Journal Of Reconstructive Microsurgery[JOURNAL]
Sun
200 papers
Orthoplastic Limb Salvage Centers: A Survey to Determine Essential Components and Framework for Implementation.
Moussa O, Caragher SP, Raasveld FV … +8 more , Oflazoglu K, Rakhorst H, Crandell D, Stenquist D, Haleem AM, Valerio IL, Tuaño KR, Eberlin KR
J Reconstr Microsurg · 2026 Mar · PMID 41734816 · Publisher ↗
Management of patients with limb-threatening pathology represents a clinical challenge. Orthoplastic limb salvage centers have been developed to streamline care and improve patient outcomes for complex extremity patholog...
Management of patients with limb-threatening pathology represents a clinical challenge. Orthoplastic limb salvage centers have been developed to streamline care and improve patient outcomes for complex extremity pathology. However, no formal criteria exist for the establishment of orthoplastic limb salvage centers. We conducted a survey of orthoplastic limb salvage centers to assess current practice patterns and establish consensus-based criteria for the development of such centers.The American Society of Reconstructive Microsurgery membership was used to survey self-identified members of orthoplastic limb salvage centers in the United States. We evaluated current practices and recommended characteristics for team service structure, outcome tracking, quality systems, and barriers to standard implementation. Consensus rates (%) were calculated for current and recommended practice patterns, demonstrating implementation gaps.Strong consensus exists for four criteria: orthoplastic multidisciplinary teams (100%), high case volume (96%), 24/7 service availability (87%), and standardized outcome tracking (83%). Specialist integration demonstrated strong agreement for vascular surgery, infectious disease, and physiatrists (83% each). Gaps in implementation were identified, including dedicated operation room (OR) time (48% current vs. 65% recommended) and standardized outcome measurement (52% current vs. 65% recommended). Primary barriers to development included lack of standardized outcome reporting (83%), insufficient institutional support (70%), and financial constraints (61%).This study provides a consensus-based framework for the development of orthoplastic limb salvage centers (of excellence). National survey results identify comprehensive multidisciplinary care, outcome metrics tracking, and quality systems as priority areas for standardization. Barriers to collaborative quality initiative development include the lack of universal standards, institutional support, and financial constraints.
Surgical Treatment for Extremity Lymphedema Reduces Frequency of Cellulitis Episodes: A Cohort Study and Meta-Analysis.
Shimbo K, Aoki Y
J Reconstr Microsurg · 2026 Mar · PMID 41730304 · Publisher ↗
Dysfunction of the lymphatic system causes lymphedema, a chronic disease that can lead to cellulitis. However, the optimal treatment modality for preventing cellulitis has not yet been established. This cohort study inve...
Dysfunction of the lymphatic system causes lymphedema, a chronic disease that can lead to cellulitis. However, the optimal treatment modality for preventing cellulitis has not yet been established. This cohort study investigated the outcomes of cellulitis by treatment modality in lymphedema of the extremities. A meta-analysis was conducted to evaluate the change in frequency of cellulitis episodes according to the surgical procedure.This single-center retrospective cohort study included patients with extremity lymphedema who were treated at our department. We performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from 2000 to March 2025 with a primary outcome of change in the frequency of cellulitis episodes before and after treatment. The meta-analysis was conducted using a random-effects model.Our cohort study included 183 patients (nonsurgical treatment: 91; surgical treatment: 92). The change rate in frequency of cellulitis episodes before and after treatment increased by 27.0% in the nonsurgical group but decreased by 85.4% in the surgical group. Thirty-five studies, comprising 2,241 patients, were included in the meta-analysis. The mean reduction rates of cellulitis episodes per year before and after surgery were 84.8, 78.2, 80.6, and 87.6% for lymphaticovenous anastomosis, vascularized lymph node transfer (VLNT), liposuction, and combined surgery, respectively. Compared to before surgery, the number of cellulitis episodes per year was significantly reduced after lymphaticovenous anastomosis, VLNT, liposuction, and combined surgery, with standard mean differences of 0.91 ( = 87%), 1.78 ( = 94%), 0.68 (heterogeneity not calculable), and 1.66 ( = 88%), respectively.The findings of this cohort study showed that surgical treatment was superior to nonsurgical treatment in preventing the development of cellulitis in extremity lymphedema. The meta-analysis results demonstrated that surgical procedures tailored to the severity of lymphedema can significantly reduce the development of cellulitis.
Access to Reconstructive Plastic Surgery and Nerve Procedures in Lower Extremity Amputations.
Shah JK, Najafali D, Lakhlani D … +3 more , Amakiri UO, Nazerali R, Sheckter CC
J Reconstr Microsurg · 2026 Mar · PMID 41730303 · Publisher ↗
Neuroma complicates lower extremity (LE) amputations causing significant morbidity. This study examines the relationship between access to plastic surgery and the likelihood of receiving a neuroma-preventing nerve proced...
