Background:Free tissue transfer is the standard for complex reconstruction, yet flap failure remains an inevitable reality of microsurgical practice. Beyond patient impact, these events can profoundly affect surgeons through psychological, physical, and professional sequelae. Comprehensive data on prevalence, risk factors, and support systems specific to microsurgeons remain limited. Methods:Following IRB approval, a 15-item REDCap survey was distributed to American Society for Reconstructive Microsurgery members. The survey assessed demographics, flap experience, psychological and physical symptoms following flap loss, symptom duration and impact, coping strategies, available institutional support, and desired support. Statistical analyses included descriptive statistics, Fisher's exact test, Spearman correlation, and logistic regression. Free-text responses underwent thematic content analysis. Results:Eighty-two microsurgeons completed the survey (63.4 male and 36.6% female; mean: 12.2 years in practice). Sixty-seven point one percent experienced guilt, 61.0% fear of future poor outcomes, 58.5% difficulty sleeping, and 56.1% anxiety and questioning of surgical ability. While most experienced short-term symptoms, 17.1% reported prolonged duration (several months or longer). Female-identifying surgeons experienced prolonged symptoms significantly more often than male-identifying surgeons (30.0% vs. 9.6%, p = 0.031). Having ≤ 5 microsurgical colleagues was associated with prolonged symptoms (27.3% vs. 5.3%, p = 0.009). Years in practice were modestly associated with shorter symptom duration and lower perceived impact. The most common coping strategy was discussing events with colleagues (72.8%). A substantial gap existed between available and desired support: only 25.9% had access to counseling services, while 51.9% desired peer support programs. Conclusion:Psychological sequelae after flap loss are nearly universal among microsurgeons, with female-identifying surgeons and those in smaller practices particularly vulnerable. Institutions and microsurgical societies should develop structured, psychologically safe support systems to improve surgeon well-being, promote professional sustainability, and strengthen a culture of reflection and learning.
Background:Several surface anatomy landmarks have been described to aid in the surgical dissection of facial nerve donor branches for neurotization purposes yet are limited by considerable anatomical variability. High-frequency ultrasound has shown promise for facial nerve imaging and could be a more precise complementary tool to intraoperative neurostimulation. We aimed to validate a systematic ultrasound examination technique to determine the exact location for each main extratemporal branch and to assess its preliminary clinical feasibility and safety profile for preoperative mapping. Methods:Ten cadaveric hemifaces with a total of 56 facial nerve extratemporal branches were examined to validate a branch-by-branch ultrasound-based mapping technique. The accuracy of skin markings and ultrasound-guided methylene blue injections for each branch was confirmed by subsequent dissection. Additionally, a retrospective clinical series, comprising five cross-face nerve grafts and one facial nerve-to-muscle neurotization, was analyzed to assess reproducibility in the clinical setting. Results:In the cadaveric series, branch-by-branch analysis demonstrated a sensitivity of 92.9% (95% confidence interval [CI]: 84.2-97.7), a positive predictive value of 92.9% (95% CI: 84.2-97.7), and an overall agreement between ultrasound findings and dissection of 86.7% (95% CI: 75.4-93.3). In the clinical series, the targeted facial nerve branches were successfully identified without complications. Conclusion:The proposed systematic ultrasound-based mapping technique, readily performed by surgeons trained in ultrasonography, shows promising accuracy in the identification of facial nerve arborization and a good preliminary feasibility and safety profile in the clinical setting.
Background:Prospective national registry data provide a unique opportunity to evaluate whether increasing experience and structured certification translate into improved microsurgical breast reconstruction outcomes over time. Methods:All microsurgical free-flap breast reconstructions recorded in the prospective quality assessment database of the German Society of Plastic, Reconstructive, and Aesthetic Surgeons between 2011 and 2018 were analyzed. Data from 22 certified centers were included. Temporal trends in flap selection, operative parameters, and clinical outcomes were assessed at national, center, and surgeon levels. Results:A total of 5,671 microsurgical flaps in 4,909 patients were evaluated. Overall flap-loss rates remained stable throughout the study period (2.6-4.2%, p = 0.894) despite increasing center participation and surgeon experience. Additional flap techniques were gradually introduced; however, diversification remained limited with heterogeneous uptake across centers, and deep inferior epigastric perforator (DIEP) remained the predominant reconstructive option. Operative duration decreased significantly in high-volume centers (mean difference: -38 minutes, 95% CI: -69 to -7; p = 0.020) and among more experienced surgeons (mean difference: -30 minutes, 95% CI: -49 to -11; p = 0.003), but no overall reduction in operative duration was observed over time. In contrast, ischemia time showed an overall trend toward prolongation. Conclusion:Microsurgical breast reconstruction within a nationwide network of certified centers achieved consistently high and internationally comparable outcomes. Despite increasing institutional experience and the introduction of additional flap techniques, flap-loss rates remained stable, and DIEP remained the predominant reconstructive option. Although learning-curve effects were identifiable at both the institutional and surgeon level, they did not translate into further reduction in complications. Further quality improvement is therefore more likely to benefit from structured benchmarking and regular feedback of operative and outcome metrics than from technical refinements alone.
