Journal Of Reconstructive Microsurgery[JOURNAL]
Sun
200 papers
Functional Salvage of Ischemic Myopathy at the Neuromuscular Junction Level: A Mouse Model Study on Prolonged Muscle Ischemia in the Upper Limb.
Chen AC, Huang YH, Chuang DC … +1 more , Lu JC
J Reconstr Microsurg · 2026 Feb · PMID 40393655 · Publisher ↗
Ischemic myopathy in the upper limb may develop progressively in cases of peripheral arterial disease or acutely following traumatic vascular injuries. Prolonged ischemia can lead to catastrophic damage to distal muscles...
Ischemic myopathy in the upper limb may develop progressively in cases of peripheral arterial disease or acutely following traumatic vascular injuries. Prolonged ischemia can lead to catastrophic damage to distal muscles, with a significant risk of irreversible motor function loss. It is hypothesized that the neuromuscular junction (NMJ) sustains substantial damage beyond a critical threshold of arterial ischemia. Furthermore, concomitant upstream nerve injuries may exacerbate NMJ degeneration, potentially resulting in permanent dysfunction. This study aims to evaluate the NMJ-level changes in target muscles and investigate the impact of nerve injury and repair, with a particular focus on the potential benefits of the supercharge end-to-side (SETS) nerve transfer technique.A mouse forelimb ischemia model was created by clamping the brachial artery and ablating collateral vessels. The first aim assessed NMJ changes with increasing ischemia time. The second investigated the impact of ischemia on muscle reinnervation after transection and repair of the median nerve. Lastly, the ulnar nerve was used for SETS to the distal median nerve following nerve repair to evaluate its effect on muscle recovery. Functional grip tests, electrophysiological assessments, and immunohistochemical analyses were performed.Prolonged ischemia significantly decreased CMAP and grip strength, with markedly declined after 8 hours of prolonged arterial ischemia. When the upstream median nerve was cut and repaired, NMJ innervation of the target muscle dropped significantly at 12 hours, with fully innervated NMJs reduced to 27 to 39% compared with 67 to 72% at 4 to 8 hours (control = 81%). SETS transfers significantly improved CMAP, grip strength, and NMJ innervation, particularly in the 12-hour ischemia group.Prolonged ischemia leads to severe NMJ degeneration within the target muscle, with 8 hours being the critical time point at limb ischemia, and 12 hours being the time point after ischemia and nerve injury. As an alternative to limb amputation or muscle loss, SETS nerve transfer to augment the innervating median nerve can initiate partial NMJ innervation within the remaining target muscles to attempt to restore functional capacity.
Comparison of Biomechanical and Histopathological Properties of Robot-Assisted Anastomoses Using the Symani Surgical System® versus Conventional Anastomoses in a Preclinical Microsurgical Model.
Guillaume VGJ, Ammo T, Leypold S … +4 more , Praster M, Jonigk D, Beier JP, Leypold T
J Reconstr Microsurg · 2026 Feb · PMID 40389220 · Publisher ↗
The Symani surgical system (Symani) is the first robotic system specifically designed for microsurgical purposes and attracted substantial interest in recent times. Despite some initial investigations, no independent ana...
The Symani surgical system (Symani) is the first robotic system specifically designed for microsurgical purposes and attracted substantial interest in recent times. Despite some initial investigations, no independent analysis of the histopathological/biomechanical properties and anastomoses quality of Symani-sutured anastomoses have been conducted so far. This study aims to compare in-depth robotic-assisted microsurgical anastomoses using the Symani versus conventional anastomoses regarding anastomosis quality, biomechanical, and histopathological properties.We compared 12 microsurgical end-to-end anastomoses sewn by the Symani versus 12 by the conventional technique in a preclinical artery chicken-thigh-model regarding time until completion of the anastomosis, anastomosis quality (modified MARS10-rating and anastamosis lapse index (ALI)) and diameter. Additionally, histopathological analysis of the thread hole diameter, and knot firmness as well as biomechanical tests for intraluminal resistance and tensile strength of the anastomoses were conducted.Anastomosis quality was comparable between both techniques. The Symani-assisted anastomosis took a significantly longer time to perform than conventional anastomosis. Histopathological analysis revealed similar vessel wall damage while showing greater variability in knot spacing and bite width in the robotic anastomoses. No significant differences were observed in the tensile strength test or intraluminal resistance. However, the knot firmness of Symani-assisted anastomosis was significantly less than conventionally performed knots.This study demonstrates that the Symani performs on par with conventional anastomosis techniques regarding anastomosis quality, vessel wall damage, intraluminal resistance, and tensile strength. Long-term continuous training and/or further innovations of the Symani system may lower the time required to perform the anastomosis and improve knot firmness.
