Microsurgery[JOURNAL]
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200 papers
Surgical Management of Genital Lymphedema Using the Combined Charles' Procedure and Lymphatic Superficial Circumflex Iliac Artery Perforator Flap Transfer (CHASCIP).
Ciudad P, Escandón JM, Escandón L … +2 more , Mayer HF, Manrique OJ
Microsurgery · 2025 Jul · PMID 40448967 · Publisher ↗
BACKGROUND: Despite various therapeutic options, evidence remains limited on optimal medical or surgical management of genital lymphedema in male patients. This study evaluated postoperative outcomes of male patients und...
BACKGROUND: Despite various therapeutic options, evidence remains limited on optimal medical or surgical management of genital lymphedema in male patients. This study evaluated postoperative outcomes of male patients undergoing a combination of the Charles Procedure and lymphatic superficial circumflex iliac artery perforator (SCIP) flap reconstruction for penoscrotal lymphedema. METHODS: Male patients with International Society of Lymphology stage III genital lymphedema involving the scrotum and penis were included. All underwent the Charles Procedure combined with bilateral pedicled lymphatic SCIP flap transfer. Data on demographics, indocyanine green lymphography and lymphoscintigraphy findings, symptom duration, pre- and postoperative duration of complex decongestive therapy (CDT), estimated blood loss, surgical time, length of stay, and complications were analyzed. Genital Lymphedema Score (GLS) were evaluated. RESULTS: Eight patients were included. The mean age was 43 years, and BMI was 28.4 kg/m. The mean follow-up was 34 months. Secondary genital lymphedema was the most common type (75%). The average weight of resected lymphedematous tissue was 1772.7 g. The mean estimated blood loss was 200.6 mL, and mean surgical time was 160 min. Two patients (25%) experienced postoperative complications: one developed seroma formation and dehiscence, while the other had partial skin graft loss. No cases of lymphedema recurrence were observed. Sexual dysfunction improved in all patients (87.5% versus 0%; p < 0.001). GLS scores significantly decreased after the procedure (6.6 versus 0.6; p < 0.001). CONCLUSION: The combined Charles Procedure and bilateral lymphatic SCIP flap transfer is an effective surgical approach for penoscrotal lymphedema, optimizing postoperative outcomes with a low complication and recurrence rate.
The Gastroepiploic Vascularized Lymph Node Transfer in the Treatment of Male Genital Lymphedema: A Report of Three Cases.
Morelli Coppola M, Gawel W, Elia R … +4 more , Uldry E, Nicod Lalonde M, Maruccia M, di Summa PG
Microsurgery · 2025 Jul · PMID 40439457 · Publisher ↗
Male genital lymphedema (MGL) is a debilitating condition that may require surgical intervention. Lymphaticovenous anastomosis (LVA) can be ineffective in primary and advanced cases because of lymphatic disruption, where...
Male genital lymphedema (MGL) is a debilitating condition that may require surgical intervention. Lymphaticovenous anastomosis (LVA) can be ineffective in primary and advanced cases because of lymphatic disruption, whereas vascularized lymph node transfer (VLNT) can overcome this limitation by promoting neolymphangiogenesis but traditionally carries some risk of donor site complications. Gastroepiploic vascularized lymph node transfer (GEVLNT) has recently emerged as an effective treatment option for upper and lower limb lymphedema, with negligible complications. However, its role in genital lymphedema remains unexplored. This is the first short series reporting the use of GEVLNT in MGL. Three male patients (44, 61, and 52 years old) with GL underwent GEVLNT. The first patient had idiopathic disease, which relapsed after previous treatment with LVA; the other two had secondary lymphedema due to cancer treatment and hydrocele surgery, respectively. In all patients, the right gastroepiploic lymphosome was harvested laparoscopically, with flap sizes of 14 × 5 cm, 15 × 4 cm, and 12 × 4 cm, respectively. The recipient vessels were the deep inferior epigastric artery and vein in the first case, and the superficial external pudendal vessels in the other two. Post-operative courses were uneventful for all patients, with no complications reported. Follow-up periods were 36, 23, and 12 months, respectively. In all cases, GEVLNT resulted in significant clinical improvements and reductions in genital lymphedema severity (GLS) scores (7-1, 9-4, and 8-4). Our preliminary experience suggests that GEVLNT could be a viable and effective option for treating male genital lymphedema with minimal donor site morbidity and stable results over time. However, further research with larger patient cohorts, comparative studies, and long-term follow-up is needed to fully establish its efficacy.
Robotic Harvest of the Free Ileocolon Flap for Esophageal Reconstruction: A Case Report.
Sert G, Akkapulu N
Microsurgery · 2025 May · PMID 40423500 · Publisher ↗
The ileocolon flap is a fully autologous, single-stage option in the reconstruction of challenging laryngoesophageal defects, restoring voice and swallowing in patients. This procedure represents one of the most sophisti...
