Journal Of Reconstructive Microsurgery[JOURNAL]
Sun
200 papers
Single Port Robotic Vascularized Omental Lymph Node Transfer for Lymphedema: A Novel Comparison to Open Technique.
Jeger JL, Kandi L, Yi J … +4 more , Jungbauer WN, Teven CM, Casey WJ, Rebecca A
J Reconstr Microsurg · 2025 Oct · PMID 41072481 · Publisher ↗
The da Vinci Single-Port (SP) system is a robotic surgery platform that allows access into the abdominal cavity through a single short surgical incision. The omentum is an attractive donor site for vascularized omental l...
The da Vinci Single-Port (SP) system is a robotic surgery platform that allows access into the abdominal cavity through a single short surgical incision. The omentum is an attractive donor site for vascularized omental lymph node transfer (VOLT) in the treatment of lymphedema. We hypothesize that SP robotic VOLT will allow for improvement in perioperative outcomes as compared to open laparotomy for omental flap harvest.A retrospective cohort study was performed, comprised of a study sample of patients with a diagnosis of lymphedema who presented to our institution for VOLT using either an open or SP robotic technique between May 2020 and February 2023. The primary outcome was length of hospital stay. The secondary outcomes included intraoperative complication rate, postoperative complication rate, and length of surgery.Fifteen patients underwent da Vinci SP omental flap harvest, and 14 patients underwent open harvest. There was no significant difference in average age, BMI, sex, or lymphedema etiology between the two groups. Average length of stay was 2.2 ± 1.7 days in the SP group and 2.3 ± 2.1 days in the open group ( = 0.91). There were no significant differences in terms of intraoperative or postoperative complications between the two groups. Ninety-three percent of SP robotic and 86% of open patients reported at least partial subjective improvement following VOLT ( = 0.50).Our findings suggest that SP robotic omental harvest for VOLT is feasible. Perioperative outcomes show comparable results in terms of length of hospital stay, complications, and subjective postoperative improvement when comparing the open to the SP approach.
Patient Demographics Associated with Latissimus Dorsi Muscle Dimension for Flap Coverage Planning.
Jacobi S, Sadeh O, Davidovic-Katz E … +3 more , Moll S, Barrera J, Hacquebord JH
J Reconstr Microsurg · 2025 Oct · PMID 41072480 · Publisher ↗
The latissimus dorsi (LD) is a common workhorse flap used in reconstructive surgery to cover large wound defects. Estimating the area of possible coverage is necessary for preoperative planning and surgical success. The...
The latissimus dorsi (LD) is a common workhorse flap used in reconstructive surgery to cover large wound defects. Estimating the area of possible coverage is necessary for preoperative planning and surgical success. The aim of this study is to investigate the relationship between patient factors and the measurable dimensions of the LD flap in order to inform more personalized preoperative planning and evidence-based flap selection.This is a retrospective study of individuals who underwent computed tomography (CT) angiography of the chest and abdomen. Patient demographics - height, age, sex, and body mass index (BMI) were collected. The primary outcome was the dimensions of the LD muscle edges and length of the thoracodorsal pedicle measured on CT. Multivariable linear regression was performed to determine the independent effects of patient demographics on the dimensions of the LD muscle.A total of 50 patients were included in this study. Patient demographics were significantly associated with all LD muscle dimensions. The length of the vascular pedicle was 9.502 ± 1.281 cm and was significantly associated with height ( < 0.001). Patient demographics had a strong correlation ( = 0.957) with this length. The average wound defect area the LD can cover was 209.99 cm (range: 114.24-312.40 cm). This area increases or decreases by 1.498 cm per centimeter change in a patient's height ( = 0.011).An understanding of how patient factors are associated with LD muscle dimensions is critical for preoperative planning and surgical success. Our study found that height, BMI, age, and sex all have associations with the dimensions of the LD muscle. As well, height is strongly correlated with the length of the thoracodorsal vascular pedicle, influencing the possible rotation arc of the flap.
Keep Your Friends Close and Your Teammates Closer: The Impact of Staffing with Familiar Personnel in Microsurgical Breast Reconstruction.
Haravu PN, Foster JA, Phillips BT
J Reconstr Microsurg · 2025 Oct · PMID 41072479 · Publisher ↗
Microsurgical breast reconstruction is intraoperatively complex. Evidence of standardized workflows improving outcomes exists, but the impact of staffing cases with familiar personnel is not documented.All microsurgical...