Should Caffeine Be Avoided Following Free Flaps: Fact or Fiction?
Dharmarajah N, Chon J, DiChiaro B … +1 more , Bucholz E
J Reconstr Microsurg · 2026 Feb · PMID 40373811 · Publisher ↗
Many microsurgeons recommend that their patients avoid all compounds containing caffeine after free tissue transfer, however, there is little in the literature to implicate caffeine as a contributor to flap loss. While c...
Many microsurgeons recommend that their patients avoid all compounds containing caffeine after free tissue transfer, however, there is little in the literature to implicate caffeine as a contributor to flap loss. While caffeine has historically been viewed as a vasoconstrictor that could theoretically impair flap perfusion, its physiological effects are complex, involving both vasoconstrictive and vasodilatory mechanisms. This review aims to determine whether caffeine consumption may increase flap-related complications including ultimate failure.A narrative review was conducted through PubMed and Google Scholar to evaluate the mechanism of action of caffeine. Articles were included if they provided insights into caffeine's mechanisms of action in the central nervous system, cardiovascular system, endothelium, and microcirculation.Caffeine causes the release of neurotransmitters in the CNS promoting wakefulness through the antagonism of adenosine receptors. In both smooth muscle and vascular endothelium, caffeine promotes vasodilation through the activation or inhibition of different types of receptors including adenosine, inositol triphosphate, and nitrous oxide. Studies in both human and animal models suggest that caffeine does not significantly affect microvascular perfusion or anastomotic patency. Data suggest that habitual caffeine consumers show blunted vascular responses, further mitigating concerns in flap outcomes.Despite current recommendations for caffeine restriction following free tissue transfer, the existing evidence does not support caffeine as a major risk factor for flap failure. Postoperative caffeine avoidance may be unnecessary, particularly for habitual users. Larger prospective studies are needed to further elucidate caffeine's role in microsurgical outcomes and to explore the effects of other stimulants, such as ADHD medications, on microvascular circulation.
Complex Open Fractures of the Lower Extremity: What is the Optimal Time from Bone Fixation to Flap Coverage?
Parlamas SF, Swiekatowski KR, Kahramangil B … +3 more , Rizvi I, Bhadkamkar MA, Wu-Fienberg Y
J Reconstr Microsurg · 2026 Feb · PMID 40300763 · Publisher ↗
Shorter delays from presentation to soft tissue coverage in patients with lower extremity open fractures are associated with fewer infections. Orthoplastic teams should know how long flaps can be safely delayed after int...
Shorter delays from presentation to soft tissue coverage in patients with lower extremity open fractures are associated with fewer infections. Orthoplastic teams should know how long flaps can be safely delayed after internal fixation (IF), rather than presentation, because concurrent life-threatening injuries delay limb salvation. We compared infection rates (IRs) of flap coverage delays within 24, 24 to 72, and over 72 hours of IF.This is a retrospective cohort study of adult patients in a Level I trauma center from 2011 to 2021. Patients sustained Gustilo III lower extremity fractures and received flap coverage after fixation. IRs between various delays of flap coverage were compared. A multivariate logistic regression model (including patient demographics, flap composition, bone fixation technique, perioperative antibiotics, three aforementioned time intervals, time from presentation to flap coverage, and time from fixation to flap coverage) was used to determine significant predictors of infections.Of 274 patients, 76 (27.7%) developed an infection. The average time between fixation and flap coverage was 84.9 hours and 106.6 hours in non-infected and infected patients ( = 0.074). IRs among the time intervals were 23.2%, 25.0%, and 31.5% ( = 0.40). Time from fixation to flap coverage was the only significant predictor of infection ( = 0.04).Time from fixation to flap placement is an effective predictor of wound infection. Although the IRs of the >72-hour group did not reach significance, we believe larger cohorts would yield statistical significance. We recommend soft tissue coverage within 72 hours of IF to mitigate infections.
Efficacy of Microsurgical Venous Couplers in Lymphovenous Anastomosis of the Thoracic Duct: An Examination of Outcomes and Patency at Follow-Up.
Crystal DT, Gala Z, Brkic S … +4 more , Broach R, Azoury SC, Itkin M, Kovach SJ
J Reconstr Microsurg · 2026 Mar · PMID 40300762 · Publisher ↗
Central lymphatic disruption can result in devastating lymphedema, chylothorax, chylous ascites, metabolic deficiencies, and death. Literature from our institution has previously demonstrated the technical feasibility of...
