Journal Of Reconstructive Microsurgery[JOURNAL]
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200 papers
Enhancing Microvascular Anastomosis Using an Axial-View Microscope.
Fukuyama S, Okochi M, Ishihara R … +4 more , Dogo K, Fukuba M, Nakagawa M, Komuro Y
J Reconstr Microsurg · 2026 Jul · PMID 42385776 · Publisher ↗
BACKGROUND: Under a conventional digital microscope, the cross-section of a vessel is visualized as a long oval because it is observed from a bird's-eye perspective (bird's-eye view microscope, bMS). This limited perspec...
BACKGROUND: Under a conventional digital microscope, the cross-section of a vessel is visualized as a long oval because it is observed from a bird's-eye perspective (bird's-eye view microscope, bMS). This limited perspective can hinder accurate identification of the vascular lumen and tunica intima during microvascular anastomosis. To overcome this limitation, we developed a novel microscope system that provides an axial view of the vascular stump (axial-view microscope, aMS). METHODS: In this experimental study, we used our proprietary digital microscope, which integrates a low-resolution digital camera with the aMS system, and defined this system as the bMS. Ten chicken femoral arteries were used, and two arterial anastomoses were created for each artery. One anastomosis was performed using both the bMS and aMS (aMS-assisted group), whereas the other was performed using the bMS alone (bMS-only group). Anastomosis creation was divided into two stages. Stage 1 consisted of identifying the tunica intima and inserting the surgical needle through the vascular wall. Stage 2 included all remaining procedures, excluding rotation of the vascular clamp, intraluminal irrigation, and adjustment of vessel position. Operative times were recorded and compared between groups. RESULTS: The ratio of the average duration of Stage 1 (front and back sides combined) in the aMS-assisted group relative to the bMS-only group was 0.58 ± 0.19, indicating a significantly shorter Stage 1 duration with aMS use (p < 0.001). The ratio of the average total anastomosis time was 0.88 ± 0.08, demonstrating a significant reduction in overall anastomosis time in the aMS-assisted group (p < 0.001). CONCLUSION: The aMS provides direct visualization of the vascular cross-section and facilitates rapid identification of the tunica intima without prolonging other steps of microvascular anastomosis. These findings indicate that this system may enhance the operative view and reduce anastomosis time in microsurgical procedures.
Beyond BMI: Using Abdominal Wall Thickness to Guide Patient Selection for DIEP Flap Breast Reconstruction.
Cui JX, Zeng E, Duet ML … +5 more , Tapp M, Dos Santos A, Robinson JM, Steele T, Calder B
J Reconstr Microsurg · 2026 Jul · PMID 42385775 · Publisher ↗
INTRODUCTION: BMI limits of 30.0 to 32.7 kg/m2 have been recommended to reduce post-operative complications in autologous breast reconstruction. However, BMI does not accurately represent body composition for all individ...
INTRODUCTION: BMI limits of 30.0 to 32.7 kg/m2 have been recommended to reduce post-operative complications in autologous breast reconstruction. However, BMI does not accurately represent body composition for all individuals. This study evaluates the relationship between abdominal wall thickness (AWT) and post-operative complication rates using a novel, accessible measuring method. METHODS: A retrospective chart review of 793 patients (1310 flaps) who underwent DIEP flap reconstruction from November 2017 to May 2024 at two medical institutions was conducted. Demographics, medical history, operative course, and post-operative complications were reviewed. Subcutaneous AWT was measured on pre-operative CT angiogram at four standardized anatomical landmarks. Patients were stratified by BMI (<25, 25-30, 30-35, and >35) and AWT (<20 mm, 20-40 mm, and >40 mm). Statistical analysis was conducted in R. RESULTS: The mean patient age was 50.5 years, and mean BMI was 30.3 kg/m2. BMI was strongly correlated with AWT (r = 0.68, p < 0.001), and both variables were strong predictors for complication rates (p < 0.001, p < 0.001). Stepwise increases in wound dehiscence, infection, and fat necrosis were observed across AWT groups. ROC analysis identified AWT threshold of 26.3 mm for overall complications. AWT and BMI models demonstrated comparable predictive ability for complication rates. Patients with mismatched BMI and AWT highlighted cases where BMI alone underestimated risk. CONCLUSION: Abdominal wall thickness may serve as a valuable adjunct tool in determining DIEP flap eligibility, particularly for patients with a high BMI and thin abdominal wall, or vice versa.
Influence of Body Mass Index on Perioperative Outcomes of Oncologic Head and Neck Free Flaps: Comprehensive Analysis Using a Prospective Institutional Database.
Xu HH, Dominguez ED, Mroueh V … +3 more , Duncan AM, Bottegal M, Solari M
J Reconstr Microsurg · 2026 Jun · PMID 42372795 · Publisher ↗
BACKGROUND: The impact of body mass index (BMI) extremes on the outcomes after head and neck cancer (HNC) reconstruction remains uncertain. Herein, we investigate the influence of low and high BMI on the intraoperative a...
