Journal Of Reconstructive Microsurgery[JOURNAL]
Sun
200 papers
Differential Perfusion Patterns of Perforator and Random Flaps Assessed by Indocyanine Green Imaging.
AlQhtani AZ, Lee N, Kim H … +2 more , Eom JS, Han HH
J Reconstr Microsurg · 2025 Oct · PMID 40962273 · Publisher ↗
Indocyanine green angiography (ICGA) is widely used to evaluate flap perfusion in reconstructive surgery, but the optimal timing for assessment may differ by flap type. This study compared the perfusion dynamics of perfo...
Indocyanine green angiography (ICGA) is widely used to evaluate flap perfusion in reconstructive surgery, but the optimal timing for assessment may differ by flap type. This study compared the perfusion dynamics of perforator and random pattern flaps in a rat model using ICGA.ICGA dynamics were compared between perforator and random flaps in a rat model. Sixteen Sprague-Dawley rats (275-300 g) were randomly assigned to either a perforator or a random flap group. A 0.25-mg dose of indocyanine green (ICG) was administered via the femoral vein, and fluorescence images were acquired at predefined intervals over 4 minutes. Hypoperfusion was defined as fluorescence intensity below 30% of the peak value. Necrosis was assessed on postoperative day 7. Statistical analyses included the Mann-Whitney U and log-rank tests with Expectation-Maximization Iterative Convex Minorant (EMICM) modeling.In the perforator flap group, the final area of necrosis corresponded to the ICGA-defined perfusion boundary observed between 10 and 50 seconds postinjection. In contrast, necrosis in the random flap group aligned with the ICGA-defined perfusion boundary captured between 30 and 150 seconds. The most accurate time points for necrosis prediction were 50 seconds for perforator flaps and 150 seconds for random flaps, both demonstrating statistical significance ( = 0.0028).ICGA timing requirements differ between flap types. Implementing flap-specific assessment windows may enhance intraoperative interpretation and reduce false-positive findings. These findings support the development of flap-specific ICGA protocols to improve intraoperative decision-making in reconstructive surgery.
Intraoperative Vasopressor Use Does Not Adversely Impact Free Flap Outcomes in Lower Extremity Limb Salvage Procedures in a Highly Comorbid Atraumatic Wound Population.
Rohrich RN, Episalla NC, Lin RP … +9 more , Ferdousian S, Suh J, Noshin M, Llaurado LJ, Youn RC, Attinger CE, Akbari CM, Wall RT, Evans KK
J Reconstr Microsurg · 2026 Jul · PMID 40912274 · Publisher ↗
BACKGROUND: The use of vasopressors during microsurgical reconstruction is debated. Their effect on the comorbid lower extremity (LE) wound population is unstudied. This study characterizes the impact of intraoperative v...
BACKGROUND: The use of vasopressors during microsurgical reconstruction is debated. Their effect on the comorbid lower extremity (LE) wound population is unstudied. This study characterizes the impact of intraoperative vasopressor use in LE free tissue transfer (FTT) for limb salvage. METHODS: A review of LE FTT from February 2017 to June 2024 was conducted. Flap outcomes within 7 and 42 days were evaluated, as well as long-term limb salvage. RESULTS: Of 258 LE FTT performed, vasopressors were used in 177 cases (68.6%). Most vasopressors were administered via intermittent bolus only (75.7%) or combined with continuous infusion (23.7%). American Society of Anesthesiologists Class was significantly higher in the vasopressor group compared with controls ( = 0.001). The vasopressor group trended to have higher median Charlson Comorbidity Indices (4, interquartile range [IQR]: 3 vs. 3, IQR: 3; = 0.055), and rates of diabetes (65.0% vs. 54.3%, = 0.103), peripheral vascular disease (63.8% vs. 51.9%, = 0.068), and chronic kidney disease (14.7% vs. 6.2%, = 0.063). The rate of reoperation, microvascular thrombosis, or flap success at 7 and 42 days did not differ between groups. By a median long-term follow-up of 24.5 (IQR: 39.2) months, rates of major limb amputation (vasopressor: 10.7% vs. control: 7.4%, = 0.402) and mortality (6.8% vs. 2.5%, = 0.237) were similar between groups. CONCLUSION: In this complex population, intraoperative use of vasopressors does not appear to negatively impact flap viability or limb salvage.
Robotic DIEP Flap Surgery: The Need for a Balanced Discussion of Intra-Abdominal Risks and Outcomes.
Horch RE, Arkudas A
J Reconstr Microsurg · 2025 Oct · PMID 40865914 · Publisher ↗
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Revisiting Heparin-Induced Thrombocytopenia among Patients Undergoing Free Tissue Transfer: A Systematic Review.
Yamin M, Tobin M, Raquepo T … +11 more , Park JB, Lee D, Escobar-Domingo MJ, Foppiani J, Fanning JE, Zhu E, Posso AN, Ma H, Lin SJ, Lee BT, Cauley RP
J Reconstr Microsurg · 2026 Jul · PMID 40840544 · Publisher ↗
BACKGROUND: Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can a...