Microsurgical breast reconstruction is intraoperatively complex. Evidence of standardized workflows improving outcomes exists, but the impact of staffing cases with familiar personnel is not documented.All microsurgical breast reconstructions (July 2021-June 2024) at our institution were analyzed for staff familiarity at granular time intervals (T: setup to incision, T-T: each third of procedure). Staff were deemed "unfamiliar" if they staffed <2 microsurgical breast reconstructions with the attending in past 4 months. Intraoperative setbacks included anastomotic revisions, vessel damage, switching recipient vessels, or mastectomy flap defect. Major complications included operative takeback or flap loss.Among 291 surgeries (5 attendings, 2 hospitals), 35.1% were immediate, 77.3% used standard hemiabdominal DIEP flaps, 58.4% were bilateral, and 49.5% had prior radiation. Intraoperative setbacks occurred in 19.7%, major complications in 7.4%, average duration was 631.6 minutes, and supply costs averaged $5,216. Unfamiliar scrub-techs correlated with increased intraoperative setbacks (OR: 2.11, < 0.05), particularly in early time intervals (T: 1.91, = 0.06; T: 2.09, < 0.05). Unfamiliar circulators correlated with increased supply costs (+12.2%, < 0.05), especially in later time intervals (T: +12.2%, < 0.05; T: +16.0%, < 0.05). In addition to staff familiarity, at univariate level, intraoperative setbacks also correlated with prior radiation ( < 0.05), duration correlated with laterality, immediate reconstructions, mastectomy type, and anastomoses ( < 0.05), and costs correlated with anastomoses ( < 0.05). Multivariate analysis confirmed unfamiliar scrub-techs and circulators were significantly correlated with increased intraoperative setbacks and higher costs ( < 0.05), with a trend toward longer duration ( = 0.06).In microsurgical breast reconstruction, unfamiliar teams correlated with increased intraoperative setbacks, costs, and durations. Adjusting staffing models to prioritize familiarity may provide medical, financial, and logistical benefits.
Anatomical Study of Venous Valves and Valve-Like Structures in the Superficial Temporal Veins: Implications for Reconstructive Surgery.
Wang Y, Cao Z, Yue Q … +3 more , Rui S, Zhang T, Liu L
J Reconstr Microsurg · 2026 Jan · PMID 41067268 · Publisher ↗
Detailed knowledge of venous valves and valve-like structures is essential in reconstructive surgery, as these structures may contribute to postoperative venous congestion following flap transfer. However, their presence...
Detailed knowledge of venous valves and valve-like structures is essential in reconstructive surgery, as these structures may contribute to postoperative venous congestion following flap transfer. However, their presence in the superficial temporal veins (STVs), which are frequently utilized in craniofacial reconstruction, remains unclear. The authors performed morphological and morphometrical examinations of venous valves and valve-like structures in the STVs through cadaver dissection.This study involved the longitudinal dissection of 24 STVs from 12 cadavers. The veins were then examined under a stereomicroscope to determine the presence of venous valves or valve-like structures, and their quantity and location were recorded.The STVs contain both venous valves and valve-like structures known as venous cristae. All observed venous valves were bicuspid, whereas venous cristae were characterized by ridge-like protrusions of venous wall into the lumen. A total of 5 venous valves and 69 cristae were identified across 24 STVs. Venous valves were exclusively located in the main trunks of the STVs, whereas venous cristae were classified into five types based on their locations, with venous bifurcations being the most common sites. Most main trunks (22/24)contained either one venous valve or one crista, and the average distances from these structures to the superior margin of the zygomatic arch were 8.42 ± 0.80 and 9.03 ± 0.86 mm, respectively.A comprehensive understanding of the characteristics, quantity, and distribution of venous valves and cristae in the STVs could provide valuable insights for surgeons in preventing postoperative venous congestion.
The Impact of Intraoperative Methadone on Perioperative Opioid Requirements in Autologous Free Flap Breast Reconstruction.
Somers S, Vitale A, Dadzie A … +4 more , French M, Eddington D, Agarwal JP, Kwok AC
J Reconstr Microsurg · 2025 Oct · PMID 41067267 · Publisher ↗
The use of intraoperative methadone has received considerable attention due to reports of reduced postoperative pain and opioid consumption without increased risk of opioid-related side effects. The purpose of this study...
The use of intraoperative methadone has received considerable attention due to reports of reduced postoperative pain and opioid consumption without increased risk of opioid-related side effects. The purpose of this study was to compare perioperative opioid requirements in patients who received intraoperative methadone to those who did not receive intraoperative methadone following autologous breast reconstruction (ABR).A retrospective review of patients who underwent ABR from July 2023 to August 2024 was performed. Patients were stratified into an intraoperative methadone and nonintraoperative methadone cohort. Patient demographics, operative characteristics, hospital length of stay, and perioperative opioid consumption per patient were collected. The primary outcome was daily postoperative opioid requirements, recorded in morphine milligram equivalents (MME).A total of 112 patients who underwent ABR breast reconstruction were identified, 54 in the intraoperative methadone cohort and 58 in the nonintraoperative methadone cohort. Mean opioid consumption was significantly less for the methadone cohort intraoperatively (23.7 ± 13.7 MME vs. 44.5 ± 18.8 MME, < 0.01), on postoperative day (POD) 1 (29.04 ± 28.9 MME vs. 44.4 ± 37.9 MME, = 0.04), POD-2 (22.9 ± 25.7 MME vs. 38.7 ± 38.2 MME, = 0.04), and overall throughout hospitalization compared with the nonintraoperative methadone patients (87.4 ± 87.1 vs. 139.1 ± 121.2; = 0.03).Intraoperative methadone significantly reduces inpatient opioid use after undergoing ABR on POD-1, POD2, and overall throughout hospitalization. Our findings support the need for well-designed prospective trials to further assess the effectiveness of intraoperative methadone in managing perioperative pain and reducing opioid use during ABR.