BACKGROUND: The impact of body mass index (BMI) extremes on the outcomes after head and neck cancer (HNC) reconstruction remains uncertain. Herein, we investigate the influence of low and high BMI on the intraoperative and postoperative outcomes of oncologic head and neck microvascular reconstruction. METHODS: We analyzed a prospective institutional database (09/2019-12/2024). Patients were stratified into underweight, normal weight, overweight, and obesity I, II, and III. Flaps were categorized by donor site (thigh, back, fibula, or forearm). Demographics, intraoperative events, and donor, recipient, and systemic postoperative complications were assessed. RESULTS: Among 542 patients, BMI distribution was: 9.6% underweight (<18.5 kg/m), 34.7% normal weight (≥18.5 kg/m, <25 kg/m), 29.5% overweight (≥25 kg/m, <30kg/m), and 15.5%, 7.0%, and 3.7% within obesity I (≥30 kg/m, <35 kg/m), II (≥35 kg/m, <40 kg/m), and III (≥40 kg/m), respectively. Flaps employed significantly differed between low and high BMI groups (<0.001). Underweight patients demonstrated increased odds of donor-site (OR 4.60; =0.011) and recipient-site (OR 2.49; =0.007) complications, noteworthily salivary leaks (24.0% vs ≤11.2%; =0.0322). In subgroup analyses, obesity II patients undergoing thigh-based reconstructions saw increased flap loss (16.7% vs ≤2.4%, =0.0002); obesity II and III patients trended towards increased recipient-site hematoma (16.7% vs ≤3.6%, =0.1376) and dehiscence (20.0% vs ≤7.1%, =0.0824), respectively. BMI extremes relate to perioperative risk in HNC microvascular reconstruction. Underweight status is associated with higher perioperative complications across flaps, while obesity-related risk concentrates in class II/III patients undergoing thigh-based flaps. Findings support BMI-informed preoperative optimization and flap selection strategies.
Homocysteine Levels as a Potential Contributor to Impaired Wound Healing in Plastic and Reconstructive Surgery.
Kiel L, Egan K, Secanho M … +2 more , Mathes DW, Kaoutzanis C
J Reconstr Microsurg · 2026 Jun · PMID 42372794 · Publisher ↗
Plastic and reconstructive surgery (PRS) relies heavily on dependable tissue perfusion. Though evidence supports the effect of homocysteine levels, including the presence of hyperhomocysteinemia (HHcy), on wound healing...
Plastic and reconstructive surgery (PRS) relies heavily on dependable tissue perfusion. Though evidence supports the effect of homocysteine levels, including the presence of hyperhomocysteinemia (HHcy), on wound healing and flap thrombosis, it is typically not incorporated into perioperative risk assessment models. Homocysteine disrupts tissue healing by inducing endothelial dysfunction, generating reactive oxidative species, reducing nitric oxide availability, and impairing vasodilation. It also activates inflammatory signals and interferes with collagen cross-linking, a process necessary for wound strength. This is particularly important in PRS, where healing occurs across large reconstructive fields, including those that have been previously operated on or irradiated. PRS-specific data remain limited, as only one animal-model study has demonstrated that severe HHcy significantly increased flap necrosis rates, microangiography, and inflammatory infiltration, suggesting a direct impairment to tissue viability and repair. In microsurgical reconstruction, patients with underlying hypercoagulable states, including HHcy, demonstrated high rates of thrombotic complications and a complete lack of salvage once thrombosis occurred, suggesting that even moderate detriments to endothelial function and coagulation may cause significant flap compromise. The gap of homocysteine integration in PRS risk models is important due to its potential modifiability through factors such as folate and B-vitamin status. Homocysteine levels may offer an opportunity for perioperative optimization without added resource or significant cost burdens, and integrating it into assessment frameworks could provide a feasible opportunity to reduce wound healing complications among high-risk patients. Prospective trials are needed to evaluate this and whether the improvement of homocysteine levels enhances healing in complex reconstructive cases. Standardized clinical endpoints, including time to epithelialization, wound dehiscence, partial flap necrosis, and infection rates, should be documented. Flap-specific variables such as flap type, staged reconstruction, and anesthetic agents can also be evaluated, while patient factors such as albumin, diabetes, peripheral disease, and tobacco use should be controlled for.
Infrared Temperature Monitoring in Vascularized Flaps with Simulated Arterial and Venous Thrombosis: An Animal Study.
Schettino M, Fara G, Tognon G … +4 more , Mori F, Salmaso L, Axelsson P, Sassu P
J Reconstr Microsurg · 2026 Jun · PMID 42285166 · Publisher ↗
BACKGROUND: Early recognition of postoperative vascular compromise is critical for the success of vascularized free tissue transfer, with vascular thrombosis occurring in approximately 10% of cases. This study aimed to e...
BACKGROUND: Early recognition of postoperative vascular compromise is critical for the success of vascularized free tissue transfer, with vascular thrombosis occurring in approximately 10% of cases. This study aimed to evaluate whether a portable infrared camera (FlirOne; FO) can detect skin surface temperature changes following simulated vascular occlusion in an animal model. Secondary objectives were to assess agreement between FO and an intracutaneous thermistor and to compare temperature patterns following arterial versus venous occlusion. METHODS: A pedicled groin flap was raised in 32 female Sprague-Dawley rats. Animals were divided into four groups with simulated arterial or venous occlusion. The right side served as the intervention side, while the left acted as either a positive or negative control. Skin surface temperature was recorded at predefined time points before and after vessel ligation using FO and an intracutaneous thermistor. RESULTS: Venous thrombosis was associated with an increase in flap temperature, whereas a consistent temperature decrease following arterial occlusion was not observed. The agreement between FO and the intracutaneous thermistor was moderate. CONCLUSION: Infrared temperature monitoring demonstrated a tendency toward temperature elevation in venous congestion, while temperature changes associated with arterial ischemia appeared to develop more slowly. These findings suggest that infrared thermography may be more sensitive to venous than arterial vascular compromise in this experimental model.