The ileocolon flap is a fully autologous, single-stage option in the reconstruction of challenging laryngoesophageal defects, restoring voice and swallowing in patients. This procedure represents one of the most sophisticated cases in the field of reconstructive microsurgery. However, the traditional approach to harvesting the ileocolon flap requires a midline laparotomy, which is associated with several donor site complications. In the literature, a minimally invasive approach for the harvest of this flap, which is complex, associated with numerous morbidities related to laparotomy, and has many modifications to perfect its outcomes, has not yet been defined. The purpose of this report is to describe the technique of robotic harvest of the free ileocolon flap to avoid the risks associated with laparotomy. A 53-year-old patient who underwent laryngectomy and cervical esophagectomy (15-cm defect) for treatment of laryngeal squamous cell carcinoma has been admitted to our department for restoration of voice and swallowing. The robotic surgery system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the ileum, colon, and ileocolic artery and vein by providing optimized high-definition visualization of the surgical field and enhanced control through robotic arms, which offer a much greater range of motion than the surgeon's hand or laparoscopic systems. The flap included 15 cm of ascending colon, ileocecal valve, 10 cm ileum (voice tube), and 5 cm of chimeric ileal segment (seromuscular patch flap). The flap insetted in the neck in an isoperistaltic fashion; ascending colon end-to-end to the esophageal stumps and voice tube anastomosed to tracheal stump in end-to-side fashion. The microvascular anastomoses were performed to the facial artery and external jugular vein. During a 4-month follow-up period, no complications were observed. The patient can eat solid food and speak with his own voice postoperatively. We believe that robotic harvesting of the free ileocolon flap is a safe, feasible, and effective technique that significantly reduces the risk of morbidity related to the invasiveness of the traditional flap harvesting technique.
Advancing Temporomandibular Joint Reconstruction: A Cadaveric Study on the Design of the Fourth Chondrocostal Joint Flap.
Alpat SE, Aydın M, Kaya B … +1 more , Açar Hİ
Microsurgery · 2025 May · PMID 40401738 · Publisher ↗
BACKGROUND: The free fibula flap is the gold standard for reconstructing mandibular defects caused by trauma, tumors, dysplastic diseases, osteoradionecrosis, and atrophy. However, it has not yet been shown to be the ide...
BACKGROUND: The free fibula flap is the gold standard for reconstructing mandibular defects caused by trauma, tumors, dysplastic diseases, osteoradionecrosis, and atrophy. However, it has not yet been shown to be the ideal method for condylar reconstruction. This anatomical study proposes a surgically pragmatic approach to temporomandibular joint and condylar reconstruction by defining the vascularity of the chondrocostal joint. METHODS: One fresh frozen and six fixed cadavers were dissected to assess the suitability of the 4th rib for the planned procedure. Bilateral internal thoracic vessels and branches surrounding chondrocostal joints were identified. The 4th chondrocostal joint flap was dissected with care to preserve the joint surface and perichondral vascularity. Digital calipers were used for precise measurements of maximal flap and pedicle length. The vascular anatomy was further explored in a fresh frozen cadaver through fluoroscopic imaging by radiopaque latex injection. The flap's suitability for temporomandibular joint reconstruction was tested by surgically removing the original temporomandibular joint from the cadaveric skull and positioning the chondrocostal joint flap in the resultant defect. RESULTS: The dominant pedicle to the fourth chondrocostal joint was shown to be the perforators of the internal thoracic vessels. The mean pedicle length was 4.7 cm, which was sufficient to reach recipient vessels in the neck. The compatibility between the fourth chondrocostal joint and the glenoid fossa was confirmed. CONCLUSION: This study demonstrates that the fourth chondrocostal joint flap is a promising free flap for temporomandibular joint and condylar reconstruction. It offers ideal pedicle positioning, length, and vascular size match at the anastomosis, making it a suitable technique for reconstructing the challenging temporomandibular region. This approach adds a new option to the reconstructive surgeon's armamentarium, addressing previous limitations in condylar reconstruction.
Photoacoustic Imaging of Midline-Crossing Vessels and Implications for Surgical Strategy in Patients With Midline Abdominal Scars.
Takaya A, Tsuge I, Makino A … +5 more , Munisso MC, Kosaka T, Yamanaka H, Saito S, Morimoto N
Microsurgery · 2025 May · PMID 40387360 · Publisher ↗
INTRODUCTION: Blood vessels are severed in patients with midline vertical abdominal scars, but detailed reports on the status of vessels penetrating the scar or vertical location from the umbilicus of the midline-crossin...