Does Academic Quarter or Operative Day of the Week Affect Free Flap Success?
Sobba WD, Jacobi S, Barrera J … +5 more , Gursky AK, Wyatt HP, Levine JP, Agrawal NA, Hacquebord JH
J Reconstr Microsurg · 2025 Nov · PMID 41067266 · Publisher ↗
The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, although its impact on surgical fields remains uncertain. Additionally, few studies have exa...
The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, although its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures.A retrospective review was conducted between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage.A total of 769 free flaps met inclusion criteria for analysis. No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared with the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%.We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.
Efferent Lymphaticovenular Anastomosis for Pelvic and Lower Extremity Lymphedema after Gynecologic Cancer Treatment: Indication and Timing Criteria Based on Nodal Function.
Seki Y, Nemoto H, Okino T … +3 more , Asai R, Tomochika M, Kajikawa A
J Reconstr Microsurg · 2025 Oct · PMID 41067265 · Publisher ↗
Efferent lymphaticovenular anastomosis (ELVA) uses efferent lymphatic vessels from inguinal lymph nodes, which receive multiple afferent inputs from the lower extremity, to drain substantial lymphatic fluid. However, nod...
Efferent lymphaticovenular anastomosis (ELVA) uses efferent lymphatic vessels from inguinal lymph nodes, which receive multiple afferent inputs from the lower extremity, to drain substantial lymphatic fluid. However, nodal degeneration during disease progression may impair function and affect ELVA efficacy. This study evaluated ELVA outcomes for lower extremity and pelvic lymphedema based on the presence or absence of nodal degeneration.This retrospective study included 30 patients who underwent LVA using the ELVA technique for pelvic and lower extremity lymphedema (LEL) following gynecological cancer treatment. Preoperative ultrasonography was performed to assess the vascularity of the inguinal lymph nodes. Patients with preserved nodal vascularity were classified into the primary ELVA group and underwent ELVA as the initial treatment. Those without detectable vascular flow were initially treated with leg LVA; ELVA was subsequently performed once the vascularity of the inguinal nodes improved. Treatment efficacy was evaluated based on changes in pelvic and leg volume indices.Based on preoperative ultrasonography, seven patients were classified into the primary ELVA group and 23 into the secondary ELVA group. Preoperative ICG lymphography revealed significantly lower severity in the primary group ( < 0.01). The mean postoperative follow-up period was 31.5 months. Significant volume reductions were observed in leg and pelvic regions, with LEL index reduced from 275.1 ± 33.8 to 247.8 ± 28.2 ( < 0.01), and pelvic lymphedema index from 1,053.2 ± 81.2 to 972.7 ± 76.5 ( < 0.01). No significant differences in volume reduction were found between the two groups.ELVA may be effective for both pelvic and LEL, even in advanced cases when performed after nodal function recovery.
Go Deep or Go Home: Evaluating Venous Drainage Systems in Microvascular Lower Extremity Reconstruction.
Rizvi I, Kahramangil B, Wang E … +4 more , Swiekatowski K, Nye JR, Trost JG, Bhadkamkar MA
J Reconstr Microsurg · 2025 Oct · PMID 41067264 · Publisher ↗
No consensus exists regarding the utilization of the lower extremity superficial venous system compared with the deep veins in free flap procedures for limb salvage. This study analyzed the risks of venous complications...
No consensus exists regarding the utilization of the lower extremity superficial venous system compared with the deep veins in free flap procedures for limb salvage. This study analyzed the risks of venous complications associated with superficial and deep venous anastomoses for lower extremity reconstruction.A retrospective review was performed on patients who required free flap reconstruction of the lower extremity between 2016 and 2024. The recipient veins were characterized as deep (venae comitantes) or superficial (saphenous veins). Flaps with two venous anastomoses were further classified as deep, superficial, or combined venous drainage. The primary study outcome was composite venous complications, which included venous congestion, flap hematoma, and partial and total flap necrosis during index hospitalization.A total of 333 patients underwent free flap reconstruction of the lower extremity. Of these patients, 31 (9.3%) experienced the primary outcome. Free flaps with superficial-only drainage had a significantly higher rate of venous complications (27.8%) than those with deep (8.6%) or combined (4.3%) drainage systems. Multivariate analysis showed that flaps anastomosed to superficial veins had significantly higher odds of venous complications (OR = 4.11, CI: 1.24-11.9, = 0.049) than those utilizing a deep drainage system.This study showed higher rates of venous complications with the use of superficial venous drainage in lower-extremity free flaps. Although efforts should be made to incorporate a deep venous recipient, superficial veins may be used as an adjunct in certain situations with good reconstructive outcomes.
Investigation of Routine Venous Augmentation in Deep Inferior Epigastric Artery Perforator Flap and Intraoperative Decision Pathway.