Sequential, Noninvasive, Neurosensory Monitoring During Chemotherapy: Clinical Consequences of Identifying Neuropathy.
Oles N, Iverson A, Williams NH … +3 more , Wagner-Johnson N, Grossman S, Dellon AL
J Reconstr Microsurg · 2026 Jun · PMID 42276145 · Publisher ↗
BACKGROUND: A significant proportion of patients experience symptoms of sensory nerve damage from chemotherapy known as chemotherapy-induced peripheral neuropathy (CIPN). CIPN is a major dose-limiting toxicity of many ch...
BACKGROUND: A significant proportion of patients experience symptoms of sensory nerve damage from chemotherapy known as chemotherapy-induced peripheral neuropathy (CIPN). CIPN is a major dose-limiting toxicity of many chemotherapeutic regimens. Early detection and quantification of CIPN is a significant challenge. It is hypothesized that noninvasive, nonpainful, pressure-specified sensory device (PSSD) will be a sensitive and specific tool for measuring CIPN. If CIPN can be detected early, then oncology might alter the drug regimen. Additionally, it is known that more than 33% of diabetics with neuropathy have a chronic nerve entrapment, as determined by a positive Tinel sign. If CIPN persisted after chemotherapy stopped, then presence of a peripheral nerve entrapment could be evaluated. METHODS: A prospective cohort of patients receiving chemotherapy were referred by their oncologist. During the administration of their intravenous (IV) chemotherapy, the patient had PSSD testing of the index, little finger, and finger and big toe pulp. Quality-of-life outcome instruments QLQ-CIPN20, and the Michigan Neuropathy Symptom Score Instrument were administered. Each patient was evaluated for the presence of a Tinel sign at known sites of nerve entrapment. Inclusion criteria were patients receiving neurotoxic chemotherapy (Vincristine, Taxol, or Cisplatin). RESULTS: Thirteen patients were enrolled. There were no complications from neurosensory testing. The PSSD was 80% sensitive and 100% specific identifying symptomatic neuropathy, < 0.014, chi square and < 0.05 using the Fisher's exact test. PSSD testing became abnormal prior to the patient becoming symptomatic and prior to the presence of a positive Tinel sign. CONCLUSION: Noninvasive and nonpainful neurosensory testing is feasible to do during chemotherapy IV infusion. This can identify changes in peripheral nerve function that correlate with a patient's symptoms and therefore might be used by the oncologist to alter the patient's chemotherapy dosage and limiting chemotherapy toxicity.
"Finger-Touch Approach" for Novice Microsurgical Assistants: A Simulation Study.
Ogura A, Ishibashi S, Miyazaki T … +4 more , Tsukuura R, Matsui C, Yamamoto N, Yamamoto T
J Reconstr Microsurg · 2026 Jun · PMID 42248603 · Publisher ↗
BACKGROUND: Microsurgical procedures demand precise hand-eye coordination, yet the surgeon's hands often remain outside the visual field until instruments enter the microscope view, impairing spatial awareness. We develo...
BACKGROUND: Microsurgical procedures demand precise hand-eye coordination, yet the surgeon's hands often remain outside the visual field until instruments enter the microscope view, impairing spatial awareness. We developed the finger-touch approach (FTA) to provide an additional proprioceptive reference point, hypothesizing it would improve safety and confidence without compromising efficiency. METHODS: A simulation task was designed to replicate microsurgical suture-cutting assistance, one of the most common procedures performed by a microsurgery assistant. Postgraduate-year 1 to 2 junior residents (JR), and plastic surgery residents/fellows (PSF) performed the task using two approaches: a conventional method and the FTA, which involved touching the instrument to the assistant's index finger before entering the microscopic field. The number of unintended contacts, time to reach the microscopic field, and trajectory variability were measured. Microsurgical precision and psychological responses were compared between the methods. RESULTS: Eighteen JRs and five PSFs participated. FTA significantly reduced unintended contacts among JRs compared with the conventional approach (0.1 vs. 0.0, = 0.003), without affecting the time to reach the field or trajectory variability. In contrast, no significant differences were observed among PSFs. Posttask questionnaire revealed higher positive psychological responses among JRs compared with PSFs in comfort with the FTA (94.4% vs. 40.0%, = 0.021) and interest in incorporating the technique into actual surgery (100% vs. 60.0%, = 0.040). CONCLUSION: FTA improves safety and psychological comfort among novice microsurgical assistants. The technique requires minimal instruction without additional equipment, making it readily implementable in training programs and clinical practices for beginners.
Assessing the Availability and Need for Microsurgery-Trained Reconstructive Surgeons in Sub-Saharan Africa.
Park MO, Devisetti N, Thrikutam N … +4 more , Muzinda O, Meyers N, Muguti G, Chang J
J Reconstr Microsurg · 2026 Jun · PMID 42235574 · Publisher ↗
BACKGROUND: Microsurgery is an essential component of plastic and reconstructive surgery, yet access remains limited in low- and middle-income countries (LMICs). The College of Surgeons of East, Central, and Southern Afr...