INTRODUCTION: Blood vessels are severed in patients with midline vertical abdominal scars, but detailed reports on the status of vessels penetrating the scar or vertical location from the umbilicus of the midline-crossing vessels in vivo are lacking. We revealed the effects of the scar and anatomical features of midline-crossing vessels using photoacoustic imaging. METHODS: Women in the outpatient follow-up period of the gynecology and gastrointestinal surgery department of our institution were included. Ultrasonography and photoacoustic imaging were performed. The region of interest (ROI) was set 3-12 cm below the umbilicus. Patients were categorized into three groups: Group 1, no surgical scars within the ROI; Group 2, surgical scars along the entire length of the ROI; Group 3, a mixture of areas with and without scars. The numbers of midline-crossing arteries (MCA) and veins (MCV) were compared between Groups 1 and 2. The vertical position of the MCA and MCV from the umbilicus was investigated in Group 1. RESULTS: MCA and MCV were observed in all patients in Group 1 (n = 14), and the median number of MCA was 2, while the median number of MCV was 5. Three patients in Group 2 (n = 17) had MCV, although none of the patients had MCA. In Group 3 (n = 6), residual MCA was found apart from the scar. In half of Group 1, the MCA was not visualized within 4 cm caudal to the umbilicus, but MCV was visualized in all cases. CONCLUSIONS: Although MCA was not depicted within the scar, MCV was visualized penetrating the scar in some patients. The results of Group 1 showed that there are individual differences in the location of the MCA. Detecting residual MCA and MCV in Group 3 implies the ability of photoacoustic tomography to assess a surgical application for a single-pedicle transverse abdominal flap in breast reconstruction.
Reconstruction of Wagner Grade 4 Diabetic Foot Ulcers With the Superficial Circumflex Iliac Artery Perforator Free Flap.
Evin N
Microsurgery · 2025 May · PMID 40357875 · Publisher ↗
BACKGROUND: Microsurgical free tissue transfers are inevitable for Wagner grade 4 diabetic foot ulcers that cannot be treated conservatively and have a high risk of amputation. In this study, the results of the multidisc...
BACKGROUND: Microsurgical free tissue transfers are inevitable for Wagner grade 4 diabetic foot ulcers that cannot be treated conservatively and have a high risk of amputation. In this study, the results of the multidisciplinary management of Wagner grade 4 diabetic foot ulcers and their reconstruction using the SCIP free flap are presented. METHODS: Twenty-one patients with Wagner grade 4 diabetic foot ulcers who underwent reconstruction with the SCIP free flap were retrospectively reviewed. The pain, disability, and activity limitations were evaluated using the foot function index. The foot contour and esthetic satisfaction were evaluated using a 5-point Likert scale. RESULTS: Fifteen patients were male and 6 were female. Reconstruction was performed with chimeric SCIP flaps in five patients and with single-skin-island SCIP flaps in 16 patients. Thirteen flaps were suprafascial and eight were fasciocutaneous. All flaps survived; however, venous congestion (n = 2) and flap dehiscence (n = 2) were observed, which resolved spontaneously within 24 h and were treated conservatively. Seroma (n = 3) and dehiscence (n = 2) were observed in the donor area of fasciocutaneous flaps and treated conservatively with primary suturing. The mean pain, disability, and activity limitation scores were 9 ± 0.7, 8.5 ± 0.5, and 7.9 ± 0.4 preoperatively and 2.3 ± 0.7, 2.2 ± 0.5, and 1.9 ± 0.6 12 months postoperatively, respectively, showing statistically significant improvements (p < 0.001). The foot contour and esthetic satisfaction were excellent (mean Likert score = 5) in patients with suprafascial flaps and good to excellent (mean Likert score = 4.5 ± 0.5) in those with fasciocutaneous flaps, with a statistically significant difference (p = 0.0012). All flaps adapted well to the recipient areas. CONCLUSIONS: Wagner grade 4 diabetic foot ulcers can be salvaged from amputation through multidisciplinary management and advanced microsurgical techniques, and that suprafascial SCIP flaps provide significant advantages in restoring the form and function of diabetic feet owing to their thin structure and the ability to create chimeric designs for multiple defects.
Analysis of the Effects of Arterial Anastomosis Techniques and Vein Selection in Free Flap Surgery After Extremity Trauma.
Erol K, Güntürk ÖB
Microsurgery · 2025 May · PMID 40353558 · Publisher ↗
BACKGROUND: Decision making about the selection of artery and vein anastomosis techniques is a challenging dilemma in free flap surgery, especially in trauma cases in which it is difficult to distinguish the zone of inju...
BACKGROUND: Decision making about the selection of artery and vein anastomosis techniques is a challenging dilemma in free flap surgery, especially in trauma cases in which it is difficult to distinguish the zone of injury. This study aimed to analyze the effects of the selection of end to end (ETE) or end to side (ETS) artery anastomosis, one or two venous anastomoses, and the deep or superficial venous anastomoses on the flap survival and re-exploration rates. We further aimed to investigate whether there were any differences between lower and upper extremity free flaps. PATIENTS AND METHODS: A total of 447 patients were included in the study. Upper and lower extremity reconstructions were performed in 281 and 166 patients, respectively. The most commonly used flap was the anterolateral thigh (ALT) flap (42%). Flap survival and re-exploration status, number of recipient veins, deep/concomitant or superficial/subcutaneous venous anastomosis, and type of arterial anastomosis were analyzed. RESULTS: The overall flap survival rate was 94.9%. Flap re-exploration and flap failure rates were higher in the ETE group, although the difference was not statistically significant. Single venous anastomosis was performed in 56.8% of flaps. Most flaps were anastomosed with the deep/concomitant venous system (45.6%). There were no statistically significant differences regarding these venous anastomosis data. There was not any statistically significant difference between upper and lower extremities, either. CONCLUSION: ETS or ETE arterial anastomosis, number of the veins or the selection of the deep/concomitant or superficial/subcutaneous system do not affect the flap survival and re-exploration rates, so the decision should be made according to the flap strategy or the condition of the vessels regarding the zone of injury. All techniques provide similar outcomes when performed properly.