Meyer AM, Bird C, Nazir N … +5 more , Collins M, Farmer R, Lai E, Butterworth J, Holding J
J Reconstr Microsurg · 2025 Nov · PMID 41067263 · Publisher ↗
Data supporting use of prophylactic venous augmentation in the deep inferior epigastric perforator flap (DIEP) is limited. This study aims to assess the outcomes of single vein DIEP flaps compared with those with venous...
Data supporting use of prophylactic venous augmentation in the deep inferior epigastric perforator flap (DIEP) is limited. This study aims to assess the outcomes of single vein DIEP flaps compared with those with venous augmentation and present an intraoperative decision pathway.A retrospective chart review was performed on patients who underwent DIEP flap reconstruction at a single institution from 2009 to 2023. Statistical analysis was performed and -values less than 0.05 were considered statistically significant.A total of 1,099 patients had DIEP flap breast reconstruction resulting in 1,745 flaps. Two or more veins were utilized in 32.4%, whereas 67.6% had a single venous anastomosis. Prophylactic augmentation was documented for 24.5% of flaps. The rate of return to operating room was 5.8% with no significant difference found in the rate of return for all causes ( = 0.14) and suspected venous compromise ( = 0.95). Suspected venous compromise was documented in 41flaps (2.3%), with no significant difference between the single vein and prophylactic vein group ( = 0.95). There was no difference in rates of early ( = 0.10) or late flap loss ( = 0.15). Difference in operative duration was increased for flaps with prophylactic venous anastomoses (559.4 ± 127.8 vs. 505.6 ± 130.8 minutes; < 0.001).This study demonstrates no significant difference in postoperative complications as well as demonstrating prophylactic multivein anastomosis was associated with significantly longer operative times. With the use of an intraoperative decision pathway, one can determine which flaps will benefit from additional venous outflow and avoid unnecessary routine augmentation without benefit.
Largest Investigation of Branching Patterns of the Popliteal Artery.
Lin CH, Yeh JP, Chen YT … +1 more , Chen MH
J Reconstr Microsurg · 2025 Oct · PMID 41067262 · Publisher ↗
Head and neck squamous cell carcinoma accounts for 4.5% of all new cancers diagnosed. A fibula free flap is often performed after tumor resection. Preoperative acknowledgment of the branching patterns of the popliteal ar...
Head and neck squamous cell carcinoma accounts for 4.5% of all new cancers diagnosed. A fibula free flap is often performed after tumor resection. Preoperative acknowledgment of the branching patterns of the popliteal artery is important to avoid flap failure or leg ischemia after flap harvest. We performed this extensive study using a modified classification to help thoroughly recognize variations.The subjects were Taiwanese patients who received radiologic examinations of their lower limbs at a single medical center from May 2006 to December 2022. Only digital subtraction angiography, computed tomography angiography, and magnetic resonance angiography, which reveal the vasculature of the lower limbs, were included. All images were viewed by the same plastic surgeon on the same computer screen. Statistical analysis was subsequently performed on the data.In total, 1,244 right legs and 1,198 left legs (2,442 legs in total) from 1,485 Taiwanese patients were included in this study. In addition to normal branching, type IA, other branching patterns as variations occurred in 4.1% ( = 100) of the included legs. The second and third common patterns were type IIIA (1.06%, = 26) and IB (0.98%, = 24), respectively. Forty-seven patients presented with variation and had both legs evaluated, and 29.8% of them presented with bilateral variations.A preoperative vascular examination is strongly recommended before harvesting a free fibular flap because some patients might have a blood supply to the foot and lower leg, mainly from the planned-to-be-harvested peroneal artery (PR), or might not have a workable PR. Using fibular vessels as a flap pedicle might not be able to be performed in up to 1.84% of legs.
Impact of Obesity on Surgical and Patient-Reported Outcomes Following Immediate Lymphatic Reconstruction.
Hassan AM, Hajj JP, Lewis JP … +8 more , Fisher CS, Imeokparia FO, Ludwig KK, Danforth RM, VonDerHaar RJ, Bamba R, Lester ME, Hassanein AH
J Reconstr Microsurg · 2025 Oct · PMID 41067261 · Full text
While obesity is a known risk factor for developing breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND), its impact on outcomes of immediate lymphatic reconstruction (ILR) is yet to be elu...
While obesity is a known risk factor for developing breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND), its impact on outcomes of immediate lymphatic reconstruction (ILR) is yet to be elucidated. The purpose of this study is to assess the influence of obesity on BCRL incidence and patient-reported outcomes following ILR.We retrospectively studied consecutive patients who underwent ILR following ALND between 2017 and 2024 across a university hospital system. BCRL prevalence and condition-specific (LYMPH-Q) quality-of-life performance were compared and correlated via multivariable regression.We identified 172 patients (mean body mass index [BMI]: 29.5 ± 6.9 kg/m) with 72 patients (41.9%) categorized as obese (BMI ≥ 30). BCRL incidence was 7.0% with no significant difference between groups (obese, 8.3% vs. nonobese, 6.0%; = 0.553). In adjusted models, obesity was not associated with higher risk of BCRL (OR, 0.90; 95% CI, 0.23-3.47; = 0.875), surgical complications (OR, 1.18; 95% CI, 0.50-2.74, = 0.708) or unplanned reoperation (OR, 0.72; 95% CI, 0.29-1.80, = 0.479). However, obese patients showed significantly lower mean scores in the LYMPH-Q symptom scale (66.7 ± 27.7 vs. 84.7 ± 16.8, = 0.004) when compared with nonobese patients. In adjusted models, obesity was associated with independently lower LYMPH-Q symptom scores (-13.8; 95% CI, -26.7 to -0.81; = 0.038).ILR mitigated the risk of BCRL associated with obesity following ALND. However, obesity remained associated with significantly worse patient-reported lymphedema symptom burden following ILR. These findings highlight a dissociation between objective risk reduction and subjective symptom burden, underscoring the need for integrated assessment and targeted symptom management protocols.