Central lymphatic disruption can result in devastating lymphedema, chylothorax, chylous ascites, metabolic deficiencies, and death. Literature from our institution has previously demonstrated the technical feasibility of lymphovenous anastomosis (LVA) for thoracic duct (TD) bypass. Here, we present our complete patient series with expanded follow-up utilizing a microsurgical venous coupler to facilitate LVA.A single-institution, retrospective review was conducted for adult patients who underwent LVA for TD bypass between 2019 and 2024. Demographic, etiological, and perioperative information was collected. Symptomatic resolution with or without radiographically confirmed patency was considered a successful bypass at follow-up.A total of 23 patients underwent LVA of the TD. The mean age was 49.7 years. Median postoperative follow-up was 395 days (interquartile range [IQR]: 150.5-554.5). Anastomotic targets included the EJV ( = 15), IJV ( = 4), AJV ( = 2), or another regional vein ( = 3). The technical success of the venous coupler was 100%. Three patients experienced a surgical site complication (13.0%). At follow-up, 13 patients (56.5%) had a patent TD anastomosis with symptomatic resolution. One patient (4.3%) had a patent anastomosis confirmed on imaging but experienced mild symptomatic recrudescence. The remaining patients (39.1%) had nonpatent anastomoses. The median venous coupler size was 3.0 mm for both the patent cohort and the nonpatent cohort.LVA for TD bypass with an anastomotic coupler is well tolerated and provided durable relief of symptoms in over half of our cohort. This data supports venous coupler utilization in LVA for thoracic TD occlusion. Patient accrual is ongoing to further evaluate and optimize outcomes.
Upper Eyelid Postseptal Weight Placement for Treatment of Paralytic Lagophthalmos: Long-Term Outcomes.
Rail B, Bhatia SS, Rozen SM
J Reconstr Microsurg · 2026 Feb · PMID 40300643 · Publisher ↗
Paralytic lagophthalmos, a common consequence of facial nerve palsy, leads to corneal exposure and ophthalmic complications. The postseptal upper eyelid weight technique was first described in 2013 to address complicatio...
Paralytic lagophthalmos, a common consequence of facial nerve palsy, leads to corneal exposure and ophthalmic complications. The postseptal upper eyelid weight technique was first described in 2013 to address complications associated with the traditional pretarsal approach including weight visibility, extrusion, migration, eyelid ptosis, entropion, and astigmatism. This follow-up study assesses the long-term efficacy of the postseptal technique.Patients treated with postseptal upper eyelid weight implantation from 2008 to 2023 were included. Outcome measures included the presence of complications and degree of eye closure, assessed through videographic and photographic review.One hundred twenty-three patients were included. The mean follow-up time was 46 months, ranging from 12 to 143 months. The overall complication rate was 16%, with 9% experiencing extrusion. The adjusted extrusion rate in the present study was 2.3 extrusions per 100 person-years while the mean adjusted extrusion rate was 2.9 extrusions per 100 person-years for the evaluated studies in the literature ( = 0.005). No entropion or astigmatism was observed. Complete or near-complete eye closure was achieved by 98% of patients. A history of previous upper eyelid blepharoplasty was associated with more complications ( = 0.024).The postseptal technique is safe, reproducible, and effective for primary and secondary lid weight implantation, even in high-risk cases. Complication rates for the postseptal approach are similar to or lower than those reported in the literature for the pretarsal approach, with similar functional outcomes, and improved aesthetics. Upper eyelid skin resection prior to lid weight insertion was associated with increased complications.
Corrigendum: Dynamic Eye Closure Restoration in Facial Palsy with Neurotized Platysma Muscle Graft in Rats.
Voravitvet TY, Huang Y, Voravitvet S … +5 more , Larsson J, Lien PH, Chuang DC, Lu JC, Chang TN
J Reconstr Microsurg · 2025 May · PMID 40216377 · Publisher ↗
Abstract loading — click title to view on PubMed.
MICRO: Microsurgical Index for Complication Risk and Outcomes.
Johnstone TM, Najafali D, Cevallos PC … +4 more , Kang A, Sheckter CC, Nazerali RS, Lee GK
J Reconstr Microsurg · 2026 Feb · PMID 40194539 · Publisher ↗
Free tissue transfer (FTT) is determined by a multitude of patient and surgeon factors. However, no tool exists to quantify patient risk for complications following FTT. This study developed the microsurgical index for c...
Free tissue transfer (FTT) is determined by a multitude of patient and surgeon factors. However, no tool exists to quantify patient risk for complications following FTT. This study developed the microsurgical index for complication risk and outcomes (MICRO) to address this.Patients were queried from the 2007 to 2015 MarketScan Databases with CPT codes for FTT requiring microsurgical anastomosis. ICD-9 codes were used to query comorbidity and 90-day postoperative complication data for each patient. The Charlson and Elixhauser Comorbidity Indexes were constructed for each patient. The MICRO was then constructed with a forward stepwise selection from Elixhauser comorbidities and domain expert input. Indexes were used as covariates in multivariate logistic regression models with patient age, sex, and flap tissue type to predict complications following FTT. The area under the receiver operating characteristic curve and fivefold cross-validation classification accuracy was determined.A total of 5,595 patients were included. The final MICRO consists of seven variables (Charlson: 19; Elixhauser: 30). It had the highest area under the receiver operating characteristic curve (0.60) and accuracy (60.4%) of all indexes when predicting complications.The MICRO outperforms available patient comorbidity indexes at predicting complications following FTT with far fewer variables. Future studies could augment the MICRO with more granular or institutional data consisting of surgeon, donor-site, and recipient-site data to create a sharper risk-stratification tool for the plastic surgeon.