Neuroma complicates lower extremity (LE) amputations causing significant morbidity. This study examines the relationship between access to plastic surgery and the likelihood of receiving a neuroma-preventing nerve procedure with LE amputation in the United States.Using the National Inpatient Sample, 2016 to 2021, ICD-10 codes identified encounters undergoing above- or below-knee LE amputation with or without concurrent nerve procedures (targeted muscle reinnervation and regenerative peripheral nerve interface). Plastic surgery volume was determined using ICD-10-PCS codes. Outcomes included population-adjusted LE amputation incidence, odds of concurrent nerve procedures, and their incidence relative to facility plastic surgery volume. Statistical analysis included univariate analysis and multivariate Poisson and logistic regression models.A total of 245,170 weighted encounters underwent LE amputation, of which only 1,525 (0.6%) included concurrent nerve procedures. Population-adjusted LE amputation incidence remained stable throughout the study period ( = 0.159). Higher LE amputation incidence was associated with higher comorbidity burden and Black and Native American race ( ≤ 0.036). Odds of nerve procedures increased with more recent surgery year, younger age, higher income, and Black race ( ≤ 0.044). Nerve procedure incidence at facilities in the highest quartile of plastic surgery volume was significantly higher than that of facilities in the lowest quartile (incidence rate ratio: 21.949; 95% confidence interval: 16.493-29.211; < 0.001).Amidst stable population LE amputation incidence, Black and Native American race increased LE amputation incidence. Higher income and Black race elevated odds of concurrent nerve procedures. Increasing facility plastic surgery volume was associated with increased concurrent nerve procedure incidence in LE amputation.
Systematic Review of Vascularized Lymphatic Vessel Transfer for the Treatment and Prevention of Lymphedema.
Meroni M, Martini F, Scaglioni MF
J Reconstr Microsurg · 2026 Mar · PMID 41730302 · Publisher ↗
Lymphatic surgery has gained increasing attention over the years due to significant advancements and successful outcomes in treating lymphedema and other lymphatic complications. Cornerstone treatments remain lymphovenou...
Lymphatic surgery has gained increasing attention over the years due to significant advancements and successful outcomes in treating lymphedema and other lymphatic complications. Cornerstone treatments remain lymphovenous anastomosis and vascularized lymph node transfer. However, the transfer of lymphatic-rich tissues, known as vascularized lymphatic vessels transfer (VLVT), represents a technically simpler alternative. Once largely overlooked, this has recently gained attention as studies have shown its promising potential.A systematic review of PubMed, Google Scholar, and Scopus was performed using relevant keywords. Only human studies in English were included, excluding case reports. References cited in selected articles were also reviewed. The study aimed to evaluate the effectiveness of VLVT for immediate lymphatic reconstruction (ILR) to prevent lymphatic sequelae and for lymphedema treatment (LT) based on both objective and subjective symptom improvement. Complication rates at donor sites were also assessed. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.After removing duplicates, the literature search identified 213 articles, of which 12 studies, including 182 patients, were deemed eligible. VLVT was used for LT in 59 patients and for ILR in 123 patients. Among patients treated for lymphedema, most showed subjective and objective improvement, statistically significant reductions in circumference, decreased cellulitis incidence, and symptom relief, as reported in questionnaires. However, the evaluation of results varied significantly across studies. No cases of condition worsening were reported. For the ILR cases, when lymph axiality was maintained, the treatment succeeded in all cases.VLVT represents a promising addition to the surgical armamentarium for the surgical treatment and prevention of lymphedema, offering significant potential for physiological lymphatic restoration and improved patient outcomes.
Color Doppler versus Handheld Doppler: Which is More Accurate for Preoperative Mapping of Osteocutaneous Fibula Free Flap Perforators?
Walczak DA, Oprychał J, Żółtaszek A … +6 more , Migacz E, Krakowczyk Ł, Visconti G, Maciejewski A, Szymczyk CA, Bula DM
J Reconstr Microsurg · 2026 Mar · PMID 41707692 · Publisher ↗
Accurate preoperative mapping of skin-paddle perforators is vital for osteocutaneous fibula free flap (FFF) success. While handheld Doppler (HHD) is widely used due to its convenience, its performance compared with color...
Accurate preoperative mapping of skin-paddle perforators is vital for osteocutaneous fibula free flap (FFF) success. While handheld Doppler (HHD) is widely used due to its convenience, its performance compared with color Doppler ultrasound (CDU) in FFF planning remains uncertain.In this prospective study, 50 consecutive patients undergoing FFF reconstruction after head and neck cancer resection were evaluated. Each patient underwent HHD and CDU mapping on the day before surgery. Perforator skin surface location, anatomical type (septocutaneous vs. musculoseptocutaneous), peak systolic velocity, and source vessel (peroneal vs. posterior tibial) were recorded. Mapping marks were concealed between examinations.A total of 185 perforators were confirmed intraoperatively (mean 3.7 per limb). CDU identified 179 candidates, yielding 95% sensitivity, 92% specificity, and 94% accuracy. HHD detected 155 sites, achieving 59% sensitivity, 6% specificity, and 48% accuracy, with significantly more false positives and negatives ( < 0.001). Both overall and dominant perforators clustered in the fourth decile of the lower leg (counting from lateral malleolus to fibular head). Distal regions were dominated by septocutaneous vessels, while musculoseptocutaneous types were more common in proximal regions. Anatomical variants-perforators draining into the posterior tibial instead of the peroneal vessels-occurred in 8% of cases and were identified exclusively by CDU.CDU outperforms HHD for preoperative perforator mapping in osteocutaneous FFF, combining high spatial precision with reliable hemodynamic assessment and variant detection. Incorporation of CDU into routine surgical planning promises to enhance flap design accuracy and minimize intraoperative uncertainty.