Mix and Match: Enhancing Microsurgical Breast Reconstruction Outcomes with Hybrid Techniques.
Daytz AE, Yom J, Aiello C … +6 more , Sultan DL, Minasian RA, Smith IT, Howell AM, Smith ML, Tanna N
J Reconstr Microsurg · 2025 Nov · PMID 41067260 · Publisher ↗
Hybrid breast reconstruction can alleviate the discordance between donor flap and desired breast volume in patients previously excluded from flap-based modalities. The authors review their consecutive experiences with tw...
Hybrid breast reconstruction can alleviate the discordance between donor flap and desired breast volume in patients previously excluded from flap-based modalities. The authors review their consecutive experiences with two novel hybrid microsurgical breast reconstruction techniques.A review of all consecutive patients who received microsurgical flap reconstruction was performed over a 5-year period, both with and without hybrid techniques. The HyPAD® technique combines flap reconstruction with stacked prepectoral acellular dermal matrix (ADM), while the HyFIL® technique combines a flap, prepectoral implant, and fat transfer (lipofilling). Demographic, health-related, surgical, and outcome indicators were measured for comprehensive qualitative and quantitative analysis.During the study period (2018-2023), 101 patients with hybrid breast reconstruction (HyPAD® = 40, HyFIL® = 61) were compared with 208 patients who received DIEP flap reconstruction alone. Hybrid patients were significantly younger (47.3 versus 52.9 years, < 0.01), had lower BMIs (24.9 versus 30.3 kg/cm, < 0.01), and had reduced mastectomy weights (452.1 versus 652.0 g, < 0.01) and flap weights (348.7 versus 683.5 g, < 0.01). Hybrid patients had fewer clinically significant readmissions after discharge (1 versus 15, = 0.02). No significant differences were found for length of stay of index admission ( = 0.56) or returns to the operating room upon index admission ( = 0.64). No implant or ADM extrusions occurred in the hybrid cohort.Hybrid microsurgical breast reconstruction is a safe and reliable method to enhance core projection and volume.
Basic versus Complex Arteriovenous Loop Positions in Reconstructive Free Flap Surgery: An Outcome Analysis Focusing on the Antithrombotic Treatment Regimen.
Geierlehner A, Hirtreiter J, Lang W … +4 more , Rother U, Ströbel A, Horch RE, Arkudas A
J Reconstr Microsurg · 2026 Jul · PMID 41061748 · Publisher ↗
BACKGROUND: Arteriovenous (AV) loop followed by free flap reconstruction remains a challenging and high-risk intervention and is therefore reserved for a selective patient population. It is unclear to what extent factors...
BACKGROUND: Arteriovenous (AV) loop followed by free flap reconstruction remains a challenging and high-risk intervention and is therefore reserved for a selective patient population. It is unclear to what extent factors such as defect localization, choice of free flap, positioning of the AV loop, and especially the antithrombotic regimen have an influence on complications such as thromboembolic events or flap failure. METHODS: Medical records from 123 patients between 2003 and 2023 were reviewed. Postoperative outcomes were compared between the complexity of AV loop positioning, one- and two-stage reconstruction, defect locations, free flap type, and antithrombotic regimen. RESULTS: After AV loop creation and before free flap transfer (first-stage), loop thrombosis ( = 0.025) and loop failure ( = 0.003) rates differed significantly between defect sites. The flap failure rate after free flap transfer (second-stage), which was performed on average 8 days after AV loop creation, differed significantly between defect sites with basic (3%) and complex (17%) AV loop positioning and routing ( = 0.028). Low-dose heparin was applied significantly more frequently in cases with basic loop positioning, while high-dose heparin was applied significantly more frequently in complex loop cases ( = 0.002). The combined use of low-dose heparin with acetylsalicylic acid in complex loops is associated with a significantly higher thrombosis rate than in basic loops ( = 0.046). CONCLUSION: Defect localization and the complexity of the AV loop position have an influence on the occurrence of vascular thrombosis and flap failure. For this reason, consideration of defect localization and AV loop position is crucial for the choice of the appropriate antithrombotic regimen.
TMR/RPNI Awareness and Pain Outcomes: A Nationwide Survey of Amputees.
