Michel Saint-Cyr

Vascular anatomy of the anterolateral thigh flap: a systematic review.

Background: The most untoward aspect of the anterolateral thigh is the complexity of the local vasculature. Failure to understand its variability can lead to vascular flap embarrassment and tissue loss. The authors present a comprehensive summary of the vascular anatomy of the anterolateral thigh. Methods: A MEDLINE search was performed for articles published between 1948 and 2012 on the anterolateral thigh flap. Two levels of screening and manual reference check identified 44 relevant studies. Results: The descending branch of the lateral circumflex femoral artery was variably found to originate from the deep femoral (6.25 to 13 percent) or common femoral artery (1 to 6 percent), instead of the lateral circumflex femoral artery. Dominant perforator supply to the anterolateral thigh was most commonly from the descending (57 to 100 percent), transverse (4 to 35 percent), oblique (14 to 43 percent), or ascending (2.6 to 14.5 percent) branch. Septocutaneous perforators were present in 19.8 percent (0 to 61.5 percent) of cases overall (n = 2486). No perforators were found in 1.8 percent of cases overall (n = 2895). The majority of perforators were found in the central third of the thigh. The previously undescribed musculoseptocutaneous perforator was observed in 21 to 52.3 percent of vascular mapping or anatomic studies, but not in clinical studies. Conclusions: As knowledge of pertinent vascular anatomy for the anterolateral thigh flap has increased, so has insight into the amount of existing variation. This systematic review summarizes the wide spectrum of normal and variant anatomy described in the literature to date. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Enhanced recovery after surgery in microvascular breast reconstruction

BACKGROUNDnEnhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery, but they have not been described for patients undergoing microvascular breast reconstruction.nnnSTUDY DESIGNnA standardized ERAS pathway was developed through multidisciplinary collaboration which addressed all phases of surgical care for patients undergoing free-flap breast reconstruction using an abdominal donor site. Two surgeons used the ERAS pathway, and results were compared with a historical cohort of the same 2 surgeons patients treated by traditional care after surgery (TRAS). All patients underwent surgery between September 2010 and September 2013. The primary outcome measure was hospital LOS.nnnRESULTSnA total of 100 patients were analyzed: 49 in the ERAS cohort, and 51 in the TRAS cohort, with a total of 181 flaps. Mean hospital LOS was shorter with ERAS than TRAS (3.9 vs 5.5 days; P<0.001). Total inpatient postoperative opioid usage for the first 3 days, in oral morphine equivalents, was less for ERAS than TRAS (167.3 vs 574.3 mg; P<0.001), a decrease of 71%, with similar pain scores for the 2 groups. Overall 30-day major complication rates were not significantly different between the groups (P=0.21).nnnCONCLUSIONSnThe initiation of an ERAS pathway significantly decreased hospital LOS in our study. The pathway also significantly decreased the amount of opioids used postoperatively by 71%, without a consequent increase in patient-reported pain.

Repair and reconstruction of thumb and finger tip injuries: a global view.

In this review, an international group of senior hand surgeons was asked to provide their currently used methods, views, and advice on thumb and fingertip repair. The basic requirements and methods of thumb and fingertip repair are first outlined, followed by descriptions of the methods favored by individual units or surgeons. More recent innovative methods and modifications are described and challenging topics are discussed. This review ends by illustrating and discussing a few exploratory treatments that hold promise of greatly changing future perspectives of this common clinical problem.

Free tissue transfers and replantation.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. Summary: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper débridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.

Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report.

Background: The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations. Methods: A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction. Results: Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction. Conclusions: No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety.

Microsurgical free flaps for reconstruction of soft tissue defects in lower extremity have evolved into a reliable procedure over last decades; however, there lacked high level of evidence.

Comparison of subcutaneous versus submuscular expander placement in the first stage of immediate breast reconstruction

BACKGROUND AND AIMnTissue expander-based two-stage reconstruction remains the most commonly used technique in immediate breast reconstruction. This study compares the subcutaneous expander placement to the traditional submuscular placement and describes our early experience with the expander insertion plane-choosing algorithm.nnnMETHODSnA retrospective study of patients who underwent two-stage immediate breast reconstruction from May 2012 to October 2014 was conducted. All expander insertion planes were chosen using the same algorithm. Expansion, pain, and complications were compared between two groups.nnnRESULTSnThe study included 88 patients (158 expanders; 50 subcutaneous and 108 submuscular). The subcutaneous group had a higher intraoperative expansion ratio (pxa0<xa00.001), high first postoperative expansion ratio (pxa0<xa00.001), shorter duration of expansion (pxa0=xa00.02), less number of expansion visits (pxa0=xa00.002), and less average pain during admission (pxa0=xa00.004). Significant differences in the intraoperative and first postoperative expansion ratios in patients with postmastectomy radiation therapy were also found between the two groups (pxa0=xa00.005 and 0.01, respectively). Complications during expansion and after second-stage autologous flap reconstruction were comparable between two groups.nnnCONCLUSIONnThe subcutaneous expander placement was associated with greater intraoperative and first postoperative expansion, shorter expansion duration, less expansion visits, and less pain. With the expander insertion plane-choosing algorithm, subcutaneous expander placement could be performed with comparable complications rates with the submuscular placement during expansion and after second-stage autologous flap reconstruction. Further studies can be performed due to the lack of long-term complications following second-stage implant reconstruction in the subcutaneous approach.

Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction.

Vulvar defects following tumor extirpation are most commonly closed primarily by the gynecologist but larger and/or radiated defects often require reconstruction with flaps for adequate coverage and wound healing. Recurrence of vulvar carcinomas remains a challenge, so secondary reconstruction becomes increasingly problematic where locoregional flaps (i.e., gracilis, rectus, anterolateral thigh, and gluteal flaps) may have already been utilized, radiated, or have resulted in unacceptable cosmetic or functional morbidity. We present two cases of recurrent vulvar carcinoma following radiation therapy requiring total vulvectomy and a novel approach for soft-tissue reconstruction. Previous authors have reported the use of thinned and split flaps, but we combine these techniques to split and thin a transversely oriented deep interior epigastric artery perforator (DIEP) flap to maximize aesthetic results and minimize donor-site morbidity. The DIEP flap is commonly performed by microsurgeons for autologous free-tissue transfer in breast reconstruction but also serves as a useful option for large vulvar or perineal defects, either in primary or secondary reconstruction.

Modified aesthetic abdominoplasty approach in perforator free-flap breast reconstruction: Impact of drain free donor site on patient outcomes

BACKGROUNDnThe use of progressive tension sutures alone has been shown to be comparable to using abdominal drains in aesthetic abdominoplasty. This study reviews outcomes with the use of barbed progressive tension suture technique without drains in DIEP donor site closure compared to standard closure with drains.nnnMETHODSnA two year retrospective review was conducted of DIEP flap reconstructions in the enhanced recovery program at Mayo Clinic, Rochester (USA). Donor site closure was divided into barbed progressive tension sutures (B-PTS) without drains, and standard abdominal closure with drains(S-AD). Demographics, perioperative data and donor site complications were documented.nnnRESULTSn93 patients were included in the study, 42 in the B-PTS no drain group and 51 in the S-AD with drains. 81% of all procedures were bilateral and 39% were immediate. Patients were discharged faster to the ward postoperatively and total hospital admission was reduced in the B-PTS group, 3.7 (SDxa0=xa01.4) days versus 4.7 (SDxa0=xa02.1) days in the standard group (Pxa0=xa00xa0<xa00.001 and 0.004 respectively). Less morphine was required postoperative day (POD) 1, 2 and 3 (Pxa0=xa00.04, 0.03, 0.02 respectively), and time to mobilize was quicker but not statistically significant (Pxa0=xa00.09) in the B-PTS group. Overall there were 18 patients in the S-AD group who had complications versus 9 in the B-PTS group (Pxa0=xa00.14). The incidence of complications occurring within 30 days were lower in the B-PTS group (Pxa0=xa00.05). The overall seroma rate was 5.4% and rates in the B-PTS group was 2.4% versus 7.8% in the S-AD group, Pxa0=xa00.37.nnnCONCLUSIONSnUse of barbed progressive tension sutures for abdominal closure after DIEP flap harvest can obviate the need for abdominal drains, reduce postoperative pain and encourage early discharge from the hospital without an increased risk in complications.nnnLEVEL OF EVIDENCEnIII.

Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction.

BackgroundSeveral approaches to minimize postoperative pain, nausea, and enhance recovery are available for patients undergoing mastectomy with immediate tissue expander (TE) reconstruction. We compared the effectiveness of intraoperative local infiltration of liposomal bupivacaine (LB) to preoperative paravertebral block (PVB).MethodsWe retrospectively reviewed patients who underwent mastectomy with immediate TE reconstruction between May 2012 and October 2014 and compared patients with preoperative ultrasound-guided PVB to those with intraoperative LB infiltration.ResultsFifty-three patients (54.6xa0%) received LB and 44 received PVB. LB was associated with less opioid use in the recovery room (pxa0<xa00.001), fewer patients requiring antiemetics (pxa0=xa00.03), and lower day of surgery pain scores (pxa0=xa00.008). LB also was associated with longer time to first opioid use (pxa0=xa00.04). On multivariable analysis controlling for expander placement location, year of surgery, and axillary lymph node dissection (ALND), the only variable that remained statistically significant was lower opioid use in the recovery room for patients with LB (pxa0=xa00.03) and day of surgery pain scores approached significance (pxa0=xa00.05). There was no difference in the proportion of patients discharged within 36xa0h of surgery between the groups. Focusing on first cases of the day (where PVBs are performed in the OR) showed average time to skin incision was 15xa0min shorter in the LB group (pxa0=xa00.004).ConclusionsLocal infiltration of LB in patients undergoing mastectomy with immediate TE reconstruction decreases narcotic requirements in the recovery room, shortens preoperative anesthesiology time, and provides similar, if not better, perioperative pain control compared with PVB.