Comparison of Surgical Time in TDAP Free Flap Procedures: Right vs. Left Donor Site.
Ha YS, Jung SY, Kim JT … +2 more , Hong SE, Kim YH
J Reconstr Microsurg · 2026 Feb · PMID 41688090 · Publisher ↗
Although free flap reconstruction is well established, the influence of donor site laterality on operative efficiency has not been thoroughly explored. This study evaluated the effect of flap laterality (right vs. left)...
Although free flap reconstruction is well established, the influence of donor site laterality on operative efficiency has not been thoroughly explored. This study evaluated the effect of flap laterality (right vs. left) on operative time in thoracodorsal artery perforator (TDAP) free flap surgery, with a focus on ergonomic implications for right-handed surgeons.A retrospective review was conducted on patients who underwent TDAP free flap reconstruction at a single center. Operative times were compared between left- and right-sided flaps. Clinical variables, flap dimensions, and donor site closure techniques were analyzed. Multivariate regression was performed to assess the independent effect of laterality on operative duration, adjusting for confounders.Left-sided TDAP flaps were associated with significantly longer operative times compared to right-sided flaps ( < 0.01). These cases also involved larger flap dimensions and more frequent use of skin grafts for donor site closure. Multivariate analysis confirmed that left-sided laterality independently predicted increased operative time. All procedures were performed by right-handed surgeons, suggesting that ergonomic factors are a key contributor to these differences. Technical recommendations were proposed to improve efficiency during left-sided harvests.Donor site laterality significantly affects operative time in TDAP free flap reconstruction, likely due to ergonomic disadvantages for right-handed surgeons. Surgeons should consider laterality during preoperative planning and prioritize right-sided flaps when feasible. Incorporating ergonomic strategies into training and technique may enhance surgical efficiency and outcomes.
Systemic Elimination Rather than Redistribution: Segmental Body Water Analysis after Leg Lymphovenous Anastomosis.
Kinjo Y, Yasunaga Y, Kondoh S … +3 more , Kondoh S, Umeda M, Yuzuriha S
J Reconstr Microsurg · 2026 Feb · PMID 41651005 · Publisher ↗
Lymphovenous anastomosis (LVA) is a microsurgical procedure that redirects stagnant lymph flow into the venous circulation, reducing fluid stasis in patients with secondary limb lymphedema. Although previous studies have...
Lymphovenous anastomosis (LVA) is a microsurgical procedure that redirects stagnant lymph flow into the venous circulation, reducing fluid stasis in patients with secondary limb lymphedema. Although previous studies have reported that complex decongestive therapy redistributes fluid from the affected leg to other body segments, whether fluid reduction after LVA results from systemic elimination or intersegmental redistribution remains unclear. This study aimed to clarify the mechanism by analyzing the changes in segmental body water (SBW) volume using bioelectrical impedance analysis (BIA).We retrospectively analyzed the data of 40 Japanese women with unilateral stage II secondary leg lymphedema who underwent LVA from 2013 to 2021. Multifrequency segmental BIA was used to assess extracellular water, intracellular water, and SBW in the legs, trunk, and arms. Measurements were performed preoperatively and at least 12 months postoperatively. Changes in segmental and total body water (TBW) were statistically evaluated.Significant reductions were observed in SBW in the affected leg, and in the TBW (affected leg: 5.80-5.20 L, < 0.001; TBW: 25.6-25.0 L, = 0.002), with no significant changes in the unaffected leg, trunk, or arms. Extracellular and intracellular water in the affected leg decreased significantly ( = 0.001 and < 0.001, respectively), whereas the percentage of extracellular water remained stable.LVA achieved sustained reductions in segmental and TBW volumes, localized to the affected leg, without compensatory increases in other body segments. These findings support the efficacy of leg LVA in achieving long-term fluid homeostasis through systemic elimination of excess lymphatic fluid rather than redistribution.
The Obesity Paradox in Fibular Free-Tissue Reconstruction: Does Higher BMI Improve Outcomes?
Kurnick B, Powers LD, Martin H … +1 more , Salama A
J Reconstr Microsurg · 2026 Feb · PMID 41638241 · Publisher ↗
Head and neck squamous cell carcinoma is widespread and projected to increase in prevalence by approximately 30% by 2030. This study evaluates the association between body mass index (BMI), perioperative frailty, and pos...