Efficacy and Morbidity of Heparin Infusion in Salvaging Autologous Breast Reconstruction Free Flaps.
Odorico SK, Mazroua MS, Wang L … +5 more , Awadallah A, Day S, Harless C, Martinez-Jorge J, Vijayasekaran A
Microsurgery · 2025 May · PMID 40341693 · Publisher ↗
BACKGROUND: Abdominal-based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well-documented. When flap compromise occurs, operative salvage is the gold standa...
BACKGROUND: Abdominal-based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well-documented. When flap compromise occurs, operative salvage is the gold standard. However, when-and if-to place these patients on heparin infusions is unclear. The goal of this study was to investigate abdominal-based free flap compromise and compare outcomes with and without heparin infusion. MATERIALS AND METHODS: This was a single-institution, multiple-surgeon, retrospective chart review of patients undergoing autologous, abdominal-based free flap breast reconstruction who experienced anastomotic compromise within a 6-year period. Treatment and outcomes data collected include flap salvage, hematoma, seroma, surgical site infection (SSI), transfusion requirement, and length of hospital stay. RESULTS: Fifty-one flaps had evidence of compromise. A total of 31 (60.8%) patients were placed on heparin infusions after experiencing anastomotic compromise, compared to 20 who did not receive heparin infusion. Thirty-five patients (68.6%) underwent deep inferior epigastric perforator flaps. Twenty-six patients (51%) experienced venous congestion, 22 patients (43.1%) experienced arterial compromise, and three (5.9%) experienced both. Twenty-eight patients (54.9%) received tissue plasminogen activator; in the heparin infusion group, 21 patients (67.7%) received tissue plasminogen activator. The total salvage rate of compromised flaps was 94.1% (48/51). There was no significant difference between heparin infusion and standard cares in length of hospital stay, length of drains in-place, successful salvage (93.5% vs. 95%), hematoma (19.4% vs. 15%), fat necrosis, SSI, hospital readmission (19.4% vs. 15%), and return rates to the operating room (48.4% vs. 50%). However, there was a significantly higher transfusion rate in patients receiving heparin infusion (38.7% vs. 10%). Of the 25 flaps with evidence of thrombosis, 72% were placed on heparin infusions while 28% were not; there was no significant difference in salvage rate in this sub-group. CONCLUSIONS: This review of autologous breast reconstruction free flap compromise provides evidence of similar safety profiles, with similar salvage rates, when comparing salvage with and without heparin infusion; there is a higher transfusion requirement when treating with heparin infusion.
Drain Fluid Amylase as an Early Negative Predictor of Salivary Fistula Following Free Flap Reconstruction.
Harris MK, Kubik M, Solari MG … +6 more , Contrera KJ, Odeniyi O, Morton Z, Gardiner L, Spector ME, Sridharan SS
Microsurgery · 2025 May · PMID 40331398 · Full text
OBJECTIVES: Salivary fistula is a known complication following head and neck free flap reconstruction involving the aerodigestive tract. We sought to examine the association between surgical drain fluid amylase and saliv...
OBJECTIVES: Salivary fistula is a known complication following head and neck free flap reconstruction involving the aerodigestive tract. We sought to examine the association between surgical drain fluid amylase and salivary fistula formation during postoperative hospitalization. METHODS: Eighty patients who underwent head and neck reconstruction involving the aerodigestive tract at our institution between 2019 and 2023 were included. Amylase concentration (IU/L) was measured from a Jackson-Pratt drain located along the mucosal closure line on postoperative days 1-5. RESULTS: Twelve patients (15%) developed salivary fistulas. The change in drain amylase concentration between postoperative day 1 and day 2 was found to be significantly higher in those who developed a fistula during postoperative hospitalization. A receiver operating characteristic curve found that a threshold of 15% provided a sensitivity of 58.3% and specificity of 80.6% (area under the curve 0.767) to predict salivary fistula. This threshold remained significant on multivariate analysis (odds ratio 5.35, 95% confidence interval 1.79-24.3) when controlling for prior radiation, perioperative transfusion, and total laryngectomy. When retrospectively applied to our cohort, a cutoff of 15% resulted in a positive predictive value of 35% and a negative predictive value of 91.5%. CONCLUSION: Change in surgical drain fluid amylase from postoperative day 1 to 2 was associated with fistula formation following free flap reconstruction of the aerodigestive tract. Importantly, a change in amylase of < 15% from postoperative day 1 to 2 was best at identifying patients who are at low risk of developing salivary fistula during postoperative hospitalization, with a negative predictive value of 91.5%.
Evaluating the Role of Digital Subtraction Angiography in Traumatic Lower Extremity Flap Reconstruction: A Comparative Analysis With CT Angiography.