BACKGROUND: Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can arise in patients exposed to heparin products. This systematic review aims to examine patterns in demographics, flap characteristics, diagnostic approaches, and treatment protocols for HIT following free flap reconstruction. METHODS: A systematic search was conducted across PubMed, MEDLINE, and Web of Science, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "heparin-induced thrombocytopenia," "HIT syndrome," "free flaps," "microsurgery," "plastic surgery," and "reconstructive surgery." Case reports or series written in English that presented patients developing HIT following free flap procedures were included. Eligibility criteria are accessible on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42025650125). RESULTS: A total of 15 articles were included, encompassing a total of 23 free flap reconstruction cases. The median patient age was 52 years, with male predominance (69.6). Lower extremity reconstruction was most common (47.8%), primarily using anterolateral thigh flaps (39.1%). Median 4T score was 6, median time to HIT diagnosis was 6 days, and median nadir platelet count was 72 × 10/μL. Thrombotic complications were common, with venous thrombosis (34.8%) predominating. Argatroban (26.1%) was the most frequently used alternative anticoagulant, while warfarin (30.4%) was the most common discharge medication. Overall flap survival was 43.5%. Meta-analysis revealed no significant difference in flap survival between anticoagulation strategies (95% CI: 0.38-2.63, = 1.000). CONCLUSION: HIT represents a rare but devastating complication in free flap reconstruction, with approximately half of the affected flaps failing despite intervention. Although no single anticoagulation strategy demonstrated superior outcomes, expeditious diagnosis and treatment may improve flap salvage rates. This review provides a foundation for developing standardized protocols for HIT management in microsurgical patients.
Surgeon Experience and Outcomes in Microsurgical Breast Reconstruction: A 10-Year Single Surgeon Analysis.
Rothchild E, Smith IT, Popoola SO … +2 more , Ricci JA, Tanna N
J Reconstr Microsurg · 2026 Jul · PMID 40840543 · Publisher ↗
BACKGROUND: Microsurgical breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has become increasingly popular. While surgeons undergo rigorous training, it is believed that plastic surgeons contin...
BACKGROUND: Microsurgical breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has become increasingly popular. While surgeons undergo rigorous training, it is believed that plastic surgeons continue to refine and enhance their performance through independent practice. This study evaluates the effect of surgeon experience on clinical outcomes in DIEP flap breast reconstruction. METHODS: A retrospective review was conducted on consecutive DIEP flap procedures performed by a single surgeon from fellowship completion in 2013 to 10 years of independent professional practice in 2023. Patients were categorized into "early" and "late" groups, separated by a midpoint surgery date (July 30, 2018). Statistical analyses included student's -tests, chi-squared analysis with Fisher's exact test, and multivariable regressions controlling for comorbidities. RESULTS: The study included a total of 1,182 DIEP flaps in 632 patients, with 238 in the early group and 394 in the late group. The late group had a lower mean body mass index (28.83 vs. 29.98, = 0.004), prevalence of hypertension (26.6% vs. 35.3%, = 0.021), and prevalence of diabetes (7.9% vs. 14.3%, = 0.010) than the early group. After controlling for potential confounders, the late group was independently associated with decreased length of stay (incidence rate ratio [IRR] = 0.611, < 0.001) and fewer revision surgeries (IRR = 0.689, < 0.001). CONCLUSION: This large, single-surgeon series demonstrates that even with extensive initial training, plastic surgeons continue to evolve their surgical outcomes through accumulated experience. These findings emphasize the importance of consistent volume over time in achieving optimal results in microsurgical breast reconstruction.
Functional Rehabilitation and Quality of Life After Fibula Free Flap Reconstruction in Mandibular Defects.
Fiedler M, Brunnhuber C, Eichberger J … +8 more , Gottsauner M, Schuderer JG, Maurer M, Taxis J, Meier JK, Gerken M, Reichert TE, Ettl T
J Reconstr Microsurg · 2026 Jul · PMID 40840542 · Publisher ↗
BACKGROUND: Patients undergoing mandibular reconstruction often experience long-term functional and aesthetic challenges, impacting their quality of life (QOL). The objective of this study was to identify factors that mo...
BACKGROUND: Patients undergoing mandibular reconstruction often experience long-term functional and aesthetic challenges, impacting their quality of life (QOL). The objective of this study was to identify factors that most powerfully impact the long-term QOL and functional outcome of patients following mandibular reconstruction with free fibula flaps. This investigation was undertaken to enhance the treatment of this patient population. METHODS: QOL was assessed between March 2022 and May 2023 in 47 consecutive patients undergoing mandibular reconstruction with fibula free flaps (FFFs) using the University of Washington QOL Questionnaire. Evaluation of functional outcome was based on mouth opening, jaw deviation, tissue atrophy, tongue mobility, lip competence, and speech intelligibility. RESULTS: The study found that loss of chewing was the strongest impairment of QOL (score: 63.83). The most important negative predictors for QOL were female gender ( = 0.047), radiotherapy (QOL subcategory -values: = 0.007 to = 0.034), anterior segment resection (QOL subcategory -values: = 0.038 to = 0.045), advanced defect size (QOL subcategory -values: = 0.008 to = 0.035), and free-hand fibula reconstruction (QOL subcategory -values: = 0.003 to = 0.041). Long-term outcomes revealed that reduced tissue atrophy (QOL subcategory -values: < 0.001 to = 0.025) and preserved tongue mobility (QOL subcategory -values: = 0.002 to = 0.043) were associated with better QOL scores. Functional limitations such as reduced mouth opening (QOL subcategory -values: = 0.008 to = 0.049) and impaired speech intelligibility (QOL subcategory -values: < 0.001 to = 0.015) were significantly correlated with lower QOL in several domains. CONCLUSION: Mandibular reconstruction with FFFs provides a favorable long-term QOL and functional outcomes, though certain clinical factors, including radiotherapy, anterior segment resection, and defect size, significantly reduce patient-reported QOL.
