Microsurgery[JOURNAL]
Sun
200 papers
Modified Open Guide Suture for Both Vessel Walls in Microvascular Anastomosis.
Kitai R, Katayama R, Suzuki S … +1 more , Yasunaga Y
Microsurgery · 2026 May · PMID 42163472 · Publisher ↗
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Feasibility of Flexor Hallucis Muscle-Based Fibula Bone Segment for Ramus Reconstruction in Head and Neck Cancers.
Reddy M, Mantri M, Kumar V … +5 more , Bindu A, Mokhale K, Jaiswal D, Mathews S, Shankhdhar VK
Microsurgery · 2026 May · PMID 42163471 · Publisher ↗
INTRODUCTION: In mandibular reconstruction with a free fibula flap, ramus reconstruction is very important to match the ramus height, which eventually helps in good mouth opening and mastication. The fibula bone segment...
INTRODUCTION: In mandibular reconstruction with a free fibula flap, ramus reconstruction is very important to match the ramus height, which eventually helps in good mouth opening and mastication. The fibula bone segment attached to the pedicle is used for ramus reconstruction. But when the bone requirement is large and the pedicle is short, we propose an alternate method in which the bone segment is separated from the pedicle but is attached to the flexor hallucis longus (FHL) muscle from which it receives its vascularity indirectly. Through this article, we aim to examine the non-inferiority of the FHL-based ramus in such cases. PATIENTS AND METHODS: This is a retrospective observational report carried out in a tertiary care cancer institute and includes the segmental mandibular defects reconstructed with free fibula flaps (FHL-based vs. vascularized ramus) between January 2019 and December 2021, with a follow-up of a minimum of 1 year. The primary objective is to assess the complication rates for FHL-based ramus for osteoradionecrosis (ORN), hardware exposure, bone union rates, chronic sinus/discharge, and the need for secondary procedures in cases of free fibula flaps. RESULTS: In 100 patients included in this report, the plate/hardware exposure rate (14% vs. 12%) (p = 1), nonunion rate (5.3% vs. 4%) (p = 1), sinus rate (4% vs. 0%) (p = 0.57), ORN (5.3% vs. 4%) (p = 1), and secondary procedures (16% vs. 16%) (p = 1) in FHL-based ramus versus vascularized ramus fibula flaps. p value is one suggesting the proportion of complications is the same in both groups. CONCLUSION: An FHL-based ramus provides an additional tool in the armamentarium when the bone requirement is huge and is not inferior to a vascularized ramus in terms of complication rate related to hardware exposure and bone necrosis.
When Fewer Complications Cost More: A Value-Based Reanalysis of Donor-Site Reconstruction.
Karamitros G, Lamaris GA, Lineaweaver WC
Microsurgery · 2026 May · PMID 42163040 · Publisher ↗
BACKGROUND: Reconstructive strategies are commonly evaluated according to complication rates and technical success at the individual patient level. However, interventions that reduce complications may simultaneously incr...
BACKGROUND: Reconstructive strategies are commonly evaluated according to complication rates and technical success at the individual patient level. However, interventions that reduce complications may simultaneously increase cumulative procedural exposure, operative utilization, and healthcare resource consumption across patient populations. This distinction reflects a broader epidemiologic trade-off between universal prophylactic intervention and selective escalation following clinically significant failure. METHODS: We performed a value-based reinterpretation of the donor-site reconstruction study by Angela Alnemri et al., comparing staged reconstruction of radial forearm free flap donor sites using Integra followed by delayed split-thickness skin grafting (STSG) with primary STSG closure. Using published cohort data, we conducted a composite procedural burden analysis evaluating cumulative donor-site closure procedures under observed treatment patterns and under a procedural-economy counterfactual in which all patients underwent primary STSG with selective operative salvage only when clinically necessary. RESULTS: The original study demonstrated lower rates of skin graft breakdown and tendon exposure with staged reconstruction. However, staged reconstruction required a second operative episode for nearly all patients by design, resulting in substantially greater cumulative procedural exposure. Across 179 patients, the observed treatment strategy resulted in 313 donor-site closure procedures. In contrast, the modeled procedural-economy strategy resulted in 179 + r procedures, where r represented patients requiring operative salvage following donor-site complications. Under the base-case assumption (r = 0), this corresponded to 134 fewer operative procedures. Even under conservative sensitivity assumptions permitting selective reoperation, substantial procedural reduction persisted before parity with universal staging was reached. CONCLUSIONS: Lower complication rates do not necessarily translate into lower healthcare utilization or greater value at the population level. In donor-site reconstruction, staged strategies reduce individual-level morbidity but do so through universal escalation of procedural intensity. Reconstructive decision-making should therefore incorporate procedural economy, operative exposure, and health-system resource utilization alongside conventional complication-based endpoints. Integrating epidemiologic and health-economic principles into reconstructive algorithms may better align technical outcomes with value-based surgical care.
Timing of Antioxidant Pretreatment With Melatonin, Vitamin C, and Vitamin E in Ischemia-Reperfusion Injury: A Rat Inferior Epigastric Island Flap Model.