Manasyan A, Stanton EW, Wolfe E … +3 more , Roohani I, Carey JN, Daar DA
Microsurgery · 2025 May · PMID 40309948 · Publisher ↗
BACKGROUND: Despite its high sensitivity and specificity, CTA can yield inconclusive or inaccurate results due to technical limitations such as metallic streak artifacts or inadequate opacification of arteries. On the ot...
BACKGROUND: Despite its high sensitivity and specificity, CTA can yield inconclusive or inaccurate results due to technical limitations such as metallic streak artifacts or inadequate opacification of arteries. On the other hand, digital subtraction angiography (DSA), a fluoroscopic technique used extensively in interventional radiology for visualizing blood vessels, stands as a gold standard for the assessment of arterial injuries, offering high-resolution and dynamic imaging. METHODS: Patients undergoing lower extremity reconstruction with a free flap at a Level 1 trauma center between 2015 and 2022 were retrospectively queried. Demographic data, details of arterial injuries assessed by CTA/DSA, flap and wound details, complications, and ambulatory outcomes were recorded. The study data were assessed and presented qualitatively. RESULTS: A total of 175 patients underwent microsurgical lower extremity reconstruction from 2015 to 2023, 98 (56.0%) of whom had CTA, and 14 (8.0%) underwent DSA preoperatively. The mean patient age was 47.1 ± 15.6 years, ranging from 21 to 68 years, with 10 (71.4%) males and four (28.6%) females. The most common indications for DSA were inconclusive CTA results of vessel runoff status (n = 6), evaluation of clinically suspected vascular injury not clearly delineated by CTA (n = 3), and artifact/streak due to orthopedic hardware (n = 2). DSA in six of the 14 cases revealed discrepancies with initial CTA findings, providing clarification on the location and extent of vascular injury preoperatively. Four of these patients experienced a change in surgical plan following formal angiography. There was no significant difference in postoperative flap complications (p = 0.189) or ambulation status (p = 0.074) between the DSA and CTA cohorts. CONCLUSION: DSA effectively overcomes limitations encountered with CTA, such as issues related to hardware interference. In select patients where CTA limitations are significant, DSA might offer improved outcomes, highlighting the need for further research to validate these preliminary findings and better define the contexts in which DSA could be more beneficial.
Pedicled Vascularized Common Peroneal Nerve Graft in Sciatic Nerve Reconstruction With Involvement of Inner Pelvic Lumbar and Sacral Nerve Roots: A Case Report and Literature Review.
Wan R, Sarcon AK, Aristizabal A … +3 more , Tunaboylu MF, Houdek MT, Moran SL
Microsurgery · 2025 May · PMID 40285651 · Publisher ↗
Long segment losses exceeding 10 cm in the sciatic nerve are challenging in both the reconstructive techniques and optimizing sensory and motor function recovery. This case report and literature review describes our expe...
Long segment losses exceeding 10 cm in the sciatic nerve are challenging in both the reconstructive techniques and optimizing sensory and motor function recovery. This case report and literature review describes our experience of using a pedicled vascularized common peroneal nerve graft to repair a 14-cm sciatic nerve defect, involving L4, L5, and S1 nerve roots. Additionally, we conducted a literature review of various types of nerve autografts for large sciatic nerve defects, summarizing their characteristics and outcomes to aid clinicians in decision-making and expected results in different scenarios. The patient, a 23-year-old female diagnosed with neurofibromatosis type I, underwent R0 tumor resection of the proximal left sciatic nerve due to a malignant peripheral nerve sheath tumor. She received an ipsilateral pedicled vascularized common peroneal nerve graft. The reconstruction included the L4, L5, and S1 nerve roots beyond the greater sciatic foramen into the inner pelvis. The patient's postoperative course was uneventful. At the 26-month follow-up, she showed MRC grade 4/5 strength in hamstrings with 90°knee flexion and a steady gait pattern. At the 32-month follow-up, she could ambulate very well with an ankle-foot orthosis. The outcomes support the use of a pedicled vascularized common peroneal nerve graft in a single-staged surgery to restore motor function for large sciatic nerve defects. Our literature review revealed that in cases where sural nerves are insufficient or injured for sciatic nerve reconstruction, the common peroneal nerve is a viable alternative to help patients regain functional independence.
Critical Review of Targeted Muscle Reinnervation (TMR) Studies in Neuroma Management.
Savitz BL, Dean YE, Myers A … +5 more , Karagoz H, Hill JB, Bhandari P, Elmaraghi S, Lineaweaver W
Microsurgery · 2025 May · PMID 40235220 · Publisher ↗
BACKGROUND: In modern surgical practice, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) offer amputees promising options for painful neuroma management, with the potential to signi...