A Novel Lymphosome-Based Long-Lasting Rat Tail Model of Lymphedema.
Chen J, Wang Y, Tu S … +6 more , Zhou Y, Qin H, Tang Z, Chen Y, Xiao S, Deng C
J Reconstr Microsurg · 2026 Jul · PMID 40840541 · Full text
BACKGROUND: Secondary extremity lymphedema is a chronic and progressive condition caused by obstructed lymphatic drainage, commonly following lymphadenectomy, infection, or trauma. Rodent models are preferred for experim...
BACKGROUND: Secondary extremity lymphedema is a chronic and progressive condition caused by obstructed lymphatic drainage, commonly following lymphadenectomy, infection, or trauma. Rodent models are preferred for experimental lymphedema research due to cost-effectiveness and reproducibility. Currently, rat tail models encounter limitations due to transient swelling and their inability to fully replicate the comprehensive pathophysiology of lymphedema, particularly concerning the effects of lymph node removal. METHODS: We developed a series of rat tail lymphedema models incorporating skin resection, deep lymphatic vessel disruption, and gluteal lymph node (GLN) excision to assess effects on lymphatic architecture, inflammation, and fibrosis. Indocyanine green (ICG) lymphography was used to visualize lymphatic function. Tail volume and circumference were measured weekly, and histological assessments quantified fibrosis and fibroadipose thickening. Bulk RNA sequencing was performed to characterize the inflammatory processes triggered by GLN removal. RESULTS: The combined model (skin removal, deep lymphatic disruption, and GLN excision) resulted in severe and persistent lymphedema marked by progressive swelling and pronounced fibrosis. ICG lymphography confirmed disruption of superficial lymphatic flow with partial recanalization of deep channels. Notably, lymphangiogenesis was observed at the GLN excision site, forming compensatory pathways connecting the tail to the popliteal lymph nodes. Histology revealed extensive collagen deposition and fibroadipose thickening in groups with lymph node removal, with the combined model showing the most pronounced changes. Bulk RNA-sequencing confirmed the removal of GLN involving the inflammatory and fibrosis process in the tail model. CONCLUSION: This lymphosome-based rat tail model successfully replicates key features of lymphedema, including sustained swelling, lymphatic disruption, inflammation, and fibrosis.
Ex Vivo Rabbit: A Novel High-Fidelity Training Model for Microsurgical and Supermicrosurgical Training.
Andresen-Lorca B, Heredia-Alcalde I, Alvedro-Ruiz P … +3 more , García-García M, Ruiz-Cases A, Pérez-Del-Caz MD
J Reconstr Microsurg · 2026 Jul · PMID 40840540 · Publisher ↗
BACKGROUND: The development of appropriate microsurgical and supermicrosurgical skills is essential for reconstructive surgeons. Training courses frequently employ in vivo models, which have various drawbacks: Limited av...
BACKGROUND: The development of appropriate microsurgical and supermicrosurgical skills is essential for reconstructive surgeons. Training courses frequently employ in vivo models, which have various drawbacks: Limited availability, high cost, and/or ethical conflicts. To overcome these limitations, we looked for an inert model that was analogous to the gold standard in vivo, surpassing the classic ex vivo models at the same time. METHODS: We studied the ex vivo rabbit as an animal training model by means of 10 specimen dissections, microscopically analyzing the mean caliber and length of its main vascular pedicles and comparing them to those of the most common flaps and recipient vessels employed in reconstructive surgery. We designed a routine with increasingly difficult exercises, which we propose as a training plan. RESULTS: The rabbit's main vascular pedicles have a mean caliber of 0.4 mm (internal mammary), 0.8 mm (iliolumbar), 0.9 mm (brachial), 1.2 mm (femoral), 1.5 mm (renal), 1.9 mm (common carotid), and 2.8 mm (aorta). They allow for a progressive increase in the level of complexity, as well as the practice of a wide variety of techniques (end-to-end anastomosis between vessels of different sizes, end-to-side anastomosis, neurorrhaphies, nerve transfers, ortho- and heterotopic replants, and free flaps). CONCLUSION: The ex vivo rabbit serves as a valid alternative to other recognized high-fidelity microsurgical models, overcoming the limitations of in vivo-it is easily accessible, inexpensive, and inert-as well as ex vivo-it offers a wide range of calibers and the possibility of practicing advanced techniques-models which have been used in the past.
Reconstruction of the Acute Isolated Common Peroneal Nerve Palsy Using Primarily Nerve Repair and/or Nerve Graft: A Single-Center 28-Year Experience.
Izadpanah A, Aytac YA, Sakarya AH … +6 more , Lee CH, Daniel B, Chen LW, Lu JC, Chuang DC, Chang TN
J Reconstr Microsurg · 2026 Jun · PMID 40840493 · Publisher ↗
BACKGROUND: Drop foot is a devastating problem in patients with common peroneal nerve palsy (CPN). The standard surgical treatments are categorized into three main categories: nerve-related procedures, tendon transfers,...