Weitzner AS, Zamore ZH, Biswas A … +5 more , Khong J, Kuo KT, Lee EB, Padovano W, Tuffaha SH
J Reconstr Microsurg · 2026 Jul · PMID 40967608 · Publisher ↗
BACKGROUND: Amputation leads to a symptomatic neuroma in 5 to 25% of amputees, causing debilitating pain. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are novel peripheral nerve...
BACKGROUND: Amputation leads to a symptomatic neuroma in 5 to 25% of amputees, causing debilitating pain. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are novel peripheral nerve interventions used to prevent/treat neuromas. Our objective was to assess whether amputees who underwent TMR or RPNI at primary amputation reported less pain and greater ability to use prosthetics than those receiving a delayed (secondary) TMR/RPNI or no TMR/RPNI. METHODS: A REDCap survey was administered to 1,377 amputees and 294 responded. Participants were recruited via social media and the Amputee Coalition Web site. Amputees were queried on demographics, amputation, and quality-of-life characteristics. Knowledge of TMR/RPNI procedures was also assessed. RESULTS: About 13 and 7% of patients had a primary and secondary TMR/RPNI, respectively. Outcomes were adjusted for amputation physician and clinical setting. Patients receiving primary TMR/RPNI had significantly lower pain severity score ( = 0.019) and pain interference score ( = 0.046) compared with no intervention. Pain with prosthetic use and proportion experiencing severe pain were not significantly lower among those receiving prophylactic TMR or RPNI. CONCLUSION: Compared with no or secondary peripheral nerve intervention, primary TMR/RPNI led to a significant reduction in pain interference and pain severity. Although not significant, preliminary trends also show reduction in pain with prosthetic use, proportion experiencing severe pain, and sustained opioid use with primary TMR/RPNI. As utilization of TMR/RPNI as a primary procedure yields better pain outcomes in a nationwide cohort, we must identify and address barriers to performance.
Evaluation of Surgical Techniques for End-to-Side Neurorrhaphy in a Rat Model: A Quantitative and Qualitative Analysis of Postoperative Neural Repair and Recovered Nerve Function.
Staribacher D, Kuzmin D, Velnar T … +2 more , Britz G, Feigl GC
J Reconstr Microsurg · 2026 Jul · PMID 40962279 · Publisher ↗
BACKGROUND: There are two basic techniques to surgically reconstruct peripheral nerves for the recovery of function after traumatic nerve injuries. The end-to-end (EtE) neurorrhaphy, and in case of loss of the proximal s...
BACKGROUND: There are two basic techniques to surgically reconstruct peripheral nerves for the recovery of function after traumatic nerve injuries. The end-to-end (EtE) neurorrhaphy, and in case of loss of the proximal stump, the end-to-side (EtS) neurorrhaphy, where the distal end of the acceptor nerve is connected to the side of a donor nerve. The current study was designed to further contribute to finding the best surgical technique for an EtS neurorrhaphy, comparing the functional outcome in a rat model. METHODS: Using a rat sciatic nerve model, qualitative and quantitative analyses were performed to evaluate peripheral nerve regeneration after EtS. A total of 22 female Lewis rats (Charles River Wiga, 190 g, 8 weeks old) were used for this study. In one test group (E1/ = 6), an EtS was conducted without, and in the other (E2/ = 8) with performing a partial neurotomy (PN) through the epineurial partial flap (EPF). RESULTS: In the test groups (E1/E2), animals with EtS neurorrhaphy without PN reached the best mean functional score of 1.8 points according to our grading scale. Animals with EtS and PN scored with a mean of 2.2 points. These rats with EtS neurorrhaphy and PN had the poorest outcome. The control group C1 with EtE neurorraphies showed the best functional outcome with an average score of 1. CONCLUSION: The EtE represents the best surgical option for reconstruction of a nerve's anatomical continuity after transection if both ends are preserved. The EtS, on the other hand, represents a good alternative with almost equally good functional outcome in cases where the proximal nerve stump was lost. Results also indicate that an EPF should be created for optimal collateral axonal sprouting and the best possible results when performing an EtS. However, all other additional injuries of the donor nerve, such as a PN, should be avoided.
Population Assessment of Anatomic Eligibility for Robotic-Assisted DIEP Flap.
Roth JM, Godek M, Fung E … +7 more , Shah R, Yu B, Hawa AAE, Montalmant KE, Kagen A, Yao A, Henderson PW
J Reconstr Microsurg · 2025 Oct · PMID 40962278 · Publisher ↗
Compared with traditional deep inferior epigastric perforator (DIEP) flap breast reconstruction procedures, robotic-assisted DIEP (R-DIEP) minimizes abdominal wall morbidity by reducing fascial incision length. Optimal R...