BACKGROUND: In modern surgical practice, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) offer amputees promising options for painful neuroma management, with the potential to significantly reduce pain and enhance prosthetic control. Despite these advancements, a lack of consensus on the standard of care persists, largely due to methodological inconsistencies in the current literature. Variations in control group selection, small sample sizes, and inadequate follow-up periods obstruct the reproducibility and generalizability of findings, complicating clinical decision-making. This critical review identifies key limitations in existing TMR studies, including biases introduced by heterogeneity in study design and an absence of direct comparisons between TMR and RPNI. METHODS: A systematic review was conducted following PRISMA guidelines to identify controlled TMR studies related to neuroma management. The data extracted included control group selection, sample size, TMR cohort size, and mean follow-up period. RESULTS: Eleven studies evaluating TMR for neuroma management were analyzed. Control groups varied significantly, including amputation without reinnervation, neuroma excision, nerve burial, or preoperative pain assessments of participants. The heterogeneity in study design and small sample sizes limited further interpretation across studies. Moreover, only one randomized clinical trial was identified. CONCLUSIONS: Recommendations are proposed for standardizing methodologies, implementing robust control groups, and prioritizing randomized controlled trials with extended follow-up periods. Bridging these gaps in future research can pave the way for evidence-based guidelines to improve patient outcomes in postamputation pain management.
Using Smartphone Thermal Imaging to Determine Safe Window for Cross-Leg Free Flap Detachment.
Ciudad P, Llanca L, Manrique OJ … +1 more , Escandón JM
Microsurgery · 2025 May · PMID 40207781 · Publisher ↗
Abstract loading — click title to view on PubMed.
Immediate Versus Delayed Skin Grafting of Free Muscle Flaps for Limb Salvage: Does Timing Matter?
Li KR, Rohrich RN, Episalla NC … +7 more , Deleonibus SF, Li WW, Lava CX, Akbari CM, Youn RC, Attinger CE, Evans KK
Microsurgery · 2025 May · PMID 40207753 · Publisher ↗
BACKGROUND: Lower extremity (LE) muscle free flaps (MFF) require split-thickness skin grafts (STSG) for coverage. Medically comorbid patients undergoing MFFs have demonstrated surprisingly high rates of skin graft failur...
BACKGROUND: Lower extremity (LE) muscle free flaps (MFF) require split-thickness skin grafts (STSG) for coverage. Medically comorbid patients undergoing MFFs have demonstrated surprisingly high rates of skin graft failure over the MFF. This study therefore characterizes the risks for STSG failure and the effect of staging STSG on graft outcomes in medically comorbid patients. METHODS: A retrospective review of patients undergoing STSG for LE MFF coverage between 2011 and 2023 was performed. Demographics, comorbidities, MFF details, STSG details, and complications were collected. The primary outcome was graft failure. RESULTS: Ninety-one patients underwent MFF and STSG, with 65 (71.4%) undergoing immediate STSG and 26 (28.6%) undergoing delayed STSG, at a median of 12 days (IQR = 9) after MFF. The delayed group had a significantly higher Charlson Comorbidity Index (5.6 vs. 3.7, p < 0.001). The overall graft failure rate was 31.5%, with no differences between groups (immediate: 27% vs. delayed: 42.3%, p = 0.157). On multivariable analysis, elevated preoperative HbA1c (OR: 1.5, CI = 1.1-1.9), low levels of albumin preoperatively (OR: 0.3, CI: 0.1-0.9), and a history of Charcot arthropathy (OR: 8.6, CI: 1.3-55.2) were independent predictors of graft failure. CONCLUSION: Little evidence exists to help guide the decision to perform immediate versus delayed skin grafting of MFFs in a highly comorbid population undergoing limb salvage. Delaying skin grafts in patients with significant comorbidities that threaten flap viability and wound healing capacity may improve graft take. Patient comorbidities, nutritional status, and intraoperative factors should also be considered when determining the timing of skin grafts over MFF.
Free Flap Reconstruction of Abdominal Wall Defects: A Systematic Review and Pooled Analysis.
Kim MI, Manasyan A, Stanton EW … +4 more , Jimenez C, Carey JN, Daar DA, Koesters EC
Microsurgery · 2025 May · PMID 40192162 · Publisher ↗
BACKGROUND: Reconstruction of extensive abdominal wall defects poses significant challenges, often requiring free tissue transfer when traditional methods are inadequate. This review examines the past decade's literature...
BACKGROUND: Reconstruction of extensive abdominal wall defects poses significant challenges, often requiring free tissue transfer when traditional methods are inadequate. This review examines the past decade's literature on free flaps for abdominal wall reconstruction to guide decision-making. METHODS: A systematic review following PRISMA guidelines was conducted on July 17, 2024, using PubMed, Cochrane Library, Web of Science, Embase, and Scopus. Studies from 2013 to 2023 involving free flap reconstruction with at least 3 months follow-up were included. Surgical complications and outcomes were analyzed. RESULTS: Of 2269 articles, 32 met inclusion criteria, involving 104 free flaps. There were no reports of flap loss. The average defect size was 330.0 ± 200.8 cm. Oncologic resection was the leading indication (57%), with the latissimus dorsi flap used most frequently (36%). The most common recipient vessels were the deep inferior epigastric vessels (66.7%). The most common recipient vessels were the deep inferior epigastric vessels (66.7%). Mesh was used in 53% of cases, predominantly in a sublay position. The majority of reconstructions were immediate (52.9%), followed by delayed (31.8%) and staged (15.3%). Complications included partial flap necrosis (5.8%), surgical site infection (5.8%), and hernia development (4.8%). There were no significant differences in outcomes when stratified by reconstruction timing, flap choice, recipient vessels, or mesh characteristics. Infection as the defect etiology independently predicted surgical site infection (p = 0.03), whereas mesh usage (p = 0.07) and diabetes (p = 0.09) trended toward increased infection risk. Donor site complications were minimal. CONCLUSION: Free flap reconstruction is safe and effective for large abdominal wall defects, with similar outcomes across flap types. Infection as the initial etiology was the strongest predictor of postoperative infection. Further studies are needed to establish guidelines for patient and flap selection.