BACKGROUND: Drop foot is a devastating problem in patients with common peroneal nerve palsy (CPN). The standard surgical treatments are categorized into three main categories: nerve-related procedures, tendon transfers, and functioning free muscle reconstruction. The outcomes of nerve surgeries such as neurolysis, nerve repair, transfer, or graft remain controversial. In this study, we present our experience in acute CPN palsy, employing neurolysis, nerve repair, and nerve grafting in a single institution. METHODS: Between 1980 and 2016, 50 patients with CPN injury underwent either primary nerve repair, neurolysis, or nerve graft. Thirty-eight patients met our final inclusion criteria. The functional outcomes of CPN injury were reviewed, categorizing surgical outcomes into three groups based on total ankle ROM and muscle strength. Those with total ROM less than 20 or < M2 muscle strength, 20 to 30 or ≥M2, and ≥30 degrees or ≥M3 were believed to have poor, good, and excellent outcomes, respectively. RESULTS: Nerve grafts shorter than 6 cm are associated with better functional outcome in CPN. Seventy-one percent of patients with nerve grafts shorter than 6 cm achieved good-excellent functional results. Furthermore, 100% of patients in the neurolysis and primary nerve repair groups achieved excellent functional outcomes. CONCLUSION: CPN surgery is often associated with underwhelming outcomes. With appropriate patient selection and meticulous surgical techniques, one could expect acceptable outcomes in such a patient population. The correct diagnosis and early intervention, along with postoperative immobilization and aggressive rehabilitation, are crucial for improving the outcomes.
The Clinical Pearls and Pitfalls of Using the Symani System in Microsurgery.
Ratnaparkhi A, Finkelstein E, Chaudhry AS … +6 more , Xu K, Tadisina K, Medina M, Danker S, Singh D, Mella-Catinchi JR
J Reconstr Microsurg · 2026 Jun · PMID 40812343 · Publisher ↗
BACKGROUND: The improved stability and controllability of robotics has the potential to expand the spectrum of reconstructive surgery. Until recently, however, no robot was designed specifically for microsurgery. The pre...
BACKGROUND: The improved stability and controllability of robotics has the potential to expand the spectrum of reconstructive surgery. Until recently, however, no robot was designed specifically for microsurgery. The present study aims to summarize the clinical pearls and pitfalls of utilizing the Symani Surgical System in microsurgical practice. METHODS: The PubMed Database was queried using the search term "Symani Robot System" from inception until January 2025. Data regarding demographics, study design, technique, and surgical outcomes were extracted from the full text by two independent reviewers. RESULTS: In the present analysis, 21 publications encompassing the results of 397 patients (range: 1-100) and 642 robotic anastomoses were included. Of the 335 patients included in the studies that reported complication rates, pooled analysis yielded an overall complication rate of 14.03% ( = 47) and a partial or complete flap loss rate of 2.09% ( = 7). Of 642 robotic total anastomoses, only 1.24% ( = 8) required a transition to a manual approach. A total of 19 groups (90.47%) reported high precision of Symani, 15 (71.43%) highlighted improved surgical access to deeper anatomical fields, and 12 (57.15%) reported enhanced microsurgical ergonomics. Regarding limitations, 13 (61.90%) cited the expense of the system, 5 (23.81%) reported a lack of haptic feedback, 5 (23.81%) identified instrument "stickiness" as a factor slowing operations, and 3 (14.29%) highlighted the need for improved grip. The learning curve associated with Symani was discussed in 15 studies (71.43%). CONCLUSION: The results of the present literature review demonstrate that the Symani robot offers numerous benefits that will help advance the field of microsurgery. It provides complete tremor elimination, motion scaling, and improved operative ergonomics, leading to patent anastomosis and complication rates comparable to a traditional manual approach. However, more data are needed before widespread clinical implementation to determine whether the increased precision and controllability outweigh the cost and learning curve. LAY SUMMARY: The present study highlights the use of the Symani Surgical System, a novel robotic system designed specifically for microsurgery. Symani offers increased precision, dexterity, controllability, and numerous benefits that will help advance the field.
Abdominal Peripheral Nerve Blocks Do Not Impact Postoperative Pain in Free Flap Breast Reconstruction.
Aryanpour Z, Wallace A, Winocour J … +3 more , Mathes DW, Kaoutzanis C, Egan KG
J Reconstr Microsurg · 2026 Jun · PMID 40812342 · Publisher ↗
BACKGROUND: Transverse abdominis plane (TAP) and rectus sheath (RS) blocks are utilized in enhanced recovery after surgery protocols, but with highly variable methodologies and outcomes in reported literature. The purpos...
BACKGROUND: Transverse abdominis plane (TAP) and rectus sheath (RS) blocks are utilized in enhanced recovery after surgery protocols, but with highly variable methodologies and outcomes in reported literature. The purpose of this study was to evaluate the efficacy of abdominal peripheral nerve blocks in free flap breast reconstruction as they pertain to postoperative pain medication requirements and hospital length of stay (LOS). METHODS: Retrospective review was conducted on patients undergoing breast reconstruction with deep inferior epigastric artery perforator free flaps at a large academic institution. Target variables included history of chronic pain diagnosis, laterality, and nerve block type (TAP or RS). Outcomes included daily and total opioid oral morphine milligram equivalents on postoperative days one to three. Patient cohorts were analyzed by TAP block, RS block, or no block. Blocks were performed intraoperatively by the surgical team. RESULTS: Between 2021 and 2023, 225 patients met the inclusion criteria; 87 received TAP blocks, 72 received RS blocks, and 66 received no block. Patients with chronic pain diagnoses who underwent bilateral reconstruction had higher total postoperative opioid requirements. There were no significant differences in hospital LOS or postoperative pain medication requirements between the three groups before or after controlling for multiple co-variables. CONCLUSION: In this large cohort of abdominal-based free flap breast reconstruction patients, there was no impact of peripheral nerve block or nerve block type on postoperative pain medication requirement or hospital LOS. Bilateral flap reconstruction and a history of chronic pain diagnoses were the only factors found to affect perioperative opioid utilization in patients undergoing abdominally based breast reconstruction.