Background:The anterolateral thigh (ALT) and parascapular (PS) flaps are commonly used fasciocutaneous free flaps for extremity reconstruction, offering large reliable soft tissue coverage with low donor site morbidity. However, comparative data on donor site functional outcomes remain limited. This review evaluates and compares reported donor site morbidity associated with ALT and PS flaps. Methods:A systematic review of MEDLINE, Embase, Scopus, and the Cochrane Library was conducted through October 6, 2025. Studies reporting binary outcomes for donor site complications after ALT or PS flap harvest were included. Data on hematoma, seroma, delayed healing, dehiscence, weakness, functional deficit, and numbness were pooled and analyzed using Fisher's exact or Chi-square tests. Results:Of 1,167 studies screened, 46 met inclusion criteria: 43 reported on ALT flaps, 2 on PS flaps, and 1 on both, totaling 3,380 ALT and 50 PS flaps. For ALT flaps, pooled complication rates were: numbness 51.7%, dehiscence 9.6%, delayed healing 7.5%, weakness 5.0%, seroma 4.5%, functional deficit 1.5%, and hematoma 1.3%. For PS flaps, complication rates were: numbness 26.3%, dehiscence 16.7%, delayed healing 10.0%, weakness 10.0%, functional deficit 10.0%, seroma 8.0%, and hematoma 0%. ALT flaps were associated with significantly greater numbness (p = 0.01), while PS flaps showed higher functional deficits (p = 0.04). No other outcomes differed significantly. Conclusion:ALT and PS flaps both offer effective reconstruction with low overall morbidity. ALT flaps are more often associated with numbness, while PS flaps may pose a higher risk of functional impairment; however, this latter finding should be interpreted cautiously given the limited number of PS flap studies and small sample size. These differences may guide flap selection when clinical factors are otherwise equivalent.
Background:In complex cervical nerve surgeries, ensuring the integrity of the phrenic nerve (PN) adjacent to the anterior scalene muscle is critical. However, we have encountered a clinical paradox: Postoperative diaphragmatic dysfunction occurred even when the main PN trunk was preserved intraoperatively. This suggests the potential involvement of PN variations (PNVs), such as the accessory PN, which merges with the main trunk, and separate branches that maintain an independent course. Methods:Using contralateral C7 nerve transfer (CC7) as a surgical model, this study aimed to characterize the prevalence and electrophysiology of the cervical PNV by combining cadaveric dissection with intraoperative electromyography (EMG) monitoring. Results:Anatomical dissection revealed a PNV prevalence of 31.8% (7/22 sides), whereas intraoperative EMG identified PNVs in 63.3% of cases (19/30 sides). Intraoperatively, the PNV was typically observed coursing lateral to the main PN (47.4%, 9/19), overlying the anterior scalene muscle. Electrophysiological analysis demonstrated a moderate correlation between PNV- and PN-evoked responses (latency ρ = 0.661; amplitude ρ = 0.673; p < 0.05). The PN generally exhibited larger amplitudes (p < 0.001), confirming its role as the primary motor supply to the diaphragm. Notably, in 44.4% of cases with recordable signals, the PNV amplitude reached ≥50% of the ipsilateral PN amplitude, suggesting that these PNVs may contribute to diaphragmatic innervation. All identified branches were successfully preserved, with no severe postoperative complications observed. Conclusion:Conventional anatomical studies may underestimate the prevalence of the PNV relative to intraoperative electrophysiological assessment. Intraoperative EMG monitoring is not required for all cervical nerve procedures; however, when feasible, particularly in procedures that may involve bilateral PNs, it can help identify and preserve functionally important branches, thereby reducing the risk of iatrogenic injury.