Targeted Nipple Areola Complex Reinnervation in Gynecomastia Mastectomy: A Case Report.
Blears EE, Remy K, Diaconu S … +2 more , Valerio IL, Gfrerer L
Microsurgery · 2025 May · PMID 40177928 · Publisher ↗
Targeted nipple areola complex (NAC) reinnervation (TNR) to restore nipple and chest sensation has been previously described in patients undergoing breast reconstruction and gender-affirming mastectomy. A healthy 32-year...
Targeted nipple areola complex (NAC) reinnervation (TNR) to restore nipple and chest sensation has been previously described in patients undergoing breast reconstruction and gender-affirming mastectomy. A healthy 32-year-old male, with grade II gynecomastia with severe skin laxity and a BMI of 25 kg/m, underwent bilateral mastectomy with free nipple grafting (FNG) for persistent gynecomastia and chest wall soft tissue laxity. The mastectomy weight was 242.5 (range: 242-243) grams. Three lateral intercostal nerves (3rd, 4th and 5th) were preserved and directly coaptated to the new NAC on each side. Quantitative and patient-reported sensory evaluation was conducted at 18 months follow-up, revealing a median monofilament detection threshold of 3.61 (range: 2.83-3.61) at the NAC and 2.83 (2.83-3.61) at the chest wall as well as pain from pressure at a median of 100.0 kPa (range: 77.4-122.5) at the NAC and 151.5 kPa (range: 116.6-183.3) at the chest. While the median two-point discrimination was 3.0 cm (range: 1.5-4.0) at the chest wall, two-point discrimination could not be detected at the NAC. The patient was "very satisfied" with nipple and chest sensation and did not report any nipple hypersensitivity, nipple/chest pain, or phantom sensation/pain. TNR was able to restore various quantitative and patient-reported sensory functions at the NAC and chest with high patient satisfaction. This report provides the first quantitative sensory outcomes from TNR for restoration of sensation after mastectomy for the treatment of gynecomastia in a male patient.
Minimally Invasive Bilateral Autologous Breast Reconstruction by Double SCIP-SB Free Flap With Internal Mammary Perforator and Rib-Sparing Internal Mammary Anastomoses: A Case Report.
Martini F, Meroni M, Scaglioni MF
Microsurgery · 2025 May · PMID 40171919 · Publisher ↗
Minimizing invasiveness has become a primary goal in autologous breast reconstruction, with a shift toward perforator-based flaps over musculocutaneous flaps to reduce donor site morbidity. The deep inferior epigastric a...
Minimizing invasiveness has become a primary goal in autologous breast reconstruction, with a shift toward perforator-based flaps over musculocutaneous flaps to reduce donor site morbidity. The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard due to its reliable perfusion and high-level esthetic outcomes; however, it requires intramuscular dissection, which might be tedious and carry the risk of abdominal wall weakening. At the recipient site, traditional anastomosis techniques often involve the removal of costal cartilage, contributing to a higher morbidity and discomfort or long-lasting localized pain. A 56-year-old female patient presenting with a recurrent right breast tumor was referred to our department for a bilateral skin-reducing mastectomy and immediate autologous reconstruction. Preoperative imaging revealed small DIEA perforators and the presence of a suitable perforator of the superficial branch of the superficial circumflex iliac artery (SCIP-SB) bilaterally. Intraoperative ICG evaluation confirmed adequate flap perfusion based on the SCIP-SB, allowing for flap harvest based on these vessels without opening the rectus fascia or performing intramuscular dissection. At the recipient site, on the right side, an internal mammary artery perforator was preserved and used for anastomosis, while on the left side, we isolated the internal mammary vessels in a rib-sparing fashion. This approach minimized morbidity at donor and recipient sites, improving postoperative comfort and recovery. The patient reported mild pain and no complications post-surgery and expressed high satisfaction at 6 months. This case highlights how focusing on the reduction of morbidity at different stages of the reconstructive procedure may allow obtaining better patient-centered outcomes. In this perspective, the SCIP-SB flap represents a viable, minimally invasive option, expanding the possible reconstructive choices in autologous breast reconstruction.
Editorial Self-Publication in Plastic Surgery Journals.