Sirkeci CB, Yalcin CE, Aydın SY … +4 more , Sağır MS, Yılmaz Ç, Kılıç Ş, Demiröz A
Microsurgery · 2026 May · PMID 42157414 · Publisher ↗
BACKGROUND: Free flap surgeries represent significant advancements in reconstructive surgery. Despite surgical progress, ischemia-reperfusion injury (IRI) due to vascular complications remains a challenge, potentially le...
BACKGROUND: Free flap surgeries represent significant advancements in reconstructive surgery. Despite surgical progress, ischemia-reperfusion injury (IRI) due to vascular complications remains a challenge, potentially leading to flap loss. Various strategies, including surgical methods and pharmacological treatments, have been explored to mitigate IRI. Among these, antioxidant treatments have garnered interest, but research on the optimal timing of antioxidant administration is lacking. This study addresses this gap by investigating the timing of antioxidant pretreatment. METHODS: In this experimental study, a 6 × 3 cm inferior epigastric island flap was elevated in 40 male Wistar Albino rats and subjected to 8 h of ischemia followed by reperfusion. The animals were divided into five groups: a control group without ischemia-reperfusion (IR), an IR group receiving saline, and three treatment groups pretreated with melatonin (10 mg/kg), vitamin C (200 mg/kg), and vitamin E (40 mg/kg), administered 7 days preoperatively, 30 min before ischemia, or 30 min before reperfusion. Blood samples were obtained on postoperative days 1 and 7 to assess total antioxidant capacity. Flap photographs were taken and tissue biopsies were collected on postoperative day 7 for histopathological, immunohistochemical, and biochemical analyses. RESULTS: The mean necrosis rate was 33.5% in the IR group compared to 6.3% in the 7-day pretreatment group (I7) (p < 0.001). Histopathological evaluation showed significant improvement in inflammatory and vascular parameters in antioxidant-treated groups compared to IR (p < 0.05), while collagen organization was significantly better only in the I7 group (p = 0.0014). Immunohistochemical analysis revealed reduced eNOS, caspase-3, and IL-1β expression in antioxidant-treated groups and higher VEGF expression in the I7 group (p < 0.05). No significant differences were observed between groups in biochemical parameters. CONCLUSION: Initiating antioxidant pretreatment 7 days prior to surgery significantly enhances flap viability, highlighting the importance of timing for optimal outcomes in elective free flap procedures.
Clinical Performance of Digital Microscopes in Microsurgery: A Retrospective Analysis of Operative Time and Intraoperative/Postoperative Thrombosis Rates.
Ito T, Ichikawa Y, Seki Y … +3 more , Tobita M, Takeishi M, Mizuno H
Microsurgery · 2026 May · PMID 42152506 · Publisher ↗
BACKGROUND: Digital microscopes (DMs) have been increasingly adopted in microsurgery; however, clinical evidence regarding their operative efficiency, safety, and learning curve compared with conventional optical microsc...
BACKGROUND: Digital microscopes (DMs) have been increasingly adopted in microsurgery; however, clinical evidence regarding their operative efficiency, safety, and learning curve compared with conventional optical microscopes (OMs) remains limited. In particular, anastomosis-specific operative time and intraoperative thrombosis-an indicator closely related to technical precision-have not been sufficiently evaluated in clinical settings. Therefore, this study aimed to evaluate the learning curve associated with digital microscope adoption in microsurgical reconstruction using operative time metrics and to assess thrombotic events as exploratory safety outcomes. METHODS: We retrospectively reviewed 123 consecutive free-flap reconstructions performed by three experienced plastic surgeons between June 2022 and March 2025. The cases were categorized into three groups: OM, early-phase DM (DM-T1), and late-phase DM (DM-T2). The choice of visualization system was determined by operating room availability rather than surgeon preference. Microscope usage time, arterial and venous anastomosis times, and intraoperative and postoperative arterial or venous thromboses were analyzed. Intraoperative arterial patency was assessed by palpation and pinprick tests, and venous patency was assessed by the patency test. Learning curve effects were evaluated by comparing DM-T1 and DM-T2. RESULTS: The number of cases in each group was 37, 34, and 52 in the DM-T1, DM-T2, and OM groups, respectively. Mean microscope usage time was longer in DM-T1 than in DM-T2 and OM (71.9 ± 15.0 vs. 57.6 ± 13.4 vs. 58.5 ± 19.8 min; p = 0.0055 and p = 0.0021). Mean arterial anastomosis time was also longer in DM-T1 compared with DM-T2 and OM (22.5 ± 7.2 vs. 19.0 ± 5.1 vs. 17.4 ± 4.9 min; p = 0.048 and p = 0.0028). Venous anastomosis time showed a decreasing trend from DM-T1 to DM-T2 but did not reach statistical significance. The incidence of intraoperative and postoperative thrombosis did not differ among groups (intraoperative arterial thrombosis: 18.9%, 14.7%, and 15.4% in the DM-T1, DM-T2, and OM groups, respectively; p ≥ 0.05). CONCLUSION: DM demonstrates a measurable learning curve, with operative efficiency improving to levels comparable to those of OM, while maintaining similar thrombotic safety. DMs are a reliable visualization platform for microsurgical reconstruction.