The Efficacy of Upper Extremity Neuroma Surgery in Reducing Long-Term Opioid Use in Patients with Preoperative Opioid Use.
Emovon Iii EO, Langdell H, Rebello E … +5 more , Albright JA, Ong E, Joh DY, Mithani SK, Li NY
J Reconstr Microsurg · 2026 Feb · PMID 40194538 · Publisher ↗
Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use h...
Neuromas can cause severe neuropathic pain, leading to functional decline and psychosocial distress. For pain relief, patients refractory to medications for neuropathic pain may be prescribed opioids; however, such use has been shown to have unfortunate adverse effects. With increasing awareness and diagnostic capabilities for neuroma formation, this study evaluates whether upper extremity neuroma excision may reduce opioid use and if adjunctive nerve procedures further reduce opioid use.The PearlDiver database was queried for patients undergoing upper extremity neuroma excision surgery from 2010 to 2020. Patients with opioid prescription fill records preoperatively were extracted and stratified by an operative technique involving either (1) excision alone, (2) nerve implantation into bone or muscle, or (3) nerve reconstruction. Records were then assessed at 1, 3, and 6 months postoperatively to assess for opioid use. Prescription fill rates at 1, 3, and 6 months postoperatively were then assessed across techniques.Of the 14,330 patients that underwent upper extremity neuroma excision, 4,156 filled opioids preoperatively. Excision led to significant reductions in opioid prescription fill rates postoperatively, decreasing to 67.4% at 1 month and to 57.5% by 6 months ( < 0.001). Excision alone resulted in lower opioid use compared with excision with implantation at all postoperative time points ( < 0.05). At 6 months, opioid use was also significantly less following excision with nerve reconstruction compared with implantation (56.4% vs. 65.6%, = 0.0096). There were no differences between excision alone and excision with nerve reconstruction.Neuroma excision significantly reduces opioid use in patients with preoperative opioid use while adjunctive operative techniques did not potentiate opioid reduction. This highlights the importance of understanding patient complaints, neuroma localization, and candidacy for excision as an effective measure for addressing opioid use in patients with preoperative opioid dependence.
Twelve Commandments of Reconstructive Microsurgery.
Walczak DA, Bula D, Chang TN … +1 more , Opyrchał J
J Reconstr Microsurg · 2026 Feb · PMID 40127883 · Publisher ↗
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Optimizing Postoperative Anticoagulation Regimen to Improve Lower Extremity Free Flap Outcomes.
Swiekatowski KR, Woods DE, Wang EB … +4 more , Acevedo E, Hopkins DC, Bhadkamkar MA, Wu-Fienberg Y
J Reconstr Microsurg · 2026 Feb · PMID 40068896 · Publisher ↗
Free flap reconstruction for lower extremity (LE) trauma has a higher failure rate than free flaps in other anatomic regions. Postoperative anticoagulation and antiplatelet therapy may influence LE free flap outcomes, bu...
Free flap reconstruction for lower extremity (LE) trauma has a higher failure rate than free flaps in other anatomic regions. Postoperative anticoagulation and antiplatelet therapy may influence LE free flap outcomes, but an optimal regimen has not been established. This study aims to evaluate complication rates associated with different anticoagulation and antiplatelet protocols in LE free flap reconstruction.Adult patients (≥18 years of age) with LE trauma requiring free flap reconstruction at our level 1 trauma center from 2016 to 2021 were included for retrospective chart review. Complications requiring reoperation were grouped into a composite variable named major complications (i.e., hematoma, flap thrombosis, flap necrosis >10%, infection requiring reoperation). Nonrandomized patients were categorized into three groups based on postoperative anticoagulation or antiplatelet regimen (aspirin only, heparin only, and aspirin + heparin), with heparin being a subtherapeutic fixed-dose heparin infusion at 500 to 800 units/hour. Complication rates were compared across groups, and both univariate and multivariate analyses were conducted to identify associations with major complications. -Values were set at < 0.05.Of 191 patients, 37 (19.4%) received aspirin only, 76 (39.8%) received heparin only, and 78 (40.8%) received aspirin + heparin. Demographics were similar between the groups. On univariate analysis, the heparin group had a significantly lower rate of major complications (5.26%) compared with aspirin only (18.92%) and aspirin + heparin (20.51%; = 0.016); however, on multivariate analysis, when accounting for additional perioperative factors, no association between anticoagulation group and major complications was found.Our study found that neither aspirin alone, heparin alone, or aspirin + heparin demonstrated a more favorable association with LE free flap outcomes. To reduce bias from the study's retrospective design and the surgeon's discretion in choosing anticoagulation protocols, future research should randomize patients to standardized postoperative regimens to assess differences in complications.