Head and neck squamous cell carcinoma is widespread and projected to increase in prevalence by approximately 30% by 2030. This study evaluates the association between body mass index (BMI), perioperative frailty, and postoperative outcomes, including hospital length-of-stay and perioperative complications for patients undergoing fibular free-tissue reconstruction for head and neck defects.We conducted a retrospective, multi-institutional cohort study using the American College of Surgeons National Surgical Quality Improvement Program database, encompassing subjects of mandibular malignancy radical excision with free myocutaneous and fibular flap reconstruction between 2012 and 2022. Primary independent variables were BMI and modified frailty index-11 (mFI-11) scores. Descriptive statistics and logistic regression analyses were employed to explore the relationship between BMI, frailty, hospital stay, and perioperative complications.A total of 4,808 patients were included (3,082 males, 1,723 females). Within this cohort, 36.5% were normal BMI (18.5-25.0; = 1,755), 5.3% were underweight (BMI < 18.5; = 255), and 58.2% were overweight or obese (BMI > 25.0; = 2,798). A total of 2,288 (47.6%) were robust (mFI = 0), 1,624 (33.8%) prefrail (mFI = 1), and 896 (18.6%) frail (mFI ≥ 2). Perioperative complication risk was 38.4% for normal-weight patients, 55.3% for underweight patients ( < 0.001), and 28.8% for overweight/obese patients ( < 0.001). Multivariate analysis revealed that overweight/obese patients had shorter hospital stays (β: -1.0 days, 95% [CI]: -1.5 to -0.5, < 0.001) compared with normal-weight patients. Normal-weight patient complication rates increased from 26.9% (robust) to 39.0% (frail, = 0.0003). Conversely, robust patient complication rates were lower in overweight (23.2%) and obese (23.1%) compared with underweight (42.4%). The highest-risk group consisted of underweight, frail patients (56.2%).Underweight BMI and physiologic frailty function as independent yet synergistic risk factors for poor outcomes after free myocutaneous or fibular flap reconstruction following radical mandibular tumor excision. Notably, decreased BMI confers a greater risk than frailty. These findings challenge the obesity paradox and mandate assessing both nutritional status and physiologic reserve for optimal risk stratification.
Risk Scale to Guide Prophylactic Paraspinous Flap Closure in High-Risk Spine Surgery.
Karwoski AS, Jung E, Schlidt K … +1 more , Rasko YM
J Reconstr Microsurg · 2026 Feb · PMID 41638240 · Publisher ↗
Wound failure after posterior spine surgery can lead to infection, hardware loss, and reoperation. Prophylactic paraspinous muscle flaps are used selectively, but the criteria to select which patients benefit most have n...
Wound failure after posterior spine surgery can lead to infection, hardware loss, and reoperation. Prophylactic paraspinous muscle flaps are used selectively, but the criteria to select which patients benefit most have not been consistent.We conducted a retrospective cohort study (2011-2022) of complex posterior spine operations closed by plastic surgery at a single center. The exposure was a prophylactic paraspinous flap at the index operation versus standard primary closure. The primary outcome was a plastic surgery-managed wound complication requiring clinical intervention or return to the operating room. Using only routine pre- and intraoperative variables, we created a five-factor bedside score (obesity; lumbar/sacral level; albumin < 35 g/L [3.5 g/dL]; operative time > 250 minutes; American Society of Anesthesiologists [ASA] class ≥ 3) and a parallel logistic model that excluded treatment to estimate baseline risk and support decision making.Among 281 operations, 150/281 (53%) received prophylactic paraspinous closure. Plastic-surgery-managed wound complications occurred in 35/281 (12.5%). A simple baseline-risk model separated patients into low, intermediate, and high-risk groups with observed complication rates of 7.9, 11.7, and 23.2%, respectively. Model performance was modest (area under the ROC curve [AUC] 0.66; optimism-corrected AUC 0.56; Brier 0.106). In adjusted analyses, ASA ≥ 3 was associated with higher odds of a wound complication (adjusted OR: 9.35; 95% CI: 1.20-73.02). In the high-risk (4-5 points) group of the five-factor score, prophylactic closure reduced reoperations from 20.0% (4/20) to 0% (0/27; absolute risk reduction: 20%; number needed to treat: 5; = 0.027). No significant differences were seen in the lower-risk groups.A simple five-factor score stratifies baseline wound risk after posterior spine surgery and identifies patients most likely to benefit from prophylactic paraspinous flap closure. Selective, preoperative use in high-risk patients may reduce returns to the operating room.
Screening for Posttraumatic Lower Extremity Lymphedema: Patient Characteristics, Risk Factors, and Quality of Life Outcomes.
Allen-Brough CA, Hahn BA, Romijn P … +5 more , Hummelink S, Berger AC, Egmond PV, Ulrich DJO, Jong T
J Reconstr Microsurg · 2026 Feb · PMID 41638239 · Publisher ↗
Lower extremity lymphedema (LEL) is a frequent, under-recognized, and chronic condition. The prevalence of this condition in patients with lower limb trauma is unclear. A self-reported lower extremity lymphedema screenin...