BACKGROUND: Microsurgery is an essential component of plastic and reconstructive surgery, yet access remains limited in low- and middle-income countries (LMICs). The College of Surgeons of East, Central, and Southern Africa (COSECSA) region has identified a shortage of microsurgeons due to limited formal training, infrastructure needs, and resource constraints. This study aimed to assess the current microsurgical landscape in the COSECSA region, identifying key barriers and opportunities for training and practice development. METHODS: A cross-sectional, survey-based needs assessment was conducted among plastic surgery attending microsurgeons and trainees in the COSECSA region ( = 20). The survey collected quantitative and qualitative data on microsurgical exposure, training experiences, clinical and structural needs, and opportunities for international collaboration. RESULTS: Limited access to reliable equipment and supplies, insufficient funding, and inadequate institutional support were identified as major barriers to the development of microsurgical practices in this region. Key clinical needs included lower extremity and head and neck reconstruction, followed by reconstruction of craniofacial and burn conditions. Respondents emphasized the need for structured hands-on training, improved access to equipment, and international exchange programs to enhance microsurgical capacity in the COSECSA region. CONCLUSION: Addressing workforce shortages, improving microsurgery-specific training, and strengthening infrastructure are critical for expanding reconstructive microsurgical care in the COSECSA region. Given the current dearth of local training programs, international collaborations continue to play a vital role in bridging the gap in microsurgical training. However, to be effective, these partnerships should prioritize longitudinal, local engagement and capacity-building efforts to support the development of sustainable microsurgical practices in LMICs.
The Role of Preoperative Lower Extremity CT Angiography in Mandible Reconstruction: A Retrospective Cohort Analysis.
Mohr J, Ketschau J, Leonhardt Y … +7 more , Grabenhorst A, Singer H, Kram H, Krautkremer N, Pippich K, Wolff KD, Ritschl LM
J Reconstr Microsurg · 2026 Jun · PMID 42235573 · Publisher ↗
BACKGROUND: Preoperative computed tomography angiography (CTA) of the lower extremities is commonly performed before fibula free flap (FFF) harvest for mandibular reconstruction. While CTA is intended to improve harvest...
BACKGROUND: Preoperative computed tomography angiography (CTA) of the lower extremities is commonly performed before fibula free flap (FFF) harvest for mandibular reconstruction. While CTA is intended to improve harvest side safety, its actual impact on reconstructive decision-making and postoperative outcomes remains insufficiently characterized. METHODS: In this retrospective, single-center cohort study, patients undergoing mandibular continuity resection between July 2012 and June 2023 who received preoperative lower extremity CTA were analyzed. CTA-derived vascular parameters, including plaque presence, three-vessel run-off, and a bilateral vascular anomaly score, were systematically assessed. Associations with fibula flap selection (yes/no) and postoperative outcomes were analyzed using logistic regression and non-parametric statistical methods. Discriminatory performance was evaluated by receiver operating characteristic (ROC) analysis, including a combined CTA-based multivariable model. RESULTS: A total of 247 patients were included. CTA-derived parameters were strongly associated with the decision to perform a reconstruction with FFF, but showed no consistent association with postoperative outcomes such as revision surgery, flap loss, or length of hospitalization. After directional alignment of predictors, ROC analysis demonstrated moderate to good discrimination for individual parameters, including absence of plaque on any side (area under the ROC curve [AUC] 0.745) and the inverted bilateral vascular anomaly score (AUC 0.686). A combined multivariable CTA-based model integrating all vascular parameters achieved excellent discrimination for FFF selection (AUC 0.826). None of the CTA-derived variables independently predicted postoperative complications. Notably, FFF reconstruction was also performed in a small subset of patients despite the absence of three-vessel run-off, without an apparent increase in postoperative complications. CONCLUSION: Lower extremity CTA primarily serves as a preoperative decision-support tool guiding FFF selection rather than as a predictor of postoperative outcomes. CTA-based vascular assessment enables effective upstream risk stratification and supports individualized reconstructive planning in mandibular reconstruction.
Ultrasound Hemodynamics of SCIA-SIEA System: A Foundation for Groin Flap Planning.
Navarro ZC, Blasi M, Aranda Domenech D … +2 more , Lopez CC, Suñe CH
J Reconstr Microsurg · 2026 Jun · PMID 42235572 · Publisher ↗
BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap has become an essential option in reconstructive microsurgery. However, the arterial anatomy of the groin region demonstrates substantial variati...
BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap has become an essential option in reconstructive microsurgery. However, the arterial anatomy of the groin region demonstrates substantial variation, with reports of superficial circumflex iliac artery (SCIA) hypoplasia necessitating reliance on the superficial inferior epigastric artery (SIEA) as an alternative vascular source. This study aimed to characterize and compare hemodynamic differences among these arteries to determine whether physiological, in addition to morphological, variability exists. METHODS: Ultrasound was used to assess morphological and physiological parameters of the SCIA superficial and deep branches, as well as the SIEA, in 54 inguinal regions from 27 healthy volunteers. Measurements were obtained at defined anatomical landmarks, recording peak systolic velocity (PSV) and resistance index (RI). Cases were categorized based on PSV distribution patterns to describe relative flow predominance and potential variations in vascular contribution between arteries. RESULTS: Significant differences were noted in PSV among the three arteries ( < 0.00001), primarily between the SCIA branches and the SIEA (superficial SCIA vs. SIEA, < 0.00001; deep SCIA vs. SIEA, < 0.00001). Three main flow distribution patterns were described: Dominance of a single artery (18.5%), a single underdeveloped artery with reduced PSV (64.8%), and balanced flow among all three arteries (16.7%). No significant side-to-side differences were observed (all > 0.75). CONCLUSION: Distinct interindividual hemodynamic patterns of arterial perfusion in the groin region can be identified using ultrasound, and baseline reference values are established to support further validation of preoperative mapping for SCIP and SIEA flaps.