Strategic Muscle Coverage in Free Fibular Mandibular Reconstruction: An Osteotomy Approach to Minimize Plate Exposure, A Retrospective Analysis of 580 Consecutive Patients.
Arora R, Mishra KS, Kumar A … +3 more , Prasad N, Alagarasan AR, Gupta S
Microsurgery · 2026 May · PMID 42138482 · Publisher ↗
BACKGROUND: Free fibula flap reconstruction represents the gold standard for mandibular reconstruction following oncologic resection. However, plate exposure remains a significant complication, particularly in patients r...
BACKGROUND: Free fibula flap reconstruction represents the gold standard for mandibular reconstruction following oncologic resection. However, plate exposure remains a significant complication, particularly in patients receiving postoperative radiotherapy. Traditional reconstructive approaches emphasize precise hardware contouring and basic soft tissue coverage but frequently fail to provide adequate muscle protection over hardware, especially in irradiated tissues. METHODS: A retrospective analysis was conducted of 580 consecutive free fibula flap reconstructions performed between 2018 and 2024. Patients were stratified into two cohorts based on plate exposure occurrence. The modified surgical technique involved strategic fibular segment rotation to position the flexor hallucis longus muscle directly over critical hardware fixation points. Statistical analyses included Mann-Whitney U tests, Fisher's exact tests, and logistic regression modeling to identify significant risk factors for plate exposure. RESULTS: Adequate muscle coverage was present in 33.33% of patients with plate exposure compared with 97.02% of those without exposure (p < 0.0001). Among patients receiving postoperative radiotherapy, adequate muscle coverage was achieved in 96.34% of cases without exposure compared to 50% in the exposure group (p = 0.001). Multivariate analysis confirmed inadequate muscle coverage as an independent predictor of plate exposure (OR: 22.669, 95% CI: 3.79-135.596). CONCLUSION: The described osteotomy modification was associated with consistent muscle coverage over reconstructive hardware and was associated with lower plate exposure rates, particularly in patients undergoing postoperative radiotherapy. Prospective studies are required for long-term assessment.
Arteriovenous Loop-Assisted Free Functional Gracilis Transfer in Vessel-Compromised Patients: A Salvage Strategy for Facial Reanimation.
Osterloh J, Weiss JBW, Fricke M … +3 more , Nguyen CT, Kollár B, Eisenhardt SU
Microsurgery · 2026 May · PMID 42108985 · Full text
BACKGROUND: Free functional gracilis transfer (FFGT) is the gold standard for dynamic facial reanimation in long-standing facial paralysis and its success depends on the availability of reliable recipient vessels. In pat...
BACKGROUND: Free functional gracilis transfer (FFGT) is the gold standard for dynamic facial reanimation in long-standing facial paralysis and its success depends on the availability of reliable recipient vessels. In patients with compromised vessels due to prior surgery, radiation, or trauma, arteriovenous (AV) loops are a well-established reconstructive strategy. However, their role in facial reanimation remains scarcely reported. METHODS: We retrospectively analyzed all patients with facial paralysis receiving facial reanimation with FFGT at our center between January 2010 and March 2025. All patients with absent or compromised standard recipient vessels, who underwent facial reanimation using FFGT in combination with an AV loop, were included. A sequential approach with preoperative Doppler examination, intraoperative flow assessment, AV loop construction, and continuous Cook-Schwartz Doppler monitoring was used before gracilis harvest. Each case was compared with an age-matched cohort of patients who underwent conventional FFGT without AV loops to contextualize operative and ischemia times. Primary outcomes were technical success and perioperative complications. RESULTS: Out of 196 patients who underwent facial reanimation, four patients (4/196, 2.0%) with compromised recipient vessels who received AV loop-assisted FFGT were identified (mean age 57 years (range: 40-65) years). The mean follow-up time was 19.3 months (13-30 months). No AV-loop thrombosis, flap loss, hematoma, wound complications, or donor-site morbidity occurred. Compared with age-matched controls, operative times were prolonged, whereas ischemia times remained comparable. Functional smile restoration was achieved in two of four patients within 12 months. CONCLUSIONS: AV loop-assisted FFGT is a technically feasible salvage approach for facial reanimation in patients with compromised recipient vessels, enabling restoration of vascular access and expanding reconstructive options. TRIAL REGISTRATION: FRKS (Freiburger Reister Klinischer Studien), No. FRK005908.
3D Printing of a Patient-Specific Biomodel and Cutting Guide for Metatarsal Reconstruction With an Osteocutaneous SCIP Flap Using Open-Source Software: A Case Report.
