handsewn group (artery: 7.86 ± 0.51 vs. 5.86 ± 0.67, = 0.035, vein: 12.63 ± 0.49 vs. 9.57 ± 0.99, = 0.055). The SARMS scores became nonsignificant between the two groups on the fourth trial. The SEM showed a higher tendency of unevenly spaced sutures, infolding, and tears in the vessel wall for the handsewn group.Using the robot, similar patency, accuracy, and proficiency can be reached through a fast but steep learning process within four trials (anastomosis of eight vessels) as the handsewn group. The robotic anastomosis may take longer time, but this is due to the increased number of sutures reflecting higher precision and accuracy. Further insight of precision and accuracy was found through the SEM demonstrating the possibility of the robot to prevent unexpected and unwanted complications.
Surgical Complications after Targeted Muscle Reinnervation at a Safety-Net Hospital.
Obinero CG, Green JC, Swiekatowski KR … +6 more , Obinero CV, Manisundaram A, Greives MR, Bhadkamkar M, Wu-Fienberg Y, Marques E
J Reconstr Microsurg · 2025 Jul · PMID 39374923 · Publisher ↗
BACKGROUND: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) can reduce neuroma formation and phantom limb pain (PLP) after lower extremity (LE) amputation. These techniques have no...
BACKGROUND: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) can reduce neuroma formation and phantom limb pain (PLP) after lower extremity (LE) amputation. These techniques have not been studied in safety-net hospitals. This study aims to examine the surgical complication rates after TMR and/or RPNI at an academic safety-net hospital in an urban setting. METHODS: This was a retrospective review of patients older than 18 years who had prior above-knee guillotine amputation (AKA) or below-knee guillotine amputation (BKA) and underwent stump formalization with TMR and/or RPNI from 2020 to 2022. Demographics, medical history, and operative and postoperative characteristics were collected. The primary outcome was any surgical complication, defined as infection, dehiscence, hematoma, neuroma, or reoperation. Univariate analysis was conducted to identify variables associated with surgical complications and PLP. RESULTS: Thirty-two patients met the inclusion criteria. The median age was 52 years, and 75% were males. Indications for amputation included diabetic foot infection (71.9%), necrotizing soft tissue infection (25.0%), and malignancy (3.1%). BKA was the most common indication for formalization (93.8%). Most patients (56.3%) had formalization with TMR and RPNI, 34.4% patients had TMR only, and 9.4% had RPNI alone. The incidence of postoperative complications was 46.9%, with infection being the most common (31.3%). The median follow-up time was 107.5 days. There was no significant difference in demographics, medical history, or operative characteristics between patients who did and did not have surgical complications. However, there was a trend toward higher rates of PLP in patients who had a postoperative wound infection ( = 0.06). CONCLUSION: Overall complication rates after LE formalization with TMR and/or RPNI at our academic safety-net hospital were consistent with reported literature. Given the benefits, including reduced chronic pain and lower health care costs, we advocate for the wider adoption of these techniques at other safety-net hospitals.
On a Hunt for the "True" Septocutaneous Perforator: A Histology Cross-Section Study.
Kubat M, Dvorak Z, Zoufaly D … +3 more , Hermanova M, Joukal M, Hallock GG
J Reconstr Microsurg · 2025 Jul · PMID 39374922 · Publisher ↗
BACKGROUND: Modern trends in reconstructive surgery involve the use of free perforator flaps to reduce the donor site morbidity. The course of perforator vessels has a great anatomic variability and demands detailed kno...
BACKGROUND: Modern trends in reconstructive surgery involve the use of free perforator flaps to reduce the donor site morbidity. The course of perforator vessels has a great anatomic variability and demands detailed knowledge of the anatomical relationships and the variability of the course of the perforators. The numerous modifications to perforator nomenclature proposed by various authors resulted in confusion rather than simplification. In our study, we focused on the hypothesis that a septocutaneous perforator traverses from the given source vessel to the deep fascia adherent to but not to within the septum itself. METHODS: Sixty-nine septocutaneous perforators from three different limb donor sites (lateral arm flap, anterolateral thigh flap, and radial forearm free flap) were collected from the gross pathology specimens of 14 fresh cadavers. The gross picture and the cross-sections with the histological cross-sections on different levels were examined to determine the position of the vessel to the septal tissue. RESULTS: Of the observed 69 septal perforators, 61 (88.5%) perforators were adherent to but not within the septum. The remaining eight (12.5%) perforators passed through the septum. All these eight perforators were found in multiple different cross-section levels (2 of 19 in lateral arm flap, 3 of 27 in anterolateral thigh flap, and 3 of 23 in radial forearm free flap). CONCLUSION: Although septocutaneous vessels appear identical macroscopically, microscopically two types of vessels with paraseptal and intraseptal pathways are observed. The majority of these vessels are merely adherent to the septum having a paraseptal pathway, while a minority are within the septum and are "true" septocutaneous perforators. It is advisable to dissect with a piece of the septum in order to avoid damage or injury to the perforator.