Do We Need a Negative Culture? Examining the Role of Final Debridement Cultures in Microsurgical Limb Salvage: Recommendations from Our 13-Year Experience.
Rohrich RN, Carreras JP, Sharma S … +6 more , Lin RP, Ferdousian S, Currin ME, Youn RC, Attinger CE, Evans KK
J Reconstr Microsurg · 2026 May · PMID 40795903 · Publisher ↗
Lower extremity free tissue transfer (LE FTT) expands limb salvage options for patients with chronic wounds. Infected wounds require serial debridement to optimize the wound bed before reconstruction, but the role of qua...
Lower extremity free tissue transfer (LE FTT) expands limb salvage options for patients with chronic wounds. Infected wounds require serial debridement to optimize the wound bed before reconstruction, but the role of qualitative microbiological cultures in guiding surgical wound closure timing remains unclear. This study evaluates the impact of final preoperative culture results on postoperative outcomes, including flap success, infection rates, and limb salvage.A retrospective review of 344 patients undergoing LE FTT at a single institution was conducted. All patients underwent serial debridement, with final cultures obtained from the final debridement prior to flap reconstruction. Patients were stratified into positive and negative final culture groups. Subgroup analyses assessed the impact of polymicrobial colonization and comorbidity burden (Charlson Comorbidity Index [CCI] >6) on outcomes. Primary outcome was flap infection, defined as any documented clinical concern for infection, including cellulitis, purulent drainage, abscess formation, or initiation of targeted antibiotic therapy.Polymicrobial final cultures were associated with increased infection ( = 0.003) and flap complications ( = 0.041). Among patients with CCI >6, positive final culture was associated with significantly higher infection rates ( = 0.032), but not among those with CCI ≤6. In the total cohort, comparing positive final culture to negative final culture, flap outcomes were similar between groups.Final culture positivity alone does not predict poor outcomes, but polymicrobial cultures and host factors may increase flap infection risk. A risk-stratified approach should guide surgical decision-making, with additional debridement and/or wound bed optimization considered for polymicrobial wounds and polymorbid patients (CCI >6).
Artificial Intelligence in Microsurgical Education: A Systematic Review of Its Role in Training Surgeons.
Raquepo TM, Tobin M, Puducheri S … +4 more , Yamin M, Dhillon J, Bridgeman M, Cauley RP
J Reconstr Microsurg · 2026 Jun · PMID 40744105 · Publisher ↗
BACKGROUND: Microsurgery is associated with a steep learning curve that requires extensive training through supervised surgeries, cadaver practice, and simulations. The emergence of artificial intelligence (AI) in medica...
BACKGROUND: Microsurgery is associated with a steep learning curve that requires extensive training through supervised surgeries, cadaver practice, and simulations. The emergence of artificial intelligence (AI) in medical education offers a new potential avenue for microsurgery training by providing real-time feedback, performance analytics, and advanced simulation. This study aims to evaluate the scope, implementation, and outcomes of AI in microsurgical education for trainees across all levels. METHODS: A systematic review was performed in October 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis with extension for Scoping Reviews (PRISMA-ScR) guidelines. Four databases, including Embase, PubMed, Scopus, and Web of Science, returned 3,323 citations. Inclusion criteria were studies investigating the use of AI in the medical education of microsurgical trainees. Abstracts, commentaries, editorials, systematic reviews, and non-English studies were excluded. After two-stage screening, a total of 16 studies were included in this review. RESULTS: The assessed AI interventions appeared in the following number of studies: Computer Vision ( = 13), Sensor-Driven Models ( = 2), Classical/Statistical Machine Learning ( = 4), Task-Specific Neural Networks ( = 4), Transfer Learning of Neural Networks ( = 3), Zero-Shot Inference of Pretrained Models ( = 5), Augmented/Virtual Reality ( = 5), and Anatomical Landmark Tracking ( = 5). Upon full data extraction, three overarching themes were identified among studies: (1) Objective Assessment of Microsurgical Skills, (2) Innovations in Microsurgical Education Materials, and (3) Improvement of Surgeon Workload and Performance. AI improved skill assessment (accuracy: 0.74-0.99), training, and workload optimization. AI-enhanced microsurgical training reduced training time ( = 0.015), improved ergonomics, and minimized cognitive load, accelerating learning (β = 0.86 vs. β = 0.25). CONCLUSION: AI has transformative potential in microsurgical education and practice, as emphasized by its capacity to enhance skill assessment, educational tools, and ergonomic support. Despite these enhancements, additional work is needed to address challenges such as data bias, standardization, and real-world implementation.