Obaíd ML, Núñez A, Parada L … +4 more , Oñate V, Almeida C, Roa R, Pereira N
Microsurgery · 2026 May · PMID 42087565 · Publisher ↗
Technology-assisted planning is increasingly integrated into reconstructive plastic surgery, including virtual reality, augmented reality, and three-dimensional (3D) printing. 3D printing has been especially useful in ma...
Technology-assisted planning is increasingly integrated into reconstructive plastic surgery, including virtual reality, augmented reality, and three-dimensional (3D) printing. 3D printing has been especially useful in maxillofacial surgery, both for patient-specific cutting guides for osteotomies and for biomodels to customize osteosynthesis plates. However, to our knowledge, there have been no reports of a 3D-printed cutting guide to harvest a custom iliac crest bone flap based on the deep branch of the superficial circumflex iliac artery perforator (SCIP) flap, together with a biomodel of the foot skeleton with the bone defect for intraoperative use. We report a 36-year-old man with a 45-mm bone defect of the first metatarsal and a 9 × 8 cm skin defect on the dorsum of the right foot after firearm trauma. Computer-aided design and computer-aided manufacturing (CAD/CAM) using open-source software were used to prepare a cutting guide that allowed harvesting a bone flap of precise dimensions and a biomodel that enabled intraoperative adjustment of the flap without pedicle division. Reconstruction was achieved with a 45-mm bone flap based on the deep branch of the SCIP and a 9 × 8 cm skin flap based on the superficial branch of the SCIP. Both flaps survived without complications; bone consolidation was observed at 4 months, and at 10 months, the patient had an adequate, pain-free gait. This case illustrates that an open-source, low-cost 3D-printing workflow may be a useful adjunct for planning and execution of metatarsal reconstruction with osteocutaneous free flaps.
Re-Evaluation of the Ideal Injury to Flap Time Frame for Lower Extremity Free Flap Reconstruction: Is 72 h Still the Gold Standard?
Clark A, Abdallah C, Ash M … +3 more , Knaus W, Brown C, Ghareeb P
Microsurgery · 2026 May · PMID 42047372 · Publisher ↗
BACKGROUND: Traumatic lower extremity injuries often require free tissue transfer (FTT) for limb salvage when local tissue is insufficient. Traditionally, reconstruction within 72 h has been considered optimal; however,...
BACKGROUND: Traumatic lower extremity injuries often require free tissue transfer (FTT) for limb salvage when local tissue is insufficient. Traditionally, reconstruction within 72 h has been considered optimal; however, advancements in wound management and perioperative care have challenged this paradigm. OBJECTIVE: To evaluate outcomes of lower extremity FTT based on time from injury to reconstruction. METHODS: A retrospective review was performed on patients undergoing lower extremity FTT after trauma at a single Level 1 trauma center (2014-2022). Patients were grouped by time from injury to flap: (< 3 days, 4-21 days, 22-90 days, and > 90 days). Ninety nine percent of patients were managed with negative-pressure wound therapy (NPWT) prior to definitive reconstruction. Outcomes included flap loss, complications, infection, osteomyelitis, nonunion, and amputation. Associations with comorbidities, surgical techniques, and fracture characteristics were assessed. RESULTS: Among 102 patients, timing of reconstruction showed no significant differences in flap loss (p = 0.56), complications (p = 0.42), nonunion (p = 0.54), osteomyelitis (p = 0.19), or amputation (p = 0.58). No independent predictors of flap loss or complications were identified. Nonunion was associated with middle/proximal fracture levels (p = 0.0092), Masquelet technique (p = 0.0004), and higher Modified Frailty Index (p = 0.05). Osteomyelitis correlated with male gender (p = 0.01), proximal fracture level (p = 0.0098), and Masquelet technique (p = 0.0095). Amputation was associated with latissimus and radial forearm flaps (p = 0.0081), ipsilateral femur fracture (p = 0.0063), hypertension (p = 0.011), and higher ASA score (p = 0.0021). CONCLUSION: In this series, delayed FTT beyond 72 h was not associated with increased flap loss or limb-threatening complications. Delayed reconstruction may optimize patient and wound factors, though aggressive wound management is essential. Given the retrospective design, uneven group sizes, and small early reconstruction cohort, these findings should be interpreted cautiously. Further research with larger cohorts and long-term outcomes is warranted.
The Effect of Ulnar Nerve Motor Branch Transfer in Cubital Tunnel Syndrome Surgery: A Comparison With In Situ Decompression Alone.
Yenidünya MK, Adıgüzel İF, Yenidünya ESO
Microsurgery · 2026 May · PMID 42037461 · Publisher ↗
BACKGROUND: Advanced cubital tunnel syndrome causes progressive sensory and motor dysfunction, leading to hand weakness, intrinsic muscle atrophy, and functional impairment. Although surgical decompression relieves mecha...