Lower extremity lymphedema (LEL) is a frequent, under-recognized, and chronic condition. The prevalence of this condition in patients with lower limb trauma is unclear. A self-reported lower extremity lymphedema screening questionnaire (LELSQ) was recently validated for screening LEL. The primary aim of this study was to investigate the clinical and demographic characteristics of posttraumatic LEL (PTLEL) in patients with a history of severe lower extremity trauma using the LELSQ. Secondary objectives were to identify risk factors for PTLEL, to investigate the relationship between LELSQ scores, health-related quality of life (HR-QoL), and lower extremity functioning.Patients treated for complex lower extremity trauma between January 1, 2009, and December 31, 2019, in two level one trauma centers who meet inclusion criteria were sent three questionnaires: LELSQ, Eq. 5D-5L, and the Lower Extremity Functional Scale (LEFS). Additionally, baseline demographic and trauma data were collected.A total of 115 patients (46.0%) responded, of which 95 were included. LELSQ screened 59 patients (62.1%) positive for PTLEL. Those with PTLEL reported more problems with daily life, with a lower median EQ-VAS and EQ-index score (70.0 and 0.700, respectively) compared with non-PTLEL (90.0 and 0.874, respectively). A clinically reported difference was found in the LEFS median scores, with PTLEL 39.0 compared with 66.0 in non-PTLEL.Among patients who participated in this study, 62.1% screened positive for PTLEL following complex lower limb trauma. PTLEL patients reported reduced HR-QoL and lower extremity functioning compared with non-PTLEL patients, indicating that this is a frequent and important issue following lower limb trauma.
Supercharged Pedicled Jejunal Interposition for Esophageal Reconstruction: A Systematic Review and Meta-analysis of Adult and Pediatric Patients.
Haas EJ, Thurimella K, Baghshomali Y … +7 more , Egan K, Kaoutzanis C, Irwin T, McCarter M, David EA, Mathes DW, Yu JW
J Reconstr Microsurg · 2026 Jan · PMID 41534855 · Publisher ↗
This study aims to compare demographic, risk, and complication profiles of pediatric and adult patients who underwent supercharged pedicled jejunal interposition for esophageal reconstruction.A systematic review and meta...
This study aims to compare demographic, risk, and complication profiles of pediatric and adult patients who underwent supercharged pedicled jejunal interposition for esophageal reconstruction.A systematic review and meta-analysis were performed, which included patients who underwent esophageal reconstruction with supercharged jejunum from 23 published studies. Patients were divided into two groups: pediatric/young adults (≤18 years), and adults (>18 years). The primary outcome was postoperative complications. Python 3.11 with pandas was used for data management, scikit-learn for Ridge regression and imputation of missing values, and SciPy for statistical analysis. Ridge regression analysis was utilized with regularization (α = 0.1), while examining the relationship between demographic factors and overall complication rates in adult patients to account for limited sample sizes.A total of 254 manuscripts were reviewed, and 23 studies met inclusion criteria. Of 477 included patients, 415 were adults (87%) and 62 were pediatric patients (13%). Adult patients had significantly higher odds of developing an anastomotic leak (OR 8.63, < 0.01) and dysphagia (5.99, < 0.02) following surgery. Preoperative radiation was positively associated with postoperative dumping symptoms (β = 0.56), stricture formation (β = 0.27), poor wound healing (β = 0.27), and need for reoperation (β = 0.27). A history of cancer was most positively associated with anastomotic leak (β = 0.22) following surgery. Preoperative radiation was positively associated with anastomotic leak (β = 0.12). Smoking demonstrated a strong inverse association with the need for reoperation (β = - 0.66), and a weaker inverse association with leakage (β = - 0.25).Adult patients have a significantly greater likelihood of experiencing postoperative anastomotic leakage and dysphagia compared with pediatric patients. Preoperative radiation was associated with dumping symptoms, stricture, need for reoperation, poor wound healing, and pulmonary complications. Smoking was associated with decreased need for reoperation and anastomotic leakage.
Refining Surgical Precision: The Impact of Color Doppler Ultrasound-Guided Perforator Mapping on Anterolateral Thigh Flap for Oncologic Patients.
Kim TH, Chao JS, Kwon JG … +3 more , Pak CJ, Suh HP, Hong JP
J Reconstr Microsurg · 2025 Dec · PMID 41360097 · Publisher ↗
This study investigates the impact of preoperative ultrasound mapping using color Doppler ultrasound (CDU) on surgical outcomes for anterolateral thigh (ALT) free flap reconstructions.A retrospective review was conducted...
This study investigates the impact of preoperative ultrasound mapping using color Doppler ultrasound (CDU) on surgical outcomes for anterolateral thigh (ALT) free flap reconstructions.A retrospective review was conducted on patients who were diagnosed with cancer and underwent ALT free flap reconstruction. Patients were grouped based on the use of either computed tomography angiography (CTA) with a handheld Doppler (HHD) or CDU for preoperative planning. Patient demographics, operation times, flap elevation durations, and postoperative outcomes were evaluated.A total of 63 patients were included in this study (23 in the CTA + HHD group and 40 in the CDU group). Preoperative CDU planning was associated with a significantly shorter total operation time (214 vs. 252 minutes, = 0.05) compared with conventional imaging. The CDU group also demonstrated significantly lower rates of revision surgery ( = 0.006), total flap loss ( = 0.05), and partial flap loss ( = 0.05). In multivariate linear regression analysis, CDU use was the only factor independently associated with shorter flap elevation time ( = 0.04) among the evaluated surgical variables.The findings suggest that incorporating preoperative ultrasound mapping enhances surgical outcomes by optimizing flap elevation and reducing complications. The use of CDU proves valuable in achieving better preoperative planning, leading to improved efficiency and overall success in reconstructive surgeries using ALT free flaps.