Intraoperative Versus Postoperative Correction of Vascular Compromise: Comparison of Flap and Patient Outcomes in Free Flap Breast Reconstruction.
Deguchi AN, Lemdani M, Khan S … +7 more , Botros D, Kim J, Hornick MM, Voytik M, Motomura H, Broach R, Serletti JM
J Reconstr Microsurg · 2026 Jun · PMID 42229433 · Publisher ↗
BACKGROUND: Although flap complications due to vascular compromise are rare with patent anastomoses, it can be devastating when it leads to flap failure, occurring in 3 to 5% of free flap breast reconstructions. The unpr...
BACKGROUND: Although flap complications due to vascular compromise are rare with patent anastomoses, it can be devastating when it leads to flap failure, occurring in 3 to 5% of free flap breast reconstructions. The unpredictable nature of vascular compromise presents a significant challenge to microsurgeons. Preventative interventions such as revision of the vascular anastomosis can occur as early as intraoperatively, but how these actions impact postoperative outcomes has not been thoroughly investigated. This study assesses the efficacy of intraoperative microsurgical interventions for vascular compromise on outcomes in free flap breast reconstruction. METHODS: A retrospective review was conducted of patients who underwent free flap breast reconstruction at a single academic institution between January 2005 and June 2023. Flaps that underwent intraoperative repeat anastomosis due to vascular compromise were compared with those that did not undergo intraoperative intervention but returned postoperatively for anastomosis revisions. RESULTS: Among 3,120 patients and 5,003 flaps reviewed, 182 flaps experienced intraoperative microsurgical revisions, and 79 flaps underwent postoperative repeat vascular anastomosis. Patient demographics, comorbidities, and flap types were not significantly different between the two groups. Multivariate regression analysis revealed that the intraoperative re-anastomosis cohort had significantly lower odds of surgical site infection, seroma, hematoma, skin necrosis, and flap loss rate due to vascular compromise. The rate of overall flap loss was 1.28%. CONCLUSION: Proactive intraoperative management of vascular compromise is ideal as it optimizes clinical outcomes and flap success rate. The findings from our study promote refinement of both surgical skills and decision-making among surgeons for optimal patient safety in free flap breast reconstruction.
Beyond the Chest X-Ray: Comparative Performance of Preoperative Tests for Phrenic Nerve Dysfunction in Brachial Plexus Injuries.
Yen PS, Lee CH, Adidharma W … +4 more , Hu HC, Chang TN, Chuang DC, Lu JC
J Reconstr Microsurg · 2026 May · PMID 42214444 · Publisher ↗
BACKGROUND: The phrenic nerve, arising from C3-C5 and innervating the diaphragm, is frequently affected in brachial plexus injuries (BPI). Given its role in respiration, preoperative assessment is essential to anticipate...
BACKGROUND: The phrenic nerve, arising from C3-C5 and innervating the diaphragm, is frequently affected in brachial plexus injuries (BPI). Given its role in respiration, preoperative assessment is essential to anticipate respiratory compromise in high-risk patients (e.g., elderly, obese, pediatric, smokers) and to determine its suitability as a donor nerve in selected cases. Traditional tests such as inspiratory-expiratory chest radiographs (CXR) are commonly used but have limited sensitivity. More recent modalities-including chest sonography, pulmonary function testing (PFT), and magnetic resonance neurography (MRN)-have been described, though their relative performance in BPI remains unclear. This study systematically compared these methods against intraoperative phrenic nerve stimulation as the reference standard. METHODS: A retrospective review was performed of patients undergoing brachial plexus reconstruction between 2020 and 2024. Inclusion required documented intraoperative phrenic nerve stimulation and at least one preoperative diagnostic test. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were calculated. McNemar's test assessed diagnostic agreement, DeLong's test compared AUCs, and logistic regression identified predictors of phrenic nerve injury. RESULTS: Among 113 patients, chest sonography provided the highest diagnostic accuracy, with 100% sensitivity, 80% specificity, and an AUC of 0.900. CXR showed the greatest specificity (93%) but low sensitivity (44%), yielding an AUC of 0.687. PFT demonstrated moderate sensitivity (86%) and low specificity (58%), with an AUC of 0.718. MRN performed poorly: MRN of the injured C4 root showed 22.2% sensitivity, 84.4% specificity, and an AUC of 0.533, while MRN of the injured C5 root yielded high sensitivity (87%) but very low specificity (6.5%), with an AUC of 0.467. CONCLUSION: Chest sonography provides the most reliable assessment of phrenic nerve function in BPI. Although CXR offers high specificity, its low sensitivity limits its use as a standalone test. A combined approach with sonography and CXR may enhance diagnostic accuracy.
The Unappreciated Morbidity of Brachial Plexus Injuries Following Low Energy Shoulder Trauma: Understanding Risk Factors and Natural History.
Sadeh O, Muller JN, Sobba WD … +2 more , Nicholas R, Hacquebord JH
J Reconstr Microsurg · 2026 Jun · PMID 42167342 · Publisher ↗
BACKGROUND: Brachial plexus injury (BPI) following shoulder trauma is an uncommon but potentially disabling complication that is often underrecognized, leading to delayed diagnosis. This study aimed to define the institu...