BACKGROUND: Advanced cubital tunnel syndrome causes progressive sensory and motor dysfunction, leading to hand weakness, intrinsic muscle atrophy, and functional impairment. Although surgical decompression relieves mechanical compression, functional recovery in McGowan Stage 3 patients is often limited due to irreversible axonal degeneration and delayed reinnervation of distal muscles. Distal end-to-side anterior interosseous nerve transfer has therefore been proposed as an adjunct to decompression to enhance reinnervation. The aim of this study was to evaluate the effects of this distal nerve transfer on intrinsic muscle recovery, clinical function, and electrophysiological outcomes in patients with advanced cubital tunnel syndrome. PATIENTS AND METHODS: This retrospective study included 23 adult patients with McGowan Stage 3 ulnar neuropathy treated between February 2022 and June 2024. Patients were assigned to decompression alone (Group 1, n = 13) or decompression combined with distal end-to-side anterior interosseous nerve to ulnar motor branch transfer (Group 2, n = 10). Functional outcomes were evaluated using QuickDASH, British Medical Research Council (BMRC) grading, lateral pinch, and grip strength. Electrophysiological assessments included compound muscle action potential (CMAP) amplitude and motor conduction velocity (MCV) measured preoperatively and at 6 and 12 months postoperatively, with subgroup analyses based on preoperative fibrillation status. RESULTS: At 12 months, QuickDASH improved significantly in both groups (Group 1: 52.4 ± 5.6 to 36.5 ± 10.0, p = 0.001; Group 2: 55.1 ± 8.8 to 34.2 ± 9.8, p = 0.005). British Medical Research Council grades also increased in both groups (Group 1: 2.6 ± 0.8 to 2.9 ± 0.6, p = 0.005; Group 2: 2.1 ± 0.7 to 3.1 ± 0.7, p = 0.047). Lateral pinch improved significantly only in Group 2 (7.8 ± 1.8 kg to 9.4 ± 2.0 kg, p = 0.011), while grip strength showed no significant change (Group 1: 33.6 ± 6.9 kg to 36.1 ± 5.2 kg, p = 0.057; Group 2: 31.9 ± 5.7 kg to 35.0 ± 7.9 kg, p = 0.078). CMAP increased significantly at 12 months in both groups (Group 1: 5.28 ± 1.93 mV to 5.9 ± 1.7 mV, p = 0.017; Group 2: 6.4 ± 1.7 mV to 7.6 ± 2.4 mV, p = 0.036), and MCV also improved (Group 1: 37.9 ± 10.4 m/s to 43.6 ± 9.1 m/s, p = 0.039; Group 2: 42.0 ± 8.5 m/s to 58.1 ± 8.5 m/s, p = 0.008). Among patients with preoperative fibrillation, Group 2 demonstrated better postoperative lateral pinch (10.7 ± 1.2 vs. 8.0 ± 1.0 kg, p = 0.013), QuickDASH (27.5 ± 5.5 vs. 42.3 ± 6.8, p = 0.011), and BMRC grades (3.5 ± 0.6 vs. 3.1 ± 0.4, p = 0.037) compared with Group 1. CONCLUSION: Distal end-to-side anterior interosseous nerve to ulnar motor branch transfer combined with decompression is associated with improved intrinsic muscle recovery and functional outcomes compared with decompression alone in patients with advanced cubital tunnel syndrome, particularly in patients demonstrating active denervation on preoperative needle EMG, as indicated by the presence of fibrillation potentials.
Application of the SCIA-Pure Skin Perforator Flap in Bilateral Upper Eyelid Reconstruction: A Case Report and Review of the Literature.
Morillo CP, Lin Wu ZQ, Domènech JS … +3 more , Bulla A, Barret JP, Nicolls DAR
Microsurgery · 2026 May · PMID 42028898 · Publisher ↗
Facial burns often result in cicatricial eyelid retraction, causing corneal exposure, ulceration, and vision loss. Traditional reconstructive methods, such as full-thickness skin grafts or local flaps, frequently fail in...
Facial burns often result in cicatricial eyelid retraction, causing corneal exposure, ulceration, and vision loss. Traditional reconstructive methods, such as full-thickness skin grafts or local flaps, frequently fail in extensive burns due to limited healthy tissue and a high risk of recurrent contracture. Achieving durable functional and aesthetic outcomes in such cases remains a major challenge. We report the use of bilateral free superficial circumflex iliac artery pure skin perforator (SCIA-PSP) flaps for upper eyelid reconstruction in a 50-year-old man with severe facial burns and recurrent bilateral upper eyelid retraction, leading to persistent lagophthalmos despite prior skin grafting. Preoperative color Doppler ultrasound was used to map SCIA perforators. Bilateral PSP flaps were elevated from the groin in the subdermal plane and transferred as free flaps to the eyelids, with microvascular end-to-end anastomoses to the supraorbital vessels. The postoperative course was uneventful, with no flap-related complications. At 52 months follow-up for the left eyelid and 31 months for the right, the patient achieved stable bilateral eyelid closure, resolution of lagophthalmos, excellent tissue pliability, and satisfactory aesthetic integration. The SCIA-PSP flap offers ultra-thin, vascularized tissue, effectively preventing recurrent contracture, and represents a reliable alternative in complex burn-related eyelid reconstruction.