The Efficacy of Transversus Abdominis Plane Blocks in Abdominal Tissue Free Flap Breast Reconstruction.
Park RH, Odega UK, DeVito RG … +3 more , Chou J, Campbell CA, Stranix JT
J Reconstr Microsurg · 2026 Jun · PMID 40744104 · Publisher ↗
BACKGROUND: Regional blocks are effective adjuncts in autologous breast reconstruction. Data on specific regional blocks and agents remain unclear. METHODS: We performed a retrospective review of patients who underwent a...
BACKGROUND: Regional blocks are effective adjuncts in autologous breast reconstruction. Data on specific regional blocks and agents remain unclear. METHODS: We performed a retrospective review of patients who underwent abdominal free flap breast reconstruction between July 2017 and June 2022. A total of 256 patients were included with 181 who received Exparel transversus abdominis plane (TAP) blocks, 54 with non-Exparel TAP blocks, and 21 without a TAP block. Length of stay (LOS), intensive care unit length of stay (ICU LOS), average daily morphine milligram equivalents (MME), and average total MME were collected. RESULTS: Comparing the Exparel TAP block cohort and non-Exparel TAP block cohort, there was no difference in LOS (2.71 vs. 2.72 days, = 0.96), ICU LOS (0.35 vs. 0.56 days, = 0.18), daily MME (29.08 vs. 29.71 MME, = 0.85), and total MME (113.69 vs. 113.92 MME, = 0.99). Comparing the Exparel TAP block cohort and non-TAP block cohort, there were significant differences in LOS (2.71 vs. 3.62 days, = 0.003), ICU LOS (0.35 vs. 1.1 days, = 0.001), daily MME (29.08 vs. 39.56, = 0.04), and total MME (113.69 vs. 195.55, = 0.001). When comparing the non-Exparel TAP block cohort and the non-TAP block cohort, there were differences in LOS (2.72 vs. 3.62 days, = 0.004), ICU LOS (0.56 vs. 1.1 days, = 0.04), and total MME (113.92 vs. 195.55 MME, = 0.006). CONCLUSION: TAP block can effectively reduce the LOS and postoperative narcotic use in patients undergoing autologous breast reconstruction regardless of the choice of local anesthetic.
Adipose-Derived Stem Cell Sheets Prepared with Ascorbate 2-Phosphate Enhance Nerve Regeneration in Rat Sciatic Nerve Autografts.
Murai A, Tada K, Akahane M … +9 more , Nakamura Y, Honda S, Matsuta M, Mori A, Demura S, Roboon J, Hattori T, Hori O, Tsuchiya H
J Reconstr Microsurg · 2026 Jun · PMID 40744103 · Publisher ↗
BACKGROUND: Autologous nerve grafts remain the gold standard for peripheral nerve repair, but have limited regenerative potential. Adipose-derived stem cells (ADSCs) have been investigated for their potential in nerve re...
BACKGROUND: Autologous nerve grafts remain the gold standard for peripheral nerve repair, but have limited regenerative potential. Adipose-derived stem cells (ADSCs) have been investigated for their potential in nerve regeneration, and ascorbate 2-phosphate (A2P) enables the formation of ADSC sheets. This study examined whether ADSC sheets applied around autologous nerve grafts enhance functional and histological recovery in a rat sciatic nerve model. METHODS: A 15 mm sciatic nerve segment was excised, inverted, and sutured for autologous grafting in rats. Three groups were compared: phosphate-buffered saline (control), ADSC suspension, and ADSC sheets. Functional recovery was assessed at 12 weeks ( = 10 per group) using the sciatic functional index (SFI), nerve conduction studies (NCS; latency and amplitude), and tibialis anterior muscle wet weight. Histological analyses, including toluidine blue staining, evaluated axonal changes at 1, 2, 4, 8, and 12 weeks ( = 3 per group per time point). DiI-labeled ADSCs were tracked at 1 week to assess cell retention ( = 3 per group). RESULTS: At 12 weeks, the ADSC sheet group showed significantly improved SFI and muscle wet weight compared with controls and ADSC suspension groups. NCS revealed shorter distal latency in the ADSC sheet group versus controls, with no significant differences in the suspension group. While histological analysis did not demonstrate statistically significant differences among the groups, qualitative observations suggested that the ADSC sheet group tended to exhibit a greater number of myelinated axons at 12 weeks and fewer degenerative changes at earlier time points (1 and 2 weeks). DiI-labeled ADSCs were more frequently observed around the graft in the sheet group compared with the suspension group. CONCLUSION: Application of ADSC sheets to autologous nerve grafts may promote functional recovery. Forming ADSC sheets with A2P may represent a favorable approach for improving outcomes in peripheral nerve repair.
Achieving Textbook Outcomes in Bilateral DIEP Flap Breast Reconstruction: Does a Co-Surgeon Matter?
DeVito RG, Newson C, Ke BG … +5 more , Yang H, Pawly J, Hollenbeck ST, Campbell CA, Stranix JT
J Reconstr Microsurg · 2026 Jun · PMID 40744102 · Publisher ↗
BACKGROUND: It is essential to examine predictors of ideal outcomes in surgery. "Textbook outcomes" are optimal surgical results based on multiple quality measures. It is important that patients have access to trusted ce...