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.
Introduction:Body mass index (BMI) limits of 30.0 to 32.7 kg/m2 have been recommended to reduce postoperative 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 postoperative complication rates using a novel, accessible measuring method. Methods:A retrospective chart review of 793 patients (1,310 flaps) who underwent deep inferior epigastric perforator (DIEP) flap reconstruction from November 2017 to May 2024 at two medical sites was conducted. Demographics, medical history, operative course, and postoperative complications were reviewed. Subcutaneous AWT was measured on preoperative computed tomography angiogram at four standardized anatomical landmarks. Patients were stratified by BMI (<25, 25-30, 30-35, and >35) and AWT (<20, 20-40, 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. Receiver operating characteristic 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:AWT 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.
Background: Accurate preoperative mapping of skin‐paddle perforators is vital for osteocutaneous fibula free flap (FFF) success. While hand‐held Doppler (HHD) is widely used for its convenience, its performance compared to color Doppler ultrasound (CDU) in FFF planning remains uncertain. Methods: In this prospective study, 50 consecutive patients undergoing fibula free flap reconstruction after head and neck cancer resection were evaluated. Each patient underwent HHD and CDU mapping on the day before surgery. Perforator skin‐surface location, anatomical type (septocutaneous vs. musculoseptocutaneous), peak systolic velocity, and source vessel (peroneal vs. posterior tibial) were recorded. Mapping marks were concealed between examinations. Results: A total of 185 perforators were confirmed intraoperatively (mean 3.7 per limb). CDU identified 179 candidates, yielding 95% sensitivity, 92% specificity, and 94% accuracy. HHD detected 155 sites, achieving 59% sensitivity, 6% specificity, and 48% accuracy, with significantly more false positives and negatives (p < 0.001). Both overall and dominant perforators clustered in the fourth decile of the lower leg (counting from lateral malleolus to fibular head). Distal regions were dominated by septocutaneous vessels, while musculoseptocutaneous types were more common in proximal regions. Anatomical variants—perforators draining into posterior tibial instead of peroneal vessels—occurred in 8% of cases and were identified exclusively by CDU. Conclusions: CDU outperforms HHD for preoperative perforator mapping in osteocutaneous FFF, combining high spatial precision with reliable hemodynamic assessment and variant detection. Incorporation of CDU into routine surgical planning promises to enhance flap design accuracy and minimize intraoperative uncertainty.
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 (September 2019-December 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/m2), 34.7% normal weight (≥18.5 and <25 kg/m2), 29.5% overweight (≥25 and <30 kg/m2), and 15.5, 7.0, and 3.7% within obesity I (≥30 and <35 kg/m2), II (≥35 and <40 kg/m2), and III (≥40 kg/m2), respectively. Flaps employed significantly differed between low and high BMI groups (p < 0.001). Underweight patients demonstrated increased odds of donor-site (odds ratio [OR]: 4.60; p = 0.011) and recipient-site (OR: 2.49; p = 0.007) complications, notably salivary leaks (24.0% vs. ≤11.2%; p = 0.0322). In subgroup analyses, obesity II patients undergoing thigh-based reconstructions saw increased flap loss (16.7% vs. ≤2.4%, p = 0.0002); obesity II and III patients trended toward increased recipient-site hematoma (16.7% vs. ≤3.6%, p = 0.1376) and dehiscence (20.0% vs. ≤7.1%, p = 0.0824), respectively. Conclusion: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.
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.
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, p < 0.014, chi square and p < 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.
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, p = 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%, p = 0.021) and interest in incorporating the technique into actual surgery (100% vs. 60.0%, p = 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.
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 (n = 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.
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.
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 (p < 0.00001), primarily between the SCIA branches and the SIEA (superficial SCIA vs. SIEA, p < 0.00001; deep SCIA vs. SIEA, p < 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 p > 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.
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.
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.
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, p = 0.004), and fracture-dislocations were more common (p < 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, p = 0.002), whereas dislocation (OR: 5.43, p = 0.017) and fracture-dislocation (OR: 5.60, p = 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.
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 (HD1), first five harmonics (HD5), and first ten harmonics (HD10). 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 (p > 0.05), whereas larger venous diameter correlated with higher flow, lower PI, and lower HD (p < 0.05). Flow and PI showed a strong inverse relationship (p < 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.