Levine E, Lineaweaver W, Drolet B
Microsurgery · 2025 May · PMID 40156181 · Publisher ↗
BACKGROUND: The general practice of journal editors publishing original articles in their own journals has been examined in several reviews. No such study has been reported for plastic surgery journals. This study analyz...
BACKGROUND: The general practice of journal editors publishing original articles in their own journals has been examined in several reviews. No such study has been reported for plastic surgery journals. This study analyzes editorial publication practice in plastic surgery journals over an 8-year period. METHODS: A retrospective analysis of twelve PubMed indexed journals, including Plastic and Reconstructive Surgery (PRS), Plastic and Reconstructive Surgery Global Open (PRS-GO), Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Plastic, Reconstructive & Aesthetic Surgery (JPRAS), Journal of Plastic, Reconstructive, & Aesthetic Surgery Open (JPRAS-Open), The Journal of Craniofacial Surgery, Archives of Plastic Surgery, the Journal of Plastic Surgery and Hand Surgery, Indian Journal of Plastic Surgery, Microsurgery, and Journal of Reconstructive Microsurgery. We reviewed all articles between 2014 and 2021 to identify articles published by the journal's editor. Editorials and articles appearing in supplements were excluded from this analysis. RESULTS: The proportion of editor authorship ranged from 0% to 5.88%. We found that editors of PRS and Journal of Plastic Surgery and Hand Surgery had a significantly greater authorship proportion than the other journals reviewed. CONCLUSION: This study found that almost all the studied journals had original articles published by their respective editors. Two journals: PRS and the Journal of Plastic Surgery and Hand Surgery had higher rates of editor article publication compared to the other journals.
The Use of "Spare Parts" En Bloc Anterior Compartment Myocutaneous Free Flap to Reconstruct the Transmetatarsal Amputation Stump After Contralateral Below Knee Amputation: Report of Two Cases.
Jagasia P, Shah SA, Bagdady K … +2 more , Dumanian GA, Fracol ME
Microsurgery · 2025 May · PMID 40156151 · Publisher ↗
The aim of reconstruction after lower extremity amputation is to provide adequate soft tissue coverage that is compatible with prosthetics to optimize functional status. We present two cases where the anterior compartmen...
The aim of reconstruction after lower extremity amputation is to provide adequate soft tissue coverage that is compatible with prosthetics to optimize functional status. We present two cases where the anterior compartment myocutaneous free flap used in a "spare parts" fashion was valuable in preserving the length of residual limbs for patients needing simultaneous below-knee amputation (BKA) and contralateral transmetatarsal amputation (TMA). The first case involved a 48-year-old woman undergoing TMA and BKA to address bilateral lower extremity necrosis secondary to septic shock. The anterior compartment muscles were taken en bloc as a myocutaneous free flap measuring ~4 × 12 cm based on the anterior tibial artery. A standard BKA was completed with a posterior flap, and the flap was used to cover exposed metatarsals on the opposite limb. After 4 years, she had no complications or additional surgeries and was able to ambulate independently. The second case involved a 55-year-old woman undergoing BKA and TMA for bilateral lower extremity gangrene. Again, the anterior compartment muscles were taken as a myocutaneous free flap measuring ~5 × 15 cm to cover the resulting TMA defect. This patient underwent debulking at 2 and 10 weeks postoperatively, after which she had no complications at 1 year of follow-up and returned to independent ambulation. This technique provided effective soft tissue coverage and successfully preserved limb length without additional donor site morbidity. As a myocutaneous free flap, the anterior compartment muscles may effectively preserve the length of residual limbs in patients undergoing BKA and TMA, allowing for improved functional outcomes and quality of life.
Lateral Humeral Pure Periosteal Flap for Nonunion of Humerus Pathologic Fracture in an Elderly Patient: A Case Report.
Buendía Perez J, Iniesta B, Asensio Ramos S … +1 more , Soldado F
Microsurgery · 2025 Mar · PMID 40134148 · Publisher ↗
Pathological fractures associate a complex tumoral microenvironment that can culminate in a complex bone nonunion. Surgical treatment with vascularized periosteal flaps has resulted into an excellent option in children b...
Pathological fractures associate a complex tumoral microenvironment that can culminate in a complex bone nonunion. Surgical treatment with vascularized periosteal flaps has resulted into an excellent option in children because of their angiogenic and osteogenic properties; nonetheless, it has been scarcely reported in the adult. We present a case report that challenges the classical concept of not using pure periosteal flaps in the adult, widening surgical options for nonunion. A 67-year-old male patient diagnosed with multiple myeloma presented nonunion after pathological fracture in the left humerus. He was treated with a pedicled lateral humeral pure periosteal flap based in the posterior collateral radial vessels. It measured a 6 cm × 4 cm and was pedicled proximally, wrapping it around the nonunion site after compression plate osteosynthesis. Post operatory was uneventful and the patient was followed 9 months after surgery. Periosteal callus and bony bridges were formed 4 months after surgery. This case avoids the need of a free flap such as the Sakai, with conservation of the advantages of the cambium layer such as demonstrated in children.
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