BACKGROUND: It is essential to examine predictors of ideal outcomes in surgery. "Textbook outcomes" are optimal surgical results based on multiple quality measures. It is important that patients have access to trusted centers that consistently produce high-quality surgical outcomes. METHODS: A retrospective review of all bilateral Deep Inferior Epigastric Perforator (DIEP) flap breast reconstructions at our institution from 2017 to 2022 was performed. Criteria for "textbook outcome" were operating room (OR) time within one standard deviation of institutional average or less, length of stay ≤ 4 days, no intraoperative complications, no operative complications, no readmission within 30 days, no infection requiring IV antibiotics, no systemic complications, and no mortality. Propensity score matching was used to control for common comorbidities, reconstruction timing, and oncologic factors. This resulted in 47 matched pairs of bilateral DIEP flap reconstructions for comparison between a single-surgeon cohort and a co-surgeon cohort. RESULTS: Textbook outcomes occurred at a significantly higher rate in the co-surgeon cohort compared with the single surgeon cohort (79% vs. 57%, = 0.025). The average OR time was significantly shorter in the co-surgeon cohort compared with the single surgeon cohort (403 minutes vs. 572 minutes, < 0.0001), and elevated OR time was the most common reason for not achieving a textbook outcome. There were no differences in the other criteria for a "textbook outcome." CONCLUSION: Textbook outcomes in bilateral DIEP flap breast reconstruction are achieved at significantly higher rates with a co-surgeon. This is primarily due to significantly shorter OR times. Further research into factors affecting textbook outcomes is needed.
Evaluating Dynamic Smile Outcomes of Free Gracilis Muscle Transfer in Pediatric Facial Palsy Using Image-Based Analysis.
Bakovic M, Pekcan A, Patel R … +7 more , Mejia V, Danto S, Lazar M, Magee Iii WP, Lee J, Urata MA, Hammoudeh J
J Reconstr Microsurg · 2026 Jun · PMID 40738135 · Publisher ↗
BACKGROUND: Facial nerve palsy in children leads to significant functional impairment and facial asymmetry. While free gracilis muscle transfer (FGMT) is a cornerstone technique for smile reanimation in both pediatric an...
BACKGROUND: Facial nerve palsy in children leads to significant functional impairment and facial asymmetry. While free gracilis muscle transfer (FGMT) is a cornerstone technique for smile reanimation in both pediatric and adult patients, its evaluation has mainly focused on the single metric of commissure excursion. This study seeks to evaluate the effectiveness of FGMT in restoring dynamic smiles in pediatric patients with facial palsy using image analysis. METHODS: A retrospective review was conducted in children who underwent FGMT for facial palsy at a major children's hospital between 2007 and 2020. Data collection included pre- and postoperative chart reviews and image analysis. Anthropometric measurements were obtained using a machine learning-based smile analysis software. Primary outcomes included commissure excursion, commissure angle, dental show, and smile symmetry. Statistical analysis was performed using the Wilcoxon signed-rank test. RESULTS: A total of 31 patients with an average age of 10 years underwent FGMT for smile reanimation during the study period. The most common diagnosis was Moebius syndrome (48%). Donor nerves for gracilis neurotization included 18 ipsilateral trigeminal nerves (58.1%) and 12 contralateral facial nerves via cross-face sural nerve grafts (38.7%). Overall, 84% of patients demonstrated active gracilis contraction within a mean of 2.5 years postoperative follow-up. Commissure excursion increased by 9.7 mm at 1 year ( < 0.05), and symmetry significantly improved for commissure height, commissure excursion, upper lip height, and smile angle. There were no significant improvements in dental show, commissure angle, symmetry of dental show, and lower lip height. Furthermore, only 16% of patients demonstrated clinically symmetric smiles within the follow-up period. CONCLUSION: While FGMT effectively restores commissure excursion in pediatric patients with facial palsy, achieving multidimensional smile reanimation remains a challenge. New techniques in multi-vector free tissue transfer may help optimize FGMT outcomes in pediatric patients.
Optimizing Donor Site Morbidity in DIEP Flap Reconstruction: Advancements in Minimizing Anterior Fascial Defects: A Systematic Review.
Phuyal D, Mordukhovich I, Gaston J … +7 more , Rios-Diaz AJ, Darras O, Obeid R, Djohan R, Schwarz G, Gurunian R, Bishop SN
J Reconstr Microsurg · 2026 Jun · PMID 40681157 · Publisher ↗
BACKGROUND: Numerous minimally invasive deep inferior epigastric perforator flap (MI-DIEP) techniques have been described in the literature to reduce donor site morbidities. This systematic review aimed to summarize exis...