BACKGROUND: Brachial plexus injury (BPI) following shoulder trauma is an uncommon but potentially disabling complication that is often underrecognized, leading to delayed diagnosis. This study aimed to define the institutional incidence, nerve distribution, and recovery patterns of BPI after shoulder trauma and to identify factors associated with injury severity and recovery. METHODS: We performed a retrospective review of adult patients diagnosed with BPI following isolated shoulder trauma at a single academic center from January 2016 to July 2023. Patients with BPI were compared with a randomized cohort of shoulder trauma patients without BPI. Variables included demographics, mechanism of injury, injury pattern, nerve involvement, severity grading, management, and ≥1-year outcomes. BPI severity was categorized using a standardized clinical grading system. Logistic regression was used to evaluate factors associated with severity and predictors of recovery. RESULTS: Among 6,195 patients with shoulder trauma, 111 (1.8%) were diagnosed with BPI. Patients with BPI were younger than controls (51.5 years vs. 58.8 years, = 0.004), and fracture-dislocations were more common ( < 0.001). The axillary nerve was most frequently affected (67.1%), followed by radial (41.5%), median (36.6%), ulnar (32.9%), and musculocutaneous nerves (22.0%). Most patients (74.4%) achieved complete recovery within 1 year, and 85.4% were managed nonoperatively. Musculocutaneous nerve injury was associated with reduced odds of recovery (OR: 0.17, = 0.002), whereas dislocation (OR: 5.43, = 0.017) and fracture-dislocation (OR: 5.60, = 0.020) were associated with improved recovery compared with isolated fracture. CONCLUSION: BPI occurred in 1.8% of shoulder trauma cases and was most associated with fracture-dislocations. Musculocutaneous nerve injury and female sex were independently associated with a lower likelihood of recovery, whereas dislocation and fracture-dislocation patterns were associated with improved recovery compared with isolated fractures. These findings underscore the importance of early, nerve-specific evaluation and more refined prognostic stratification following shoulder trauma.
Flow, Resistance, and Turbulence: Elucidating the Hemodynamics of Free Flaps.
Ruta MR, Solari MG, Egro FM … +3 more , Sammer D, Zhang AY, Odobescu A
J Reconstr Microsurg · 2026 Jun · PMID 42167341 · Publisher ↗
BACKGROUND: The hemodynamics of free flaps remain incompletely characterized. Free flaps introduce nonphysiologic inflow conditions, where abrupt geometric changes can generate reflected waves that distort local flow. Fo...
BACKGROUND: The hemodynamics of free flaps remain incompletely characterized. Free flaps introduce nonphysiologic inflow conditions, where abrupt geometric changes can generate reflected waves that distort local flow. Fourier-domain analyses can isolate these reflections to quantify alterations in flow conditions. This study characterizes the hemodynamics of free flaps by linking flow, resistance, turbulent waveform changes, and intrinsic flap characteristics. METHODS: A retrospective review was conducted for patients who underwent free tissue transfer. For each flap, transit-time flow data, including flow and pulsatility index (PI), as well as arterial and venous pedicle calibers, were recorded intraoperatively. A short-time Fourier transform was applied to sequential segments of each flow signal. Harmonic distortion (HD), defined as the ratio of the cumulative power of the first n harmonics to the power at the fundamental, was calculated for the first harmonic (HD), first five harmonics (HD), and first ten harmonics (HD). RESULTS: Seventy free flaps in 51 patients were analyzed. Across all flaps, mean arterial inflow was 9.0 mL/minute (SD = 5.9) and mean PI was 3.8 (SD = 3.8). Flow was lowest in anterolateral thigh (ALT) flaps, intermediate in deep inferior epigastric perforator (DIEP) flaps, and highest in latissimus dorsi (LD) flaps. PI showed the inverse pattern. ALT flaps exhibited the greatest HD; DIEP flaps had the lowest HD at low-order harmonics but converged with LD flaps at high orders. Arterial pedicle caliber did not correlate significantly with hemodynamic metrics ( > 0.05), whereas larger venous diameter correlated with higher flow, lower PI, and lower HD ( < 0.05). Flow and PI showed a strong inverse relationship ( < 0.001). CONCLUSION: Free flap perfusion reflects a dynamic interplay among flow, resistance, and turbulence. PI and HD provide markers of resistance and waveform complexity. Venous caliber, not arterial, correlates with favorable hemodynamic profiles. Flap spectral signatures may enable functional characterization beyond anatomic descriptors.
The Role of the Medial Vastus Branch of the Descending Genicular Artery as a Recipient for Free Flap Transfer: Anatomical Study and Clinical Application.
Nakatsuka K, Karakawa R, Yano T … +4 more , Watanabe T, Torigoe T, Kawata S, Itoh M
J Reconstr Microsurg · 2026 Jun · PMID 42167340 · Publisher ↗
BACKGROUND: Free flap reconstruction after wide resection of sarcomas around the knee is challenging due to anatomical complexity and limited recipient vessels. The medial vastus branch of the descending genicular artery...