Compared with traditional deep inferior epigastric perforator (DIEP) flap breast reconstruction procedures, robotic-assisted DIEP (R-DIEP) minimizes abdominal wall morbidity by reducing fascial incision length. Optimal R-DIEP candidates have large perforators with short intramuscular courses, but no large-scale studies have quantified their prevalence. This study aims to identify the proportion of patients who are anatomically eligible for R-DIEP.A retrospective review of patients who underwent magnetic resonance angiography perforator mapping prior to DIEP flap breast reconstruction between 2019 and 2023 was conducted. Patient demographics were collected. "Dominant perforator" was defined as the largest perforator at or below the level of the umbilicus. The intramuscular course of each perforator was calculated as the hypotenuse of a theoretical prism connecting its entry and exit points with respect to the rectus abdominis muscle. Perforator diameter was measured at the anterior rectus sheath. "Conservative" (intramuscular course ≤ 2.5 cm) and "liberal" (intramuscular course ≤ 5 cm) eligibility criteria were applied. Perforator diameter > 2 mm was used as a secondary criterion.A total of 574 dominant perforators were identified in 287 patients. The average intramuscular length of each perforator was 3.8 ± 1.9 cm (range: 0-11.0 cm). Twenty-nine percent of dominant perforators ( = 165) had an intramuscular course length ≤ 2.5 cm, 77% ( = 441) had an intramuscular course length ≤ 5 cm, and 2.3% ( = 13) were paramuscular (no intramuscular course). Forty-six percent of patients ( = 132) had at least one dominant perforator (i.e., left- or right-sided) with an intramuscular course ≤ 2.5 cm, and 93% of patients ( = 268) had at least one dominant perforator with an intramuscular course ≤ 5 cm. Thirty-one percent of dominant perforators ( = 185) had a diameter > 2 mm and an intramuscular course ≤ 2.5 cm, and 49% of dominant perforators ( = 281) had a diameter > 2 mm and an intramuscular course ≤ 5 cm.A substantial portion of the population is anatomically eligible for R-DIEP breast reconstruction, especially when liberal criteria are applied.
Simultaneous Microsurgery During Bilateral Autologous Breast Reconstruction Reduces Ischemia Time Without Increasing Complications.
Roth JM, Godek M, Frost J … +7 more , Yu B, Fung E, Sbitany H, Jacobs JMS, Sultan SM, Suydam R, Henderson PW
J Reconstr Microsurg · 2025 Oct · PMID 40962277 · Publisher ↗
In bilateral deep inferior epigastric perforator (DIEP) flap reconstruction procedures, the microsurgical anastomoses are usually performed consecutively, where one side is completed before the other side is started. How...
In bilateral deep inferior epigastric perforator (DIEP) flap reconstruction procedures, the microsurgical anastomoses are usually performed consecutively, where one side is completed before the other side is started. However, when a co-surgeon model and loupe magnification are used, it is possible to perform both sides simultaneously. This study assesses the implications of simultaneous versus consecutive microsurgery on ischemia time and postoperative outcomes in bilateral DIEP flap reconstruction.A retrospective chart review was conducted on bilateral DIEP flap breast reconstruction patients between 2017 and 2023. Ischemia time was used to categorize the microsurgical anastomosis, with an overlap of 10 or more minutes between sides classified as "simultaneous microsurgery," and an overlap of less than 10 minutes classified as "consecutive microsurgery." Data were collected on patient demographics, total ischemia time (total time when one or both sides of the abdomen were undergoing microsurgical anastomoses), total operating time, postoperative complications, 90-day postoperative events, hospital length of stay (LOS), and morphine milligram equivalents (MME) required for pain management. Regression analyses assessed the impact of simultaneous versus consecutive microsurgery on key outcomes. Statistical significance was set at < 0.05.Seventy-four patients met the inclusion criteria for this study. Thirty-one (42%) had undergone simultaneous microsurgery, and 43 (58%) had undergone consecutive microsurgery. There were no significant differences between the two groups in age, body mass index (BMI), race, ethnicity, or baseline comorbidities. Univariate analysis revealed a statistically significant reduction in total ischemia time associated with simultaneous microsurgery (111 minutes vs. 147 minutes; < 0.001), and no differences in total operating time, complications, 90-day postoperative events, LOS, or MME. These findings were unchanged on multivariate regression controlling for age, BMI, comorbidities, and flap weight.Simultaneous microsurgery during bilateral DIEP flap reconstruction significantly reduces total ischemia time without increasing complications, hospital LOS, or pain management requirements.
Surgical Technique for Anterolateral Thigh Flap Harvesting: A Questionnaire Study From 263 International Microsurgeons.
Meuli JN, Shyu S, Chen KY … +5 more , Elham E, Chen LW, Lu JC, Huang JJ, Chang TN
J Reconstr Microsurg · 2026 Jul · PMID 40962276 · Publisher ↗
BACKGROUND: The anterolateral thigh (ALT) flap is a very popular perforator flap, but variations in design and in harvest techniques result in a broad spectrum of approaches that considerably differ from literature descr...