Cervical Spine Reconstruction With Vascularized Osteoadipofascial Fibular Flap and Periosteum Extension After Chordoma Resection and Adjuvant Proton Therapy: A Case Report.
Buendía Pérez J, Sanz Medrano S, Carrascosa Granada Á … +4 more , Asensio Ramos S, Iniesta Lima B, Gomez-Martinez de Lecea C, Soldado F
Microsurgery · 2026 May · PMID 42007509 · Publisher ↗
Cervical spine reconstruction is essential following en bloc tumor resections, particularly in defects exceeding four centimeters. Traditional mechanical solutions or non-vascularized grafts are often suboptimal, with co...
Cervical spine reconstruction is essential following en bloc tumor resections, particularly in defects exceeding four centimeters. Traditional mechanical solutions or non-vascularized grafts are often suboptimal, with complications such as non-union, infections, and instability. The vascularized osteoadipofascial fibular flap offers a durable alternative with structural and biological benefits. We present the case of a 55-year-old woman with an 8-month history of cervicobrachialgia and left upper limb paresis. Imaging revealed a 7-cm lesion spanning C4-T1 with foraminal infiltration, and histopathology confirmed a chordoma. A two-stage surgery was performed: posterior stabilization and partial tumor resection, followed by anterior corpectomies (C5, C6, C7) and reconstruction with a vascularized fibular flap. The flap was anastomosed to the superior thyroid vessels, and its adipofascial component isolated the esophagus from the anterior cervical plate. Postoperative proton therapy was administered. Postoperative recovery was uneventful, with a 10-day hospital stay. At 24 months, the patient showed no recurrence, complete symptom resolution, and stable osteosynthesis with evidence of bone callus formation at graft-vertebra junctions. This case suggests that vascularized fibular reconstruction may provide reliable structural support and biological integration in complex cervical oncologic defects.
Comments on "Prevalence of Subclinical Internal Jugular Vein Thrombosis After Microvascular Head and Neck Reconstruction".
Mahida K, Jagtap SR
Microsurgery · 2026 May · PMID 42003400 · Publisher ↗
Abstract loading — click title to view on PubMed.
Comments on "Flap Choice in Gender Affirming Phalloplasty Affects Postoperative Complication Rates".
Peddapalegani P, Gupta R, Bansal P … +2 more , Nainwal P, Srinivasan H
Microsurgery · 2026 May · PMID 41994982 · Publisher ↗
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Impact of Microscope Versus Loupes on Sensation Disturbances After Digital Nerve Repair: A Propensity Score-Matched Analysis.
Posso AN, Mustoe A, Tobin M … +5 more , Ma CC, Yamin M, Escobar-Domingo MJ, Lee BT, Celestin A
Microsurgery · 2026 May · PMID 41988657 · Publisher ↗
BACKGROUND: Digital nerve repair is a procedure performed to restore sensation in fingers. While surgical microscopes are used to achieve optimal outcomes, their cost may limit accessibility. Loupes, in contrast, offer a...
BACKGROUND: Digital nerve repair is a procedure performed to restore sensation in fingers. While surgical microscopes are used to achieve optimal outcomes, their cost may limit accessibility. Loupes, in contrast, offer a more affordable alternative, particularly in resource-limited settings. This study compares the risk of developing skin sensation disturbances in patients who underwent digital nerve repair using microscopes versus loupes. METHODS: The TriNetX database was queried to identify patients who underwent digital nerve repair. Patients were classified into two cohorts: microscope and loupes groups. A propensity score matching analysis was performed, adjusted for multiple covariates. The primary outcome was paresthesia, while secondary outcomes included anesthesia, hypoesthesia, and hyperesthesia. These outcomes were assessed at 3, 6, and 12 months following surgery. RESULTS: After matching, the microscope group consisted of 1208 patients, with the same number in the loupes group. At 3, 6, and 12 months following surgery, the risk of developing skin sensation disturbances was not significantly different between the two groups. At 12 months, the risk ratios (RR) for the outcomes were as follows: paresthesia (RR 1.24, p = 0.379), anesthesia (RR 1.50, p = 0.102), hypoesthesia (RR 1.71, p = 0.102), and hyperesthesia (RR 1.71, p = 0.102). CONCLUSION: The use of loupes for digital nerve repair appears to yield outcomes comparable to those achieved with a microscope in terms of sensation disturbances.
A 25-Year Bibliometric and Scientometric Analysis of Facial Paralysis Rehabilitation: Knowledge Structure, Influential Works, and Emerging Research Frontiers (2000-2025).
Doğan M, Ayvat F
Microsurgery · 2026 May · PMID 41978278 · Full text
BACKGROUND: Facial paralysis rehabilitation has progressed substantially over the past two decades, yet the scientific landscape of this field remains highly fragmented across surgical, neurological, and rehabilitation d...