The Impact of Needle Geometry on Tissue Damage and Anastomotic Leakage: A Combined Analysis of Human Skin and Porcine Cardiovascular Models.
Jeong D, Badran S, Schanbacher JM … +6 more , Potter CT, Maloney ME, Montilla RD, Sacks J, Fudem G, Schanbacher CF
J Reconstr Microsurg · 2025 Nov · PMID 41314401 · Publisher ↗
Surgical needles have evolved to optimize tissue approximation while minimizing tissue damage. Needle point geometry is a critical operative factor that impacts surgical dexterity. This study aims to compare the effects...
Surgical needles have evolved to optimize tissue approximation while minimizing tissue damage. Needle point geometry is a critical operative factor that impacts surgical dexterity. This study aims to compare the effects of taper point (TP) and reverse cutting (RC) needles on tissue damage and anastomotic bleeding risk across different tissue types and needle diameters.Two experimental models were employed. The Tissue Damage Model pierced 10 abdominal and 10 cheek skin samples using TP and RC needles. Histologic impact on skin layers was analyzed. The Anastomosis Leakage Model measured fluid leakage after 30 porcine aortas were punctured by TP and RC needles of varying diameters in an ex vivo pulsatile flow system. Both experiments ensured controlled variables and consistent methodologies.In the Tissue Damage Model, RC needles caused twice as much dermal disruption in both abdominal and cheek skin as TP needles ( < 0.01). Abdominal skin exhibited twice the histological damage compared to facial skin, irrespective of needle geometry ( < 0.05).In the Anastomosis Leakage Model, RC needles caused 5.6-, 4.0-, and 8.7-fold more leakage than TP needles at small, medium, and large needle diameters, respectively ( < 0.002). Leakage from RC needles increased with needle diameter ( < 0.001). TP needles did not exhibit this effect.RC needles caused significantly more dermal disruption compared to TP needles. Greater tissue damage was observed in abdominal skin than in facial skin. Additionally, RC needles led to progressively higher fluid leakage as needle diameter increased, while TP needles did not.
From Galen to the Modern Anatomy Lab: The Evolving Role of Anatomy and Dissection in Microsurgery.
Gu K, Bogue JT, Levin LS
J Reconstr Microsurg · 2025 Dec · PMID 41309086 · Publisher ↗
Anatomy has long served as the foundation of surgical education and innovation. From the anatomical plates of the Renaissance to dissection theaters of the 18th century and currently modern cadaveric simulation labs and...
Anatomy has long served as the foundation of surgical education and innovation. From the anatomical plates of the Renaissance to dissection theaters of the 18th century and currently modern cadaveric simulation labs and courses, the understanding of the human body has facilitated the evolution of microsurgery. This manuscript traces the historical connections between anatomical study and surgical advancement, focusing on anatomy's foundational role in the development of modern microsurgery.A narrative historical review was undertaken, examining primary and secondary sources describing the progression of anatomical study, its integration into surgical education, and its influence on the emergence and refinement of microsurgical techniques. Key contributions by early anatomists, the rise of microsurgery, and the construction of dedicated cadaver labs and respective flap courses are described and examined here.This review demonstrates that anatomical investigation has continuously informed and shaped microsurgical practice. Early anatomists established the groundwork for understanding vascular and soft-tissue relationships, while later innovations-including detailed mapping of cutaneous and perforator vessels, refinement of vascular anastomosis techniques, and the introduction of specialized microsurgical tools-emerged from anatomical inquiry. The establishment of dedicated cadaver labs and flap courses further strengthened this link, providing structured environments where anatomical knowledge and operative technique could be integrated, rehearsed, and advanced. Across centuries, these developments collectively illustrate the central role of anatomical dissection in enabling the precision and innovation that define modern microsurgery.As microsurgery advances alongside emerging technologies, the cadaver lab remains an irreplaceable cornerstone across all levels of surgical training-linking centuries of anatomical knowledge to the evolving demands of modern microsurgical practice.
Reusing Motor Branches of the Neurotized Median Nerve for Functioning Free Muscle Transplantation to Augment Finger Flexion in Total Brachial Plexus Palsy.
Lin JA, Ribeiro LM, Chang TN … +2 more , Chuang DC, Lu JC
J Reconstr Microsurg · 2025 Nov · PMID 41290190 · Publisher ↗
In total brachial plexus injury (BPI), there are inadequate donor nerves to adequately reinnervate the limb to regain full upper limb function. Free vascularized ulnar nerve grafts have been used to connect root stumps t...