BACKGROUND: Free flap reconstruction after wide resection of sarcomas around the knee is challenging due to anatomical complexity and limited recipient vessels. The medial vastus branch of the descending genicular artery (DGA) may serve as a favorable recipient artery, but its anatomical characteristics and clinical applicability remain unclear. METHODS: An anatomical study was conducted on 30 lower limbs from 15 formalin-fixed cadavers to investigate the course and diameter of the medial vastus branch of the DGA. In addition, the clinical applicability of this vessel was evaluated in knee reconstruction. RESULTS: The medial vastus branch was identified in 86.7% of specimens, with an average diameter of 1.4 mm (range: 1.0-1.7), 1.6 mm (range: 1.2-1.9), 1.7 mm (range: 1.3-2.0), and 1.9 mm (range: 1.6-2.3), at 2.5, 5.0, 7.5, and 10-cm above the medial upper margin of the patella. Its superficial location allowed for easy dissection and anastomosis. The medial vastus branch of the DGA was successfully used as a recipient artery for free flap transfer in clinical application. CONCLUSION: The medial vastus branch of the DGA is a reliable recipient artery for free flap reconstruction around the knee. Its favorable anatomical characteristics enable safe dissection and vascular anastomosis without the need for positional changes during surgery. This vessel may be a valuable option for complex soft tissue reconstructions around the knee defects.
Development and Validation of FlapCheck.ai, a Fully Automated Artificial Intelligence Model for Postoperative Flap Viability Assessment.
Karir A, Ferbers SJ, Lancaster J … +5 more , Holzer EY, Wang AP, Sigurdson L, Buchel EW, Petropolis CJ
J Reconstr Microsurg · 2026 May · PMID 42140205 · Publisher ↗
BACKGROUND: Postoperative flap monitoring is critical for early detection and salvage of compromised flaps. As shorter hospital stays and outpatient procedures become common, accurate and user-friendly tools for remote f...
BACKGROUND: Postoperative flap monitoring is critical for early detection and salvage of compromised flaps. As shorter hospital stays and outpatient procedures become common, accurate and user-friendly tools for remote flap viability assessment are needed. This study describes the development and validation of FlapCheck.ai, an automated artificial intelligence (AI) custom vision model that classifies flap viability from nonstandardized clinical images. METHODS: Images of postoperative flaps were obtained through a single-center retrospective review and literature search and labeled as healthy or compromised. Two hundred nine images were split into training (80%) and testing (20%) sets with class balance preserved. Data augmentation (rotation, flipping, brightness, contrast adjustments) expanded the training set to 1,432 training images. The model was trained using Microsoft Azure Custom Vision and evaluated on the testing dataset. Performance metrics included accuracy, sensitivity, specificity, precision, F1 score, and area under the receiver operating characteristic curve (AUC-ROC) with 95% confidence intervals (CI). RESULTS: The model correctly classified 40 of 41 test images (30/31 healthy, 10/10 compromised), yielding an accuracy of 97.6% (95% CI: 87.4-99.6), sensitivity of 100% (95% CI: 72.2-100), specificity of 96.8% (95% CI: 83.8-99.4), precision of 90.9% (95% CI: 70.0-100), F1 score of 95.2% (95% CI: 82.4-100), and an AUC of 0.997. CONCLUSION: A fully automated AI model was successfully developed and validated for postoperative flap viability assessment using nonstandardized images. FlapCheck.ai demonstrated excellent diagnostic performance and may enable reliable outpatient flap monitoring and earlier detection of flap compromise. Future work will expand datasets and evaluate the impact in prospective studies.
Creating a Prelaminated Chondrocapsular Tissue Model in Composite Defect Reconstruction Accompanied by Cartilage Tissue Deficiency: An Experimental Study.
Aytaç YA, Yasar EK, Gürbüz MC … +3 more , Bayram M, Alagoz S, Duman Öztürk S
J Reconstr Microsurg · 2026 May · PMID 42140204 · Publisher ↗
BACKGROUND: Reconstruction of composite tissue defects, particularly those involving cartilage deficiency, remains highly challenging. This study aimed to develop a chondrocapsular tissue by prelaminating avascular carti...
BACKGROUND: Reconstruction of composite tissue defects, particularly those involving cartilage deficiency, remains highly challenging. This study aimed to develop a chondrocapsular tissue by prelaminating avascular cartilage with vascularized capsule tissue to enhance cartilage viability. METHODS: Twenty-seven rats were divided into three groups. In Group 1, two silicone sheets were implanted around the femoral vessels to induce double-layer capsule formation, followed by insertion of autologous auricular cartilage between the layers. In Group 2, a single silicone sheet was used for capsule induction before cartilage implantation. Group 3 served as the control, with direct cartilage implantation. Vascularity and cartilage viability were assessed using histology and immunohistochemistry. RESULTS: Capsule formation occurred only in Groups 1 and 2. Group 2 demonstrated the highest chondrocyte viability, while Group 1 exhibited the strongest neovascularization. Immunohistochemistry (CD31, CD44, Col2A1) confirmed superior vascularity and chondrogenic activity in Groups 1 and 2 compared with Group 3. CONCLUSION: Prelamination of cartilage with vascularized capsule tissue resulted in a viable, vascularized chondrocapsular construct. This model shows potential as a clinically applicable strategy for reconstructing composite tissue defects involving cartilage loss.
Beyond the Anastomosis: Is Pedicle Length the Critical Determinant of Thrombosis in Free Flaps?
Cengiz İZ, Yavuz E, Tan Ö
J Reconstr Microsurg · 2026 May · PMID 42091046 · Publisher ↗
BACKGROUND: This study aims to evaluate the effect of vascular pedicle length on arterial and venous thrombosis rates in free flap surgery. METHODS: This retrospective study evaluated 546 patients who underwent free flap...