BACKGROUND: The anterolateral thigh (ALT) flap is a very popular perforator flap, but variations in design and in harvest techniques result in a broad spectrum of approaches that considerably differ from literature descriptions. We therefore designed this study to assess the differences in surgical techniques and practice preferences toward this flap across world regions. METHODS: The study was conducted via an online questionnaire covering demographic data, surgical techniques, and preferences in 21 questions. The participants were divided into six geographical regions that were compared. Two questions that are the subject of debate amongst microsurgeons (limitation of vasopressor use and anticoagulation before flap division) were further analyzed using a logistic regression to identify predicting variables. RESULTS: There were 263 respondents worldwide with notable differences in demographics, experience, level, and technique across different world regions. The main differences were noted in intraoperative evaluation of perforators, in the primary instrument for dissection, and in the use of loupe magnification. Microsurgeons in North America with limited experience were more likely to limit vasopressor use during flap harvest. There were also discrepancies regarding the use of systemic anticoagulation prior to flap division, but not of the same magnitude. CONCLUSION: This study is the first attempt to offer a clinical reference to apprehend differences in surgical preferences regarding ALT flap harvest techniques. Vasopressor use is notably limited by microsurgeons in North America, as well as by less experienced microsurgeons, despite available clinical evidence.
Reliability and Efficacy of Microvascular Coupler Devices for End-to-Side Venous Anastomosis in Head and Neck Reconstruction: A Systematic Review and Meta-Analysis.
Kim J, Lee KT
J Reconstr Microsurg · 2025 Oct · PMID 40962275 · Publisher ↗
While the efficacy of coupling devices in venous anastomosis has been well-studied, most evidence focuses on end-to-end techniques. In head and neck reconstruction, end-to-side (ETS) venous anastomoses involving the inte...
While the efficacy of coupling devices in venous anastomosis has been well-studied, most evidence focuses on end-to-end techniques. In head and neck reconstruction, end-to-side (ETS) venous anastomoses involving the internal/external jugular vessels are common, yet evidence for using couplers in this context is limited. This study systematically evaluates the reliability and efficacy of couplers versus the hand-sewn method for ETS venous anastomosis in head and neck reconstruction.A literature search was conducted for articles reporting outcomes of ETS anastomosis in head and neck reconstruction. Studies were divided into two groups based on the anastomosis method: Hand-sewn and couplers. Pooled analysis was performed to compare the outcomes between the two groups. Using double-arm studies reporting outcomes for both methods, meta-analysis was conducted.Forty studies representing 2,664 cases were included, with 663 using couplers and 2,001 using hand-sewn methods. Most studies were retrospective cohorts. In the pooled analysis, the venous thrombosis rate was 1.8% for hand-sewn anastomoses and 2.5% for couplers, while the flap failure rate was 2.5% for hand-sewn and 1.9% for couplers, with no significant differences in either outcome. Meta-analysis based on four studies showed comparable venous thrombosis rates between the two groups. Anastomosis time was significantly shorter with couplers (standardized mean difference -3.93, < 0.0001).ETS venous anastomosis using a coupler device in head and neck reconstruction seems to be as safe as the hand-sewn method and may offer time-saving benefits. However, additional well-designed studies are needed to confirm these findings.
Free Flap Reconstruction Following Mohs Surgery: Our Approach to Complex Skin Cancer on the Scalp.
Deguchi AN, Milbar N, Pregnall A … +9 more , Voytik M, Hornick MM, Khan S, Wang S, Motomura H, Miller C, Kovach SJ, Broach RB, Wink JD
J Reconstr Microsurg · 2026 Jul · PMID 40962274 · Publisher ↗
BACKGROUND: Scalp reconstruction following Mohs micrographic surgery (MMS) presents significant challenges when defects are complicated by radiation, extensive defect size and depth, and the use of implants. As a result,...
BACKGROUND: Scalp reconstruction following Mohs micrographic surgery (MMS) presents significant challenges when defects are complicated by radiation, extensive defect size and depth, and the use of implants. As a result, free flap reconstruction may provide optimal coverage for these complex cases. This study aims to highlight free flap reconstruction as an effective approach for treating complicated scalp defects after MMS and to identify risk factors associated with complications. METHODS: A single-center retrospective chart review of patients who underwent MMS and subsequent free flap reconstruction of the scalp between March 2010 and June 2024 was conducted. Demographics, comorbidities, and perioperative details were collected and analyzed. Scalp defect complexity was categorized based on factors such as radiation exposure, defect size, and depth, and implant use. Outcomes were compared between patients with complex and noncomplex defects. Multivariate regression analysis and comparative analysis were performed. RESULTS: Sixty free flaps in 56 patients were included in our study. Most skin cancers were basal cell carcinoma (BCC; 64%) and squamous cell carcinoma (SCC; 23%), located predominantly on the vertex or multi-focally throughout scalp. The median defect size was 112 cm (IQR: 65.3-169). The anterolateral thigh (58.3%) and latissimus dorsi flaps (38.3%) were commonly used for reconstruction. Age and body mass index were associated with higher overall complication rates, while comorbidities, cancer diagnosis, lesion locations, and flap types were not. Highly complex defects were associated with significantly higher incidences of delayed wound healing (OR: 26.2, = 0.0182) and dehiscence (OR: 9.94, = 0.0242). CONCLUSION: This study demonstrates a comprehensive exploration of free flap reconstruction as a standard treatment for complicated scalp defects following MMS, highlighting its efficacy and identifying risk factors for complications. Our findings underscore the importance of a collaborative approach between microsurgeons and Mohs surgeons to optimize patient outcomes in the treatment of challenging scalp defects.
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