In total brachial plexus injury (BPI), there are inadequate donor nerves to adequately reinnervate the limb to regain full upper limb function. Free vascularized ulnar nerve grafts have been used to connect root stumps to the distal median nerve (MN) for hand neurotization. Axonal regeneration arrives by presenting with a sensate hand, but unpredictable motor reinnervation of the target muscles renders a paralyzed hand without extrinsic finger flexion. Thus, we describe the strategy of recycling the motor branches from the MN and replacing the forearm muscles with free functioning muscle transplantations (FFMTs).Between 1998 and 2017, a total of 34 patients received gracilis-FFMT for finger flexion, using previously reinnervated MN motor branches as the motor neurotizer. The muscle power of finger flexion [Medical Research Council (MRC)] and the satisfactory rate (≥M2) were recorded. The patient-reported outcomes, including the shortened version of the Disability of Arm, Shoulder and Hand (QuickDASH) and the Michigan Hand Outcomes Questionnaire (MHQ), were obtained.About 67.7% of the patients achieved finger flexion of M2 or greater after FFMT. The average postoperative QuickDASH score significantly decreased from 76.3 ± 13.8 to 65 ± 15.8 ( = 0.042). The overall MHQ score showed significant improvement in the domains of overall hand function and work.FFMT neurotized by previously reinnervated MN branches can serve as a salvage or adjunctive strategy to augment finger flexion. The surgical strategy of recycling previously innervated MN to an FFMT helps with efficient planning of donor nerves in reconstruction for total BPI.
An Algorithmic Approach to Arterial Coupler Use in Microsurgical Breast Reconstruction: Comparison with Hand-Sewn Sutures.
Kim HB, Kang HI, Han HH … +1 more , Eom JS
J Reconstr Microsurg · 2025 Dec · PMID 41285410 · Publisher ↗
Microsurgical breast reconstruction offers superior outcomes after mastectomy, but vascular microanastomosis remains technically demanding. Venous couplers are widely adopted, whereas the use of arterial couplers remains...
Microsurgical breast reconstruction offers superior outcomes after mastectomy, but vascular microanastomosis remains technically demanding. Venous couplers are widely adopted, whereas the use of arterial couplers remains controversial. This study aimed to establish an algorithmic approach for arterial coupler use and compare outcomes with hand-sewn sutures.A retrospective review was performed on 105 patients undergoing deep inferior epigastric perforator flap breast reconstruction by a single surgeon. Patients were divided into an arterial coupler group ( = 62) and a hand-sewn suture group ( = 43). An intraoperative algorithm guided coupler use, requiring the absence of atherosclerosis, intact intima, and adequate vessel laxity. Demographics, operative details, microanastomosis time, and postoperative outcomes were analyzed.Patients in the coupler group were younger (47.6 ± 8.6 vs. 53.0 ± 7.9 years, = 0.001) and underwent more robot-assisted procedures (16.1% vs. 2.3%, = 0.025). Microanastomosis time was significantly shorter with couplers (19.6 ± 8.9 vs. 26.1 ± 6.5 minutes, < 0.01). Flap survival was comparable between groups (96.8% vs. 100%, = 0.512). Complication rates, including arterial/venous insufficiency, hematoma, and infection, showed no significant differences. Two coupler failures occurred: One venous congestion and one late thrombosis, both attributed to multifactorial causes rather than device failure.Arterial couplers, when used under strict algorithmic selection criteria, provide reliable outcomes comparable to hand-sewn sutures while significantly reducing operative time. This approach enhances efficiency in microsurgical breast reconstruction and may guide future standardized practice.
Peripheral Nerve Injuries in Laparoscopic and Open Thoracoabdominal Surgeries: A Systematic Review and Meta-Analysis.
Nguyen JD, Chen AJ, Snee I … +5 more , Khong J, Poisler MA, Elhelali A, Tuffaha SH, Dellon AL
J Reconstr Microsurg · 2025 Nov · PMID 41270964 · Publisher ↗
Following open thoracoabdominal surgery, patients are at risk of chronic pain due to unintentional peripheral nerve injury (PNI), such as nerve transection, compression, or stretching of peripheral nerves. While laparosc...