A Systematic Review of the Complications Associated with Free Fibular Flaps in Adult and Pediatric Spinal Reconstruction.
Zhu KJ, Cho AM, Beckett JS … +6 more , Macyszyn L, Mathes D, Nguyen P, Irwin T, Kaouzanis C, Yu JW
J Reconstr Microsurg · 2025 Jul · PMID 39362646 · Publisher ↗
BACKGROUND: Free fibular flaps have been suggested as a modality of reconstruction for complex spinal deformities. However, there is limited data that describes associated postoperative outcomes. The purpose of this sys...
BACKGROUND: Free fibular flaps have been suggested as a modality of reconstruction for complex spinal deformities. However, there is limited data that describes associated postoperative outcomes. The purpose of this systematic review was to characterize outcomes after spinal reconstruction using the free fibular flap for both adults and children. METHODS: Thirty-nine articles among four databases were identified as having met inclusion criteria. Patient demographics, indications for spinal reconstruction as well as location and anastomosis, history of chemotherapy and radiation therapy, and postoperative outcomes including complications were identified. Major complications were defined as complications requiring reoperation, while minor complications were those that did not require reoperation. Systemic complications were defined as complications affecting sites or organ systems beyond the local donor and recipient sites. Statistical analysis was performed using Fischer's exact, chi-squared, and -tests. RESULTS: We identified 218 adult patients (mean age 47.7 years, 56.4% male) and 27 pediatric patients (mean age 12.7 years, 55.6% male). While there was no significant difference in the rates of bony union between the two groups (adults: 90.8%, children: 90%, > 0.9), adults had significantly higher rates of major (27% vs. 7.4%, = 0.026), minor (26.1% vs. 7.4%, = 0.032), and systemic (14.2% vs. 0%, = 0.047) complications. CONCLUSION: Free fibular flaps are effective for spinal reconstruction for both adults and children, as evidenced by the high rates of bony union. However, adults exhibited significantly higher complication rates. Further research is required to better understand the patient and clinical risk factors associated with increased rate of complications.
When Bell's Palsy Is Cancer: Avoiding Misdiagnosis and Its Implications.
Wen YE, Rail B, Sanchez CV … +2 more , Gorman AR, Rozen SM
J Reconstr Microsurg · 2025 Jul · PMID 39362645 · Publisher ↗
BACKGROUND: Facial paralysis due to cancer can be misdiagnosed as Bell's palsy. This study aims to clearly identify and quantify diagnostic differentiators and further evaluate the prognostic implications of misdiagnosi...
BACKGROUND: Facial paralysis due to cancer can be misdiagnosed as Bell's palsy. This study aims to clearly identify and quantify diagnostic differentiators and further evaluate the prognostic implications of misdiagnosis. METHODS: Adult patients older than 18 years with facial palsy of unknown or cancerous etiology presenting between 2009 and 2023 were reviewed. Patient characteristics, examination findings, and clinical course were compared between facial paralysis patients with cancer misdiagnosed as Bell's palsy (Cancer-Bell's-Palsy group) and patients correctly diagnosed with Bell's palsy (Bell's-Palsy group). Additionally, morbidity and mortality were compared between facial paralysis patients with cancer initially misdiagnosed with Bell's palsy and facial paralysis patients initially correctly diagnosed with cancer (Cancer-Palsy group). RESULTS: Two-hundred and forty-three patients participated including 43 Cancer-Palsy, 18 Cancer-Bell's-Palsy, and 182 Bell's-Palsy patients. Cancer-Bell's-Palsy patients were significantly less likely than Bell's-Palsy patients to develop synkinesis (odds ratio [OR] = 0.0042; 95% confidence interval [CI]: [0.0005-0.0339]; < 0.0001), significantly more likely to experience gradual onset facial paralysis (OR = 1,004.69; 95% CI: [54.40-18,555.77]; < 0.0001), and significantly more likely to have additional nonfacial cranial nerve neuropathies (OR = 49.98; 95% CI: [14.61-170.98]; < 0.0001). Cancer-Bell's-Palsy patients were more likely than Cancer-Palsy patients to have a greater than 6-month period from initial cancer-attributable symptom onset to cancer diagnosis (OR = 47.62; 95% CI: [9.26-250.00]; < 0.001), stage IV cancer (OR: 12.36; 95% CI: 1.49-102.71; = 0.006), and decreased duration of life after cancer diagnosis (median [interquartile range], 40.0 [87.0] vs. 12 [56.3] months, respectively; = 0.025). CONCLUSION: Facial paralysis related to cancer must be differentiated from Bell's palsy, as misdiagnosis leads to delayed intervention and poorer prognosis. Gradual onset facial palsy, multiple cranial nerve neuropathies, lack of synkinesis, and lack of improvement were nearly definitive differentiators for underlying cancer.
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