Prevalence of Popliteal Artery Variants in Free Tissue Transfer for Limb Salvage: A 12-Year Vasculoplastic Experience.
Rohrich RN, Li KR, Rutland JW … +6 more , Lin RP, Ferdousian S, Attinger CE, Youn RC, Akbari CM, Evans KK
J Reconstr Microsurg · 2026 Feb · PMID 40068895 · Publisher ↗
Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer...
Popliteal artery variants (PAVs) are anatomical deviations of the popliteal artery's branching pattern and should be considered in microsurgical planning for patients undergoing lower extremity (LE) free tissue transfer (FTT). However, there is a significant lack of FTT literature in this patient population. Thus, this study presents our 12-year experience with LE FTT in patients with PAV.Patients receiving LE FTT reconstruction from July 2011 to March 2024 were reviewed. Preoperative angiograms were reviewed by a single vascular surgeon, and the presence of PAV was identified and classified as IIIA, IIIB, or IIIC. Primary outcomes were flap success and limb salvage.A total of 339 LE FTT were performed in 331 patients. A total of 32 patients (9.4%) had PAV, accounting for a total of 34 LE FTT. Class IIIA was the most common category ( = 20, 58.8%) followed by IIIB ( = 8, 23.5%) and IIIC ( = 6, 11.7%). Median age and body mass index were 63.5 (interquartile range [IQR]: 22.5) years and 27.4 (IQR: 10.3) kg/m. The median Charlson Comorbidity Index was 5 (IQR: 2.5), with prevalent rates of diabetes ( = 18/32, 56.3%) and peripheral artery disease ( = 16/32, 50.0%). Median wound area was 71.0 (IQR: 80.0) cm. Flap success rate was 100% ( = 34/34). At a median follow-up of 12.8 (IQR: 22.6) months, limb salvage was 97.1% ( = 33/34) and mortality was 6.3% ( = 2/32).In this large population of LE FTT, PAV occurs in almost 1 out of 10 patients. Essential to flap success and limb salvage is appropriate preoperative vascular imaging with arteriography, as the presence of PAV changes microsurgical intraoperative planning and technical considerations.
Abdominal Wall Reinforcement Using OviTex after Deep Inferior Epigastric Perforator Flap.
McCranie AS, Blades C, Dawson S … +6 more , Foppiani JA, Allenby T, Winocour J, Cohen J, Mathes D, Kaoutzanis C
J Reconstr Microsurg · 2026 Jan · PMID 40068894 · Full text
Abdominal wall bulges and hernias are not uncommon complications following deep inferior epigastric perforator (DIEP) flap harvest. Abdominal wall reinforcement using synthetic meshes has been found to decrease bulges by...
Abdominal wall bulges and hernias are not uncommon complications following deep inferior epigastric perforator (DIEP) flap harvest. Abdominal wall reinforcement using synthetic meshes has been found to decrease bulges by up to 70%; however, such meshes can be associated with other issues such as seromas and infections. Reinforced tissue matrix (RTM) mesh can be used for abdominal wall reinforcement due to its ability to recruit fibroblasts and provide a scaffold for cellular proliferation. There is no literature on the use of OviTex mesh for abdominal wall reinforcement following DIEP flap harvest. Therefore, this study aimed to evaluate the efficacy and safety of its use in this setting.A retrospective review was performed on patients undergoing DIEP flap harvest between January 2020 and June 2023. Patients who had completed at least 12 months of follow-up visits were included. Descriptive, univariate, and multiple logistic regression analyses were completed.A total of 199 patients were included. The mean age at the time of surgery was 51.1 ± 10.0 years and the mean body mass index (BMI) was 30.2 ± 5.9 kg/m. Abdominal wall reinforcement was completed in 85 (42.7%) patients. Patients who had OviTex placed developed fewer bulges compared to the non-mesh cohort (0% vs. 5.3%, = 0.04). Furthermore, OviTex mesh did not increase adverse events and was not significantly different in seroma/hematoma rates when compared to the non-mesh cohort (10.6% vs. 5.3%, = 0.26).This study demonstrates that OviTex mesh is safe and efficacious in reducing the rate of bulges following DIEP flap harvest without increasing other complications.