BACKGROUND: Facial paralysis rehabilitation has progressed substantially over the past two decades, yet the scientific landscape of this field remains highly fragmented across surgical, neurological, and rehabilitation disciplines. Despite growing clinical and technological advances-including neuromuscular retraining, chemodenervation strategies, nerve transfer techniques, and artificial intelligence-assisted assessment-no comprehensive bibliometric synthesis has mapped the intellectual structure, global research trends, or emerging fronts of facial paralysis rehabilitation. METHODS: A bibliometric and scientometric analysis was conducted using the Web of Science Core Collection (SCI-E, SSCI, ESCI) covering the period 2000-2025. A total of 1441 publications were analyzed using Bibliometrix/R, VOSviewer, and CiteSpace. Performance indicators, collaboration networks, co-authorship and co-citation structures, keyword co-occurrence clusters, thematic evolution, and citation burst patterns were examined. RESULTS: Scientific output increased markedly, with an annual growth rate of 12.26% and a major acceleration after 2016. The United States dominated publication volume (n = 990), followed by Italy and China, while Harvard University and Massachusetts Eye and Ear emerged as the central institutional hubs. Hadlock TA represented the most influential author based on productivity and local citation impact. Source analysis demonstrated that Plastic and Reconstructive Surgery, Laryngoscope, and Otolaryngology-Head and Neck Surgery formed the journal core. Keyword and thematic analyses identified four major conceptual clusters: (1) rehabilitation and patient-centered outcomes, (2) surgical and reconstructive techniques, (3) synkinesis and chemodenervation, and (4) etiology and clinical assessment. Recent thematic fronts highlighted rapid expansion in artificial intelligence-based facial analysis, motion tracking systems, neuroplasticity-informed rehabilitation, and quality of life research. Citation burst detection revealed shifting priorities from early Bell's palsy management to contemporary technological and neurorehabilitation paradigms. CONCLUSIONS: Facial paralysis rehabilitation has evolved into a multidisciplinary and rapidly expanding field driven by innovations in surgical reanimation, neuroplasticity-based therapy, and computational assessment. However, research output remains geographically concentrated, international collaboration rates are modest, and high-quality comparative effectiveness trials are limited. Future priorities include global research capacity building, standardized outcome measurement, long-term follow-up studies, and real-world evaluation of technology-assisted interventions.
Multidisciplinary Approach to Complex Lower Extremity Limb Salvage in Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne (PAPA) Syndrome: A Case Report.
Talanker MM, Basta AV, Do T … +7 more , Tung R, Allen A, Martin M, Ruygrok BL, Kellam PJ, Trost JG, Bhadkamkar MA
Microsurgery · 2026 May · PMID 41978233 · Full text
Limb salvage using free tissue transfer in patients with rare autoinflammatory syndromes is poorly described, and the safety of microvascular reconstruction in this population remains uncertain. Hereditary pyogenic arthr...
Limb salvage using free tissue transfer in patients with rare autoinflammatory syndromes is poorly described, and the safety of microvascular reconstruction in this population remains uncertain. Hereditary pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome is characterized by dysregulated inflammation, pathergy, and impaired wound healing, raising concern for flap compromise and postoperative complications. We report a rare case of lower extremity free tissue transfer in a patient with PAPA syndrome. A 66-year-old woman with rheumatoid arthritis and PAPA syndrome presented with rapid wound breakdown, violaceous ulceration, exposed hardware, and periprosthetic joint infection following left total knee arthroplasty (TKA). Examination revealed an approximately 9 × 7 cm anterior knee defect with subtotal patellar tendon necrosis. After multidisciplinary optimization, she underwent single-stage irrigation and debridement, hardware removal, revision TKA with patellar tendon reconstruction using gracilis autograft, and immediate coverage with a 22 × 14 cm free latissimus dorsi (LD) muscle flap. The flap was anastomosed end-to-side to the anterior tibial artery with venous outflow via the venae comitantes and loosely inset to preserve future surgical access. The donor site was closed primarily. A 21 × 13 cm staged split-thickness skin graft was performed 1 week later, with adjunctive postoperative hyperbaric oxygen therapy (HBOT). Initial healing was uncomplicated, with complete graft take and donor-site healing. Four months postoperatively, the patient developed chronic sinus tracts and recurrent periprosthetic infection requiring flap re-elevation, debridement, and hardware exchange; the flap pedicle was preserved, and coverage maintained. At one-year follow-up, all wounds had healed; flap coverage was durable with acceptable cosmesis, and the patient was ambulatory for short distances without assistance. She was last seen infection-free and full-weightbearing 4 months later. This case demonstrates that microvascular limb salvage is feasible in PAPA syndrome when guided by multidisciplinary planning and strategic flap design.
Innovative Approaches for Utilizing the Fibula Flap Skin Paddle in the Presence of Alternate Vessel Anatomy-A Report of Three Clinical Cases.
Atia A, Yu P
Microsurgery · 2026 May · PMID 41978223 · Full text
The fibula free flap is a versatile option for reconstructing complex defects, particularly in the head and neck region. However, variations in the vascular anatomy of the skin paddle can pose challenges during flap harv...