BACKGROUND: Numerous minimally invasive deep inferior epigastric perforator flap (MI-DIEP) techniques have been described in the literature to reduce donor site morbidities. This systematic review aimed to summarize existing MI-DIEP techniques and postoperative outcomes relative to conventional harvest (cDIEP). METHODS: A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to include articles with novel DIEP harvesting techniques. Studies without perioperative information were excluded. Chi-square and Fisher's exact test were used to compare complication rates (partial flap loss, total flap loss, hernia or bulge, and fat necrosis) in MI-DIEP with cDIEP. Joanna Briggs Institute critical appraisal tool was used for bias assessment. RESULTS: A total of 978 patients underwent 1,272 MI-DIEP flap harvests across 17 studies. Techniques included robotic DIEP (rDIEP; = 97), abdominal perforator exchange (APEX; = 158), laparoscopic ( = 39), endoscopic ( = 94), two-staged delayed DIEP ( = 135), short fasciotomy ( = 124), short pedicle ( = 26), vascular pedicle measuring ( = 209), and microfascial incision ( = 81). No significant differences were found between endoscopic, laparoscopic, and robotic approaches compared with cDIEP. However, the short pedicle technique had higher partial flap loss (8.82% vs. 1.98%, = 0.04), while APEX and vascular pedicle measuring techniques had lower fat necrosis rates (1.99% and 0.48% vs. 5.81%, = 0.04 and 0.004 respectively). Short fasciotomy was associated with higher fat necrosis (12.9% vs. 5.8%, = 0.004) and longer hospital stay ( = 0.005). Robotic, laparoscopic, endoscopic, two-staged, and APEX techniques were associated with shorter hospital stays, and rDIEP was linked to reduced postoperative day 1 pain ( < 0.001). CONCLUSION: MI-DIEP techniques demonstrate comparable complication rates to cDIEP, with certain methods offering benefits such as reduced fat necrosis, shorter hospital stays, and less postoperative pain.
Complications and Hardware Failure Following Synthetic Cranioplasty Implants and Free Flap Coverage.
Oleck NC, Zhang KK, Shammas RL … +8 more , Nelson JA, Allen RJ, Matros E, Geng Y, Sergesketter AR, Naga HI, Erdmann D, Phillips BT
J Reconstr Microsurg · 2026 Jun · PMID 40681156 · Publisher ↗
BACKGROUND: Composite defects of the scalp and calvarium are complex reconstructive problems. Bony reconstruction is often achieved with synthetic implants, demanding robust soft tissue coverage. In cases where the nativ...
BACKGROUND: Composite defects of the scalp and calvarium are complex reconstructive problems. Bony reconstruction is often achieved with synthetic implants, demanding robust soft tissue coverage. In cases where the native scalp has been compromised, free tissue transfer may be indicated. The existing literature on this topic lacks a robust analysis of long-term outcomes and hardware retention rates. The current study is a multi-institutional review of composite calvarial reconstruction with free flap coverage of synthetic cranioplasty implants, focusing specifically on flap selection, long-term outcomes, hardware extrusion, and explantation rates. METHODS: A retrospective review was conducted at two high-volume institutions for patients who had undergone cranioplasty and free tissue transfer between 2001 and 2022. Patient demographics and comorbidities, reconstructive indications, cranioplasty material, flap type, and complications within a 90-day period were collected. Implant exposure and explantation data were collected through follow-up. RESULTS: A total of 42 patients were identified with an average age of 59 years (SD 14.9). Prior scalp radiation was present in 54.7% of cases. Cranioplasty was most commonly indicated after tumor extirpation (88.0%), with titanium mesh as the most common material utilized (64.3%). The most commonly used free flaps were latissimus (45.2%), anterolateral thigh (ALT) (16.7%), and radial forearm (16.7%). The most common recipient vessels were the superficial temporal (64.2%), facial (21.4%), and superior thyroid (9.5%). Flap compromise requiring return to the operating room occurred in two patients (4.8%) and partial flap loss occurred in three patients (7.14%). Surgical complications occurred in 60% of cases with wound complications (33.3%) and surgical site infection (28.6%) being the most common. Implant extrusion occurred in 31% of cases at an average of 7.9 months (SD 30.1) after definitive reconstruction, and explantation was required in 42.9% of cases at an average of 12.8 months (SD 33.6). The average total length of follow-up was 27.1 months. CONCLUSION: This multi-institutional analysis found that patients who undergo composite cranial vault reconstruction and free flap coverage experience high rates of surgical complications, and over one-third of these patients experience implant extrusion or explantation. Although no individual patient-related risk factor was independently associated with increased complication rates, our findings suggest that flap composition and timing of reconstruction may influence hardware retention and should be carefully considered during preoperative planning.
Cephalic Vein Transposition for Head and Neck Reconstruction: An Anatomical Study.
Bahat D, Fodor R, Suriadinata D … +6 more , Hoerger K, Siska R, Jackson D, Sebastiano AD, Albabish W, Djohan R
J Reconstr Microsurg · 2026 May · PMID 40681155 · Publisher ↗
This study aims to evaluate the anatomical feasibility and utility of cephalic vein transposition for venous outflow in head and neck reconstruction, particularly in vessel-depleted necks.Bilateral dissections were perfo...
This study aims to evaluate the anatomical feasibility and utility of cephalic vein transposition for venous outflow in head and neck reconstruction, particularly in vessel-depleted necks.Bilateral dissections were performed on 11 fresh cadavers to assess the cephalic vein's length, course, and suitability for transposition. The vein was freed, transected at the antecubital fossa, and transposed via a subcutaneous tunnel to the neck. Measurements were taken of the in situ vein length and the remaining length after transposition.Nineteen cephalic veins were suitable for transposition. The average in situ length was 31.40 ± 2.30 cm, and 29.59 ± 2.20 cm after division. Posttransposition, the residual length beyond the superior helix was 8.47 ± 2.53 cm. The average vein diameter was 3.12 ± 0.75 cm.Cephalic vein transposition is a viable option for venous anastomosis in vessel-depleted necks, providing a long, stable venous conduit with favorable anatomical characteristics for complex head and neck reconstructions.
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