Evaluating the Merit and Applications of the Caprini Risk Score as a Complications Predictor.
Khaw KL, Jones I, Fisher AH … +2 more , Hunter K, Bonawitz SC
J Reconstr Microsurg · 2026 Jan · PMID 40068893 · Publisher ↗
Venous thromboembolism (VTE) is considered a complication of free flap surgery. Prior studies investigating the use of the Caprini Risk Score (CRS) to estimate the risk of complications in free flap reconstruction are co...
Venous thromboembolism (VTE) is considered a complication of free flap surgery. Prior studies investigating the use of the Caprini Risk Score (CRS) to estimate the risk of complications in free flap reconstruction are confounded by small sample sizes, varying surgical sites, and disparate classification of risk. This study evaluates the predictive merit of CRS for complications in free flap reconstructions.A retrospective review of patients ( = 502) who underwent free flap reconstruction from January 2015 to April 2022 collected patient medical history, type and location of free tissue transfer, CRS, and prior and perioperative anticoagulation (AC). Reconstructive outcomes and complications were analyzed in low (CRS <8) and high (CRS ≥8) cohorts using chi-square tests. Complications were also analyzed by flap sites in sufficient cohort populations ( > 10).Of 502 patients, the high CRS cohort ( = 71) was associated with upper ( < 0.005) and lower ( < 0.001) extremity reconstructions while the low CRS ( = 431) cohort was associated with breast reconstructions ( < 0.001). The high CRS cohort demonstrated an increased need for intraoperative blood transfusions ( < 0.001). Other intraoperative or postoperative complications such as flap loss, intraoperative AC, return to operating room (OR), or VTE had no significant correlations. High CRS patients were more likely to be discharged on AC ( < 0.001) and have a longer length of stay (LOS; < 0.001). By flap site, there was a significant association between CRS and LOS >14 days in breast and head and neck flaps ( < 0.05) and discharge on AC in head and neck flaps only ( < 0.001).CRS may have utility in predicting the need for blood transfusion and AC requirements in free flap reconstruction but does not seem to predict the incidence of flap complications. A larger, higher-powered study may be used to assess the validity of CRS in risk of VTE and anticoagulant prophylaxis.
Risk Factors for Flap Loss in Midface Reconstruction with Vascularized Fibular Flap.
Ishida K, Makino Y, Kishi K … +6 more , Kodama H, Hirayama H, Orgun D, Nukami M, Akutsu T, Miyawaki T
J Reconstr Microsurg · 2026 Jan · PMID 40068892 · Publisher ↗
Midface reconstruction should address both functional and cosmetic aspects. The vascularized fibular osteomyocutaneous flap (VFOF) is a promising first choice because of its numerous advantages in this type of reconstruc...
Midface reconstruction should address both functional and cosmetic aspects. The vascularized fibular osteomyocutaneous flap (VFOF) is a promising first choice because of its numerous advantages in this type of reconstruction.This study aimed to investigate the causes of VFOF failure during midface reconstruction. We retrospectively reviewed patients who underwent midface defect reconstruction using VFOF from August 2011 to May 2022 at a single center. The primary outcome variable was VFOF loss within 30 days, and secondary outcomes included late complications related to VFOF occurring at least 6 months postoperatively.A total of 62 patients underwent VFOF reconstruction for midface defects. The VFOF technique was primarily used in 56 (90.3%) patients for initial reconstruction. according to the Brown and Shaw classification, most reconstructions were performed for Class III (77.4%) and Class b (83.6%) defects. Skin paddles of the VFOF were used in 51 (82.3%) patients, and a double flap technique utilizing the fibular was employed in 24 (38.7%) patients. VFOF failure occurred in 10 (16.1%) patients. Prognostic factors associated with VFOF failure included sex ( = 0.01) and maxillary Brown and Shaw classification (horizontal; = 0.01). Long-term follow-up of 47 patients revealed late complications in 11 (23.4%) patients, and diabetes mellitus was identified as a significant risk factor ( < 0.01).The VFOF is suitable for midface defect reconstruction; however, proper placement of the fibular bone, avoiding pedicle vessel kinking, ensuring tension-free vascular anastomosis during surgery, considering the use of an additional flap in addition to the fibula flap for large defects, and diligent postoperative nasal care are essential.
Microsurgery Education among U.S. Plastic Surgery Residency Programs.
Finkelstein ER, Samaha Y, Harris A … +4 more , Clark M, Singh D, Xu KY, Mella-Catinchi J
J Reconstr Microsurg · 2026 Jan · PMID 40068891 · Publisher ↗
Microsurgery is a core component of U.S. plastic surgery residency curriculum. This study compares publicly available information on microsurgery curricula and training among U.S. plastic surgery residency programs, whil...