The fibula free flap is a versatile option for reconstructing complex defects, particularly in the head and neck region. However, variations in the vascular anatomy of the skin paddle can pose challenges during flap harvest and inset. We identified three clinical cases of patients who were found to have alternative or aberrant vessel anatomy to the fibula skin paddle. Operative notes and photo documentation were used to determine variations in vessel anatomy to the fibula skin paddle. A total of three cases were identified in which alternative or aberrant vessel anatomy was noted to the fibula skin paddle. Variations identified included skin paddle perfusion via a perforating branch of the posterior tibial artery, a perforating branch of the tibioperoneal trunk, and absence of distal perfusion requiring use of a proximal peroneal artery perforator. There were no cases of partial or total flap loss or incidences of reoperation. These findings illustrate that awareness of potential vascular variations and management strategies, such as identifying alternative vascular sources and utilizing flow-through flaps or freestyle perforator flaps, can help to successfully harvest and inset the fibula skin paddle in the presence of alternate vessel anatomy. An alternate donor site may be necessary when no suitable perforators are identified.
Innervated Dorsal Digital Artery Propeller Perforator Flaps in One-Stage Reconstruction of Fingertip Defects: Experience With 45 Cases.
Liu H, Cheng Y, Jia Y … +3 more , Cheng D, Yu Y, Zhou Z
Microsurgery · 2026 May · PMID 41968808 · Publisher ↗
PURPOSE: We describe a technique to reconstruct fingertip defects with dorsal digital artery perforator flaps innervated with terminal branches of the proper digital nerve in a propeller manner. METHODS: To reconstruct f...
PURPOSE: We describe a technique to reconstruct fingertip defects with dorsal digital artery perforator flaps innervated with terminal branches of the proper digital nerve in a propeller manner. METHODS: To reconstruct fingertip defects, a dorsal digital artery perforator flap innervated with terminal branches of the proper digital nerve was performed. This retrospective study includes 44 fingers and 4 thumbs in 45 cases. Thirty-seven males and eight females with a mean age of 43.7 years were enrolled. The sizes of large paddles ranged from 2.0 cm × 1.3 cm to 6.0 cm × 1.6 cm, and the sizes of little paddles ranged from 0.4 cm × 0.6 cm to 2.1 cm × 0.4 cm. All flaps were harvested from the injured fingers. Donor sites were primarily closed in all patients. RESULTS: All flaps survived without major complications, except two cases with partial epidermis necrosis that healed after dressing changes. The mean follow-up period was 14.9 months. Postoperative appearance and texture of the flaps were close to normal, and no deficiency was observed in the sensory functions, although partial recovery of nociceptive and tactile sensation was detected in three patients. Postoperative extension and flexion functions of the fingers were assessed using active range of motion, with all patients demonstrating values within standard parameters and showing no signs of tendon adhesions or scar contractures. CONCLUSIONS: The dorsal digital artery propeller perforator flap innervated with terminal branches of the proper digital nerve is a reliable and relatively simple flap for the one-stage reconstruction of fingertip defects.
From Palliation After Angiosarcoma Resection to Totally Autologous Aesthetic Breast Reconstruction Combining Kiss Latissimus Dorsi Flap and Contralateral Breast Sharing Internal Mammary Artery Perforator Flap: A Case Report.
Brunetti B, Petrucci V, Ponzo M … +6 more , Oliveri F, Pazzaglia M, Morelli Coppola M, Barone M, Tenna S, Persichetti P
Microsurgery · 2026 May · PMID 41954429 · Publisher ↗
Angiosarcoma of the breast is a rare but aggressive disease that often requires wide-margin resection resulting in massive thoracic defects. In this report we present the unique case of a patient who underwent primary ch...
Angiosarcoma of the breast is a rare but aggressive disease that often requires wide-margin resection resulting in massive thoracic defects. In this report we present the unique case of a patient who underwent primary chest wall reconstruction with palliative intent using Kiss Latissimus Dorsi (LD) Flap after resection of a huge angiosarcoma of the right breast, followed 3 years later by a secondary shift to totally autologous aesthetic breast reconstruction which was achieved by combining the first flap with breast-sharing internal mammary artery perforator (IMAP) flap and simultaneous contralateral breast reduction. The defect after extended mastectomy, measuring 24 × 18 cm, was resurfaced with a Kiss LD flap designed with two skin paddles of 24 × 13 and 14 × 5 cm, respectively. Three years after the initial reconstruction, the patient was tumor-free and required breast symmetrization. Therefore, a left reduction mammaplasty with simultaneous breast sharing Internal Mammary Artery Perforator (IMAP) flap was performed, augmenting the hypoplastic right breast with the entire lower pole of the contralateral side, transferring an 18 × 9 cm flap based on the fifth IMAP. Vascular safety of the procedure was guaranteed by intra-operative indocyanine green angiography evaluation. Recovery was uneventful and the 6 months post-operative follow-up confirmed flap integration, volume symmetry and high aesthetic satisfaction. This report underlines the versatility of this innovative combination of flaps in complex reconstructive scenarios where complex microsurgical transfers are contraindicated.
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