Following open thoracoabdominal surgery, patients are at risk of chronic pain due to unintentional peripheral nerve injury (PNI), such as nerve transection, compression, or stretching of peripheral nerves. While laparoscopic surgery is minimally invasive, the incidence of subsequent PNI from laparoscopic surgery remains unknown.PubMed, Embase, Web of Science, and Scopus databases were searched for peer-reviewed literature discussing nerve injuries following open or laparoscopic thoracoabdominal surgeries.From 1,580 unique citations, 28 articles ( = 871 patients) qualified for inclusion. There were 555 (63.7%) males and 316 (36.3%) females. The mean age was 54.5 ± 9.6 years, ranging from 18 to 92. Following 451 open thoracoabdominal surgeries, there were 214 nerve injuries (47.5%). Following 420 laparoscopic thoracoabdominal surgeries, there were 22 nerve injuries (5.2%). Laparoscopic surgery had statistically significantly lower PNI ( < 0.0001) than open procedures. These procedures caused 236 reported cases of PNI, which included neuromas (50.4%), nerve enlargement (37.3%), nerve transection (8.5%), nerve entrapment (2.5%), perineural inflammation (2.2%), and nerve crush injury (0.4%). Of patients with PNI, surgery was performed on 170 (72.0%) patients, and nonsurgical treatments were given in 64 (27.1%) patients. The surgical interventions for PNI included neurectomy (78.8%), neuroma excision (19.4%), and scar excision (1.8%).A laparoscopic approach, versus a surgical open approach to treat thoracoabdominal surgical problems, has decreased the risk of inadvertent nerve injuries. The wide variation in the description of the types of injuries is indicative of the generally poorly understood nature of PNI, indicating an opportunity for greater emphasis on the diagnosis and treatment of this problem.
Signal Processing in Microsurgery: A Primer on Proactive Application.
Ruta MR, Odobescu A
J Reconstr Microsurg · 2025 Dec · PMID 41270963 · Publisher ↗
Abstract loading — click title to view on PubMed.
The Intersaphenous Veins in the Leg: Anatomical Considerations.
Sedlák A, Veselá M, Kachlík D
J Reconstr Microsurg · 2025 Nov · PMID 41260388 · Publisher ↗
The intersaphenous veins are inconstant veins interconnecting the great and the small saphenous veins. Due to the inclination of the superficial venous system to be rather inconsistent, this topic has never been describe...
The intersaphenous veins are inconstant veins interconnecting the great and the small saphenous veins. Due to the inclination of the superficial venous system to be rather inconsistent, this topic has never been described thoroughly and adequately before. The aim of our research was to observe intersaphenous veins and give a profound description of their variable anatomy.Sixty-three body donor limbs of Central European origin embalmed in formaldehyde were dissected. The tips of the medial and lateral malleoli were selected as suitable points of reference for measurements on the vertical axis of the leg. Additionally, each fibula was measured and related to the average length of the fibula in our examined sample. Consequently, each measurement was recalculated by this coefficient.Five types of arrangement were described: no connection (22.22%), one connection (46.03%), two connections (19.05%), three connections (11.11%), and four connections (1.59%). The average point of communication between the great saphenous vein and the intersaphenous vein was located 21.50 ± 9.64 cm proximal to the medial malleolus and between the small saphenous vein and the intersaphenous vein, 18.45 ± 6.05 cm proximal to the lateral malleolus. Multiple heatmaps were created for an easier comprehension of the topic.This research provides a detailed anatomy of intersaphenous veins of the leg. Yet variable in their arrangement, intersaphenous veins were found in the majority of investigated limbs. Thanks to their favorable anatomy, intersaphenous veins offer new alternatives to the traditional venous grafts from the saphenous veins, not only for heart bypasses.
Preoperative Deep and Superficial Venous Thrombosis in Limb Salvage Candidates: A Contraindication to Microsurgical Free Flap Reconstruction? Lessons Learned from Our 13-year Institutional Experience.
Rohrich RN, Soltani H, Lin RP … +8 more , Ferdousian S, Li KR, Currin ME, Jones LI, Youn RC, Attinger CE, Akbari CM, Evans KK
J Reconstr Microsurg · 2025 Nov · PMID 41248678 · Publisher ↗
Although arterial inflow considerations dominate microsurgical planning, venous outflow is equally vital for flap survival. Patients requiring free tissue transfer (FTT) for lower extremity (LE) reconstruction frequently...
Although arterial inflow considerations dominate microsurgical planning, venous outflow is equally vital for flap survival. Patients requiring free tissue transfer (FTT) for lower extremity (LE) reconstruction frequently present with occult preoperative venous thrombosis (VT), yet there are little data guiding perioperative management in this setting. This study examines the prevalence and clinical characteristics of patients with preoperative venous thrombosis (VT) undergoing LE FTT, as well as postoperative outcomes, to evaluate the feasibility of successful microsurgery in this high-risk cohort.A retrospective review of patients with preoperative VT undergoing LE FTT at a single institution was conducted.Among 279 patients, 43 (15.4%) were positive for VT. The overall deep VT (DVT) incidence in this population was 5.7% ( = 16/279) and the superficial VT (SVT) incidence was 10.0% ( = 28/279). Most thromboses were chronic (67.8%). There were two cases of takeback (4.7%) due to thrombosis (one arterial and one venous), of which one flap was salvaged. By a median follow-up duration of 9.7 months, a limb salvage rate of 88.4% was achieved.Preoperative VT is common in microsurgical candidates for limb salvage; however, it is not a contraindication to FTT if proper adjustments are made perioperatively. Considerations include (1) routine use of venous ultrasound to identify VT; (2) perioperative anticoagulation management, including IVC filter placement when indicated; (3) selection of recipient veins that are unaffected by VT; (4) prioritizing the use of two deep veins for anastomosis when feasible; and (5) incorporating implantable devices to monitor venous outflow.
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