Microsurgery is a core component of U.S. plastic surgery residency curriculum. This study compares publicly available information on microsurgery curricula and training among U.S. plastic surgery residency programs, while evaluating the background and experience of microsurgeon faculty at these institutions.The authors performed a cross-sectional web search on 103 accredited U.S. plastic surgery residency programs in March 2023. Publicly available information evaluated for each program included nonclinical microsurgery education, clinical microsurgical exposure, and the number of microsurgeon faculty. The perceived gender and race, professorship title, previous training, academic productivity, and scope of practice were determined for each individual faculty member.While approximately one-half of programs had evidence of microsurgical skill labs with anastomosis models ( = 56; 54%), fewer had a formal microsurgery curriculum ( = 36; 35%), or benchmark examinations ( = 25; 24%). Significantly more home institutions provided clinical exposure to breast, trauma or cancer, head and neck, and hand-related microsurgery than gender ( < 0.001) and lymphedema microsurgery ( < 0.001). Of the 724 faculty microsurgeons, most were male ( = 543), Caucasian ( = 488), and assistant professors ( = 316). Faculty underrepresented in plastic surgery were most often assistant professors with significantly fewer years of experience than their male ( < 0.001) and Caucasian counterparts ( < 0.023).Great variability exists in clinical and nonclinical microsurgery training among U.S. plastic surgery residency programs. As the demand for microsurgery continues to rise, we can expect microsurgery education to become more uniform. Most microsurgeon faculty underrepresented in plastic surgery were earlier in their career, suggesting a potential shift in diversity as these individuals ascend the academic ladder.
Thoracodorsal Artery Perforator Diameter and Flow Velocity Correlate with Muscle Thickness.
Illg C, Rachunek-Medved K, Lauer H … +3 more , Thiel JT, Daigeler A, Krauss S
J Reconstr Microsurg · 2026 Jan · PMID 40068868 · Publisher ↗
The thoracodorsal artery perforator (TDAP) flap is a versatile pedicled and free flap with low donor site morbidity and a relatively thin skin paddle. Physical patient characteristics may influence interindividual differ...
The thoracodorsal artery perforator (TDAP) flap is a versatile pedicled and free flap with low donor site morbidity and a relatively thin skin paddle. Physical patient characteristics may influence interindividual differences in perforator characteristics and, therefore, help to estimate the safety of the TDAP flap.Dynamic infrared thermography and color duplex ultrasound were applied to assess the TDAP diameter, peak systolic velocity (PSV), end-diastolic velocity, resistance index, and thickness of the latissimus dorsi muscle and the subcutaneous tissue bilaterally in 25 subjects. The effect of handedness on the symmetry of perforator characteristics was investigated.Perforator properties were not significantly altered by sex or body mass index. The mean latissimus dorsi muscle thickness correlated positively with both the perforator diameter (Pearson's = 0.25, = 0.0048, = 124) and the PSV ( = 0.29, = 0.0012, = 124). In contrast, a negative correlation was observed between subcutaneous tissue thickness and PSV ( = -0.31, = 0.0003, = 124). A comparison of the perforator diameter and the PSV in the dominant and nondominant sides showed no statistically significant difference.The findings of the study indicate that perfusion of the thoracodorsal artery flap is enhanced by the presence of a thicker latissimus dorsi muscle, a thinner subcutaneous tissue, and a reduced quantity of TDAPs.
Effect on Timing of Free Flap Breast Reconstruction on Mastectomy Skin Necrosis.
Ahmed S, Crabtree J, Fallah KN … +7 more , Rinne EJ, Hulsman L, Fisher CS, Ludwig KK, Danforth RM, Lester ME, Hassanein AH
J Reconstr Microsurg · 2026 Jan · PMID 40068867 · Publisher ↗
Deep inferior epigastric perforator (DIEP) flap is a common autologous breast reconstruction option. DIEP flap may be performed immediately on the day of mastectomy (immediate DIEP) or at a later date typically following...
Deep inferior epigastric perforator (DIEP) flap is a common autologous breast reconstruction option. DIEP flap may be performed immediately on the day of mastectomy (immediate DIEP) or at a later date typically following placement of a tissue expander during mastectomy (delayed-immediate DIEP). Preparing internal mammary vessels during microsurgical anastomoses involves prolonged retraction of the breast skin flaps, which can increase tension on acutely ischemic mastectomy skin. The purpose of this study is to investigate whether DIEP flap timing has an effect on mastectomy skin necrosis.A single-center study was performed of patients who underwent immediate or delayed DIEP flap reconstruction over a 3-year period. Patients were divided into two groups: Group I (immediate DIEP flap) and Group II (delayed-immediate DIEP with flap staged separately from mastectomy). The outcomes assessed were breast skin flap necrosis and management of skin flap necrosis.The study included 106 patients (173 flaps) in Group I (49 patients, 80 flaps) and Group II (57 patients, 93 flaps). Mastectomy skin flap necrosis rates were 11.3% (9/80) for Group I compared to 2.2% (2/93) of Group II patients ( = 0.025). Skin necrosis necessitating operative debridement was 7.5% (6/80) in Group I and 1.1% (1/93) in Group II ( = 0.0499).Immediate DIEP flaps performed on the day of mastectomy have a significantly higher risk of mastectomy skin necrosis. Patients may be counseled that another advantage of performing a DIEP flap on a different day than a mastectomy is to decrease the risk of mastectomy skin necrosis.