BACKGROUND: This study aims to evaluate the effect of vascular pedicle length on arterial and venous thrombosis rates in free flap surgery. METHODS: This retrospective study evaluated 546 patients who underwent free flap reconstruction with a single arterial and venous anastomosis between 2015 and 2024. Patients were categorized based on pedicle length (3-5, 6-8, and 9-15 cm). The relationship between pedicle length, anastomosis type, and thrombosis was analyzed using chi-square tests and multivariate logistic regression analysis. RESULTS: A total of 546 flaps were analyzed. The overall venous thrombosis rate was 10.1%, and the arterial thrombosis rate was 4.2%. A statistically significant relationship was found between increasing pedicle length and higher rates of venous thrombosis (5.8% for 3-5 cm, 8.3% for 6-8 cm, and 13.4% for 9-15 cm; < 0.05). While a similar trend was observed for arterial thrombosis, it did not reach statistical significance ( > 0.05). Multivariate logistic regression on a patient subgroup confirmed that pedicle length was an independent predictor of thrombosis ( = 0.022), whereas anastomosis type was not ( = 0.986). CONCLUSION: Increased pedicle length is a significant and independent risk factor for venous thrombosis in free flap surgery. Surgeons should consider pedicle length a critical parameter during surgical planning to minimize thrombotic complications and improve flap survival rates. The study provides therapeutic, level III evidence.
Sensory Recovery of Foot and Ankle Reconstruction with Neurotized ALT Flaps: A Systematic Review.
Chen AJ, Snee IA, Nguyen JD … +6 more , Khong J, Laning EK, Park KE, Mundy LR, Dingle AM, Poore SO
J Reconstr Microsurg · 2026 May · PMID 42066790 · Publisher ↗
BACKGROUND: The anterolateral thigh flap (ALT) is a reliable soft tissue reconstruction option, especially for lower extremity defects. Recent advancements in flap innervation methods show promise in promoting sensory re...
BACKGROUND: The anterolateral thigh flap (ALT) is a reliable soft tissue reconstruction option, especially for lower extremity defects. Recent advancements in flap innervation methods show promise in promoting sensory recovery, yet the current literature lacks a comprehensive summary of its outcomes. METHODS: A systematic review of PubMed, Embase, Web of Science, and Scopus was performed by identifying all studies examining sensory recovery outcomes in lower extremity reconstruction using innervated ALT flaps. RESULTS: Of 793 unique articles, eight studies ( = 206 patients) met the inclusion criteria. The mean age was 47.9 ± 11.1 (range: 6-80). The most common etiologies of soft tissue defect were trauma ( = 94, 45.6%), diabetic foot ulcers ( = 64, 31.1%), and malignancy ( = 45, 21.8%). There were 108 (52.4%) patients who underwent reconstruction with a neurotized ALT flap, and 98 (47.6%) without. Of patients with neurotized flap reconstruction, nerve coaptation was performed end-to-end ( = 31, 28.7%) or end-to-side ( = 14, 12.9%). Recipient nerves included the medial plantar ( = 16, 14.8%), medial dorsal cutaneous ( = 9, 8.3%), calcaneal ( = 7, 6.5%), posterior tibial ( = 5, 4.6%), superficial peroneal ( = 4, 3.7%), or sural ( = 1, 0.9%) nerves. The overall complication rate was 16.5%, of which 11 (5.3%) were major flap complications requiring a return to the operating room. Overall, three studies found evidence of improved sensory recovery when using neurotized ALT flaps. CONCLUSION: Lower extremity reconstruction with innervated ALT flaps predominantly involves the foot and ankle region (98.5%), as the improved sensory recovery may be helpful in reducing secondary injury risk, such as diabetic foot ulcers. No cases involving reconstruction of soft tissue defects above the knee were identified.
Single-Institution Analysis of Immediate and Delayed Jaw Reconstruction.
Rothchild E, Park YJ, Smith IT … +5 more , Yom J, Baker C, Odia I, Coyle L, Ricci JA
J Reconstr Microsurg · 2026 May · PMID 42020142 · Publisher ↗
BACKGROUND: Traditional methods of mandibular reconstruction commonly utilize the fibula-free flap with delayed placement of dental prostheses. Recently, immediate prosthesis placement has been introduced to eliminate th...
BACKGROUND: Traditional methods of mandibular reconstruction commonly utilize the fibula-free flap with delayed placement of dental prostheses. Recently, immediate prosthesis placement has been introduced to eliminate the period of edentulism. This study aimed to compare the surgical outcomes of patients undergoing immediate jaw reconstruction (IJR) with those undergoing traditional fibula-free flap mandibular reconstruction (FFFMR) at our institution. METHODS: Following IRB approval, a retrospective review was conducted on patients who underwent either traditional FFFMR or IJR at our institution between 2015 and 2024. Patients were divided into either the traditional or the IJR cohort. Propensity score matching was used to control for confounding variables, and the surgical outcomes of the two cohorts were compared. RESULTS: A total of 116 patients were included in the study, with 97 in the traditional group and 19 in the IJR group. Demographics and clinical factors were similar between the two groups, although patients in the traditional cohort were more likely to have malignant disease. Following propensity score matching, no significant differences in complication rates were observed between groups. The surgery duration was significantly shorter in the IJR group compared to the traditional FFFMR group in both the unmatched and matched analyses. CONCLUSION: IJR demonstrated comparable postoperative surgical outcomes to the traditional FFFMR approach. These findings suggest that IJR is not inferior, and support this method as a feasible, safe alternative to provide immediate functional and aesthetic benefits for appropriately selected patients.
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