Effects of 4-aminopyridine as an Adjuvant Therapy Following Peripheral Nerve Repair in an Animal Model of Nerve Transection Injury.
Lee JI, Kim DW, Park JW … +1 more , Lee DH
J Reconstr Microsurg · 2026 Jan · PMID 40054490 · Publisher ↗
Peripheral nerve repair is considered the gold standard treatment for complete nerve transection injuries, yet achieving satisfactory functional recovery remains challenging due to muscle atrophy during the time required...
Peripheral nerve repair is considered the gold standard treatment for complete nerve transection injuries, yet achieving satisfactory functional recovery remains challenging due to muscle atrophy during the time required for axonal regeneration. This study investigated the beneficial effects of 4-aminopyridine (4-AP), a potassium channel blocker, on neural and muscular recovery.Following complete transection of the right sciatic nerve, 40 mice underwent end-to-end nerve repair using microscopic epineural sutures and were randomly assigned to either the control or 4-AP groups immediately after surgery ( = 20 per group). The experimental animals were administered intraperitoneal injections of 200 μL normal saline or soluble 4-AP at a dose of 10 μg daily. The sciatic functional index (SFI) and nerve conduction studies were measured until 12 weeks postoperatively. Morphological analyses of nerve and muscle, and Western blotting for proteins associated with muscle atrophy were performed at 3 and 12 weeks after surgery.There were no significant differences in the SFI between the two groups. Nerve conduction study showed that 4-AP treatment increased the compound muscle action potential and decreased latency. A histomorphometric study showed that 4-AP treatment increased myelin thickness, G-ratio (axonal diameter/axoglial diameter on cross-sectioned nerve), cross-sectional area of myofibrils, and minimal Feret diameter of myofibrils. Additionally, expression levels of FoxO3 and mTORC1 were lower in the 4-AP treated mice, while myogenin expression levels showed no significant difference between the groups.4-AP treatment promotes myelination and prevents denervation-induced muscle atrophy after neurorrhaphy. These findings suggest that 4-AP may be a promising candidate for clinical consideration as an adjuvant therapy following nerve repair for transection injuries.
Surgical Treatment of Lymphedema at LE&RN Comprehensive Centers of Excellence.
Fanning JE, Friedman R, Shillue K … +4 more , Fleishman A, Repicci W, Donohoe K, Singhal D
J Reconstr Microsurg · 2026 Jan · PMID 40054489 · Full text
Despite major advancements in lymphatic care, there remains a lack of consensus across institutions regarding the evaluation and surgical management of lymphedema. The aim of this study is to describe the practices for d...
Despite major advancements in lymphatic care, there remains a lack of consensus across institutions regarding the evaluation and surgical management of lymphedema. The aim of this study is to describe the practices for diagnosis and surgical treatment of lymphedema across accredited Lymphatic Education & Research Network (LE&RN) comprehensive Centers of Excellence (COEs).A survey was distributed to directors of the 16 LE&RN comprehensive COEs in January 2023. Directors were queried on lymphatic surgeon training, evaluation of potential surgical patients, description of surgical operations offered at their center, surgical algorithms, and operative techniques for various procedures.Nine COEs completed the survey (56% response rate). Eight of nine centers reported having an interdisciplinary surgical evaluation program, including lymphatic surgery (100%, 8/8), certified lymphedema therapy (100%, 8/8), and lymphatic medicine (75%, 6/8). COEs use a variety of lymphatic imaging modalities, with indocyanine green lymphography (89%, 8/9) and lymphoscintigraphy (78%, 7/9) being the most common. While all COEs offered debulking procedures, 67% (6/9) offered physiologic procedures (lymphovenous bypass and vascularized lymph node transplant), and 56% (5/9) offered immediate lymphatic reconstruction. There was no consensus on surgical algorithms or operative approaches.LE&RN comprehensive COEs consistently use multidisciplinary care teams for medical and surgical evaluations, but there is significant variability in lymphatic imaging modalities used and lymphatic surgery types and techniques. These findings underscore the need for continued research and standardization of lymphatic surgery outcomes to develop consensus.
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